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Schipper RJ, de Bruijn A, van der Sangen MJC, Bloemen JG, van den Hoven I, Schepers EEM, Vriens BEP, Boerman T, Rijkaart DC, van de Winkel LMH, Brouwer C, van Warmerdam LJC, Gielens MPM, van Bommel RMG, van Riet YE, Voogd AC, Nieuwenhuijzen GAP. Oncologic outcomes of de-escalating axillary treatment in clinically node-positive breast cancer patients treated with neoadjuvant systemic therapy - A two center cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108472. [PMID: 38870876 DOI: 10.1016/j.ejso.2024.108472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 05/18/2024] [Accepted: 06/04/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND The aim of the present study was to report the 5-year axillary recurrence-free interval (aRFI) in clinically node-positive breast cancer patients treated according to a de-escalating axillary treatment protocol after neoadjuvant systemic therapy (NST). METHODS All patients diagnosed in two hospitals between October 2014 and March 2021 were identified retrospectively. Data on diagnostic workup, treatment and follow-up was collected. Adjuvant axillary treatment was considered based on the initial staging using 18F-FDG PET/CT and the results of axillary lymph node marking with a radioactive-iodine seed protocol or a targeted axillary dissection procedure. Follow-up was updated until 27th April 2024. Kaplan-Meier curves were calculated to report the 5-year aRFI with corresponding 95 % confident intervals (95%-CI). RESULTS A total of 199 patients were included. Axillary pathological complete response was reported in 66 (33.2 %). Based on the treatment protocol and initial clinical staging, no adjuvant axillary treatment was indicated in 30 patients (15 %), while 139 (70 %) received axillary radiotherapy without performance of an axillary lymph node dissection (ALND). The remaining 30 patients (15 %) underwent an ALND with additional locoregional radiotherapy. A median follow-up of 62 months (30-106) showed that 4 (2 %) patients experienced an axillary recurrence after 7, 8, 36 and 36 months, respectively. In all 4 patients, synchronous distant metastases were diagnosed. The estimated 5-year aRFI was 97.8 % (95%-CI 95.6-99.9 %) CONCLUSION: Although longer follow-up should be awaited before final conclusions can be drawn regarding the oncological safety of this approach, the implementation of a de-escalating axillary treatment protocol appears to be safe since the estimated 5-year aRFI is 97.8 %.
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Affiliation(s)
- Robert-Jan Schipper
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands; Department of Surgery, Anna Hospital, Geldrop, the Netherlands.
| | - Anne de Bruijn
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | | | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | | | | | - Birgit E P Vriens
- Department of Internal Medicine, Catharina Hospital Eindhoven, the Netherlands
| | - Thom Boerman
- Department of Pathology, Eurofins PAMM, Veldhoven, the Netherlands
| | - Dorien C Rijkaart
- Department of Radiotherapy, Catharina Hospital Eindhoven, the Netherlands
| | | | - Christel Brouwer
- Department of Nuclear Medicine, Catharina Hospital Eindhoven, the Netherlands
| | | | | | | | - Yvonne E van Riet
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
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van Amstel FJG, de Mooij CM, Simons JM, Mitea C, van Diest PJ, Nelemans PJ, van der Pol CC, Luiten EJT, Koppert LB, Smidt ML, van Nijnatten TJA. Disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and molecular subtype: prediction of axillary treatment response after neoadjuvant systemic therapy for breast cancer. Br J Surg 2024; 111:znae203. [PMID: 39302345 DOI: 10.1093/bjs/znae203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/19/2024] [Accepted: 07/23/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT combined with pathological axillary treatment response has been proposed to guide de-escalation of axillary treatment for clinically node-positive breast cancer patients treated with neoadjuvant systemic therapy. The aim of this study was to assess whether axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and breast cancer molecular subtype are predictors of axillary pCR. METHODS This study included clinically node-positive patients treated with neoadjuvant systemic therapy in the prospective Radioactive Iodine Seed placement in the Axilla with Sentinel lymph node biopsy ('RISAS') trial (NCT02800317) with baseline [18F]fluorodeoxyglucose PET/CT imaging available. The predictive value of axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and breast cancer molecular subtype to estimate axillary pCR was evaluated using logistic regression analysis. Discriminative ability is expressed using ORs with 95% confidence intervals. RESULTS Overall, 185 patients were included, with an axillary pCR rate of 29.7%. The axillary pCR rate for patients with limited versus advanced baseline axillary disease according to [18F]fluorodeoxyglucose PET/CT was 31.9% versus 26.1% respectively. Axillary disease extent was not a significant predictor of axillary pCR (OR 0.75 (95% c.i. 0.38 to 1.46) (P = 0.404)). There were significant differences in axillary pCR rates between breast cancer molecular subtypes. The lowest probability (7%) was found for hormone receptor+/human epidermal growth factor receptor 2- tumours. Using this category as a reference group, significantly increased ORs of 14.82 for hormone receptor+/human epidermal growth factor receptor 2+ tumours, 40 for hormone receptor-/human epidermal growth factor receptor 2+ tumours, and 6.91 for triple-negative tumours were found (P < 0.001). CONCLUSION Molecular subtype is a significant predictor of axillary pCR after neoadjuvant systemic therapy, whereas axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT is not.
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Affiliation(s)
- Florien J G van Amstel
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Cornelis M de Mooij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Janine M Simons
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
- Department of Radiotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Cristina Mitea
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patty J Nelemans
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | | | - Ernest J T Luiten
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
- Tawam Breast Care Center, Tawam Hospital, Al Ain, United Arab Emirates
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Thiemo J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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Montagna G, Mrdutt MM, Sun SX, Hlavin C, Diego EJ, Wong SM, Barrio AV, van den Bruele AB, Cabioglu N, Sevilimedu V, Rosenberger LH, Hwang ES, Ingham A, Papassotiropoulos B, Nguyen-Sträuli BD, Kurzeder C, Aybar DD, Vorburger D, Matlac DM, Ostapenko E, Riedel F, Fitzal F, Meani F, Fick F, Sagasser J, Heil J, Karanlık H, Dedes KJ, Romics L, Banys-Paluchowski M, Muslumanoglu M, Perez MDRC, Díaz MC, Heidinger M, Fehr MK, Reinisch M, Tukenmez M, Maggi N, Rocco N, Ditsch N, Gentilini OD, Paulinelli RR, Zarhi SS, Kuemmel S, Bruzas S, di Lascio S, Parissenti TK, Hoskin TL, Güth U, Ovalle V, Tausch C, Kuerer HM, Caudle AS, Boileau JF, Boughey JC, Kühn T, Morrow M, Weber WP. Omission of Axillary Dissection Following Nodal Downstaging With Neoadjuvant Chemotherapy. JAMA Oncol 2024; 10:793-798. [PMID: 38662396 PMCID: PMC11046400 DOI: 10.1001/jamaoncol.2024.0578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/07/2023] [Indexed: 04/26/2024]
Abstract
Importance Data on oncological outcomes after omission of axillary lymph node dissection (ALND) in patients with breast cancer that downstages from node positive to negative with neoadjuvant chemotherapy are sparse. Additionally, the best axillary surgical staging technique in this scenario is unknown. Objective To investigate oncological outcomes after sentinel lymph node biopsy (SLNB) with dual-tracer mapping or targeted axillary dissection (TAD), which combines SLNB with localization and retrieval of the clipped lymph node. Design, Setting, and Participants In this multicenter retrospective cohort study that was conducted at 25 centers in 11 countries, 1144 patients with consecutive stage II to III biopsy-proven node-positive breast cancer were included between April 2013 and December 2020. The cumulative incidence rates of axillary, locoregional, and any invasive (locoregional or distant) recurrence were determined by competing risk analysis. Exposure Omission of ALND after SLNB or TAD. Main Outcomes and Measures The primary end points were the 3-year and 5-year rates of any axillary recurrence. Secondary end points included locoregional recurrence, any invasive (locoregional and distant) recurrence, and the number of lymph nodes removed. Results A total of 1144 patients (median [IQR] age, 50 [41-59] years; 78 [6.8%] Asian, 105 [9.2%] Black, 102 [8.9%] Hispanic, and 816 [71.0%] White individuals; 666 SLNB [58.2%] and 478 TAD [41.8%]) were included. A total of 1060 patients (93%) had N1 disease, 619 (54%) had ERBB2 (formerly HER2)-positive illness, and 758 (66%) had a breast pathologic complete response. TAD patients were more likely to receive nodal radiation therapy (85% vs 78%; P = .01). The clipped node was successfully retrieved in 97% of TAD cases and 86% of SLNB cases (without localization). The mean (SD) number of sentinel lymph nodes retrieved was 3 (2) vs 4 (2) (P < .001), and the mean (SD) number of total lymph nodes removed was 3.95 (1.97) vs 4.44 (2.04) (P < .001) in the TAD and SLNB groups, respectively. The 5-year rates of any axillary, locoregional, and any invasive recurrence in the entire cohort were 1.0% (95% CI, 0.49%-2.0%), 2.7% (95% CI, 1.6%-4.1%), and 10% (95% CI, 8.3%-13%), respectively. The 3-year cumulative incidence of axillary recurrence did not differ between TAD and SLNB (0.5% vs 0.8%; P = .55). Conclusions and Relevance The results of this cohort study showed that axillary recurrence was rare in this setting and was not significantly lower after TAD vs SLNB. These results support omission of ALND in this population.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary M. Mrdutt
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Susie X. Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Callie Hlavin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Emilia J. Diego
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie M. Wong
- Department of Surgery, McGill University Medical School, Montreal, Quebec, Canada
- Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Andrea V. Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Neslihan Cabioglu
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - E. Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Abigail Ingham
- University of Glasgow and National Health Service Greater Glasgow and Clyde, Department of Academic Surgery, Glasgow, Scotland
| | | | | | - Christian Kurzeder
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Danilo Díaz Aybar
- Breast Service, Department of Surgery, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - Denise Vorburger
- Breast Cancer Unit, Comprehensive Cancer Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Dieter Michael Matlac
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Edvin Ostapenko
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Fabian Riedel
- Department of Gynecology and Obstetrics, Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Fitzal
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Francesco Meani
- Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Gruppo Ospedaliero Moncucco, Ticino, Switzerland
| | - Franziska Fick
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Jacqueline Sagasser
- Department of Obstetrics and Gynecology, University Hospital of Augsburg, Augsburg, Germany
| | - Jörg Heil
- Department of Gynecology and Obstetrics, Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Hasan Karanlık
- Division of Surgical Oncology, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | | | - Laszlo Romics
- University of Glasgow and National Health Service Greater Glasgow and Clyde, Department of Academic Surgery, Glasgow, Scotland
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Mahmut Muslumanoglu
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | | | - Marcelo Chávez Díaz
- Breast Service, Department of Surgery, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - Martin Heidinger
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Mattea Reinisch
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
- Charité–Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Mustafa Tukenmez
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | - Nadia Maggi
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Nicola Rocco
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital of Augsburg, Augsburg, Germany
| | | | | | - Sebastián Solé Zarhi
- Department of Radiation Oncology, IRAM–Universidad Diego Portales, Santiago, Chile
| | - Sherko Kuemmel
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
- Charité–Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Simona Bruzas
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
| | - Simona di Lascio
- Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Service of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Tanya L. Hoskin
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Uwe Güth
- Breast-Center Zurich AG, Zurich, Switzerland
| | - Valentina Ovalle
- Department of Radiation Oncology, IRAM–Universidad Diego Portales, Santiago, Chile
| | - Christoph Tausch
- Breast-Center Zurich AG, Zurich, Switzerland
- University of Basel, Basel, Switzerland
| | - Henry M. Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Abigail S. Caudle
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jean-Francois Boileau
- Department of Surgery, McGill University Medical School, Montreal, Quebec, Canada
- Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Judy C. Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Thorsten Kühn
- Department of Gynecology, Klinikum Esslingen, Esslingen, Germany
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Walter P. Weber
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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de Wild SR, Koppert LB, de Munck L, Vrancken Peeters MJTFD, Siesling S, Smidt ML, Simons JM. Prognostic effect of nodal status before and after neoadjuvant chemotherapy in breast cancer: a Dutch population-based study. Breast Cancer Res Treat 2024; 204:277-288. [PMID: 38133707 DOI: 10.1007/s10549-023-07178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/04/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE In breast cancer, neoadjuvant chemotherapy (NAC) can downstage the nodal status, and can even result in a pathological complete response, which is associated with improved prognosis. This study aimed to determine the prognostic effect of nodal status before and after NAC. METHODS Women with breast cancer treated with NAC were selected from the Netherlands Cancer Registry if diagnosed between 2005 and 2019, and classified based on nodal status before NAC: node-negative (cN0), or node-positive based on fine needle aspiration cytology or core needle biopsy (cN+). Subgroups were based on nodal status after NAC: absence (ypN0) or presence (ypN+) of nodal disease. Five-year overall survival (OS) was assessed with Kaplan-Meier survival analyses, also per breast cancer molecular subtype. To adjust for potential confounders, multivariable analyses were performed. RESULTS A total of 6,580 patients were included in the cN0 group, and 11,878 in the cN+ group. The 5-year OS of the cN0ypN0-subgroup was statistically significant better than that of the cN+ypN0-subgroup (94.4% versus 90.1%, p < 0.0001). In cN0 as well as cN+ disease, ypN+ had a statistically significant worse 5-year OS compared to ypN0. For hormone receptor (HR)+ human epidermal growth factor receptor 2 (HER2)-, HR+ HER2+, HR-HER2+, and triple negative disease, respectively, 5-year OS in the cN0ypN+-subgroup was 89.7%, 90.4%, 73.7%, and 53.6%, and in the cN+ypN+-subgroup 84.7%, 83.2%, 61.4%, and 48.8%. In multivariable analyses, cN+ and ypN+ disease were both associated with worse OS. CONCLUSION This study suggests that both cN-status and ypN-status, and molecular subtype should be considered to further improve prognostication.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Center+, GROW School for Oncology and Reproduction, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands.
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Center, University of Twente, Enschede, The Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Center+, GROW School for Oncology and Reproduction, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands
| | - Janine M Simons
- Department of Surgery, Maastricht University Medical Center+, GROW School for Oncology and Reproduction, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands
- Department of Radiotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
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5
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de Wild SR, Koppert LB, van Nijnatten TJA, Kooreman LFS, Vrancken Peeters MJTFD, Smidt ML, Simons JM. Systematic review of targeted axillary dissection in node-positive breast cancer treated with neoadjuvant systemic therapy: variation in type of marker and timing of placement. Br J Surg 2024; 111:znae071. [PMID: 38531689 PMCID: PMC10965400 DOI: 10.1093/bjs/znae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/15/2024] [Accepted: 03/02/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND In node-positive (cN+) breast cancer treated with neoadjuvant systemic therapy, combining sentinel lymph node biopsy and targeted lymph node excision, that is targeted axillary dissection, increases accuracy. Targeted axillary dissection procedures differ in terms of the targeted lymph node excision technique. This systematic review aimed to provide an overview of targeted axillary dissection procedures regarding definitive marker type and timing of placement: before neoadjuvant systemic therapy (1-step procedure) or after neoadjuvant systemic therapy adjacent to a clip placed before the neoadjuvant therapy (2-step procedure). METHODS PubMed and Embase were searched, to 4 July 2023, for RCTs, cohort studies, and case-control studies with at least 25 patients. Studies of targeted lymph node excision only (without sentinel lymph node biopsy), or where intraoperative localization of the targeted lymph node was not attempted, were excluded. For qualitative synthesis, studies were grouped by definitive marker and timing of placement. The targeted lymph node identification rate was reported. Study quality was assessed using a National Institutes of Health quality assessment tool. RESULTS Of 277 unique records, 51 studies with a total of 4512 patients were included. Six definitive markers were identified: wire, 125I-labelled seed, 99mTc, (electro)magnetic/radiofrequency markers, black ink, and a clip. Fifteen studies evaluated one-step procedures, with the identification rate of the targeted lymph node at surgery varying from 8 of 13 to 47 of 47. Forty-one studies evaluated two-step procedures, with the identification rate of the clipped targeted lymph node on imaging after neoadjuvant systemic therapy varying from 49 to 100%, and the identification rate of the targeted lymph node at surgery from 17 of 24 to 100%. Most studies (40 of 51) were rated as being of fair quality. CONCLUSION Various targeted axillary dissection procedures are used in clinical practice. Owing to study heterogeneity, the optimal targeted lymph node excision technique in terms of identification rate and feasibility could not be determined. Two-step procedures are at risk of not identifying the clipped targeted lymph node on imaging after neoadjuvant systemic therapy.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Thiemo J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Loes F S Kooreman
- Department of Pathology, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Janine M Simons
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
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6
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Ofri A, Spillane AJ, Baker C, Mann GB, Walker M, Warrier S. Current bi-national attitudes towards targeted axillary dissection. ANZ J Surg 2024; 94:11-13. [PMID: 38149761 DOI: 10.1111/ans.18841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/27/2023] [Accepted: 12/10/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Adam Ofri
- Breast and Endocrine Department, Mater Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital Institute of Academic Surgery, Sydney, New South Wales, Australia
| | - Andrew J Spillane
- Breast and Endocrine Department, Mater Hospital, Sydney, New South Wales, Australia
- Breast and Surgical Oncology at the Poche Centre, Sydney, New South Wales, Australia
- Breast Surgery Department, North Shore Private Hospital, Sydney, New South Wales, Australia
- Breast and Melanoma Surgery Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Caroline Baker
- Breast Surgery Unit, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - G Bruce Mann
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- The Breast Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melanie Walker
- Breast, Endocrine and General Surgical Unit, Alfred Health, Melbourne, Victoria, Australia
- Breast Unit, Monash Health, Melbourne, Victoria, Australia
| | - Sanjay Warrier
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital Institute of Academic Surgery, Sydney, New South Wales, Australia
- Department of Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
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Tauber N, Bjelic-Radisic V, Thill M, Banys-Paluchowski M. Controversies in axillary management of patients with breast cancer - updates for 2024. Curr Opin Obstet Gynecol 2024; 36:51-56. [PMID: 37678325 DOI: 10.1097/gco.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW For some time now, the question of de-escalation in axillary staging in breast cancer patients has been raised. The aim is to improve the patients' quality of life and reduce morbidity by optimizing surgical strategies with a high level of oncological safety. This review offers a current overview of published evidence and clinical practice, aiming to guide the surgical community as they reassess and reshape their practices. RECENT FINDINGS Years after introducing sentinel lymph node biopsy (SLNB) in clinically node negative breast cancer patients several guidelines suggest completely omitting SLNB in older patients with low-risk tumors. It is worth noting that for patients with a metastatic sentinel lymph node in the upfront surgery setting, a de-escalation of axillary surgery may in fact lead to an escalation of radiation therapy. Currently, there is limited evidence on the axillary surgical approach for patients with initially positive node status achieving complete axillary response (ycN0), resulting in heterogenous guideline recommendations. SUMMARY Innovative trials are contributing to a growing evidence on de-escalation of axillary surgery with the aim of reducing arm morbidity and improving long-term health-related quality of life.
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Affiliation(s)
- Nikolas Tauber
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck
| | | | - Marc Thill
- Department of Gynecology and Gynecological Oncology, Breast Center, AGAPLESION Markus Hospital, Frankfurt/M
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Vrancken Peeters NJMC, Kaplan ZLR, Clarijs ME, Mureau MAM, Verhoef C, van Dalen T, Husson O, Koppert LB. Health-related quality of life (HRQoL) after different axillary treatments in women with breast cancer: a 1-year longitudinal cohort study. Qual Life Res 2024; 33:467-479. [PMID: 37889384 PMCID: PMC10850260 DOI: 10.1007/s11136-023-03538-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE As life expectancy continues to rise, post-treatment health-related quality of life (HRQoL) of breast cancer patients becomes increasingly important. This study examined the one-year longitudinal relation between axillary treatments and physical, psychosocial, and sexual wellbeing and arm symptoms. METHODS Women diagnosed with breast cancer who received different axillary treatments being axilla preserving surgery (APS) with or without axillary radiotherapy or full axillary lymph node dissection (ALND) with or without axillary radiotherapy were included. HRQoL was assessed at baseline, 6- and 12-months postoperatively using the BREAST-Q and the European Organization for Research and Treatment of Cancer QoL Questionnaire Breast Cancer Module (EORTC QLQ-BR23). Mixed regression models were constructed to assess the impact of axillary treatment on HRQoL. HRQoL at baseline was compared to HRQoL at 6- and at 12-months postoperatively. RESULTS In total, 552 patients were included in the mixed regressions models. Except for ALND with axillary radiotherapy, no significant differences in physical and psychosocial wellbeing were found. Physical wellbeing decreased significantly between baseline and 6- and 12-months postoperatively (p < 0.001, p = 0.035) and psychosocial wellbeing decreased significantly between baseline and 12 months postoperatively (p = 0.028) for ALND with axillary radiotherapy compared to APS alone. Arm symptoms increased significantly between baseline and 6 months and between baseline and 12 months postoperatively for APS with radiotherapy (12.71, 13.73) and for ALND with radiotherapy (13.93, 16.14), with the lowest increase in arm symptoms for ALND without radiotherapy (6.85, 7.66), compared to APS alone (p < 0.05). CONCLUSION Physical and psychosocial wellbeing decreased significantly for ALND with radiotherapy compared to APS alone. Shared decision making and expectation management pre-treatment could be strengthened by discussing arm symptoms per axillary treatment with the patient.
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Affiliation(s)
- N J M C Vrancken Peeters
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 GD, Rotterdam, The Netherlands
| | - Z L R Kaplan
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M E Clarijs
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 GD, Rotterdam, The Netherlands
| | - M A M Mureau
- Department of Plastic & Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 GD, Rotterdam, The Netherlands
| | - T van Dalen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 GD, Rotterdam, The Netherlands
| | - O Husson
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 GD, Rotterdam, The Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - L B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 GD, Rotterdam, The Netherlands.
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Munck F, Jepsen P, Zeuthen P, Carstensen L, Hauerslev K, Paaskesen CK, Andersen IS, Høyer U, Lanng C, Gerlach MK, Vejborg I, Kroman NT, Tvedskov THF. Comparing Methods for Targeted Axillary Dissection in Breast Cancer Patients: A Nationwide, Retrospective Study. Ann Surg Oncol 2023; 30:6361-6369. [PMID: 37400618 PMCID: PMC10506928 DOI: 10.1245/s10434-023-13792-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/10/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Several techniques exist for performing targeted axillary dissection (TAD) after neoadjuvant chemotherapy with the removal of the sentinel node and a marked metastatic lymph node (LN). Two-step methods include coil-marking of the metastatic LN at diagnosis and re-marking with an intraoperatively identifiable marker before surgery. Because nondetection of the marked lymph node (MLN) warrants axillary clearance and many patients achieve axillary pathological complete response (ax-pCR), the success of TAD is crucial. We compare various two-step TAD methods in a Danish national cohort. METHODS We included patients who received two-step TAD between January 1, 2016 and August 31, 2021. Patients were identified from the Danish Breast Cancer Group database and cross-checked with locally accessible lists. Data were extracted from the patient's medical files. RESULTS We included 543 patients. In 79.4%, preoperative, ultrasound-guided re-marking was possible. Nonidentification of the coil-marked LN was more likely in patients with ax-pCR. The second markers used were hook-wire, iodine seeds, or ink marking on the axillary skin. Of patients with successful secondary marking, the MLN identification rate (IR) was 91%, and the sentinel node (SN) IR was 95%. Marking with iodine seeds was significantly more successful than ink marking with an odds ratio of 5.34 (95% confidence interval 1.62-17.60). The success rate of the complete TAD with the removal of MLN and SN was 82.3%. CONCLUSIONS With two-step TAD, nonidentification of the coiled LN before surgery is frequent, especially in patients with ax-pCR. Despite successful remarking, the IR of the MLN at surgery is inferior to one-step TAD.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark.
| | - Pernille Jepsen
- Department of Breast Surgery, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Pernille Zeuthen
- Department of Surgery and Plastic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | - Lena Carstensen
- Department of Surgery Esbjerg, Hospital of South West Jutland, Esbjerg, Denmark
| | - Katrine Hauerslev
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ute Høyer
- Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
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10
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Munck F, Andersen IS, Vejborg I, Gerlach MK, Lanng C, Kroman NT, Tvedskov THF. Targeted Axillary Dissection with 125I Seed Placement Before Neoadjuvant Chemotherapy in a Danish Multicenter Cohort. Ann Surg Oncol 2023; 30:4135-4142. [PMID: 37062781 PMCID: PMC10250439 DOI: 10.1245/s10434-023-13432-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/13/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Targeted axillary dissection (TAD), with marking of the metastatic lymph node before neoadjuvant chemotherapy (NACT), is increasingly used for breast cancer axillary staging. In the case of axillary pathological complete response (ax-pCR), axillary lymph node clearance can be omitted. Several marking methods exist, most using re-marking before surgery. Feasibility, learning curve, and identification rate (IR) vary. Marking with 125I seed before NACT makes re-marking at surgery redundant, possibly increasing feasibility and IR. Here, TAD with 125I seed placed before NACT is evaluated in a Danish multicenter cohort. METHODS Patients staged with 125I TAD in Denmark between 1 January 2016 and 31 August 2021 were included. Patients were identified in radioactivity-emitting implant registries at the radiology departments and from the Danish Breast Cancer Group database. Data were extracted from patients' medical records. Information on patient/tumor characteristics, 125I seed activity, marking period, TAD success, number of sentinel nodes (SNs), the histopathological status of excised nodes, and whether the marked lymph node (MLN) was an SN were registered. RESULTS 142 patients were included. The IR of the MLN was 99.3%, and the IR of the SLNB was 91.5%. TAD success was 91.5%. Minor challenges in marking or removal of the MLN were noted in three patients. In 72.3% of the patients, the MLN was a sentinel node. Overall, 40.8% had axillary pCR. CONCLUSION TAD with 125I seed marking before NACT is feasible without re-marking at surgery and with only minor surgical challenges. The IR is high. Staging with TAD spares 41% of breast cancer patients an axillary dissection.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark.
| | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
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11
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Weber WP, Davide Gentilini O, Morrow M, Montagna G, de Boniface J, Fitzal F, Wyld L, Rubio IT, Matrai Z, King TA, Saccilotto R, Galimberti V, Maggi N, Andreozzi M, Sacchini V, Castrezana López L, Loesch J, Schwab FD, Eller R, Heidinger M, Haug M, Kurzeder C, Di Micco R, Banys-Paluchowski M, Ditsch N, Harder Y, Paulinelli RR, Urban C, Benson J, Bjelic-Radisic V, Potter S, Knauer M, Thill M, Vrancken Peeters MJ, Kuemmel S, Heil J, Gulluoglu BM, Tausch C, Ganz-Blaettler U, Shaw J, Dubsky P, Poortmans P, Kaidar-Person O, Kühn T, Gnant M. Uncertainties and controversies in axillary management of patients with breast cancer. Cancer Treat Rev 2023; 117:102556. [PMID: 37126938 PMCID: PMC10752145 DOI: 10.1016/j.ctrv.2023.102556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/27/2023] [Accepted: 04/01/2023] [Indexed: 05/03/2023]
Abstract
The aims of this Oncoplastic Breast Consortium and European Breast Cancer Research Association of Surgical Trialists initiative were to identify uncertainties and controversies in axillary management of early breast cancer and to recommend appropriate strategies to address them. By use of Delphi methods, 15 questions were prioritized by more than 250 breast surgeons, patient advocates and radiation oncologists from 60 countries. Subsequently, a global virtual consensus panel considered available data, ongoing studies and resource utilization. It agreed that research should no longer be prioritized for standardization of axillary imaging, de-escalation of axillary surgery in node-positive cancer and risk evaluation of modern surgery and radiotherapy. Instead, expert consensus recommendations for clinical practice should be based on current evidence and updated once results from ongoing studies become available. Research on de-escalation of radiotherapy and identification of the most relevant endpoints in axillary management should encompass a meta-analysis to identify knowledge gaps, followed by a Delphi process to prioritize and a consensus conference to refine recommendations for specific trial designs. Finally, treatment of residual nodal disease after surgery was recommended to be assessed in a prospective register.
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Affiliation(s)
- Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | | | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Unit, Capio St Göran's Hospital, Stockholm, Sweden
| | - Florian Fitzal
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Austria; Austrian Breast and Colorectal Study Group ABCSG, Vienna, Austria
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Isabel T Rubio
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Madrid, Spain
| | - Zoltan Matrai
- Hamad Medical Corporation, Dept of Oncoplastic Breast Surgery, Doha, Qatar
| | - Tari A King
- Division of Breast Surgery, Brigham and Women's Hospital, Dana Farber/Brigham Cancer Center, Boston, MA, USA
| | - Ramon Saccilotto
- University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Mariacarla Andreozzi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Julie Loesch
- Gynecology Department, University Hospital Zurich, Zurich, Switzerland
| | - Fabienne D Schwab
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Ruth Eller
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Haug
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Christian Kurzeder
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Rosa Di Micco
- Breast Surgery, San Raffaele University and Research Hospital, Milan, Italy
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Nina Ditsch
- Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Régis R Paulinelli
- Federal University of Goias, Goias, Brazil; Breast Unit, Araújo Jorge Hospital, Goias, Brazil
| | - Cicero Urban
- Breast Unit, Hospital Nossa Senhora Das Graças, Curitiba, Brazil
| | - John Benson
- Cambridge Breast Unit, Addenbrooke's Hospital Cambridge, Cambridge, UK; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation TRUST, School of Medicine, Anglia Ruskin University, Cambridge, UK
| | - Vesna Bjelic-Radisic
- Breast Unit, University Hospital Helios Wuppertal, University Witten/Herdecke, Wuppertal, Germany; Medical University Graz, Graz, Austria
| | | | - Michael Knauer
- Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Marc Thill
- Department of Gynaecology and Gynaecological Oncology, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Surgery, University Medical Center, Amsterdam, Netherlands
| | - Sherko Kuemmel
- Breast Unit, Hospital Essen-Mitte, Germany; Charité - Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Joerg Heil
- Department of Obstetrics and Gynecology, University of Heidelberg, Medical School, Heidelberg, Germany
| | | | | | | | - Jane Shaw
- Patient Advocacy Group, Oncoplastic Breast Consortium, Basel, Switzerland
| | - Peter Dubsky
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland; Breast Centre, Hirslanden Clinic St. Anna, Lucerne, Switzerland
| | - Philip Poortmans
- Iridium Netwerk and University of Antwerp, Wilrijk-Antwerpen, Belgium
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, at Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Dept. Radiation Oncologv (Maastro), Maastricht, Netherlands
| | - Thorsten Kühn
- Department of Gynecology, Hospital Esslingen, Esslingen, Germany
| | - Michael Gnant
- Austrian Breast and Colorectal Study Group ABCSG, Vienna, Austria; Comprehensive Cancer Center Medical University Vienna, Vienna, Austria
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Banys-Paluchowski M, de Boniface J. Axillary staging in node-positive breast cancer converting to node negativity through neoadjuvant chemotherapy: Current evidence and perspectives. Scand J Surg 2023; 112:117-125. [PMID: 36642957 DOI: 10.1177/14574969221145892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Over the recent years, axillary staging of initially node-positive breast cancer patients converting to clinical node negativity after neoadjuvant chemotherapy has seen rapid changes. This narrative review aims to give a contemporary overview over published evidence and clinical practice, and thus provide some guidance to the surgical community in the process of re-evaluating and re-shaping surgical practice. METHODS The search strategy aimed at finding relevant studies. Only articles in English were considered. RESULTS The introduction of modern techniques offer more precise staging surgery and thus hopefully reduced arm morbidity. Clinical practice has however diverged both within countries and internationally. While some countries have adapted de-escalated axillary staging techniques such as targeted axillary dissection, targeted lymph node biopsy or sentinel lymph node biopsy, others continue to recommend a full axillary lymph node dissection. With the implementation of new techniques, many questions arise, regarding aspects of oncological safety, technical performance, budget and practicality, patient selection and indications for different levels of axillary staging procedures. CONCLUSIONS There is a growing body of evidence on de-escalation of axillary surgery in the setting of cN+ → ycN0 breast cancer treated with neoadjuvant chemotherapy. However, standards differ between countries and future studies are necessary to fully assess the optimal strategy for these patients.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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13
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Boersma LJ, Mjaaland I, van Duijnhoven F. Regional radiotherapy after primary systemic treatment for cN+ breast cancer patients. Breast 2023; 68:181-188. [PMID: 36805769 PMCID: PMC9975253 DOI: 10.1016/j.breast.2023.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/02/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
Pathologic complete response (pCR) after Primary Systemic Treatment (PST) for breast cancer is associated with excellent long-term outcomes. With increasing use of PST, the indication for regional nodal irradiation (RNI) has been challenged. The aim of this paper is to review the literature on de-escalation of RNI in patients treated with PST. We found no level 1 evidence on de-escalation of RNI after PST, but several randomized trials are ongoing. Consequently, current de-escalation strategies are based on cohort studies. These studies showed that in patients with low nodal tumour burden (LNTB) (≤3 suspicious nodes at imaging) prior to PST, and ypN0 based on Axillary Lymph Node Dissection (ALND), omission of RNI resulted in very low regional recurrences (RR) without compromising survival. In patients with LNTB and ypN0 based on Sentinel Lymph Node Biopsy (SLNB), omission of axillary treatment also resulted in low RR; the majority of these patients received local radiotherapy. Similarly, in patients with ypN1 (ALND) disease, omission of RNI resulted in low 5-year RR rates. Low RR-rates were also found in the few studies replacing ALND by RNI, in patients with ypN1 (SLNB) disease. In patients with high nodal tumour burden prior to PST and ypN0 (SLNB), replacing ALND by RNI also resulted in low RR. Due to the limited number of patients, these data should be interpreted with caution. We conclude that although level 1 evidence is lacking, de-escalation of RNI after PST can be considered in selected cases.
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Affiliation(s)
- Liesbeth J Boersma
- Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Ingvil Mjaaland
- Division of Medicine, Stavanger University Hospital, Stavanger, Norway.
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Banys-Paluchowski M, Rubio IT, Ditsch N, Krug D, Gentilini OD, Kühn T. Real de-escalation or escalation in disguise? Breast 2023; 69:249-257. [PMID: 36898258 PMCID: PMC10017412 DOI: 10.1016/j.breast.2023.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
The past two decades have seen an unprecedented trend towards de-escalation of surgical therapy in the setting of early BC, the most prominent examples being the reduction of re-excision rates for close surgical margins after breast-conserving surgery and replacing axillary lymph node dissection by less radical procedures such as sentinel lymph node biopsy (SLNB). Numerous studies confirmed that reducing the extent of surgery in the upfront surgery setting does not impact locoregional recurrences and overall outcome. In the setting of primary systemic treatment, there is an increased use of less invasive staging strategies reaching from SLNB and targeted lymph node biopsy (TLNB) to targeted axillary dissection (TAD). Omission of any axillary surgery in the presence of pathological complete response in the breast is currently being investigated in clinical trials. On the other hand, concerns have been raised that surgical de-escalation might induce an escalation of other treatment modalities such as radiation therapy. Since most trials on surgical de-escalation did not include standardized protocols for adjuvant radiotherapy, it remains unclear, whether the effect of surgical de-escalation was valid in itself or if radiotherapy compensated for the decreased surgical extent. Uncertainties in scientific evidence may therefore lead to escalation of radiotherapy in some settings of surgical de-escalation. Further, the increasing rate of mastectomies including contralateral procedures in patients without genetic risk is alarming. Future studies of locoregional treatment strategies need to include an interdisciplinary approach to integrate de-escalation approaches combining surgery and radiotherapy in a way that promotes optimal quality of life and shared decision-making.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Isabel T Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital Augsburg, Augsburg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | | | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Interdisciplinary Breast Center, Die Filderklinik, Filderstadt, Germany.
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15
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Thompson JL, Wright GP. Contemporary approaches to the axilla in breast cancer. Am J Surg 2023; 225:583-587. [PMID: 36522219 DOI: 10.1016/j.amjsurg.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Over the past decade, axillary management in breast cancer has fundamentally shifted. The former notion that any degree of axillary nodal involvement warrants axillary lymph node dissection (ALND) has been challenged. Following publication of the ACOSOG Z0011 trial, national trends demonstrated significant reductions in ALND performance. Axillary radiotherapy in lieu of ALND is a consideration for select patients with a positive sentinel lymph node, while ongoing studies are investigating the role of adjuvant regional radiotherapy in women with positive nodes prior to neoadjuvant chemotherapy. Efforts toward de-escalation of axillary surgery continue to evolve, as do the indications for sentinel node biopsy omission in select subsets of patients. This review highlights the recent advances and neoteric approaches to local therapy of the axilla in breast cancer.
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Affiliation(s)
- Jessica L Thompson
- Spectrum Health Medical Group Comprehensive Breast Clinic, 145 Michigan Street NE, Suite 4400, Grand Rapids, MI, 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 15 Michigan Street NE, Grand Rapids, MI, 49503, USA.
| | - G Paul Wright
- Spectrum Health Medical Group Comprehensive Breast Clinic, 145 Michigan Street NE, Suite 4400, Grand Rapids, MI, 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 15 Michigan Street NE, Grand Rapids, MI, 49503, USA; Spectrum Health Medical Group, Division of Surgical Oncology, 145 Michigan Street NE, Suite 5500, Grand Rapids, MI, 49503, USA.
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16
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Laws A, Kantor O, King TA. Surgical Management of the Axilla for Breast Cancer. Hematol Oncol Clin North Am 2023; 37:51-77. [PMID: 36435614 DOI: 10.1016/j.hoc.2022.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This review discusses the contemporary surgical management of the axilla in patients with breast cancer. Surgical paradigms are highlighted by clinical nodal status at presentation and treatment approach, including upfront surgery and neoadjuvant systemic therapy settings. This review focuses on the increasing opportunities for de-escalating the extent of axillary surgery in the era of sentinel lymph node biopsy, while also reviewing the remaining indications for axillary clearance with axillary lymph node dissection.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
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17
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Simons JM, van Nijnatten TJA, van der Pol CC, van Diest PJ, Jager A, van Klaveren D, Kam BLR, Lobbes MBI, de Boer M, Verhoef C, Sars PRA, Heijmans HJ, van Haaren ERM, Vles WJ, Contant CME, Menke-Pluijmers MBE, Smit LHM, Kelder W, Boskamp M, Koppert LB, Luiten EJT, Smidt ML. Diagnostic Accuracy of Radioactive Iodine Seed Placement in the Axilla With Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer. JAMA Surg 2022; 157:991-999. [PMID: 36069889 PMCID: PMC9453629 DOI: 10.1001/jamasurg.2022.3907] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/18/2022] [Indexed: 12/14/2022]
Abstract
Importance Several less-invasive staging procedures have been proposed to replace axillary lymph node dissection (ALND) after neoadjuvant chemotherapy (NAC) in patients with initially clinically node-positive (cN+) breast cancer, but these procedures may fail to detect residual disease. Owing to the lack of high-level evidence, it is not yet clear which procedure is most optimal to replace ALND. Objective To determine the diagnostic accuracy of radioactive iodine seed placement in the axilla with sentinel lymph node biopsy (RISAS), a targeted axillary dissection procedure. Design, Setting, and Participants This was a prospective, multicenter, noninferiority, diagnostic accuracy trial conducted from March 1, 2017, to December 31, 2019. Patients were included within 14 institutions (general, teaching, and academic) throughout the Netherlands. Patients with breast cancer clinical tumor categories 1 through 4 (cT1-4; tumor diameter <2 cm and up to >5 cm or extension to the chest wall or skin) and pathologically proven positive axillary lymph nodes (ie, clinical node categories cN1, metastases to movable ipsilateral level I and/or level II axillary nodes; cN2, metastases to fixed or matted ipsilateral level I and/or level II axillary nodes; cN3b, metastases to ipsilateral level I and/or level II axillary nodes with metastases to internal mammary nodes) who were treated with NAC were eligible for inclusion. Data were analyzed from July 2020 to December 2021. Intervention Pre-NAC, the marking of a pathologically confirmed positive axillary lymph node with radioactive iodine seed (MARI) procedure, was performed and after NAC, sentinel lymph node biopsy (SLNB) combined with excision of the marked lymph node (ie, RISAS procedure) was performed, followed by ALND. Main Outcomes and Measures The identification rate, false-negative rate (FNR), and negative predictive value (NPV) were calculated for all 3 procedures: RISAS, SLNB, and MARI. The noninferiority margin of the observed FNR was 6.25% for the RISAS procedure. Results A total of 212 patients (median [range] age, 52 [22-77] years) who had cN+ breast cancer underwent the RISAS procedure and ALND. The identification rate of the RISAS procedure was 98.2% (223 of 227). The identification rates of SLNB and MARI were 86.4% (197 of 228) and 94.1% (224 of 238), respectively. FNR of the RISAS procedure was 3.5% (5 of 144; 90% CI, 1.38-7.16), and NPV was 92.8% (64 of 69; 90% CI, 85.37-97.10), compared with an FNR of 17.9% (22 of 123; 90% CI, 12.4%-24.5%) and NPV of 72.8% (59 of 81; 90% CI, 63.5%-80.8%) for SLNB and an FNR of 7.0% (10 of 143; 90% CI, 3.8%-11.6%) and NPV of 86.3% (63 of 73; 90% CI, 77.9%-92.4%) for the MARI procedure. In a subgroup of 174 patients in whom SLNB and the MARI procedure were successful and ALND was performed, FNR of the RISAS procedure was 2.5% (3 of 118; 90% CI, 0.7%-6.4%), compared with 18.6% (22 of 118; 90% CI, 13.0%-25.5%) for SLNB (P < .001) and 6.8% (8 of 118; 90% CI, 3.4%-11.9%) for the MARI procedure (P = .03). Conclusions and Relevance Results of this diagnostic study suggest that the RISAS procedure was the most feasible and accurate less-invasive procedure for axillary staging after NAC in patients with cN+ breast cancer.
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Affiliation(s)
- Janine M. Simons
- Department of Radiotherapy, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
- Department of Surgical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
- Department of Surgical Oncology, Cancer Center, University Medical Center Utrecht, Utrecht, the Netherlands
- GROW—School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Thiemo J. A. van Nijnatten
- GROW—School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, the Netherlands
| | - Carmen C. van der Pol
- Department of Surgical Oncology, Cancer Center, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgical Oncology, Alrijne Hospital, Leiderdorp, the Netherlands
| | - Paul J. van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Boen L. R. Kam
- Department of Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Nuclear Medicine, Diakonessenhuis, Utrecht, the Netherlands
| | - Marc B. I. Lobbes
- GROW—School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, the Netherlands
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - Maaike de Boer
- GROW-School for Oncology and Reproduction, Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Cees Verhoef
- Department of Surgical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Paul R. A. Sars
- Department of Surgical Oncology, Bravis Hospital, Roosendaal, the Netherlands
| | - Harald J. Heijmans
- Department of Surgical Oncology, Hospital Group Twente, Breast Clinic Oost-Nederland, Hengelo, the Netherlands
| | - Els R. M. van Haaren
- Department of Surgical Oncology, Zuyderland Medical Center, Sittard, the Netherlands
| | - Wouter J. Vles
- Department of Surgical Oncology, Ikazia Hospital, Rotterdam, the Netherlands
| | | | | | - Léonie H. M. Smit
- Department of Surgical Oncology, Treant Zorggroep Hospital, Hoogeveen, the Netherlands
| | - Wendy Kelder
- Department of Surgical Oncology, Martini Hospital, Groningen, the Netherlands
| | - Marike Boskamp
- Department of Surgical Oncology, Wilhelmina Hospital, Assen, the Netherlands
| | - Linetta B. Koppert
- Department of Surgical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Ernest J. T. Luiten
- Department of Surgical Oncology, Amphia Hospital, Breda, the Netherlands
- Tawam Breast Care Center, Tawam Hospital, Al Ain, Abu Dhabi Emirate, United Arab Emirates
- Department of Surgery College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi Emirate, United Arab Emirates
| | - Marjolein L. Smidt
- GROW—School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
- Deparment of Surgical Oncology, Maastricht University Medical Center+, Maastricht, the Netherlands
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18
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Montagna G, Lee MK, Sevilimedu V, Barrio AV, Morrow M. Is Nodal Clipping Beneficial for Node-Positive Breast Cancer Patients Receiving Neoadjuvant Chemotherapy? Ann Surg Oncol 2022; 29:6133-6139. [PMID: 35902495 PMCID: PMC10109537 DOI: 10.1245/s10434-022-12240-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/06/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND In cN1 patients rendered cN0 with neoadjuvant chemotherapy, the false-negative rate of sentinel lymph node biopsy (SLNB) is < 10% when ≥ 3 sentinel lymph nodes (SLNs) are removed. The added value of nodal clipping in this scenario is unknown. Here we determine how often the clipped node is a sentinel node when ≥ 3 SLNs are retrieved. METHODS We identified cT1-3N1 patients treated between 02/2018 and 10/2021 with a clipped lymph node at presentation. SLNB was performed with a standardized approach of dual-tracer mapping and retrieval of ≥ 3 SLNs. Clipped nodes were not localized; SLNs were X-rayed intraoperatively to determine clip location. Axillary lymph node dissection (ALND) was performed for any residual disease or retrieval of < 3 SLNs. RESULTS Of 269 patients, 251 (93%) had ≥ 3 SLNs. Median age was 51 years; the majority (92%) had ductal histology; 46% were HR+/HER2-. The median number of SLNs removed was 4 (IQR 3,5). The clipped node was an SLN in 88% (220/251) of cases. Of the 31 where the clipped node was not, 13 had a positive SLN mandating ALND, and the clip was identified in the ALND specimen. In the remaining 18, where ≥ 3 negative SLNs were retrieved and an ALND was not performed, the clip was not retrieved, with no axillary failures in this group (median follow-up: 55 months). CONCLUSION When the SLNB procedure is optimized with dual tracer and retrieval of ≥ 3 SLNs, the clipped node is an SLN in the majority of cases, suggesting that failure to retrieve the clipped node should not be an indication for ALND.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Minna K Lee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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19
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de Wild SR, de Munck L, Simons JM, Verloop J, van Dalen T, Elkhuizen PHM, Houben RMA, van Leeuwen AE, Linn SC, Pijnappel RM, Poortmans PMP, Strobbe LJA, Wesseling J, Voogd AC, Boersma LJ. De-escalation of radiotherapy after primary chemotherapy in cT1-2N1 breast cancer (RAPCHEM; BOOG 2010-03): 5-year follow-up results of a Dutch, prospective, registry study. Lancet Oncol 2022; 23:1201-1210. [PMID: 35952707 DOI: 10.1016/s1470-2045(22)00482-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Primary chemotherapy in breast cancer poses a dilemma with regard to adjuvant locoregional radiotherapy, as guidelines for locoregional radiotherapy were originally based on pathology results of primary surgery. We aimed to evaluate the oncological safety of de-escalated locoregional radiotherapy in patients with cT1-2N1 breast cancer treated with primary chemotherapy, according to a predefined, consensus-based study guideline. METHODS In this prospective registry study (RAPCHEM, BOOG 2010-03), patients referred to one of 17 participating radiation oncology centres in the Netherlands between Jan 1, 2011, and Jan 1, 2015, with cT1-2N1 breast cancer (one to three suspicious nodes on imaging before primary chemotherapy, of which at least one had been pathologically confirmed), and who were treated with primary chemotherapy and surgery of the breast and axilla were included in the study. The study guideline comprised three risk groups for locoregional recurrence, with corresponding locoregional radiotherapy recommendations: no chest wall radiotherapy and no regional radiotherapy in the low-risk group, only local radiotherapy in the intermediate-risk group, and locoregional radiotherapy in the high-risk group. Radiotherapy consisted of a biologically equivalent dose of 25 fractions of 2 Gy, with or without a boost. During the study period, the generally applied radiotherapy technique in the Netherlands was forward-planned or inverse-planned intensity modulated radiotherapy. 5-year follow-up was assessed, taking into account adherence to the study guideline, with locoregional recurrence rate as primary endpoint. We hypothesised that 5-year locoregional recurrence rate would be less than 4% (upper-limit 95% CI 7·8%). This study was registered at ClinicalTrials.gov, NCT01279304, and is completed. FINDINGS 838 patients were eligible for 5-year follow-up analyses: 291 in the low-risk group, 370 in the intermediate-risk group, and 177 in the high-risk group. The 5-year locoregional recurrence rate in all patients was 2·2% (95% CI 1·4-3·4). The 5-year locoregional recurrence rate was 2·1% (0·9-4·3) in the low-risk group, 2·2% (1·0-4·1) in the intermediate-risk group, and 2·3% (0·8-5·5) in the high-risk group. If the study guideline was followed, the locoregional recurrence rate was 2·3% (0·8-5·3) for the low-risk group, 1·0% (0·2-3·4) for the intermediate-risk group, and 1·4% (0·3-4·5) for the high-risk group. INTERPRETATION In this study, the 5-year locoregional recurrence rate was less than 4%, which supports our hypothesis that it is oncologically safe to de-escalate locoregional radiotherapy based on locoregional recurrence risk, in selected patients with cT1-2N1 breast cancer treated with primary chemotherapy, according to this predefined, consensus-based study guideline. FUNDING Dutch Cancer Society. TRANSLATION For the Dutch translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands.
| | - Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Janine M Simons
- Department of Surgery, GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands; Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Janneke Verloop
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Thijs van Dalen
- Department of Surgery, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Ruud M A Houben
- Department of Radiation Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands
| | | | - Sabine C Linn
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Ruud M Pijnappel
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Netherlands
| | - Philip M P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Luc J A Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Jelle Wesseling
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Adri C Voogd
- Department of Epidemiology, GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands; CAPHRI Care and Public Health Research Institute, Maastricht, Netherlands
| | - Liesbeth J Boersma
- Department of Radiation Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands
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20
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Nodal positives Mammakarzinom: minimales versus maximales Axillastaging. Geburtshilfe Frauenheilkd 2022. [DOI: 10.1055/a-1748-8390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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