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Kustić D. Size of Extranodal Extension in the Sentinel Lymph Node as a Predictor of Prognosis in Early-Stage Breast Cancer. Clin Breast Cancer 2024:S1526-8209(24)00118-6. [PMID: 38871577 DOI: 10.1016/j.clbc.2024.05.005] [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: 03/07/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION The presence of extranodal extension (ENE) in sentinel lymph nodes (SLNs) can predict non-SLN metastases in breast cancer (BC) patients; however, the prognostic relevance of its extent remains controversial. The purpose of this study was to examine the predictive role of ENE in SLNs measured by its widest dimension (WD), highest dimension (HD), and the WD/HD ratio for non-SLN involvement, overall, and disease-free survival (OS, DFS) in cT1-2N0 BC patients with positive SLNs. MATERIALS AND METHODS A total of 511 women with cT1-2N0 BC and positive SLNs undergoing axillary lymph node dissection were retrospectively enrolled. The associations of ENE's WD, HD, and WD/HD ratio with non-SLN metastases, 5-year OS, and DFS were established through a multivariable modeling approach. RESULTS SLNs were ENE-positive in 149 (29.16%) participants, and 133 (26.03%) had non-SLN metastases. During the median 60 (16-60)-month follow-up, 69 (13.50%) patients experienced recurrences, and 62 (12.13%) died. The numbers of SLNs, non-SLNs, and total axillary LNs involved differed between the ENE-negative and ENE-positive groups, as well as between the WD/HD ≤ 1.2 and WD/HD > 1.2 subgroups (all P-values were < .001). Multivariable analyses showed significant associations of the WD/HD ratio > 1.2 with non-SLN involvement, OS, and DFS (P-values were .003, < .001, and .005, respectively). DISCUSSION Despite no predictive value of ENE's WD and HD, the WD/HD ratio > 1.2 was an independent predictor of non-SLN involvement, mortality, and recurrence. ENE's WD/HD ratio could be a valuable indicator for cT1-2N0 BC individuals with positive SLNs for whom further axillary treatment may be beneficial.
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Affiliation(s)
- Domagoj Kustić
- Department of Nuclear Medicine, Clinical Hospital Center Rijeka, Rijeka, Croatia.
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Dong L, Wei S, Huang Z, Liu F, Xie Y, Wei J, Mo C, Qin S, Zou Q, Yang J. Association between postoperative pathological results and non-sentinel nodal metastasis in breast cancer patients with sentinel lymph node-positive breast cancer. World J Surg Oncol 2024; 22:30. [PMID: 38268018 PMCID: PMC10809690 DOI: 10.1186/s12957-024-03306-8] [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: 09/11/2023] [Accepted: 01/13/2024] [Indexed: 01/26/2024] Open
Abstract
OBJECTIVE For patients with 1-2 positive sentinel lymph nodes (SLN) identified by biopsy, the necessity of axillary lymph node dissection (ALND) remains a matter of debate. The primary aim of this study was to investigate the association between postoperative pathological factors and non-sentinel lymph node (NSLN) metastases in Chinese patients diagnosed with sentinel node-positive breast cancer. METHODS This research involved a total of 280 individuals with SLN-positive breast cancer. The relationship between postoperative pathological variables and non-sentinel lymph node metastases was scrutinized using univariate, multivariate, and stratified analysis. RESULTS Among the 280 patients with a complete count of SLN positives, 126 (45.0%) exhibited NSLN metastasis. Within this group, 45 cases (35.71%) had 1 SLN positive, while 81 cases (64.29%) demonstrated more than 1 SLN positive. Multivariate logistic regression analysis revealed that HER2 expression status (OR 2.25, 95% CI 1.10-4.60, P = 0.0269), LVI (OR 6.08, 95% CI 3.31-11.14, P < 0.0001), and the number of positive SLNs (OR 4.17, 95% CI 2.35-7.42, P < 0.0001) were positively correlated with NSLNM. CONCLUSION In our investigation, the risk variables for NSLN metastasis included LVI, HER2 expression, and the quantity of positive sentinel lymph nodes. However, further validation is imperative, including this institution, distinct institutions, and diverse patient populations.
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Affiliation(s)
- Lingguang Dong
- Department of Breast and Thyroid Surgery, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Suosu Wei
- Department of Scientific Cooperation of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Zhen Huang
- Department of Breast and Thyroid Surgery, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Fei Liu
- Scientific Research and Experimental Center, The People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Yujie Xie
- Department of Breast and Thyroid Surgery, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Jing Wei
- Department of Breast and Thyroid Surgery, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Chongde Mo
- Department of Breast and Thyroid Surgery, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Shengpeng Qin
- Department of Breast and Thyroid Surgery, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Quanqing Zou
- Department of Breast and Thyroid Surgery, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China.
| | - Jianrong Yang
- Department of Breast and Thyroid Surgery, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China.
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Xu LY, Zhao J, Wang X, Jin XY, Wang BB, Fan YY, Pei XH. Non-sentinel lymph node metastases risk factors in patients with breast cancer with one or two sentinel lymph node macro-metastases. Heliyon 2023; 9:e21254. [PMID: 37964832 PMCID: PMC10641163 DOI: 10.1016/j.heliyon.2023.e21254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/16/2023] Open
Abstract
Approximately 59 % of patients with breast cancer with one or two sentinel lymph nodes (1-2 SLN) macrometastases do not benefit from axillary lymph node dissection (ALND), which may also incur morbidities. It is necessary to evaluate the association between various clinicopathological characteristics and non-sentinel lymph node metastases (non-SLNM) in patients with breast cancer with 1-2 SLN macrometastases, and determine whether they 1-2 should avoid ALND. Eight electronic literature databases (PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journal, Wanfang, and Chinese Biomedical Literature) were searched from their inception to June 30, 2023, and two reviewers independently extracted the data and assessed the risk of bias. Association strength was summarized using odds ratios (OR) and 95 % confidence intervals (CI). Heterogeneity was accounted for using a subgroup analysis. Publication bias was evaluated using funnel plots and Egger's test. There were 25 studies with 8021 participants, and 27 potential risk factors were evaluated. The risk factors for non-SLNM in patients with 1-2 SLN macrometastatic breast cancer include the following: factors of primary tumor: multifocality (OR (95 % CI (2.63 (1.96, 3.54))), tumor size ≥ T2 (2.64 (2.22, 3.14)), tumor localization (upper outer quad) (2.06 (1.23, 3.43)), histopathological grade (G3) (2.45 (1.70, 3.52)), vascular invasion (VI) (2.60 (1.35, 4.98)), lymphovascular invasion (LVI) (2.87 (1.80, 4.56)), perineural invasion (PNI) (3.16 (1.18,8.43)). Factors of lymph nodes: method of SLNs detected (blue dye) (3.85 (1.54, 9.60)), SLN metastasis ratio ≥0.5 (2.79 (2.24, 3.48)), two positive SLNs (3.55, (2.08, 6.07)), zero negative SLN (3.72 (CI 2.50, 4.29)), extranodal extension (ENE) (4.69 (2.16, 10.18)). Molecular typing: Her-2 positive (2.08 (1.26, 3.43)), Her-2 over-expressing subtype (1.83 (1.22, 2.73)). Factors of examination/inspection: axillary lymph nodes (ALNs) positive on imaging (3.18 (1.68, 6.00)), cancer antigen 15-3 (CA15-3) (4.01 (2.33,6.89)), carcinoembryonic antigen (CEA) (2.13 (1.32-3.43)). This review identified the risk factors for non-SLNM in patients with 1-2 SLN macrometastatic breast cancer. However, additional studies are needed to confirm the above findings owing to the limited number and types of studies included.
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Affiliation(s)
- Liu-yan Xu
- The Third affiliated hospital of Beijing University of Chinese Medicine, Beijing 100029, China
| | - Jing Zhao
- The Third affiliated hospital of Beijing University of Chinese Medicine, Beijing 100029, China
| | - Xuan Wang
- The Third affiliated hospital of Beijing University of Chinese Medicine, Beijing 100029, China
| | - Xin-yan Jin
- Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Bei-bei Wang
- The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
| | - Ying-yi Fan
- The Third affiliated hospital of Beijing University of Chinese Medicine, Beijing 100029, China
| | - Xiao-hua Pei
- The Xiamen Hospital of Beijing University of Chinese Medicine, Xiamen 361001, China
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Chen F, Li X, Lin X, Chen L, Lin Z, Wu H, Chen J. Can Axillary Lymph Node Dissection be Omitted in Breast Cancer Patients with Metastatic Sentinel Lymph Nodes Undergoing Mastectomy? A Systematic Review and Meta-Analysis of Real-World Evidence. World J Surg 2023; 47:2446-2456. [PMID: 37249632 DOI: 10.1007/s00268-023-07072-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND The omission of axillary lymph node dissection (ALND) in patients with breast cancer who have metastatic sentinel lymph nodes (SLNs) undergoing mastectomy remains controversial. This meta-analysis explored the clinicopathological factors affecting the selection of ALND and the influences of ALND on survival outcomes in patients receiving mastectomy with positive SLNs. METHODS Eligible studies published prior to 31 December 2022 were selected by searching the Embase, Web of Science and PubMed databases. Pooled analyses were performed using the number of events for clinicopathological parameters and HRs with 95% CIs for survival outcomes including disease-free survival (DFS), overall survival (OS), distant recurrence-free survival (DRFS) and locoregional recurrence-free survival (LRFS). RESULTS A total of 10 retrospective studies enrolling only breast cancer patients with limited SLN metastases (no more than 3 positive SLNs or micrometastatic SLNs) undergoing mastectomy were included. Performing ALND in mastectomy patients who had limited SLN metastases was significantly correlated with invasive ductal carcinomas, larger tumors, lymphovascular invasion, higher tumor grade, macrometastatic SLNs, more positive SLNs, extranodal extension, positive surgical margins, negative ER, administration of adjuvant chemotherapy and nonwhite race (P < 0.05). However, performing ALND did not result in significantly longer OS, DFS, LRFS or DRFS (P > 0.05) in these patients. CONCLUSION The present meta-analysis indicated that ALND may be safely avoided in patients with breast cancer who had limited SLN metastases undergoing mastectomy. Further well-designed randomized clinical trials are warranted to validate our results.
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Affiliation(s)
- Fulong Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Xiaowen Li
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Xianjun Lin
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Lijia Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Zhaoling Lin
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Hao Wu
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Jishang Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China.
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Rosen J, Manley LR, Patel A, Gandamihardja T, Rao A. Prediction of negative axillary node clearance by sentinel node-positive to total node ratio: a retrospective cohort study. Ann Med Surg (Lond) 2023; 85:4689-4693. [PMID: 37811068 PMCID: PMC10553108 DOI: 10.1097/ms9.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/20/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Increasing evidence suggests that de-escalation of axillary surgery is safe, without significantly impacting patient outcome. Obtaining positive lymph nodes at a sentinel lymph node biopsy (SNB) can guide decisions toward the requirement of axillary nodal clearance (ANC). However, methods to predict how many further nodes will be positive are not available. This study investigates the feasibility of predicting the likelihood of a negative ANC based on the ratio between positive nodes and the total number of lymph nodes excised at SNB. Methods Retrospective data from January 2017 to March 2022 was collected from electronic medical records. Patients with oestrogen receptor (ER) positive and HER2 negative receptor disease were included in the study. ER-negative and HER2-positive disease was excluded, alongside patients who had chemotherapy before ANC. Results Of 102 patients, 58.8% (n=60) had no macrometastasis at ANC. On average, 2.76 lymph nodes were removed at SNB. A higher SNB ratio of positive to total nodes [OR 11.09 (CI 95% 2.33-52.72), P=0.002] had a significant association with positive nodes during ANC. SNB ratio less than or equal to 0.33 (1/3) had a specificity of 79.2% in identifying cases that later had a negative completion ANC, with a 95.8% specificity of no further upgrade of nodal staging. Conclusion A low SNB ratio of less than 0.33 (1/3) has a high specificity in excluding the upgradation of nodal staging on completion of ANC, with a false-negative rate of less than 5%. This may be used to identify patients with a low risk of axillary metastasis, who can avoid ANC.
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Affiliation(s)
- Jemima Rosen
- Broomfield Hospital, Mid and South Essex NHS Foundation Trust, Broomfield, Chelmsford, UK
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Kaidar-Person O, Pfob A, Gentilini OD, Borisch B, Bosch A, Cardoso MJ, Curigliano G, De Boniface J, Denkert C, Hauser N, Heil J, Knauer M, Kühn T, Lee HB, Loibl S, Mannhart M, Meattini I, Montagna G, Pinker K, Poulakaki F, Rubio IT, Sager P, Steyerova P, Tausch C, Tramm T, Vrancken Peeters MJ, Wyld L, Yu JH, Weber WP, Poortmans P, Dubsky P. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus. EClinicalMedicine 2023; 61:102085. [PMID: 37528842 PMCID: PMC10388578 DOI: 10.1016/j.eclinm.2023.102085] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy ( ± targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - André Pfob
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Bettina Borisch
- Department of Histopathology, University of Geneva, 1202 Geneva, Switzerland
| | - Ana Bosch
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23A, 22241, Lund, Sweden
| | - Maria João Cardoso
- Breast Unit, Champalimaud Foundation and University of Lisbon Faculty of Medicine, Lisbon, Portugal
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Via Giuseppe Ripamonti, 435, 20141 Milano MI, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Jana De Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden
| | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg, Marburg, Germany
| | - Nik Hauser
- Breast Center, Hirslanden Clinic Aarau, Frauenarztzentrum Aargau AG, Baden, Switzerland
| | - Jörg Heil
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- Breast Center Heidelberg, Klinik St. Elisabeth, Heidelberg, Germany
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Sibylle Loibl
- German Breast Group (GBG), C/o GBG Forschungs GmbH 63263 - Neu-Isenberg/, Germany
- Centre for Haematology and Oncology Bethanien, Frankfurt, Germany
| | | | - Icro Meattini
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Isabel T. Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Patrizia Sager
- Breast Center Bern-Biel, Hirslanden Clinic Salem, Bern, Switzerland
| | - Petra Steyerova
- Breast Cancer Screening and Diagnostic Center, Clinic of Radiology, General University Hospital in Prague, Prague, Czech Republic
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology Netherlands Cancer Institute, Antoni van Leeuwenhoek & Amsterdam University Medical Center, Netherlands
| | - Lynda Wyld
- Department of Oncology and Metabolism, The University of Sheffield, The Medical School, Sheffield, UK
| | - Jong Han Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Walter Paul Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp 2610, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Peter Dubsky
- Breast Center, Hirslanden Clinic St Anna, 6006, Lucerne, Switzerland
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland
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Sajjad U, Rezapour M, Su Z, Tozbikian GH, Gurcan MN, Niazi MKK. NRK-ABMIL: Subtle Metastatic Deposits Detection for Predicting Lymph Node Metastasis in Breast Cancer Whole-Slide Images. Cancers (Basel) 2023; 15:3428. [PMID: 37444538 DOI: 10.3390/cancers15133428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
The early diagnosis of lymph node metastasis in breast cancer is essential for enhancing treatment outcomes and overall prognosis. Unfortunately, pathologists often fail to identify small or subtle metastatic deposits, leading them to rely on cytokeratin stains for improved detection, although this approach is not without its flaws. To address the need for early detection, multiple-instance learning (MIL) has emerged as the preferred deep learning method for automatic tumor detection on whole slide images (WSIs). However, existing methods often fail to identify some small lesions due to insufficient attention to small regions. Attention-based multiple-instance learning (ABMIL)-based methods can be particularly problematic because they may focus too much on normal regions, leaving insufficient attention for small-tumor lesions. In this paper, we propose a new ABMIL-based model called normal representative keyset ABMIL (NRK-ABMIL), which addresseses this issue by adjusting the attention mechanism to give more attention to lesions. To accomplish this, the NRK-ABMIL creates an optimal keyset of normal patch embeddings called the normal representative keyset (NRK). The NRK roughly represents the underlying distribution of all normal patch embeddings and is used to modify the attention mechanism of the ABMIL. We evaluated NRK-ABMIL on the publicly available Camelyon16 and Camelyon17 datasets and found that it outperformed existing state-of-the-art methods in accurately identifying small tumor lesions that may spread over a few patches. Additionally, the NRK-ABMIL also performed exceptionally well in identifying medium/large tumor lesions.
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Affiliation(s)
- Usama Sajjad
- Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Mostafa Rezapour
- Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Ziyu Su
- Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Gary H Tozbikian
- Department of Pathology, The Ohio State University, Columbus, OH 43210, USA
| | - Metin N Gurcan
- Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - M Khalid Khan Niazi
- Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
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Freitas GBD, Mota BS, Maesaka JY, Pinheiro CC, de Lima LGCA, Soares JM, Baracat EC, Filassi JR. Measurement of extracapsular extension in sentinel lymph node as a possible predictor of residual axillary disease in breast cancer. Clinics (Sao Paulo) 2023; 78:100216. [PMID: 37201303 DOI: 10.1016/j.clinsp.2023.100216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/11/2023] [Accepted: 04/27/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND The presence of Extracapsular Extension (ECE) in the Sentinel Lymph Node Biopsy (SLNB) is still a doubt in the literature. Some studies suggest that the presence of ECE may be related to a greater number of positive axillary lymph nodes which could impact Disease Free Survival (DFS) and Overall Survival (OS). This study searches for the clinical significance of the ECE. METHODS Retrospective cohort comparing the presence or absence of ECE in T1-2 invasive breast cancer with positive SLNB. All cases treated surgically at the Cancer Institute of the State of São Paulo (ICESP) between 2009 and 2013 were analyzed. All patients with axillary disease in SLNB underwent AD. OUTCOMES Identify the association between the presence and length of ECE and additional axillary positive lymph nodes, OS and DFS between both groups. RESULTS 128 patients with positive SLNB were included, and 65 had ECE. The mean metastasis size of 0.62 (SD = 0.59) mm at SLNB was related to the presence of ECE (p < 0.008). The presence of ECE was related to a higher mean of positive sentinel lymph nodes, 3.9 (± 4.8) vs. 2.0 (± 2.1), p = 0.001. The median length of follow-up was 115 months. The OS and DFS rates had no differences between the groups. CONCLUSION The presence of ECE was associated with additional positive axillary lymph nodes in this study. Therefore, the OS and DFS were similar in both groups after 10 years of follow-up. It is necessary for additional studies to define the importance of AD when SLNB with ECE.
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Affiliation(s)
- Gabriela Boufelli de Freitas
- Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetricia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Arnaldo, 251; 4o andar Secretária Cirúrgica, São Paulo, SP 01246-000, Brazil
| | - Bruna Salani Mota
- Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetricia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Arnaldo, 251; 4o andar Secretária Cirúrgica, São Paulo, SP 01246-000, Brazil.
| | - Jonathan Yugo Maesaka
- Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetricia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Arnaldo, 251; 4o andar Secretária Cirúrgica, São Paulo, SP 01246-000, Brazil
| | - Cintia Cardoso Pinheiro
- Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetricia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Arnaldo, 251; 4o andar Secretária Cirúrgica, São Paulo, SP 01246-000, Brazil
| | - Luiz Guilherme Cernaglia Aureliano de Lima
- Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetricia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Arnaldo, 251; 4o andar Secretária Cirúrgica, São Paulo, SP 01246-000, Brazil
| | - José Maria Soares
- Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetricia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Arnaldo, 251; 4o andar Secretária Cirúrgica, São Paulo, SP 01246-000, Brazil
| | - Edmund Chada Baracat
- Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetricia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Arnaldo, 251; 4o andar Secretária Cirúrgica, São Paulo, SP 01246-000, Brazil
| | - José Roberto Filassi
- Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetricia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Arnaldo, 251; 4o andar Secretária Cirúrgica, São Paulo, SP 01246-000, Brazil
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9
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Huang Z, Wu Z, Zou QQ, Xie YJ, Li LH, Huang YP, Wu FM, Huang D, Pan YH, Yang JR. Risk factors of non-sentinel lymph node metastasis in breast cancer with 1-2 sentinel lymph node macrometastases underwent total mastectomy: a case-control study. World J Surg Oncol 2023; 21:125. [PMID: 37024930 PMCID: PMC10077622 DOI: 10.1186/s12957-023-02888-z] [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: 09/22/2022] [Accepted: 01/09/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND The randomized trials which include ACOSOG Z0011 and IBCSG 23-01 had found that the survival rates were not different in patients with cT1/2N0 and 1-2 sentinel lymph node (SLN)-positive, macro/micrometastases who underwent breast-conserving therapy, and micrometastases who underwent total mastectomy (TM), when axillary lymph node dissection (ALND) was omitted. However, for patients with cT1/2N0 and 1-2 SLN macrometastases who underwent TM; there was still insufficient evidence from clinical studies to support whether ALND can be exempted. This study aimed to investigate the risk factors of non-sentinel lymph node (nSLN) metastasis in breast cancer patients with 1-2 SLN macrometastases undergoing TM. METHODS The clinicopathological data of 1491 breast cancer patients who underwent TM and SLNB from January 2017 to February 2022 were retrospectively analyzed. Univariate and multivariate analyses were performed to analyze the risk factors for nSLN metastasis. RESULTS A total of 273 patients with 1-2 SLN macrometastases who underwent TM were enrolled. Postoperative pathological data showed that 35.2% patients had nSLN metastasis. The results of multivariate analysis indicated that tumor size (TS) (P = 0.002; OR: 1.051; 95% CI: 1.019-1.084) and ratio of SLN macrometastases (P = 0.0001; OR: 12.597: 95% CI: 4.302-36.890) were the independent risk factors for nSLN metastasis in breast cancer patients with 1-2 SLN macrometastases that underwent TM. The ROC curve analysis suggested that when TS ≤22 mm and ratio of SLN macrometastases ≤0.33, the incidence of nSLN metastasis could be reduced to 17.1%. CONCLUSIONS The breast cancer patients with cT1/2N0 stage, undergoing TM and 1-2 SLN macrometastases, when the TS ≤22 mm and macrometastatic SLN does not exceed 1/3 of the total number of detected SLN, the incidence of nSLN metastasis is significantly reduced, but whether ALND can be exempted needs further exploration.
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Affiliation(s)
- Zhen Huang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Zhe Wu
- Department of Gynaecology, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, Nanning, China
| | - Quan-Qing Zou
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yu-Jie Xie
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Li-Hui Li
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yan-Ping Huang
- Department of Breast Surgery, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Feng-Ming Wu
- Department of Breast Surgery, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Dong Huang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yin-Hua Pan
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Jian-Rong Yang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China.
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10
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Lai BSW, Tsang JY, Li JJ, Poon IK, Tse GM. Anatomical site and size of sentinel lymph node metastasis predicted additional axillary tumour burden and breast cancer survival. Histopathology 2023; 82:899-911. [PMID: 36723261 DOI: 10.1111/his.14875] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/05/2023] [Accepted: 01/30/2023] [Indexed: 02/02/2023]
Abstract
AIMS Sentinel lymph node (SLN) biopsy is the current standard assessment for tumour burden in axillary lymph node (ALN). However, not all SLN+ patients have ALN metastasis. The prognostic implication of SLN features is not clear. We aimed to evaluate predictive factors for ALN metastasis and the clinical value of SLN features. METHODS AND RESULTS A total of 228 SLN+ and 228 SLN- (with matched year and grade) cases were included. Clinicopathological features in SLN, ALN and primary tumours, treatment data and survival data were analysed according to ALN status and outcome. Except for larger tumour size and the presence of LVI (both P < 0.001), no significant differences were found in SLN- and SLN+ cases. Only 31.8% of SLN+ cases with ALN dissection had ALN metastasis. The presence of macrometastases (MaM), extranodal extension (ENE), deeper level of tumour invasion in SLN and more SLN+ nodes were associated with ALN metastasis (P ≤ 0.025). Moreover, isolated tumour cells (ITC) and level of tumour invasion in SLN were independent adverse prognostic features for disease-free survival and breast cancer-specific survival, respectively. Interestingly, cases with ITC located in the subcapsular region have better survival than those in cortex (OS: χ2 = 4.046, P = 0.044). CONCLUSIONS Our study identified features in SLN, i.e. the level of tumour invasion at SLN and tumour size in SLN as useful predictors for both ALN metastasis and breast cancer outcome. The presence of ITC, particularly those with a deeper invasion in SLN, portended a worse prognosis. Proper attention should be taken for their management.
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Affiliation(s)
| | - Julia Y Tsang
- Department of Anatomical and Cellular Pathology and State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, NT, Shatin, Hong Kong
| | - Joshua J Li
- Department of Anatomical and Cellular Pathology and State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, NT, Shatin, Hong Kong
| | - Ivan K Poon
- Department of Anatomical and Cellular Pathology and State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, NT, Shatin, Hong Kong
| | - Gary M Tse
- Department of Anatomical and Cellular Pathology and State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, NT, Shatin, Hong Kong
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11
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Cserni G, Brogi E, Cody HS, Deb R, Farshid G, O'Toole S, Provenzano E, Quinn CM, Sahin AA, Schmitt F, Weaver DL, Yamaguchi R, Webster F, Tan PH. Reporting of Surgically Removed Lymph Nodes for Breast Tumors: Recommendations From the International Collaboration on Cancer Reporting. Arch Pathol Lab Med 2022; 146:1308-1318. [PMID: 36270029 DOI: 10.5858/arpa.2022-0060-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The International Collaboration on Cancer Reporting (ICCR), supported by major pathology and cancer organizations, aims at the standardization of evidence-based pathology reporting of different types of cancers, with the inclusion of all parameters deemed to be relevant for best patient care and future data collection. Lymph node metastasis is one of the most important prognostic factors in breast cancer. OBJECTIVE.— To produce a histopathology reporting guide by a panel of recognized experts from the fields of pathology and surgery with elements deemed to be core (required) and noncore (recommended) to report when assessing regional lymph nodes of patients with breast cancer. DATA SOURCES.— Published literature, previous guidelines/recommendations, and current cancer staging principles were the basis of the data set drafted by the expert panel. This was discussed in a series of teleconferences and email communications. The draft data set was then made available for public consultation through the ICCR Web site. After this consultation and ICCR ratification, the data set was finalized. CONCLUSIONS.— The ICCR has published a data set for the reporting of surgically removed lymph nodes (including sentinel lymph node biopsy, axillary lymph node dissection, targeted axillary surgery, and lymph node sampling specimens) for breast tumors. This is part of a series of 4 ICCR breast cancer-related data sets. It includes 10 core elements along with 2 noncore elements. This should allow for synoptic reporting, which is more precise, uniform, and complete than nonsynoptic reporting, and leads to improved patient outcomes.
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Affiliation(s)
- Gábor Cserni
- From the Department of Pathology, Albert Szent-Györgyi Medical Center, University of Szeged, Szeged, Hungary (Cserni).,The Department of Pathology, Bács-Kiskun County Teaching Hospital, Kecskemét, Hungary (Cserni)
| | - Edi Brogi
- The Department of Pathology (Brogi), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hiram S Cody
- The Breast Service, Department of Surgery (Cody III), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rahul Deb
- The Department of Pathology, Royal Derby Hospital, University Hospitals of Derby and Burton, Derby, United Kingdom (Deb)
| | - Gelareh Farshid
- The Department of Anatomical Pathology, SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia (Farshid).,School of Medicine, Adelaide University, Adelaide, South Australia, Australia (Farshid)
| | - Sandra O'Toole
- The Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia (O'Toole).,Sydney Medical School, University New South Wales, Sydney, New South Wales, Australia (O'Toole)
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Provenzano).,The Department of Histopathology, Addenbrookes Hospital, Cambridge, United Kingdom (Provenzano)
| | - Cecily M Quinn
- The Department of Histopathology, BreastCheck, Irish National Breast Screening Programme & St. Vincent's University Hospital, Dublin, Ireland (Quinn).,University College Dublin, School of Medicine, Dublin, Ireland (Quinn)
| | - Aysegul A Sahin
- Division of Pathology and Laboratory Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas (Sahin)
| | - Fernando Schmitt
- The Department of Pathology, Medical Faculty of Porto University, and Molecular Unit, Institute of Pathology and Immunology of Porto University, Porto, Portugal (Schmitt).,RISE (Health Research Network) @ CINTESIS (Center for Health Technology and Services Research), Porto, Portugal (Schmitt)
| | - Donald L Weaver
- The Department of Pathology, University of Vermont Larner College of Medicine, Burlington (Weaver)
| | - Rin Yamaguchi
- The Department of Pathology and Laboratory Medicine, Kurume University Medical Center, Fukuoka, Japan (Yamaguchi)
| | - Fleur Webster
- International Collaboration on Cancer Reporting, Sydney, NSW, Australia, and ICCR Project Manager, Surry Hills, Australia (Webster)
| | - Puay Hoon Tan
- Cambridge Experimental Cancer Medicine Centre (ECMR), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,The Division of Pathology, Singapore General Hospital, Academia, Singapore (Tan)
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12
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Liu L, Lin Y, Li G, Zhang L, Zhang X, Wu J, Wang X, Yang Y, Xu S. A novel nomogram for decision-making assistance on exemption of axillary lymph node dissection in T1–2 breast cancer with only one sentinel lymph node metastasis. Front Oncol 2022; 12:924298. [PMID: 36172144 PMCID: PMC9511144 DOI: 10.3389/fonc.2022.924298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background T1–2 breast cancer patients with only one sentinel lymph node (SLN) metastasis have an extremely low non-SLN (NSLN) metastatic rate and are favorable for axillary lymph node dissection (ALND) exemption. This study aimed to construct a nomogram-based preoperative prediction model of NSLN metastasis for such patients, thereby assisting in preoperatively selecting proper surgical procedures. Methods A total of 729 T1–2 breast cancer patients with only one SLN metastasis undergoing sentinel lymph node biopsy and ALND were retrospectively selected from Harbin Medical University Cancer Hospital between January 2013 and December 2020, followed by random assignment into training (n=467) and validation cohorts (n=262). A nomogram-based prediction model for NSLN metastasis risk was constructed by incorporating the independent predictors of NSLN metastasis identified from multivariate logistic regression analysis in the training cohort. The performance of the nomogram was evaluated by the calibration curve and the receiver operating characteristic (ROC) curve. Finally, decision curve analysis (DCA) was used to determine the clinical utility of the nomogram. Results Overall, 160 (21.9%) patients had NSLN metastases. Multivariate analysis in the training cohort revealed that the number of negative SLNs (OR: 0.98), location of primary tumor (OR: 2.34), tumor size (OR: 3.15), and lymph-vascular invasion (OR: 1.61) were independent predictors of NSLN metastasis. The incorporation of four independent predictors into a nomogram-based preoperative estimation of NSLN metastasis demonstrated a satisfactory discriminative capacity, with a C-index and area under the ROC curve of 0.740 and 0.689 in the training and validation cohorts, respectively. The calibration curve showed good agreement between actual and predicted NSLN metastasis risks. Finally, DCA revealed the clinical utility of the nomogram. Conclusion The nomogram showed a satisfactory discriminative capacity of NSLN metastasis risk in T1–2 breast cancer patients with only one SLN metastasis, and it could be used to preoperatively estimate NSLN metastasis risk, thereby facilitating in precise clinical decision-making on the selective exemption of ALND in such patients.
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Affiliation(s)
- Lei Liu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yaoxin Lin
- Chinese Academy of Sciences (CAS) Center for Excellence in Nanoscience, Chinese Academy of Sciences (CAS) Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology, Beijing, China
| | - Guozheng Li
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Lei Zhang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Zhang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jiale Wu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xinheng Wang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yumei Yang
- Department of The First Operating Room, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- *Correspondence: Shouping Xu, ; Yumei Yang,
| | - Shouping Xu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
- *Correspondence: Shouping Xu, ; Yumei Yang,
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13
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Extranodal extension, an international survey on its evaluation and reporting in breast cancer patients. Pathol Res Pract 2022; 237:154070. [PMID: 36030639 DOI: 10.1016/j.prp.2022.154070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/08/2022] [Indexed: 11/20/2022]
Abstract
Lymph node metastasis is the most important prognostic factor for breast cancer patients. In addition to the number of nodes involved and the largest metastatic focus, extranodal extension (ENE) is also used to subclassify breast cancer patients into different risk groups. More recently, pathologists are required to report the size/extent of ENE per the new CAP guideline, as it seems to be associated with more axillary nodal burden and/or a worse prognosis. Although the definition of ENE is largely understood and agreed upon among pathologists around the world, evaluation and reporting for the size of ENE are not. To understand current practice, we conducted an international survey among pathologists who are interested in breast pathology. A total of 70 pathologists responded. The results showed that (1) 98% of the participants reported the presence or absence of ENE and 61% also reported the size of ENE in millimeter (mm). (2) There was no uniform method of measuring the size of ENE; 47% measured the largest dimension regardless of orientation, while 30% measured the largest perpendicular distance from the capsule. (3) The most common factors affecting the accuracy in diagnosis of ENE are the presence of lymphovascular invasion (LVI), lack of capsule integrity, and the presence of fatty hilar or fatty replacement of a lymph node. (4) 71% felt that the H&E stain is adequate to evaluate ENE, deeper levels and IHC analysis for vascular and cytokeratin markers can be helpful if needed. (5) 75% agreed that there is an urgent need to standardize the measurement and reporting for ENE. Our survey highlights the variation in ENE evaluation and the need for its standardization in breast cancer patients with axillary node metastasis.
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14
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Alcaide SM, Diana CAF, Herrero JC, Vegue LB, Perez AV, Arce ES, Sapiña JBB, Noguera PJG, Caravajal JMG. Can axillary lymphadenectomy be avoided in breast cancer with positive sentinel lymph node biopsy? Predictors of non-sentinel lymph node metastasis. Arch Gynecol Obstet 2022; 306:2123-2131. [PMID: 35503378 DOI: 10.1007/s00404-022-06556-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Completion axillary lymph node dissection (cALND) can currently be avoided in those patients with a low tumor load (LTL) and/or a low-risk profile that tested with positive sentinel lymph node biopsy (SLNB). Our objective is to identify prognostic factors that significantly influence axillary lymph node involvement to identify patients who could benefit from surgery without axillary lymphadenectomy. METHODS This is an observational retrospective study of consecutive patients diagnosed and operated of breast cancer between 2000 and 2014 at University Hospital La Ribera (UHR). RESULTS The size of the sample was 1641 patients, from which 1174 underwent SLNB. In the multivariate analysis, we objectify a raise of risk of positive sentinel lymph node (SLN) up to 5.2% for every millimeter of increase. The risk of positive SLNB when showing lymphovascular invasion seems to be 2.80 times greater but becomes lower when SLN involvement appears in luminal A, luminal B and triple-negative types, regarding HER2. In case of triple negatives, the difference is statistically significant. 16.7% present affected additional lymph nodes. The proportion of patients with affected additional lymph nodes increase dramatically above OSNA values of 12,000 copies/μl of CK19 mRNA and it depends on tumor size and lymphovascular infiltration. CONCLUSIONS Tumors smaller than 5 cm whose OSNA SLNB analysis is less than 12,000 copies/μl of CK19 mRNA have a low chance to develop additional affected lymph nodes, thus cALND can be avoided.
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Affiliation(s)
- Sonia Martinez Alcaide
- Department of General Surgery, University Hospital La Ribera, km 1, Corbera Road, 46600, Alzira, Valencia, Spain.
| | - Carlos Alberto Fuster Diana
- Breast Unit. University Hospital General, Tres Creus Av., 2, 46014, Valencia, Spain.,Department of General Surgery, IVO Hospital, Professor Beltran Baguena St, 8, 46009, Valencia, Spain
| | | | - Laia Bernet Vegue
- Department of Anatomic Pathology, Ribera Salud Hospitals, Valencia, Spain
| | | | - Eugenio Sahuquillo Arce
- Department of Maxillofacial Surgery, University Hospital La Ribera, km 1, Corbera Road, 46600, Alzira, Valencia, Spain
| | - Juan Blas Ballester Sapiña
- Department of General Surgery, University Hospital La Ribera, km 1, Corbera Road, 46600, Alzira, Valencia, Spain
| | - Pedro Juan Gonzalez Noguera
- Department of General Surgery, University Hospital La Ribera, km 1, Corbera Road, 46600, Alzira, Valencia, Spain
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15
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Skarping I, Förnvik D, Zackrisson S, Borgquist S, Rydén L. Predicting pathological axillary lymph node status with ultrasound following neoadjuvant therapy for breast cancer. Breast Cancer Res Treat 2021; 189:131-144. [PMID: 34120224 PMCID: PMC8302508 DOI: 10.1007/s10549-021-06283-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/01/2021] [Indexed: 02/05/2023]
Abstract
Purpose High-performing imaging and predictive markers are warranted to minimize surgical overtreatment of the axilla in breast cancer (BC) patients receiving neoadjuvant chemotherapy (NACT). Here we have investigated whether axillary ultrasound (AUS) could identify axillary lymph node (ALN) metastasis (ALNM) pre-NACT and post-NACT for BC. The association of tumor, AUS features and mammographic density (MD) with axillary-pathological complete response (axillary-pCR) post-NACT was also assessed. Methods The NeoDense-study cohort (N = 202, NACT during 2014–2019), constituted a pre-NACT cohort, whereas patients whom had a cytology verified ALNM pre-NACT and an axillary dissection performed (N = 114) defined a post-NACT cohort. AUS characteristics were prospectively collected pre- and post-NACT. The diagnostic accuracy of AUS was evaluated and stratified by histological subtype and body mass index (BMI). Predictors of axillary-pCR were analyzed, including MD, using simple and multivariable logistic regression models. Results AUS demonstrated superior performance for prediction of ALNM pre-NACT in comparison to post-NACT, as reflected by the positive predictive value (PPV) 0.94 (95% CI 0.89–0.97) and PPV 0.76 (95% CI 0.62–0.87), respectively. We found no difference in AUS performance according to neither BMI nor histological subtype. Independent predictors of axillary-pCR were: premenopausal status, ER-negativity, HER2-overexpression, and high MD. Conclusion Baseline AUS could, to a large extent, identify ALNM; however, post-NACT, AUS was insufficient to determine remaining ALNM. Thus, our results support the surgical staging of the axilla post-NACT. Baseline tumor biomarkers and patient characteristics were predictive of axillary-pCR. Larger, multicenter studies are needed to evaluate the performance of AUS post-NACT. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06283-8.
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Affiliation(s)
- Ida Skarping
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund, Sweden.
| | - Daniel Förnvik
- Medical Radiation Physics, Department of Translational Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Sophia Zackrisson
- Diagnostic Radiology, Department of Translational Medicine, Department of Imaging and Functional Medicine, Skåne University Hospital, Lund University, Lund and Malmö, Sweden
| | - Signe Borgquist
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lisa Rydén
- Division of Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Surgery, Skåne University Hospital, Lund, Sweden.,Aarhus University, Aarhus, Denmark
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16
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Ortega Expósito C, Falo C, Pernas S, Pérez Carton S, Gil Gil M, Ortega R, Pérez Montero H, Stradella A, Martinez E, Laplana M, Salinas S, Luzardo A, Soler T, Fernández Montoli ME, Azcarate J, Guma A, Petit A, Benitez A, Bajen M, Reyes Junca JG, Campos M, Ruiz R, Ponce J, Pla MJ, García Tejedor A. The effect of omitting axillary dissection and the impact of radiotherapy on patients with breast cancer sentinel node macrometastases: a cohort study following the ACOSOG Z0011 and AMAROS trials. Breast Cancer Res Treat 2021; 189:111-120. [PMID: 34089119 DOI: 10.1007/s10549-021-06274-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/25/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To report the outcomes of implementing the ACOSOG Z0011 and AMAROS trials relevant to clinical practice, and to define target groups in whom to avoid or recommend axillary radiotherapy (ART). We also aimed to analyse the reduction in morbidity when axillary lymph node dissection (ALND) was omitted. METHODS A retrospective cohort study of T1-T2 patients with macrometastases at sentinel lymph node (SLN) who were treated between 2011 and 2020. Breast surgery included either lumpectomy or mastectomy. Patients with ≤ 2 positive SLN were divided into two cohorts by whether they received ART or not. Survival outcomes and morbidity were analysed by Kaplan-Meyer curves and Cox-regression, respectively. RESULTS 260 pN1a patients were included and ALND was avoided in 167 (64.2%). According the Z0011 results, 72 (43.1%) received no further ART; and based on AMAROS criteria 95 (56.9%) received ART. Median follow-up was 54 months. The 5-year overall survival was 96.8% in the non-RT cohort and 93.4% in the RT cohort (p = 0.19), while the respective 5-year disease-free survivals were 100% and 92.3% (p = 1.06). Lymphedema developed in 3.6% of patients after SLNB versus 43% after ALND (OR 20.25; 95%CI 8.13-50.43). Decreased upper-extremity range of motion appeared in 8.4% of patients after SLNB versus 31.2% after ALND (OR 4.95; 95%CI 2.45-9.98%). CONCLUSIONS Our study confirms that omitting ALND is safe and has high survival rates in patients with T1-T2 tumours and ≤ 2 positive SLNs. Adding ART could be a treatment option for patients who present other risk factors. Avoiding ALND with or without ART was associated with significantly less arm morbidity.
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Affiliation(s)
- Carlos Ortega Expósito
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain.
| | - Catalina Falo
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Sonia Pernas
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Samuel Pérez Carton
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Miguel Gil Gil
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Raul Ortega
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Héctor Pérez Montero
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Agostina Stradella
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Evelyn Martinez
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Maria Laplana
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Sira Salinas
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Ana Luzardo
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Teresa Soler
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | | | - Juan Azcarate
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Anna Guma
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Anna Petit
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Ana Benitez
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Maite Bajen
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Jose G Reyes Junca
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Miriam Campos
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Raquel Ruiz
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Jordi Ponce
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Maria J Pla
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Amparo García Tejedor
- Bellvitge University Hospital: Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
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Combi F, Andreotti A, Gambini A, Palma E, Papi S, Biroli A, Zaccarelli S, Ficarra G, Tazzioli G. Application of OSNA Nomogram in Patients With Macrometastatic Sentinel Lymph Node: A Retrospective Assessment of Accuracy. BREAST CANCER-BASIC AND CLINICAL RESEARCH 2021; 15:11782234211014796. [PMID: 33994790 PMCID: PMC8113365 DOI: 10.1177/11782234211014796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 04/14/2021] [Indexed: 11/24/2022]
Abstract
Introduction: Almost 50% to 70% of patients who undergo axillary lymph node dissection (ALND) because of a single metastatic sentinel lymph node (SLN) have no further metastatic nodes at the axillary histology. On these grounds, the one-step nucleic acid amplification (OSNA) nomogram was designed and validated. As a mathematical model, calculated through tumor size (expressed in millimeters) and CK19 mRNA copy number, it is thought to predict nonsentinel lymph node (NSLN) status. The aim of the study is to verify the diagnostic accuracy of the OSNA nomogram in a group of patients with macrometastatic SLN, with a retrospective analysis. Methods: The OSNA nomogram was retrospectively applied to a group of 66 patients with macrometastatic SLN who underwent ALND. The result of the final histology of the axillary cavity was compared to the nomogram prediction. We calculated the prevalence of NSLN metastasis in patients who underwent ALND, sensitivity and specificity, negative and positive predictive value of the nomogram. Results: In patients with macrometastasis in SLN, the prevalence of patients with metastatic NSLN was 45%. The sensitivity of the nomogram was excellent (90%). The specificity was low (36%). Positive predictive value amounted to 54%, while negative predictive value was good (81%). Conclusions: These results suggest that the OSNA nomogram is a valid instrument that can help choose the best surgical strategy for the treatment of axillary cavity. The mathematical model is useful to avoid surgery in a selected group of patients because it accurately predicts NSLN status.
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Affiliation(s)
- Francesca Combi
- Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
- Francesca Combi, Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Via Università 4, 41121 Modena (MO), Italy. Emails: ;
| | - Alessia Andreotti
- Division of Breast Surgical Oncology, Department of Medical and Surgical Maternal-Infantile and Adult Sciences, University Hospital of Modena, Modena, Italy
| | - Anna Gambini
- Division of Breast Surgical Oncology, Department of Medical and Surgical Maternal-Infantile and Adult Sciences, University Hospital of Modena, Modena, Italy
| | - Enza Palma
- Division of Breast Surgical Oncology, Department of Medical and Surgical Maternal-Infantile and Adult Sciences, University Hospital of Modena, Modena, Italy
| | - Simona Papi
- Division of Breast Surgical Oncology, Department of Medical and Surgical Maternal-Infantile and Adult Sciences, University Hospital of Modena, Modena, Italy
| | - Alice Biroli
- Faculty of Medicine and Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Guido Ficarra
- Department of Pathology, University Hospital of Modena, Modena, Italy
| | - Giovanni Tazzioli
- Division of Breast Surgical Oncology, Department of Medical and Surgical Maternal-Infantile and Adult Sciences, University Hospital of Modena, Modena, Italy
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Sun Y, Cui L, Wang S, Shi T, Hao Y, Lei Y. Comparative study of two contrast agents for intraoperative identification of sentinel lymph nodes in patients with early breast cancer. Gland Surg 2021; 10:1638-1645. [PMID: 34164308 DOI: 10.21037/gs-21-87] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The use of contrast-enhanced ultrasound (CEUS) to locate sentinel lymph nodes (SLNs) in breast cancer has been studied more and more in recent years. This prospective study aimed to compare periareolar injection of two different contrast agents, SonoVue® (SNV) and Sonazoid® (SNZ), followed by CEUS to identify SLNs in breast cancer patients with clinically negative nodes. Methods A total of 205 patients with T1-2N0M0 breast cancer were divided into the SNV group and SNZ group. All were administered a periareolar injection of SNV or SNZ and underwent US to identify contrast-enhanced SLNs. Each contrast-enhanced SLN underwent a biopsy with blue dye and examined again by CEUS in vitro. Results In all cases, contrast-enhanced lymphatic vessels were clearly visualized using US soon after the periareolar injection of SNZ, and the SLNs were easily identified. The SLN identification rates were 75.27% (210/279) for SNV and 93.58% (102/109) for SNZ. Although the accuracy of detecting SLN metastasis was slightly different between the two groups, there was no statistically significant difference between those groups (P=0.615). Moreover, it was possible to identify SLNs in vitro in the SNZ group, and these could be compared with the lymph nodes (LNs) located using SNZ during the preoperative stage and with blue dye during the procedure. This helped in determining the resection requirements. Conclusions When comparing the subdermal use of SNV and SNZ, no significant differences in the number of detected SLNs and the diagnosis of metastatic LNs were observed. Because SLNs can be detected for a longer time in living tissues with SNZ, this contrast agent may provide more intraoperative information for complete resection of all preoperative localization of SLN.
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Affiliation(s)
- Yan Sun
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Ligang Cui
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Shunmin Wang
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Tan Shi
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Yunxia Hao
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Yutao Lei
- Department of General Surgery, Peking University Third Hospital, Beijing, China
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Mikami Y, Yamada A, Suzuki C, Adachi S, Harada F, Yamamoto S, Shimada K, Sugae S, Narui K, Chishima T, Ishikawa T, Ichikawa Y, Endo I. Predicting Nonsentinel Lymph Node Metastasis in Breast Cancer: A Multicenter Retrospective Study. J Surg Res 2021; 264:45-50. [PMID: 33752166 DOI: 10.1016/j.jss.2021.01.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/14/2021] [Accepted: 01/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy has been the standard modality for breast cancer patients with clinically node negative disease. In patients who undergo axillary lymph node dissection (ALND) due to SLN metastasis, the harvested nodes (non-SLNs) often contain no metastasis. Here, we evaluated the predictive factors associated with non-SLN metastasis in breast cancer patients. MATERIALS AND METHODS This was a retrospective study of patients with operable cT1-3, cN0 invasive breast cancer who underwent SLN biopsy followed by ALND due to SLN metastasis. The clinicopathologic factors and predictive factors of non-SLN metastasis were analyzed. The optimal cutoff for the Ki67 index and the number of positive and negative SLNs that were predictive of non-SLN metastasis were evaluated using receiver operating characteristic curves. RESULTS The median number of SLN and non-SLN was 3 and 11, respectively. Of the 150 patients, 52 (35.0%) had metastases in non-SLNs. The optimal cutoffs for the Ki67 index and the number of positive and negative SLNs were of 12%, 2, and 1, respectively. In the univariate analysis, the Ki67 index and the number of positive SLNs≥2 and negative SLNs≤1 were higher in the non-SLN + group than that in the non-SLN - group. The number of negative SLNs was as a predictive factor for non-SLNs metastasis in the multivariate analysis. CONCLUSIONS The number of negative SLNs predicts the risk of non-SLN metastasis in breast cancer. When deciding on whether to omit ALND, the number of positive and negative SLNs should be considered.
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Affiliation(s)
- Yuna Mikami
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Akimitsu Yamada
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan.
| | - Chiho Suzuki
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Shoko Adachi
- Department of Breast and Thyroid Surgery, Medical Center, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Fumi Harada
- Department of Breast Surgery, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Shinya Yamamoto
- Department of Breast and Thyroid Surgery, Medical Center, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Kazuhiro Shimada
- Department of Breast Surgery, Saiseikai Yokohama-shi Nanbu Hospital, Yokohama, Kanagawa, Japan
| | - Sadatoshi Sugae
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Kazutaka Narui
- Department of Breast and Thyroid Surgery, Medical Center, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Takashi Chishima
- Department of Breast Surgery, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Takashi Ishikawa
- Department of Breast Surgery and Oncology, Tokyo Medical University, Shinjuku-ward, Tokyo, Japan
| | - Yasushi Ichikawa
- Department of Oncology, School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Reddy A, Nair NS, Mokal S, Parmar V, Shet T, Pathak R, Chitkara G, Thakkar P, Joshi S, Badwe RA. Can We Avoid Axillary Lymph Node Dissection (ALND) in Patients with 1-2 Positive Sentinel/Low Axillary Lymph Nodes (SLN/LAS+) in the Indian Setting? Indian J Surg Oncol 2021; 12:272-278. [PMID: 34295070 DOI: 10.1007/s13193-021-01297-6] [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: 09/26/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022] Open
Abstract
The ACOSOG Z0011 study, heralded as a "practice changing" trial, suggested that women with T1-2 breast cancer with 1-2 SLN+, undergoing breast conservation therapy, need not be offered further ALND. However, whether these results are applicable to all women in the Indian setting, it remains debatable. A retrospective audit of all cN0 operated from 2013 to 2018 was conducted. We analyzed the percentage of additional LN positive (LN+) in the ALND group and compared it to the ACOZOG Z11 trial. Of the 2350 cN0 with EBC who underwent LAS, 687 (29%) had positive lymph nodes on final histopathology. Five hundred ninety-seven (86.9%) patients had 1-2 LN+, 40 (5.8%) patients had 3 LN+, and 50 (7.3%) had 4 or more nodes positive. Demographic features in the ACOSOG Z11 are different from those in our study, looking at ACOZOG Z11 versus our cohort-median pT 1.7 cm versus 3 cm, 45% micrometastasis versus 99.16% macrometastasis, and 28-30% grade 3 tumors versus 73.7%. In our cohort 31.82% of the 1-2 LN positive had additional LN+ on ALND. Keeping in mind the difference in clinicopathological features between our cohort and that of ACOZOG Z0011 and that 31.82% of women had additional LN+ on ALND, it may not be appropriate to apply the results of the ACOSOG Z0011 trial directly to our general population. Possibly, only a select subset of patients who match the trial population of the ACOSOG Z11 could be offered observation of the axilla and validated nomograms can be used to identify high-risk patients.
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Affiliation(s)
- A Reddy
- Department of Surgical Oncology, Breast Service, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Nita S Nair
- Department of Surgical Oncology, Breast Service, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Smruti Mokal
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - V Parmar
- Department of Surgical Oncology, Breast Service, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - T Shet
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - R Pathak
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - G Chitkara
- Department of Surgical Oncology, Breast Service, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - P Thakkar
- Department of Surgical Oncology, Breast Service, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - S Joshi
- Department of Surgical Oncology, Breast Service, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - R A Badwe
- Department of Surgical Oncology, Breast Service, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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Li Y, Ma L. Efficacy of chemotherapy for lymph node-positive luminal A subtype breast cancer patients: an updated meta-analysis. World J Surg Oncol 2020; 18:316. [PMID: 33267822 PMCID: PMC7712980 DOI: 10.1186/s12957-020-02089-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022] Open
Abstract
Objective To assess the association between chemotherapy and prognosis of patients with breast cancer of luminal A subtype and lymph node-positive, luminal A subtype breast cancer Methods Articles published between January 1, 2010, and May 1, 2020, were collected from PubMed, Embase, and Web of Science databases. On the basis of a test for heterogeneity, we selected the random effects model or fixed effects model for meta-analysis. Article quality was evaluated by sensitivity analysis, and Begg’s and Egger’s tests were used to measure publication bias. Results Six eligible articles were identified. The hazard ratio of overall survival of luminal A breast cancer patients who received both chemotherapy and endocrine therapy was 1.73 (95% CI 1.23, 2.43). The hazard ratio of overall survival for lymph node-positive, luminal A breast cancer patients who received chemotherapy and endocrine therapy was 1.86 and 95% CI 1.26, 2.81. The hazard ratio of relapse-free survival to disease-free survival was 1.30 (95% CI 0.85, 1.77). Tumor size, vascular invasion, and age did not show significant correlations with breast cancer prognosis. Conclusion Compared with endocrine therapy alone, the addition of chemotherapy did not improve the prognosis of patients with luminal type A and lymph node positive cancer; instead, side effects of the additional chemotherapy may have negatively affected prognosis. Prospective studies are needed to determine whether the number of positive lymph nodes also correlates with efficacy of chemotherapy of luminal type A breast cancer.
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Affiliation(s)
- Yilun Li
- Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Li Ma
- Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China.
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Sansano I, Vieites B, Sancho de Salas M, García C, Amendoeira I, Bernet L, Pérez-García JM, Espinosa-Bravo M, Rubio IT, Ramón Y Cajal S, Peg V. Axillary staging based on molecular analysis: Results of the B-CLOSER-II study. Pathol Res Pract 2020; 216:153197. [PMID: 32919301 DOI: 10.1016/j.prp.2020.153197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/25/2020] [Accepted: 08/28/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Axillary staging (pN) is a strong predictor of outcome in early stage breast cancer yet following the publication of the Z0011 trial there has been an increasing tendency to spare lymph node dissection. Automated molecular detection of cytokeratin 19mRNA by one-step nucleic acid amplification (OSNA) has been demonstrated to be an accurate method to assess sentinel lymph node (SLN) metastasis. In this study we compare histological and molecular methods following complete axillary lymph node dissection (cALND), determine whether molecular axillary staging affects survival, and evaluate the predictive and prognostic value of total tumor load in ALND (AD-TTL) and in all positive nodes (G-TTL). MATERIAL AND METHODS Axillary lymph nodes were collected from 102 patients with primary breast cancer with histological confirmation of axillary involvement (cN+) or positive SLN. The central 1-mm portion of each non-SLN was processed for hematoxylin-eosin staining and the remaining tissue was analyzed by OSNA. RESULTS Non-SLNs were diagnosed as positive in 72 out of 102 patients (70.6 %) on OSNA compared with only 53 (52 %) on histology (p < 0.01). Thirteen patients would have changed staging if the diagnoses provided had been by molecular methods (p < 0.01), but without a change in prognosis. AD-TTL and G-TTL were predictive of recurrence and mortality. CONCLUSIONS Compared to molecular detection, histological examination significantly underestimates the frequency of axillary node metastases. However, the increase in pN did not show a clinical effect on survival in those patients.
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Affiliation(s)
- Irene Sansano
- Pathology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129 08035 Barcelona, Spain; Departament de Ciències morfològiques, Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 119-129 08035 Barcelona, Spain
| | - Begoña Vieites
- Pathology department, Hospital Universitario Virgen del Rocío, Avda de Manuel Siurot s/n. 41013 Sevilla, Spain
| | - Magdalena Sancho de Salas
- Pathology Department, Hospital Universitario de Salamanca Complejo Asistencial Universitario de Salamanca, Paseo de San Vicente 58-182. 37007 Salamanca, Spain
| | - Carmen García
- Pathology Department, Hospital Universitario de Salamanca Complejo Asistencial Universitario de Salamanca, Paseo de San Vicente 58-182. 37007 Salamanca, Spain
| | - Isabel Amendoeira
- Pathology Department Centro Hospitalar Universitário de S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Ipatimup - Institute of Molecular Pathology and Immunology, University of Porto, Porto, Portugal
| | - Laia Bernet
- Pathology Department, Hospital Universitario de La Ribera, Ctra. Corbera, km 1, 46600 Alcira, Valencia, Spain
| | | | - Martín Espinosa-Bravo
- Breast Cancer Unit, Hospital Universitari Valld'Hebron. Passeig de la Vall d'Hebron 119-129 08035 Barcelona, Spain
| | - Isabel T Rubio
- Breast Cancer Unit, Clínica Universitaria de Navarra, Calle Marquesado de Sta. Marta, 1, 28027 Madrid, Spain
| | - Santiago Ramón Y Cajal
- Pathology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129 08035 Barcelona, Spain; Departament de Ciències morfològiques, Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 119-129 08035 Barcelona, Spain; Spanish Medical Research Network Centre in Oncology (CIBERONC), Spain
| | - Vicente Peg
- Pathology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129 08035 Barcelona, Spain; Departament de Ciències morfològiques, Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 119-129 08035 Barcelona, Spain; Spanish Medical Research Network Centre in Oncology (CIBERONC), Spain.
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Madekivi V, Boström P, Karlsson A, Aaltonen R, Salminen E. Can a machine-learning model improve the prediction of nodal stage after a positive sentinel lymph node biopsy in breast cancer? Acta Oncol 2020; 59:689-695. [PMID: 32148141 DOI: 10.1080/0284186x.2020.1736332] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: The current standard for evaluating axillary nodal burden in clinically node negative breast cancer is sentinel lymph node biopsy (SLNB). However, the accuracy of SLNB to detect nodal stage N2-3 remains debatable. Nomograms can help the decision-making process between axillary treatment options. The aim of this study was to create a new model to predict the nodal stage N2-3 after a positive SLNB using machine learning methods that are rarely seen in nomogram development.Material and methods: Primary breast cancer patients who underwent SLNB and axillary lymph node dissection (ALND) between 2012 and 2017 formed cohorts for nomogram development (training cohort, N = 460) and for nomogram validation (validation cohort, N = 70). A machine learning method known as the gradient boosted trees model (XGBoost) was used to determine the variables associated with nodal stage N2-3 and to create a predictive model. Multivariate logistic regression analysis was used for comparison.Results: The best combination of variables associated with nodal stage N2-3 in XGBoost modeling included tumor size, histological type, multifocality, lymphovascular invasion, percentage of ER positive cells, number of positive sentinel lymph nodes (SLN) and number of positive SLNs multiplied by tumor size. Indicating discrimination, AUC values for the training cohort and the validation cohort were 0.80 (95%CI 0.71-0.89) and 0.80 (95%CI 0.65-0.92) in the XGBoost model and 0.85 (95%CI 0.77-0.93) and 0.75 (95%CI 0.58-0.89) in the logistic regression model, respectively.Conclusions: This machine learning model was able to maintain its discrimination in the validation cohort better than the logistic regression model. This indicates advantages in employing modern artificial intelligence techniques into nomogram development. The nomogram could be used to help identify nodal stage N2-3 in early breast cancer and to select appropriate treatments for patients.
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Affiliation(s)
- V. Madekivi
- Department of Oncology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - P. Boström
- Faculty of Medicine, University of Turku, Turku, Finland
- Department of Pathology, Turku University Hospital, Turku, Finland
| | - A. Karlsson
- Faculty of Medicine, University of Turku, Turku, Finland
- Auria Clinical Informatics, Turku, Finland
| | - R. Aaltonen
- Faculty of Medicine, University of Turku, Turku, Finland
- Department of Surgery, Turku University Hospital, Turku, Finland
| | - E. Salminen
- Department of Oncology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
- Finnish Nuclear and Radiation Safety, Helsinki, Finland
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Barrio AV, Downs-Canner S, Edelweiss M, Van Zee KJ, Cody HS, Gemignani ML, Pilewskie ML, Plitas G, El-Tamer M, Kirstein L, Capko D, Patil S, Morrow M. Microscopic Extracapsular Extension in Sentinel Lymph Nodes Does Not Mandate Axillary Dissection in Z0011-Eligible Patients. Ann Surg Oncol 2019; 27:1617-1624. [PMID: 31820212 DOI: 10.1245/s10434-019-08104-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND In the ACOSOG (American College of Surgeons Oncology Group) Z0011 trial and the AMAROS (After Mapping of the Axilla: Radiotherapy or Surgery?) trial, matted nodes with gross extracapsular extension (ECE), a risk factor for locoregional recurrence, were an indication for axillary lymph node dissection (ALND), but the effect of microscopic ECE (mECE) in the sentinel lymph nodes (SLNs) on recurrence was not examined. METHODS Between 2010 and 2017, 811 patients with cT1-2N0 breast cancer and SLN metastasis were prospectively managed according to Z0011 criteria, with ALND for those with more than two positive SLNs or gross ECE. Management of mECE was not specified. In this study, we compare outcomes of patients with one to two positive SLNs with and without mECE, treated with SLN biopsy alone (n = 685). RESULTS Median patient age was 58 years, and median tumor size was 1.7 cm. mECE was identified in 210 (31%) patients. Patients with mECE were older, had larger tumors, and were more likely to be hormone receptor positive and HER2 negative, have two positive SLNs, and receive nodal radiation. At a median follow-up of 41 months, no isolated axillary failures were observed. There were 11 nodal recurrences; two supraclavicular ± axillary, four synchronous with breast, and five with distant failure. The five-year rate of any nodal recurrence was 1.6% and did not differ by mECE (2.3% vs. 1.3%; p = 0.84). No differences were observed in local (p = 0.08) or distant (p = 0.31) recurrence rates by mECE status. CONCLUSIONS In Z0011-eligible patients, nodal recurrence rates in patients with mECE are low after treatment with SLN biopsy alone, even in the absence of routine nodal radiation. The presence of mECE should not be considered a routine indication for ALND.
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Affiliation(s)
- Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Stephanie Downs-Canner
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marcia Edelweiss
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa L Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Laurie Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Deborah Capko
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Biostatistics Service, Department of Epidemiology and Biostatistics, 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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Cong Y, Wang S, Zou H, Zhu S, Wang X, Cao J, Wang J, Liu Y, Qiao G. Imaging Predictors for Nonsentinel Lymph Node Metastases in Breast Cancer Patients. Breast Care (Basel) 2019; 15:372-379. [PMID: 32982647 DOI: 10.1159/000501955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 07/03/2019] [Indexed: 11/19/2022] Open
Abstract
Background The relationship between imaging features and nonsentinel lymph node (NSLN) metastasis is not clear. Objectives To determine whether imaging features could predict NSLN metastasis in sentinel lymph node (SLN)-positive breast cancer patients and to provide new clues for avoiding unnecessary axillary lymph node dissection. Method 171 patients with clinically negative axillary lymph nodes and a pathologically positive SLN were recruited between January 2007 and January 2014. According to the Breast Imaging Reporting and Data System (BI-RADS), the effects of clinicopathological factors, especially imaging features, on NSLN metastases were assessed by univariate and multivariate statistical analyses. Results The average number of dissected SLNs was 2.11 (range, 1-6); 56 of the 171 (32.75%) patients exhibited NSLN metastases. In univariate analysis, tumor size, number of positive SLNs, ratio of positive SLNs, mammographic mass margins, ultrasonographic mass margins, and ultrasonographic vascularity were significantly correlated with NSLN involvement. Furthermore, through multivariate analysis, tumor size, number of positive SLNs, mammographic mass margins, and ultrasonographic vascularity were still independent predictors of NSLN involvement. Additionally, in SLN-positive patients, number of positive SLNs and ultrasonographic vascularity could also predict the tumor burden in NSLN. Conclusions In addition to tumor size and the number of positive SLNs, mammographic mass margins and ultrasonographic vascularity were also independent predictors of NSLN metastases in SLN-positive patients of breast cancer. The number of positive SLNs and ultrasonographic vascularity could also predict the tumor burden in NSLN.
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Affiliation(s)
- Yizi Cong
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Suxia Wang
- Department of Pathology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Haidong Zou
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Shiguang Zhu
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xingmiao Wang
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Jianqiao Cao
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Ji Wang
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Yanqing Liu
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Guangdong Qiao
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
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Iacuzzo C, Scomersi S, Giudici F, Bonadio L, Troian M, Bellio G, Rizzardi C, Bonazza D, Zanconati F, Bortul M. The current role of touch imprint cytology in sentinel lymph node intra-operatory examination. Breast J 2019; 26:576-577. [PMID: 31486216 DOI: 10.1111/tbj.13619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Cristiana Iacuzzo
- Department of General Surgery, Academic Hospital of Trieste, Trieste, Italy
| | - Serena Scomersi
- Department of General Surgery, Academic Hospital of Trieste, Trieste, Italy.,Breast Unit, Academic Hospital of Trieste, Trieste, Italy
| | - Fabiola Giudici
- Biostatistics Unit, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy.,Unit of Biostatistics, Epidemiology and Public Health, University of Padua, Trieste, Italy
| | - Laura Bonadio
- Department of General Surgery, Academic Hospital of Trieste, Trieste, Italy
| | - Marina Troian
- Department of General Surgery, Academic Hospital of Trieste, Trieste, Italy
| | - Gabriele Bellio
- Department of General Surgery, Academic Hospital of Trieste, Trieste, Italy
| | - Clara Rizzardi
- Breast Unit, Academic Hospital of Trieste, Trieste, Italy.,Laboratory Medicine Unit of Pathology, Academic Hospital of Trieste, Trieste, Italy
| | - Deborah Bonazza
- Breast Unit, Academic Hospital of Trieste, Trieste, Italy.,Laboratory Medicine Unit of Pathology, Academic Hospital of Trieste, Trieste, Italy
| | - Fabrizio Zanconati
- Breast Unit, Academic Hospital of Trieste, Trieste, Italy.,Laboratory Medicine Unit of Pathology, Academic Hospital of Trieste, Trieste, Italy
| | - Marina Bortul
- Department of General Surgery, Academic Hospital of Trieste, Trieste, Italy.,Breast Unit, Academic Hospital of Trieste, Trieste, Italy
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Majid S, Rydén L, Manjer J. Determinants for non-sentinel node metastases in primary invasive breast cancer: a population-based cohort study of 602 consecutive patients with sentinel node metastases. BMC Cancer 2019; 19:626. [PMID: 31238899 PMCID: PMC6593584 DOI: 10.1186/s12885-019-5823-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 06/12/2019] [Indexed: 12/31/2022] Open
Abstract
Background Sentinel node biopsy (SNB) is the standard procedure for axillary staging in patients with clinically lymph node negative invasive breast cancer. Completion axillary lymph node dissection (c-ALND) may not be necessary for all patients as a significant number of patients have no further metastases in non-sentinel nodes (non-SN) and c-ALND may not improve survival. The first aim of our study is to identify clinicopathological determinants associated with non-SN metastases. The second aim is to determine the impact of the number of sentinel node (SN) with macro-metastases and the type of SN metastases on metastatic involvement in non-SN. Methods This is a retrospective study of 602 patients with primary invasive breast cancer operated on with SNB and c-ALND in Lund and Malmö during 2008–2013. All these patients had micro- and/or macro-metastases in SNs. Information was retrieved from the national Information Network for Cancer Care (INCA). The risk of metastases to non-SNs were analyzed in relation to clinicopathological determinants such as age, screening mammography, tumour size, tumour type, histological grade, estrogen status, progesterone status, HER2 status, multifocality and lymphovascular invasion. Additionally, we compared the association between the number of the SN and the type of metastases in SN with the risk of metastases to non-SNs. Binary logistic regression was used, yielding odds ratios (OR) with 95% confidence intervals (CI). Results We found that 211 patients (35%) had metastases in non-SNs and 391 patients (65%) had no metastases in non-SNs. Lobular type (18%) of breast cancer (1.73; 1.0 1-2.97) and multifocal (31.3%) tumours (2.20; 1.41–3.44) had a high risk of non-SNs metastases. As compared to only micro-metastases, the presence of macro-metastases in SNs was associated with a high risk of metastases to non-SNs (4.91; 3.01–8.05). The number of SN with macro-metastases, regardless of the number of SNs removed by surgery, increases the risk of finding non-SNs with metastases. The total number of SN removed by surgery had no impact on diagnosis of metastases in non-SNs. No statistically significant associations were observed regarding other studied determinants. Conclusion We conclude in the present study that lobular cancer and multifocal tumours were associated with a high risk of non-SN involvement. The presence of the macro-metastases in SNs and the number of SN with macro-metastases has a positive association with presence of metastases in non-SNs. The total number of SNs removed by surgery had no impact on finding metastases in non-SNs. These factors may be valuable considering whether or not to omit c-ALND.
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Affiliation(s)
- Shabaz Majid
- Department of Surgery, Central Hospital of Kristianstad, SE-291 85, Kristianstad, Sweden. .,Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
| | - Lisa Rydén
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Jonas Manjer
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Skåne University Hospital, Malmö, Sweden
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Tapia G, Ying V, Di Re A, Stellin A, Cai TY, Warrier S. Predicting non-sentinel lymph node metastasis in Australian breast cancer patients: are the nomograms still useful in the post-Z0011 era? ANZ J Surg 2019; 89:712-717. [PMID: 31066184 DOI: 10.1111/ans.15173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 02/04/2019] [Accepted: 03/03/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Axillary lymph node dissection (ALND) can be avoided in breast cancer patients with low-volume disease in the sentinel lymph nodes (SLNs) according to Z0011 trial. We believe that nomograms developed for predicting non-sentinel lymph node (NSLN) metastases can guide the axillary treatment in patients who do not fully match the criteria of Z0011 study. We identified risk factors and evaluated the performance of three nomograms to predict NSLN status in patients with positive SLNs. METHODS Data from 526 breast cancer patients with positive SLNs who underwent ALND at two Australian hospitals from 2002 to 2015 were studied. Univariate and multivariate associations for NSLN metastasis were analysed. Predictive models evaluated were MD Anderson Cancer Centre (MDA), Helsinki University Hospital and Memorial Sloan Kettering Cancer Centre. RESULTS Thirty-nine per cent of patients demonstrated NSLN metastasis. The multivariate analysis identified extranodal extension (OR 3.2, 95% CI 2.07-4.80), tumour size >2 cm (OR 2.5, 95% CI 1.66-3.89), macrometastasis (OR 1.9, 95% CI 1.09-3.47), positive SLN ratio >0.5 (OR 1.7, 95% CI 1.16-2.60) and lymphovascular invasion (OR 1.6, 95% CI 1.09-2.44) as independent predictors for NSLN metastasis. MDA nomogram showed the best discrimination (area under the curve of 0.74) and a 9% false negative rate for predicted probability of NSLN metastasis ≤10%. CONCLUSION Our results suggest that presence of extranodal extension and tumour size >2 cm may influence the need of further axillary treatment. Conversely, ALND can be safety spared in low risk patients identified by MDA nomogram.
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Affiliation(s)
- Grace Tapia
- Department of Breast Surgery, Royal Prince Alfred Hospital and Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,General Surgery Unit, Calvary Hospital, Canberra, Australian Capital Territory, Australia
| | - Victoria Ying
- Department of Breast Surgery, Royal Prince Alfred Hospital and Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Angelina Di Re
- General Surgery Unit, Calvary Hospital, Canberra, Australian Capital Territory, Australia
| | - Anna Stellin
- Department of Breast Surgery, Royal Prince Alfred Hospital and Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Tommy Y Cai
- Department of Breast Surgery, Royal Prince Alfred Hospital and Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Sanjay Warrier
- Department of Breast Surgery, Royal Prince Alfred Hospital and Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
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Vane MLG, Willemsen MA, van Roozendaal LM, van Kuijk SMJ, Kooreman LFS, Siesling S, de Wilt HHW, Smidt ML. Extracapsular extension in the positive sentinel lymph node: a marker of poor prognosis in cT1-2N0 breast cancer patients? Breast Cancer Res Treat 2019; 174:711-718. [DOI: 10.1007/s10549-018-05074-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/27/2018] [Indexed: 11/29/2022]
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Zheng J, Cai S, Song H, Wang Y, Han X, Wu H, Gao Z, Qiu F. Positive non-sentinel axillary lymph nodes in breast cancer with 1-2 sentinel lymph node metastases. Medicine (Baltimore) 2018; 97:e13015. [PMID: 30383658 PMCID: PMC6221619 DOI: 10.1097/md.0000000000013015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Recent clinical trials have shown that sentinel lymph node biopsy (SLNB) alone without axillary lymph node dissection (ALND) can offer excellent regional control if there is sentinel lymph nodes (SLN) metastases to 1-2 nodes. This study aimed to explore the predictive factors for non-sentinel lymph node (NSLN) metastasis in breast cancer patients with 1-2 positive SLNs.Patients with breast cancer and 1-2 positive SLN admitted between March 2009 and March 2017 and who underwent ALND after SLN biopsy (SLNB) at Beijing Chaoyang Hospital were analyzed retrospectively. Factors influencing the status of NSLN were studied by univariate and multivariate analysis.Of 1125 patients, 147 patients had SLN metastasis (13.1%) and 119 patients (81.0%) had 1-2 positive SLNs. Among them, 42 patients (35.3%) had NSLN metastasis. The invasive tumor size (P <.001), histological grade (P =.011), lymphovascular invasion (LVI) (P =.006), and over-expression of HER2 (P =.025) significantly correlated with non-SLN metastasis by univariate analysis. LVI (LVI) (P =.007; OR: 4.130; 95% confidence interval [CI]: 1.465-11.641), invasive tumor size (P <.001; OR: 7.176; 95% CI: 2.710-19.002), and HER2 over-expression (P =.006; OR: 5.489; 95% CI: 1.635-18.428) were independently associated with NSLN metastasis by the Logistic regression model. The ROC analysis identified a cut-off point of 26 mm of tumor size (area under the receiver operating characteristic [ROC] curve [AUC] 0.712, CI: 0.614-0.811) was useful for dividing patients with positive SLN (1-2 nodes) into non-SLN-positive and non-SLN-negative groups.For 1-2 positive SLNs of breast cancer, LVI, large invasive tumor size, and HER2 over-expression are independent factors affecting NSLN metastases.
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Prognostic impact of macrometastasis linear size in sentinel node biopsy for breast carcinoma. Eur J Surg Oncol 2017; 43:1421-1427. [PMID: 28576464 DOI: 10.1016/j.ejso.2017.05.007] [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: 03/11/2017] [Revised: 05/02/2017] [Accepted: 05/05/2017] [Indexed: 11/21/2022] Open
Abstract
AIM The aim of the present study was to evaluate the risk of axillary non-sentinel lymph-node metastases (ALN) in breast cancer patients presenting macrometastasis (Mac-m) in the sentinel lymph node (SN). MATERIALS AND METHODS A retrospective series of 1464 breast cancers from patients who underwent ALN dissection following the diagnosis of Mac-m in the sentinel node (SN) was studied. In all the cases the MAC-m linear size was evaluated and correlated with presence or absence of non-SN ALN metastases. RESULTS Non-SN metastases were detected in 644∖1464 cases (43.98%). The risk of further axillary metastases ranged from 20.2% (37/183) in cases with Mac-m between 2 and 2.9 mm, to 65.3% (262/401) in cases with Mac-m measuring > 10 mm. The risk of non-SN ALN metastases showed a 3% increase, parallel to each mm increment in SN metastasis size. The data evaluated with the receiver operating characteristic (ROC) curve showed that the Mac-m could be subdivided according to a new cut-off of 7 mm. pT1 tumours, with Mac-m < 7 mm had a risk of non-SN ALN metastases of <30%. Furthermore 109/127 of these (85.8%) had 3 or less non-SN ALN -metastases. CONCLUSIONS The present data give a detailed description on the risk of non-SN ALN involvement, that may be useful in the evaluation of breast cancer patients. It is suggested that a Mac-m size of <7 mm is related to a low residual axillary disease burden in breast cancer patients with small (pT1) tumours.
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Abstract
CONTEXT -Sentinel lymph node biopsy has been established as the new standard of care for axillary staging in most patients with invasive breast carcinoma. Historically, all patients with a positive sentinel lymph node biopsy result underwent axillary lymph node dissection. Recent trials show that axillary lymph node dissection can be safely omitted in women with clinically node negative, T1 or T2 invasive breast cancer treated with breast-conserving surgery and whole-breast radiotherapy. This change in practice also has implications on the pathologic examination and reporting of sentinel lymph nodes. OBJECTIVE -To review recent clinical and pathologic studies of sentinel lymph nodes and explore how these findings influence the pathologic evaluation of sentinel lymph nodes. DATA SOURCES -Sources were published articles from peer-reviewed journals in PubMed (US National Library of Medicine) and published guidelines from the American Joint Committee on Cancer, the Union for International Cancer Control, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. CONCLUSIONS -The main goal of sentinel lymph node examination should be to detect all macrometastases (>2 mm). Grossly sectioning sentinel lymph nodes at 2-mm intervals and evaluation of one hematoxylin-eosin-stained section from each block is the preferred method of pathologic evaluation. Axillary lymph node dissection can be safely omitted in clinically node-negative patients with negative sentinel lymph nodes, as well as in a selected group of patients with limited sentinel lymph node involvement. The pathologic features of the primary carcinoma and its sentinel lymph node metastases contribute to estimate the extent of non-sentinel lymph node involvement. This information is important to decide on further axillary treatment.
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Affiliation(s)
| | - Edi Brogi
- From the Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
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Blackburn HL, Ellsworth DL, Shriver CD, Ellsworth RE. Breast Cancer Metastasis to the Axillary Lymph Nodes: Are Changes to the Lymph Node "Soil" Localized or Systemic? BREAST CANCER-BASIC AND CLINICAL RESEARCH 2017; 11:1178223417691246. [PMID: 28469436 PMCID: PMC5391061 DOI: 10.1177/1178223417691246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/06/2017] [Indexed: 11/16/2022]
Abstract
Metastasis is a multistep process that is not well understood. Colonization of a secondary organ requires specific molecular alterations of the host microenvironment. To determine the temporal and spatial changes associated with metastatic dissemination to the axillary lymph nodes, gene expression profiles were compared between histologically normal lymph nodes from node-positive patients and tumor-free nodes from node-negative patients. Using a stringent false discovery rate correction (<0.05) for multiple hypothesis testing, we did not detect any differentially expressed genes between the lymph node groups. Thus, the presence of metastatic cells within the lymphatic system does not elicit widespread changes in gene expression through the axillary basin; rather, lymph nodes independently respond to disseminated tumor cells.
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Affiliation(s)
- Heather L Blackburn
- Chan Soon-Shiong Institute of Molecular Medicine at Windber, Windber, PA, USA
| | - Darrell L Ellsworth
- Chan Soon-Shiong Institute of Molecular Medicine at Windber, Windber, PA, USA
| | - Craig D Shriver
- Clinical Breast Care Project, Murtha Cancer Center, Walter Reed National Military Medical Center and Uniformed Services University, Bethesda, MD, USA
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Den Toom IJ, Bloemena E, van Weert S, Karagozoglu KH, Hoekstra OS, de Bree R. Additional non-sentinel lymph node metastases in early oral cancer patients with positive sentinel lymph nodes. Eur Arch Otorhinolaryngol 2016; 274:961-968. [PMID: 27561671 PMCID: PMC5281672 DOI: 10.1007/s00405-016-4280-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/19/2016] [Indexed: 12/17/2022]
Abstract
To determine risk factors for additional non-sentinel lymph node metastases in neck dissection specimens of patients with early stage oral cancer and a positive sentinel lymph node biopsy (SLNB). A retrospective analysis of 36 previously untreated SLNB positive patients in our institution and investigation of currently available literature of positive SLNB patients in early stage oral cancer was done. Degree of metastatic involvement [classified as isolated tumor cells (ITC), micro- and macrometastasis] of the sentinel lymph node (SLN), the status of other SLNs, and additional non-SLN metastases in neck dissection specimens were analyzed. Of 27 studies, comprising 511 patients with positive SLNs, the pooled prevalence of non-SLN metastasis in patients with positive SLNs was 31 %. Non-SLN metastases were detected (available from 9 studies) in 13, 20, and 40 % of patients with ITC, micro-, and macrometastasis in the SLN, respectively. The probability of non-SLN metastasis seems to be higher in the case of more than one positive SLN (29 vs. 24 %), the absence of negative SLNs (40 vs. 19 %), and a positive SLN ratio of more than 50 % (38 vs. 19 %). Additional non-SLN metastases were found in 31 % of neck dissections following positive SLNB. The presence of multiple positive SLNs, the absence of negative SLNs, and a positive SLN ratio of more than 50 % may be predictive factors for non-SLN metastases. Classification of SLNs into ITC, micro-, and macrometastasis in the future SLNB studies is important to answer the question if treatment of the neck is always needed after positive SLNB.
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Affiliation(s)
- Inne J Den Toom
- Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
- Department of Head and Neck Surgical Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Elisabeth Bloemena
- Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Center for Dentistry (ACTA) Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
- Department of Pathology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Stijn van Weert
- Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - K Hakki Karagozoglu
- Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Center for Dentistry (ACTA) Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Otto S Hoekstra
- Department of Radiology and Nuclear Medicine, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Remco de Bree
- Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Department of Head and Neck Surgical Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
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Predictive factors of non-sentinel lymph node involvement in breast cancer patients with positive sentinel lymph nodes; a 5‑year single centre experience. Eur Surg 2016. [DOI: 10.1007/s10353-016-0400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Extra-nodal extension of sentinel lymph node metastasis is a marker of poor prognosis in breast cancer patients: A systematic review and an exploratory meta-analysis. Eur J Surg Oncol 2016; 42:919-25. [PMID: 27005805 DOI: 10.1016/j.ejso.2016.02.259] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 02/21/2016] [Accepted: 02/29/2016] [Indexed: 01/04/2023] Open
Abstract
Invasive breast cancer is the most common malignancy in women. Its most common site of metastasis is represented by the lymph nodes of axilla, and the sentinel lymph node (SLN) is the first station of nodal metastasis. Axillary SLN biopsy accurately predicts axillary lymph node status and has been accepted as standard of care for nodal staging in breast cancer. To date, the morphologic aspects of SLN metastasis have not been considered by the oncologic staging system. Extranodal extension (ENE) of nodal metastasis, defined as extension of neoplastic cells through the nodal capsule into the peri-nodal adipose tissue, has recently emerged as an important prognostic factor in several types of malignancies. It has also been considered as a possible predictor of non-sentinel node tumor burden in SLN-positive breast cancer patients. We sought out to clarify the prognostic role of ENE in SLN-positive breast cancer patients in terms of overall and disease-free survival by conducting a systematic review and meta-analysis. Among 172 screened articles, 5 were eligible for the meta-analysis; they globally include 624 patients (163 ENE+ and 461 ENE-) with a median follow-up of 58 months. ENE was associated with a higher risk of both mortality (RR = 2.51; 95% CI: 1.66-3.79, p < 0.0001, I(2) = 0%) and recurrence of disease (RR = 2.07, 95% CI: 1.38-3.10, p < 0.0001, I(2) = 0%). These findings recommend the consideration of ENE from the gross sampling to the histopathological evaluation, in perspectives to be validated and included in the oncologic staging.
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Kubota M, Komoike Y, Hamada M, Shinzaki W, Azumi T, Hashimoto Y, Imoto S, Takeyama Y, Okuno K. One-step nucleic acid amplification assay for intraoperative prediction of advanced axillary lymph node metastases in breast cancer patients with sentinel lymph node metastasis. Mol Clin Oncol 2015; 4:173-178. [PMID: 26893855 DOI: 10.3892/mco.2015.694] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/30/2015] [Indexed: 01/29/2023] Open
Abstract
The one-step nucleic acid amplification (OSNA) assay is used to semiquantitatively measure the cytokeratin (CK)19 mRNA copy numbers of each sentinel lymph node (SLN) in breast cancer patients. The aim of the present study was to evaluate whether the diagnosis of ≥4 LN metastases is possible using the OSNA assay intraoperatively. Between May, 2010 and December, 2014, a total of 134 patients who underwent axillary lymph node dissection (ALND) of positive SLNs were analyzed. The total tumor load (TTL) was defined as the total CK19 mRNA copies of all positive SLNs. The correlation between TTL and ≥4 LN metastases was evaluated. Of the 134 patients, 31 (23.1%) had ≥4 LN metastases. TTL ≥5.4×104 copies/µl evaluated by receiver operator characteristic curve analysis was examined along with other clinicopathological variables. In the multivariate analysis, only TTL ≥5.4×104 copies/µl was correlated with ≥4 LN metastases (odds ratio = 2.95, 95% confidence interval: 1.17-7.97, P=0.022). Therefore, TTL assessed by the OSNA assay has the potential to be a predictor of ≥4 LN metastases and it may be useful for the selection of patients with positive SLNs in whom ALND may be safely omitted.
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Affiliation(s)
- Michiyo Kubota
- Department of Surgery, Kinki University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yoshifumi Komoike
- Department of Surgery, Kinki University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Mika Hamada
- Department of Surgery, Kinki University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Wataru Shinzaki
- Department of Surgery, Kinki University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Tatsuya Azumi
- Department of Surgery, Kinki University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yukihiko Hashimoto
- Department of Surgery, Kinki University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Shigeru Imoto
- Department of Breast Surgery, Kyorin University School of Medicine, Tokyo 192-8508, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Kiyotaka Okuno
- Department of Surgery, Kinki University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
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Di Filippo F, Giannarelli D, Bouteille C, Bernet L, Cano R, Cunnick G, Sapino A. Elaboration of a nomogram to predict non sentinel node status in breast cancer patients with positive sentinel node, intra-operatively assessed with one step nucleic acid amplification method. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2015; 34:136. [PMID: 26538019 PMCID: PMC4632276 DOI: 10.1186/s13046-015-0246-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/19/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUNDS Tumor-positive sentinel node(SLN) biopsy results in a risk of nonsentinel node metastases in case of micro and macro metastases ranging from 20 to 50 %, respectively. Therefore, most patients underwent unnecessary axillary lymph node dissections. Thus, the development of a mathematical model for predicting patient-specific risk of non sentinel node(NSLN) metastases is strongly warranted. METHODS The following parameters were recorded: CLINICAL hospital, age, medical record number Bio-pathological: tumor (T) size, grading (G), multifocality, histological type, LVI, ER-PR status, HER-2, ki67, molecular classification (luminal A, luminal B, HER2 like, triple negative) Sentinel and nonsentinel lymph node related: number of removed SLNs, number of positive and negative SLNs, copy number of positive sentinel nodes, ratio: number of positive SLNs to number of removed SLNs, number of removed and number of positive nodes after ALND. A total of 2460 patients have been included in the database. All the patients have been provided by the authors of this paper. RESULTS Multivariate logistic regression analysis demonstrated that only the number of a CK19 mRNA copies (p < 0.0001), T size (p < 0.0001) and LVI (p < 0.0001) were associated with NSN metastases. The discrimination of the model, quantified with the area under the receiver operating characteristics curve, was 0.71 (95 %, C.I. 0.69-0.73), thus confirming a good level of reliability. CONCLUSIONS The nomogram may be employed by the surgeon as a decision making tool on whether to perform an intraoperative axillary lymph node dissection on breast cancer patients with SLN positive. The large population employed and the standardized method of measuring the value of CK19 mRNA copies are appropiate prerequisites for a reliable nomogram.
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Affiliation(s)
- F Di Filippo
- Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00134, Rome, Italy.
| | - D Giannarelli
- Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00134, Rome, Italy.
| | | | - L Bernet
- Hospital de Xàtiva, Valencia, Spain.
| | - R Cano
- Hospital de Alzira, Valencia, Spain.
| | - G Cunnick
- Wycombe General Hospital, Buckinghamshire, England.
| | - A Sapino
- Istituto di Candiolo - IRCCS, Fpo-Ircc., Turin, Italy. .,Dept of Medical Sciences - University of Turin, Turin, Italy.
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van la Parra RFD, de Wilt JHW, Mol SJJ, Mulder AH, de Roos WK, Bosscha K. Is SLN Biopsy Alone Safe in SLN Positive Breast Cancer Patients? Breast J 2015; 21:621-6. [PMID: 26391102 DOI: 10.1111/tbj.12496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Z0011 trial demonstrated no difference in overall survival (OS) and locoregional recurrence in breast cancer patients with a positive sentinel lymph node (SLN) randomized to axillary lymph node dissection (ALND) or no further surgery. The aim of this study was to evaluate locoregional recurrence in a nonrandomized group of SLN positive patients, in whom cALND was not performed, that were retrospectively categorized by the Z0011 eligibility criteria. From two hospital breast cancer databases consisting of 656 consecutive SLN positive breast cancer patients, 88 patients, who did not undergo cALND, were identified. This population was categorized by the Z0011 inclusion criteria (e.g., eligible versus ineligible) and the groups were compared. Thirty-four patients (38.6%) were retrospectively eligible for omitting cALND according to the Z0011 criteria and 54 (61.4%) were not. The median number of SLNs removed in both groups was 1 (range 1-5). The number of positive SLNs did not differ between the groups. Tumor size was slightly larger in the ineligible group (21 mm versus 19 mm) and 76% of patients in the ineligible group underwent a mastectomy. At a median follow-up of 26 months (range 1-84 months), one axillary recurrence was observed in the ineligible group versus 0 in the eligible group. Axillary recurrence was low, even in patients who did not meet the Z0011 inclusion criteria. Future trials that randomize Z0011 ineligible patients are needed to investigate long-term results.
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Affiliation(s)
- Raquel F D van la Parra
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suzanne J J Mol
- Department of Pathology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Andries H Mulder
- Department of Pathology, Rijnstate Hospital/Gelderse Vallei Hospital, Arnhem/Ede, The Netherlands
| | - Wilfred K de Roos
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
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40
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Moosavi SA, Abdirad A, Omranipour R, Hadji M, Razavi AE, Najafi M. Clinicopathologic features predicting involvement of non- sentinel axillary lymph nodes in Iranian women with breast cancer. Asian Pac J Cancer Prev 2015; 15:7049-54. [PMID: 25227789 DOI: 10.7314/apjcp.2014.15.17.7049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Almost half of the breast cancer patients with positive sentinel lymph nodes have no additional disease in the remaining axillary lymph nodes. This group of patients do not benefit from complete axillary lymph node dissection. This study was designed to assess the clinicopathologic factors that predict non-sentinel lymph node metastasis in Iranian breast cancer patients with positive sentinel lymph nodes. MATERIALS AND METHODS The records of patients who underwent sentinel lymph node biopsy, between 2003 and 2012, were reviewed. Patients with at least one positive sentinel lymph node who underwent completion axillary lymph node dissection were enrolled in the present study. Demographic and clinicopathologic characteristics including age, primary tumor size, histological and nuclear grade, lymphovascular invasion, perineural invasion, extracapsular invasion, and number of harvested lymph nodes, were evaluated. RESULTS The data of 167 patients were analyzed. A total of 92 (55.1%) had non-sentinel lymph node metastasis. Univariate analysis of data revealed that age, primary tumor size, histological grade, lymphovascular invasion, perineural invasion, extracapsular invasion, and the number of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes ratio, were associated with non-sentinel lymph node metastasis. After logistic regression analysis, age (OR=0.13; 95% CI, 0.02-0.8), primary tumor size (OR=7.7; 95% CI, 1.4-42.2), lymphovascular invasion (OR=19.4; 95% CI, 1.4- 268.6), extracapsular invasion (OR=13.3; 95% CI, 2.3-76), and the number of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes ratio (OR=20.2; 95% CI, 3.4-121.9), were significantly associated with non-sentinel lymph node metastasis. CONCLUSIONS According to this study, age, primary tumor size, lymphovascular invasion, extracapsular invasion, and the ratio of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes, were found to be independent predictors of non-sentinel lymph node metastasis.
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41
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Brambilla T, Fiamengo B, Tinterri C, Testori A, Grassi MM, Sciarra A, Abbate T, Gatzemeier W, Roncalli M, Di Tommaso L. One-Step Nucleic Acid Amplification in Breast Cancer Sentinel Lymph Node: A Single Institutional Experience and a Short Review. Front Med (Lausanne) 2015; 2:37. [PMID: 26131451 PMCID: PMC4469115 DOI: 10.3389/fmed.2015.00037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 05/20/2015] [Indexed: 11/16/2022] Open
Abstract
Sentinel lymph node (SLN) examination is a standard in breast cancer patients, with several methods employed along its 20 years history, the last one represented by one-step nucleic acid amplification (OSNA). The latter is a intra-operative molecular assay searching for CK19 mRNA as a surrogate of metastatic cells. Our 3 years experience with OSNA (1122 patients) showed results overlapping those recorded in the same institution with a morphological evaluation (930 patients) of SLN. In detail, the data of OSNA were almost identical to those observed with standard post-operative procedure in terms of patients with positive SLN (30%) and micrometastatic/macrometastatic involvement of SLN (respectively, 38–45 and 62–55%). By contrast, when OSNA was compared to the standard intraoperatory procedure, it was superior in terms of accuracy, prompting the use of this molecular assay as a very valid, and reproducible for intra-operative evaluation of SLN. Further possibilities prompting the use of OSNA range from adhesion to quality control programs, saving of medical time, ability to predict, during surgery, additional nodal metastasis, and molecular bio-banking.
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Affiliation(s)
- Tatiana Brambilla
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Barbara Fiamengo
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Corrado Tinterri
- Senology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Alberto Testori
- Senology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | | | - Amedeo Sciarra
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Tommaso Abbate
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | | | - Massimo Roncalli
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Luca Di Tommaso
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
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Vernet-Tomás M, Baños N, Sabadell D, Corominas JM, Mestre-Fusco A, Suárez-Piñera M, Carreras R. p53 expression in breast cancer predicts tumors with low probability of non-sentinel nodes infiltration. J Obstet Gynaecol Res 2015; 41:1115-21. [PMID: 25657069 DOI: 10.1111/jog.12670] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/29/2014] [Indexed: 12/22/2022]
Abstract
AIM Several predictive tools of non-sentinel lymph nodes neoplastic involvement when a positive sentinel lymph node is found have been described. However, molecular factors have been rarely evaluated to build these tools. The aim of this study was to establish which factors predicted non-sentinel lymph nodes infiltration in our setting, including some molecular factors. MATERIAL AND METHODS We carried out a retrospective review of 161 patients with breast cancer and a positive sentinel lymph node who had undergone axillary lymph node dissection, none of whom had received neoadjuvant treatment. Features evaluated as predictive factors for non-sentinel node positivity were: menopausal status, tumor size, histological subtype, histological grade, lymphovascular invasion, extracapsular invasion, Ki67 index, hormonal receptors, CerbB2 and p53 expression, size of sentinel lymph node metastases and number of sentinel lymph nodes affected. RESULTS Tumor size (P = 0.001), size of sentinel lymph node metastases (P = 0.001), lobular invasive carcinoma (P = 0.05) and lymphovascular invasion (P = 0.006) were significantly associated with non-sentinel lymph node positivity. Tumor p53 positive expression was strongly associated with non-sentinel lymph node negativity (P = 0.000). In multivariate analysis, all these factors but tumor size maintained their significance. The discrimination power of the model calculated by the area under the receiver-operator curve was 0.811 (95% confidence interval, 0.741-0.880). CONCLUSION p53 expression in breast cancer was highly predictive of non-sentinel lymph node negativity in our study. New studies should evaluate if it would be useful to add p53 expression to other existing predictive tools.
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Affiliation(s)
- Maria Vernet-Tomás
- Obstetrics and Gynecology Department, Hospital del Mar, Bellaterra, Spain.,Breast Surgery, Breast Functional Unit, Hospital del Mar, Bellaterra, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Nuria Baños
- Obstetrics and Gynecology Department, Hospital del Mar, Bellaterra, Spain
| | - Dolors Sabadell
- Obstetrics and Gynecology Department, Hospital del Mar, Bellaterra, Spain.,Breast Surgery, Breast Functional Unit, Hospital del Mar, Bellaterra, Spain
| | - Josep-Maria Corominas
- Pathology Department, Hospital del Mar, Bellaterra, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | | | | | - Ramon Carreras
- Obstetrics and Gynecology Department, Hospital del Mar, Bellaterra, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
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Atalay C. New concepts in axillary management of breast cancer. World J Clin Oncol 2014; 5:895-900. [PMID: 25493227 PMCID: PMC4259951 DOI: 10.5306/wjco.v5.i5.895] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 05/31/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023] Open
Abstract
In the last decades, surgical treatment of breast cancer has evolved from more extensive procedures like radical mastectomy to less invasive breast conserving surgery. Similarly, surgical management of axilla has enormously changed from routine axillary dissection to sentinel lymph node biopsy. Traditional surgical approach to the axilla in case of sentinel lymph node negativity is to avoid completion axillary dissection. However, surgeons even avoid performing axillary dissection in selected patients with positive sentinel lymph node in clinical practice depending on the recent randomized controlled studies supporting this concept. All of the recent changes in the management of positive axilla necessitate surgeons to refresh their knowledge on this challenging topic.
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Gooch J, King TA, Eaton A, Dengel L, Stempel M, Corben AD, Morrow M. The extent of extracapsular extension may influence the need for axillary lymph node dissection in patients with T1-T2 breast cancer. Ann Surg Oncol 2014; 21:2897-903. [PMID: 24777858 PMCID: PMC4346337 DOI: 10.1245/s10434-014-3752-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Whether extracapsular extension (ECE) of tumor in the sentinel lymph node (SLN) is an indication for axillary lymph node dissection (ALND) in patients managed by American College of Surgeons Oncology Group Z0011 criteria is controversial. Here we examine the correlation between ECE in the SLN and disease burden in the axilla. METHODS Patients meeting Z0011 clinicopathologic criteria (pT1-2, cN0 with <3 positive SLNs) were selected from a prospectively maintained database (2006-2013). Chart review documented the presence and extent of ECE. Neoadjuvant chemotherapy patients were excluded. Comparisons were made by presence and extent (≤2 vs. >2 mm) of ECE. RESULTS Of 11,730 patients, 778 were pT1-2, cN0 with <3 positive SLNs without ECE, and 331 (2.8 %) had ECE. Of these, 180 had ≤2 mm and 151 had >2 mm of ECE. Patients with ECE were older (57 vs. 54 years; p = 0.001) and had larger (2.0 vs. 1.7 cm; p < 0.0001), multifocal (p = 0.006), hormone receptor-positive tumors (p = 0.0164) with lymphovascular invasion (p < 0.0001). Presence and extent of ECE were associated with greater axillary disease burden; 20 and 3 % of patients with and without ECE, respectively, had ≥4 additional positive nodes at completion ALND (p < 0.0001), and 33 % of patients with >2 mm ECE had ≥4 additional positive nodes at completion ALND, compared with 9 % in the <2 mm group (p < 0.0001). On multivariate analysis, >2 mm of ECE was the strongest predictor of ≥4 positive nodes at completion ALND (odds ratio 14.2). CONCLUSIONS Presence and extent of ECE were significantly correlated with nodal tumor burden at completion ALND, thus suggesting that >2 mm of ECE may be an indication for ALND or radiotherapy when applying Z0011 criteria to patients with metastases in <3 SLNs. ECE reporting should be standardized to facilitate future studies.
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Affiliation(s)
- Jessica Gooch
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tari A. King
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anne Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lynn Dengel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adriana D. Corben
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Reynders A, Brouckaert O, Smeets A, Laenen A, Yoshihara E, Persyn F, Floris G, Leunen K, Amant F, Soens J, Van Ongeval C, Moerman P, Vergote I, Christiaens MR, Staelens G, Van Eygen K, Vanneste A, Van Dam P, Colpaert C, Neven P. Prediction of non-sentinel lymph node involvement in breast cancer patients with a positive sentinel lymph node. Breast 2014; 23:453-9. [DOI: 10.1016/j.breast.2014.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 01/26/2014] [Accepted: 03/16/2014] [Indexed: 10/25/2022] Open
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Rubio IT, Diaz-Botero S, Esgueva A, Espinosa-Bravo M. Positive sentinel lymph node: the evolution of axillary surgery and intraoperative assessment of sentinel lymph nodes. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Axillary lymph node dissection (ALND) has been the treatment for breast cancer in patients with sentinel lymph node (SLN) biopsy metastasis for prognostic information, local control and maybe for a small survival benefit. In recent years, clinicians have been questioning the need for axillary dissection in patients with positive SLN as the rate of axillary recurrences remains low when no ALND is performed in this group. Several variables incorporated in nomograms have been examined to predict axillary metastasis in patients with SLN metastasis and these nomograms have helped to determine which patients can spare the morbidity of the ALND. The combined multimodality in breast cancer treatments and the improvement in targeted therapies based in tumor biology have contributed to the low recurrence rates in early-stage breast cancer. As the multimodal treatment and the screening programs will improve, more patients with SLN metastasis will spare an ALND without compromising their oncologic outcome.
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Affiliation(s)
- Isabel T Rubio
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d`Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sebastian Diaz-Botero
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d`Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Esgueva
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d`Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Martín Espinosa-Bravo
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d`Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Cserni G. Sentinel lymph node status and axillary lymph node dissection in the surgical treatment of breast cancer. Orv Hetil 2014; 155:203-15. [DOI: 10.1556/oh.2014.29816] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Axillary lymph node dissection has been traditionally perceived as a therapeutic and a staging procedure and unselectively removes all axillary lymph nodes. There still remains some controversy as concerns the survival benefit associated with axillary clearance. Sentinel lymph node biopsy removes the most likely sites of regional metastases, the lymph nodes directly connected with the primary tumour. It allows a more accurate staging and a selective indication for clearing the axilla, restricting this to patients who may benefit of it. Axillary dissection was performed in all patients during the learning phase of sentinel lymphadenectomy, but later only patients with metastasis to a sentinel node underwent this operation. Currently, even some patients with minimal sentinel node involvement, including some with macrometastasis may skip axillary clearance. This review summarizes the changes that have occurred in the surgical management of the axilla, the evidences and controversies behind these changes, along with current recommendations. Orv. Hetil., 2014, 155(6), 203–215.
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Affiliation(s)
- Gábor Cserni
- Bács-Kiskun Megyei Kórház Patológiai Osztály Kecskemét Nyíri út 49. 6000
- Szegedi Tudományegyetem, Általános Orvostudományi Kar Patológiai Intézet Szeged Állomás u. 2. 6725
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A Simple Risk Score to Predict the Presence of Non-Sentinel Lymph Node Metastases in Breast Cancer Patients with a Positive Sentinel Node. World J Surg 2013; 38:1070-6. [DOI: 10.1007/s00268-013-2387-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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49
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Giammarile F, Alazraki N, Aarsvold JN, Audisio RA, Glass E, Grant SF, Kunikowska J, Leidenius M, Moncayo VM, Uren RF, Oyen WJG, Valdés Olmos RA, Vidal Sicart S. The EANM and SNMMI practice guideline for lymphoscintigraphy and sentinel node localization in breast cancer. Eur J Nucl Med Mol Imaging 2013; 40:1932-47. [DOI: 10.1007/s00259-013-2544-2] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/13/2013] [Indexed: 02/06/2023]
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50
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Leenders M, Richir M, Broeders M, Moormann G, Mollema R, Lopes Cardozo A, Meijer S, Schreurs H. Axillary staging by ultrasound-guided fine-needle aspiration cytology in breast cancer patients. Still up to date? Breast J 2013; 19:637-42. [PMID: 24011125 DOI: 10.1111/tbj.12176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To investigate whether clinicopathological features of breast cancer patients could predict the likelihood of lymph node metastases and the likelihood of false-negative results of ultrasound-guided fine-needle aspiration cytology of suspicious lymph nodes (US+FNAC). Between 2004 and 2009, US+FNAC was performed in 1,150 axillae (18 bilateral breast carcinomas). Based on final histologic diagnosis, the true- and false-negative group of US+FNAC were defined. Subsequently, 11 clinicopathological factors were compared between these two groups. These factors were also compared between patients with and patients without lymph node metastases. Of 1,150 axillae, 429 had lymph node metastases at final histology. US+FNAC indicated metastases in 107 axillae. 1,043 axillae were negative by US+FNAC. Final histology showed metastases in 323 of these 1,043 axillae, resulting in a false-negative group of US+FNAC of 31%. Both age <60 years and a cT2/cT3 breast carcinoma were significantly associated with lymph node metastases and with false-negative results of US+FNAC. Lymph node metastases were found in 59.6% of patients <60 years with a cT2/cT3 breast carcinoma. In these patients, 52.3% of the negative US+FNAC results were falsely negative. In patients <60 years with a cT2/cT3 breast carcinoma, we recommend to omit US+FNAC preoperatively and perform a SNB directly, because lymph node metastases were found in 59.6% of these patients and 52.3% of negative US+FNAC results were falsely negative.
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Affiliation(s)
- Martijn Leenders
- Department of Surgery, Medical Centre Alkmaar, Alkmaar, The Netherlands
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