1
|
Lorentzen EH, Minami CA. Avoiding Locoregional Overtreatment in Older Adults With Early-Stage Breast Cancer. Clin Breast Cancer 2024:S1526-8209(24)00042-9. [PMID: 38461117 DOI: 10.1016/j.clbc.2024.02.004] [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: 10/31/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 03/11/2024]
Abstract
Advances in the treatment of older women with early-stage breast cancer, particularly opportunities for de-escalation of therapy, have afforded patients and providers opportunity to individualize care. As the majority of women ≥65 have estrogen receptor-positive, HER2-negative disease, locoregional therapy (surgery and/or radiation) may be tailored based on a patient's physiologic age to avoid either over- or undertreatment. To determine who would derive benefit from more or less intensive therapy, an accurate assessment of an older patient's physiologic age and incorporation of patient-specific values are paramount. While there now exist well-validated geriatric assessment tools whose use is encouraged by the American Society of Clinical Oncology when considering systemic therapy, these instruments have not been widely integrated into the locoregional breast cancer care model. This review aims to highlight the importance of assessing frailty and the concepts of and over- and undertreatment, in the context of trial data supporting opportunities for safe deescalation of locoregional therapy, when treating older women with early-stage breast cancer.
Collapse
Affiliation(s)
- Eliza H Lorentzen
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
| | - Christina A Minami
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| |
Collapse
|
2
|
Thai JN, Sevrukov AB, Ward RC, Monticciolo DL. Cryoablation Therapy for Early-Stage Breast Cancer: Evidence and Rationale. JOURNAL OF BREAST IMAGING 2023; 5:646-657. [PMID: 38141236 DOI: 10.1093/jbi/wbad064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Indexed: 12/25/2023]
Abstract
Recent advances in breast cancer research and treatment propel a paradigm shift toward less aggressive and less invasive treatment for some early-stage breast cancer. Select patients with small, low-risk tumors may benefit from a less aggressive approach with de-escalated local therapy. Cryoablation of breast cancer is an emerging nonsurgical treatment alternative to breast-conserving surgery. Advantages of cryoablation over surgery include the use of local anesthesia, faster recovery, improved cosmesis, and cost savings. Proper patient selection and meticulous technique are keys to achieving successful clinical outcomes. The best candidates for cryoablation have unifocal invasive ductal carcinoma tumors that are low grade, hormone receptor positive, and ≤1.5 cm in size. In this review, we outline the current evidence, patient selection criteria, procedural technique, pre- and postablation imaging, and the advantages and limitations of cryoablation therapy.
Collapse
Affiliation(s)
- Janice N Thai
- Massachusetts General Hospital, Harvard Medical School, Department of Radiology, Division of Breast Imaging, Boston, MA, USA
| | - Alexander B Sevrukov
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Department of Radiology, Division of Breast Imaging, Philadelphia, PA, USA
| | - Robert C Ward
- The Warren Alpert Medical School of Brown University, Rhode Island Hospital and Women and Infants Hospital, Department of Diagnostic, Imaging, Division of Breast Imaging, Providence, RI, USA
| | - Debra L Monticciolo
- Massachusetts General Hospital, Harvard Medical School, Department of Radiology, Division of Breast Imaging, Boston, MA, USA
| |
Collapse
|
3
|
Sang Y, Yang B, Mo M, Liu S, Zhou X, Chen J, Hao S, Huang X, Liu G, Shao Z, Wu J. Treatment and survival outcomes in older women with primary breast cancer: A retrospective propensity score-matched analysis. Breast 2022; 66:24-30. [PMID: 36096070 PMCID: PMC9471966 DOI: 10.1016/j.breast.2022.09.001] [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: 07/24/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Changes in biological features and functional status make management decisions in older women with primary breast cancer complicated. We aimed to provide an overview of the clinicopathological characteristics and survival outcomes of older breast cancer patients based on the current treatment strategies. METHODS Female patients diagnosed with primary invasive breast cancer at Fudan University Shanghai Cancer Centre from 2008 to 2016 were included. Patients were divided into a younger group (<65 years) and older group (≥65 years). Propensity score matching was utilised to generate balanced cohorts. RESULTS A total of 13,707 patients met the study criteria. Compared with younger patients, older patients had a higher Charlson Comorbidity Index (p < 0.001), less lymph node metastasis (p = 0.009), more advanced tumour stage (p = 0.038), and a larger proportion of estrogen receptor-positive (p < 0.001) and epidermal growth factor receptor 2-negative (p < 0.001) tumours. Older patients were likely to receive mastectomy and axillary lymph node dissection in addition to a lower proportion of adjuvant chemotherapy. Adjuvant chemotherapy (HR [hazard ratio] 0.69, p = 0.039) was independently correlated with better overall survival in the older patients. This survival benefit (HR 0.58, p = 0.041) was confirmed in matched cohorts. Among the older patients with larger tumours (HR 0.48, p = 0.038) and more lymph node involvement (HR 0.44, p = 0.040), adjuvant chemotherapy was associated with a significant survival benefit. CONCLUSION Older breast cancer patients showed less aggressive biological characteristics, intensive surgical and moderate medical preferences. The addition of adjuvant chemotherapy should be considered for older patients, especially for patients with large tumours and more lymph node involvement.
Collapse
Affiliation(s)
- Yuting Sang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Benlong Yang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Miao Mo
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Shiyang Liu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Xujie Zhou
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Jiajian Chen
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Shuang Hao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Xiaoyan Huang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Guangyu Liu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Zhimin Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China,Corresponding author. Department of Breast Surgery, Breast Cancer Institute, Shanghai Cancer Center, Fudan University, Shanghai, 200032, China.
| |
Collapse
|
4
|
Hersh EH, King TA. De-escalating axillary surgery in early-stage breast cancer. Breast 2021; 62 Suppl 1:S43-S49. [PMID: 34949533 PMCID: PMC9097808 DOI: 10.1016/j.breast.2021.11.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013-08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.
Collapse
Affiliation(s)
- Eliza H Hersh
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| |
Collapse
|
5
|
Enomoto K, Fukumoto S, Mori S, Nozaki F, Hara Y, Tada K. Survival With Surgery Is Superior to Survival Without Surgery in Breast Cancer Patients Aged 85 years or Older: A Retrospective Study. Am Surg 2021; 87:1746-1751. [PMID: 34747229 DOI: 10.1177/00031348211054067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surgical treatment of breast cancer patients aged 85 years or older is still controversial. METHODS A series of surgically treated breast cancer patients aged 85 years or older was evaluated. The clinicopathological features and outcomes of these patients were compared with the features and outcomes of breast cancer patients in the same age group who were managed without surgery. RESULTS A total of 45 patients (75%) received surgical treatment, and 15 patients (25%) were managed without surgery. Significantly more patients treated by surgery underwent systemic treatment than patients managed without surgery (P = .003). The 5-year disease-free survival rate of patients treated by surgery was 80.7% (95% confidence interval: 66.2-98.5%), which was significantly higher than that of the patients managed without surgery (P = .001). CONCLUSIONS The surgical treatment of breast cancer patients aged 85 years or older is warranted. This outcome was achieved with the use of hormonal therapy.
Collapse
Affiliation(s)
- Katsuhisa Enomoto
- Department of Breast and Endocrine Surgery, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Satsuki Fukumoto
- Department of Breast and Endocrine Surgery, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Mori
- Department of Breast and Endocrine Surgery, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Fumi Nozaki
- Division of Oncologic Pathology, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Yukiko Hara
- Department of Breast and Endocrine Surgery, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Keiichiro Tada
- Department of Breast and Endocrine Surgery, 38113Nihon University School of Medicine, Tokyo, Japan
| |
Collapse
|
6
|
Armani A, Douglas S, Kulkarni S, Wallace A, Blair S. ASO Author Reflections: Do Surgeon Practice Patterns Follow National Guidelines for Axillary Staging? Ann Surg Oncol 2021; 29:551-552. [PMID: 34383189 DOI: 10.1245/s10434-021-10601-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/02/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Ava Armani
- Department of Surgery, University of California-San Diego, San Diego, CA, USA.
| | - Sasha Douglas
- Department of Surgery, University of California-San Diego, San Diego, CA, USA
| | - Swati Kulkarni
- Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Anne Wallace
- Department of Surgery, University of California-San Diego, San Diego, CA, USA
| | - Sarah Blair
- Department of Surgery, University of California-San Diego, San Diego, CA, USA
| |
Collapse
|
7
|
Armani A, Douglas S, Kulkarni S, Wallace A, Blair S. Controversial Areas in Axillary Staging: Are We Following the Guidelines? Ann Surg Oncol 2021; 28:5580-5587. [PMID: 34304312 PMCID: PMC8418590 DOI: 10.1245/s10434-021-10443-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/11/2021] [Indexed: 11/25/2022]
Abstract
Background Sentinel lymph node biopsy (SLNB) has been the standard of care for clinically node-negative women with invasive breast cancer (IBC); however, there is less agreement on whether to perform SLNB when the risk of metastasis is low or when it does not affect survival or locoregional control. Methods An Institutional Review Board-approved survey was sent to members of the American Society of Breast Surgeons asking in which scenarios surgeons would recommend SLNB. Descriptive statistics and multivariable analysis were performed using SPSS software. Results There was a 23% response rate; 68% identified as breast surgical oncologists, 6% as surgical oncologists, 24% as general surgeons, and 2% as other. The majority practiced in a community setting (71%) versus an academic setting (29%). In a healthy female with clinical T1N0 hormone receptor-positive (HR+) IBC, 83% favored SLNB if the patient was 75 years of age, versus 35% if the patient was 85 years of age. Academic surgeons were less likely to perform axillary staging in a healthy 75-year-old (odds ratio [OR] 0.51 [0.32–0.80], p = 0.004) or a healthy 85-year-old (OR 0.48 [0.31–0.74], p = 0.001). For DCIS, 32% endorsed SLNB in women undergoing lumpectomy, with breast surgical oncologists and academic surgeons being less likely to endorse this procedure (OR 0.54 [0.36–0.82], p = 0.028; and OR 0.53 [0.34–0.83], p = 0.005, respectively). Conclusions Despite studies showing that omitting SLNB in older patients with HR+ IBC does not impact regional control or survival, most surgeons are still opting for axillary staging. In addition, one in three are performing SLNB for lumpectomies for DCIS. Breast surgical oncologists and academic surgeons were more likely to be practicing based on recent data and guidelines. Practice patterns are changing but there is still room for improvement. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10443-x.
Collapse
Affiliation(s)
- Ava Armani
- Department of Surgery, University of California-San Diego, San Diego, CA, USA.
| | - Sasha Douglas
- Department of Surgery, University of California-San Diego, San Diego, CA, USA
| | - Swati Kulkarni
- Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Anne Wallace
- Department of Surgery, University of California-San Diego, San Diego, CA, USA
| | - Sarah Blair
- Department of Surgery, University of California-San Diego, San Diego, CA, USA
| |
Collapse
|
8
|
Majid S, Bendahl PO, Huss L, Manjer J, Rydén L, Dihge L. Validation of the Skåne University Hospital nomogram for the preoperative prediction of a disease-free axilla in patients with breast cancer. BJS Open 2021; 5:6308066. [PMID: 34157725 PMCID: PMC8219350 DOI: 10.1093/bjsopen/zrab027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 02/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Axillary staging via sentinel lymph node biopsy (SLNB) is performed for clinically node-negative (N0) breast cancer patients. The Skåne University Hospital (SUS) nomogram was developed to assess the possibility of omitting SLNB for patients with a low risk of nodal metastasis. Area under the receiver operating characteristic curve (AUC) was 0.74. The aim was to validate the SUS nomogram using only routinely collected data from the Swedish National Quality Registry for Breast Cancer at two breast cancer centres during different time periods. METHOD This retrospective study included patients with primary breast cancer who were treated at centres in Lund and Malmö during 2008-2013. Clinicopathological predictors in the SUS nomogram were age, mode of detection, tumour size, multifocality, lymphovascular invasion and surrogate molecular subtype. Multiple imputation was used for missing data. Validation performance was assessed using AUC and calibration. RESULTS The study included 2939 patients (1318 patients treated in Lund and 1621 treated in Malmö). Node-positive disease was detected in 1008 patients. The overall validation AUC was 0.74 (Lund cohort AUC: 0.75, Malmö cohort AUC: 0.73), and the calibration was satisfactory. Accepting a false-negative rate of 5 per cent for predicting N0, a possible SLNB reduction rate of 15 per cent was obtained in the overall cohort. CONCLUSION The SUS nomogram provided acceptable power for predicting a disease-free axilla in the validation cohort. This tool may assist surgeons in identifying and counselling patients with a low risk of nodal metastasis on the omission of SLNB staging.
Collapse
Affiliation(s)
- S Majid
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Skåne University Hospital, Lund-Malmö, Sweden
| | - P-O Bendahl
- Department of Oncology and Pathology, Clinical Sciences, Lund University, Sweden
| | - L Huss
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | - J Manjer
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Skåne University Hospital, Lund-Malmö, Sweden
| | - L Rydén
- Department of Surgery, Skåne University Hospital, Lund-Malmö, Sweden.,Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - L Dihge
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
9
|
Luo SP, Zhang J, Wu QS, Lin YX, Song CG. Association of Axillary Lymph Node Evaluation With Survival in Women Aged 70 Years or Older With Breast Cancer. Front Oncol 2021; 10:596545. [PMID: 33585213 PMCID: PMC7877252 DOI: 10.3389/fonc.2020.596545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/23/2020] [Indexed: 12/26/2022] Open
Abstract
Background Survival in elderly patients undergoing sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) has not been specifically analyzed. This study aimed to explore the association between different types of axillary lymph node (ALN) evaluations and survival of elderly breast cancer patients. Methods A retrospective cohort study was conducted of invasive ductal breast cancer patients 70 years and older in the Surveillance, Epidemiology, and End Results database (2004–2016). Analyses were performed to compare the characteristics and survival outcomes of patients who received surgical lymph node dissection and those who did not. Breast cancer specific survival (BCSS) and overall survival were compared by using Cox proportional hazards regression analysis and propensity score matching (PSM) methods to account for selection bias from covariate imbalance. Results Of the 75,950 patients analyzed, patients without ALN evaluation had a significantly worse prognosis, while there was no significant difference for BCSS between using a sentinel lymph node biopsy (SLNB) and an axillary lymph node dissection (ALND) after adjustment for known covariates [adjusted hazard ratio (HR) = 0.991, 95% confidence interval (CI) = 0.925–1.062, p = 0.800]. In the stratification analyses after PSM, the ALND did not show a significant BCSS advantage compared with SLNB in any subgroups except for the pN1 stage or above. Furthermore, after PSM of the pN1 stage patients, SLNB was associated with a significantly worse BCSS in hormone receptor negative (HR−) patients (HR = 1.536, 95%CI = 1.213–1.946, p < 0.001), but not in the hormone receptor positive (HR+) group (HR = 1.150, 95%CI = 0.986–1.340, p = 0.075). Conclusion In our study, ALND does not yield superior survival compared with SLNB for elderly patients with pN1 stage HR+ breast cancer. Although our findings are limited by the bias associated with retrospective study design, we believe that in the absence of results from randomized clinical trials, our findings should be considered when recommending the omission of ALND for elderly breast cancer patients.
Collapse
Affiliation(s)
- Shi-Ping Luo
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jie Zhang
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qi-Sen Wu
- Department of Orthopedics, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu-Xiang Lin
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Chuan-Gui Song
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| |
Collapse
|
10
|
Gennaro M, Listorti C, Mariani L, Maccauro M, Bianchi G, Capri G, Maugeri I, Lozza L, De Santis MC, Folli S. Oncological safety of selective axillary dissection after axillary reverse mapping in node-positive breast cancer. Eur J Surg Oncol 2020; 47:1606-1610. [PMID: 33160781 DOI: 10.1016/j.ejso.2020.10.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Although the need for axillary lymph node dissection (AD) is decreasing in breast cancer patients, it remains necessary in some cases. Axillary reverse mapping (ARM) enables the detection of upper extremity lymphatic drainage that may be spared during selective axillary dissection (SAD) so as to reduce the risk of lymphedema. The ability of the ARM-SAD procedure to reduce the incidence of lymphedema is being tested in an ongoing randomized trial. Crossover between arm drainage and breast drainage is well documented in the axilla, however, and whether the procedure is oncologically safe remains controversial. We aim to assess the axillary failure rate when a few nodes draining the upper arm are being spared by the ARM-SAD. METHODS We report oncological outcomes, and axillary failure in particular, in the first 100 consecutive axillary node-positive patients treated with ARM-SAD as part of a pilot study and a randomized trial. RESULTS A median of 18 (IQR 14-22) axillary nodes were excised per patient. During the follow-up (median 51 months, IQR 34-91), 11 patients experienced a treatment failure, but only one - treated with neoadjuvant chemotherapy - developed overt axillary disease as a first (and isolated) event. The crude rate of axillary failure was 1.36% (95% CI: 0.19-9.63) with an estimated 5-year crude cumulative incidence of 1.85% (95% CI: 0-5.47%). CONCLUSIONS The axillary failure rate was low in our patients and did not exceed rates reported in the literature after standard AD, thus indicating that the ARM-SAD procedure is oncologically safe.
Collapse
Affiliation(s)
- Massimiliano Gennaro
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - Chiara Listorti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Luigi Mariani
- Department of Clinical Epidemiology and Trials Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Marco Maccauro
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Giulia Bianchi
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Giuseppe Capri
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Ilaria Maugeri
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Laura Lozza
- Radiation Therapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Maria Carmen De Santis
- Radiation Therapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Secondo Folli
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| |
Collapse
|
11
|
Aubry S, Strassle PD, Maduekwe U, Downs-Canner S. Disparities of Management of the Axilla in Women With Clinically Node Negative Breast Cancer. J Surg Res 2020; 256:13-22. [PMID: 32679224 DOI: 10.1016/j.jss.2020.05.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND In women with clinically node-negative breast cancer, sentinel lymph node biopsy is the first step in axillary staging. A randomized trial published in 2013 concluded that patients with sentinel lymph node micrometastases (N1mi) do not benefit from axillary lymph node dissection (ALND). We hypothesized that disparities exist in management of the axilla in node-negative patients. METHODS We included women aged >40 years with nonmetastatic, clinically node-negative breast cancer from 2014 to 2016 in the National Cancer Database. Women treated neoadjuvantly, with large tumors (cT4), or no tumor (cT0) were excluded. Multivariable logistic regression identified patient and facility characteristics associated with undergoing ALND as first axillary surgery and completion ALND in the setting of N1mi disease. RESULTS Of 273,951 patients, 22,898 (8%) underwent ALND first. These patients were more likely to be Hispanic (OR: 1.21, 95% CI: 1.10, 1.32), have Medicare (OR: 1.13, 95% CI: 1.03, 1.24), be uninsured (OR: 1.28, 95% CI: 1.08, 1.53), have lower educational attainment (OR: 1.24, 95% CI: 1.17, 1.32), be treated at a community hospital (OR: 1.62, 95% CI: 1.52, 1.74), or reside in the South (OR: 1.19, 95% CI: 1.12, 1.26). In the sentinel lymph node biopsy first group, 8,882 (4%) were classified as N1mi and 1,872 (21%) underwent subsequent ALND. These patients were more likely to be Hispanic (OR: 1.70, 95% CI: 1.19, 2.42) and have the lowest income (OR: 1.62, 95% CI: 1.15, 2.27). CONCLUSION Disparities persist in implementation of evidence-based management of the axilla in women with clinically node-negative breast cancer.
Collapse
Affiliation(s)
- Staci Aubry
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paula D Strassle
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ugwuji Maduekwe
- Department of Surgical Oncology, University of North Carolina At Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie Downs-Canner
- Department of Surgical Oncology, University of North Carolina At Chapel Hill, Chapel Hill, North Carolina.
| |
Collapse
|
12
|
Gui Y, Liu X, Chen X, Yang X, Li S, Pan Q, Luo X, Chen L. A Network Meta-Analysis of Surgical Treatment in Patients With Early Breast Cancer. J Natl Cancer Inst 2020; 111:903-915. [PMID: 31187142 DOI: 10.1093/jnci/djz105] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/30/2019] [Accepted: 05/15/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In early breast cancer treatment, the preferred surgical regimen remains a topic of controversy, and conventional pairwise meta-analysis cannot provide a hierarchy based on clinical trial evidence. Therefore, a network meta-analysis was performed both for direct and indirect comparisons and to assess the survival outcomes of surgical regimens. METHODS Randomized clinical trials comparing different surgical regimens for the treatment of early breast cancer were identified. Overall survival (OS) and disease-free-survival (DFS) were analyzed using random-effects network meta-analysis on the hazard ratio (HR) scale and calculated as combined HRs and 95% confidence intervals (CIs). All statistical tests were two-sided. RESULTS The network meta-analysis compared 11 different surgical regimens that consisted of 13 and 17 direct comparisons between strategies for OS (34 trials; n = 23 587 patients) and DFS (32 trials; n = 22 552 patients), respectively. The values of surface under the cumulative ranking for OS and DFS after mastectomy (M)+radiotherapy (RT) were observed to be the largest. Breast-conserving surgery (BCS)+axillary node sampling+RT almost achieved the threshold for inferiority compared with the other surgical treatment arms and was statistically significantly associated with worse OS (HR = 0.51, 95% CI = 0.24 to 0.94; HR = 0.48, 95% CI = 0.22 to 0.92; HR = 0.51, 95% CI = 0.23 to 0.96). No statistically significant difference between BCS+sentinel lymph node biopsy (SLNB)+RT vs BCS+SLNB+intraoperative RT was observed in carrying out network meta-analysis (HR = 0.95, 95% CI = 0.64 to 1.36). CONCLUSIONS M+RT has the most favorable survival outcomes among the various surgical regimens for the treatment of early breast cancer patients. For patients who receive BCS, SNLB has more favorable outcomes than axillary node sampling. Intraoperative RT and postoperative RT have similar outcomes in patients who receive SLNB.
Collapse
|
13
|
Ingvar C, Ahlgren J, Emdin S, Lofgren L, Nordander M, Niméus E, Arnesson LG. Long-term outcome of pT1a-b, cN0 breast cancer without axillary dissection or staging: a prospective observational study of 1543 women. Br J Surg 2020; 107:1299-1306. [PMID: 32335901 DOI: 10.1002/bjs.11610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/18/2019] [Accepted: 03/09/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The implementation of screening programmes in Sweden during the mid-1990s increased the number of small node-negative breast cancers. In this era before staging by sentinel node biopsy, routine axillary dissection for staging of early breast cancer was questioned owing to the increased morbidity and lack of perceived benefit. The long-term risk of axillary recurrence when axillary staging is omitted remains unclear. METHODS This prospective observational multicentre cohort study included Swedish women diagnosed with breast cancer between 1997 and 2002. The patients had clinically node-negative, pT1a-b, grade I-II tumours. No axillary staging or dissection was performed. The primary outcome was ipsilateral axillary recurrence and survival. RESULTS A total of 1543 patients were included. Breast-conserving surgery (BCS) was performed in 94·0 per cent and the rest underwent mastectomy. After surgery, 58·1 per cent of the women received adjuvant radiotherapy, 11·9 per cent adjuvant endocrine therapy and 31·5 per cent did not receive any adjuvant treatment. After a median follow-up of 15·5 years, 6·4 per cent developed contralateral breast cancer and 16·5 per cent experienced a recurrence. The first recurrence was local in 116, regional in 47 and distant in 59 patients. The breast cancer-specific survival rate was 93·7 per cent after 15 years. There were no differences in overall or breast cancer-specific survival between patients who received adjuvant radiotherapy and those who did not. Only 3·0 per cent of patients had an axillary recurrence, which was isolated in only 1·0 per cent. CONCLUSION Axillary surgery can safely be omitted in patients with low-grade, T1a-b, cN0 breast cancers. This large prospective cohort with 15-year follow-up had a very low incidence of axillary recurrences and high breast cancer-specific survival rate.
Collapse
Affiliation(s)
- C Ingvar
- Department of Surgery, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - J Ahlgren
- Regional Cancer Centre, Uppsala University Hospital, Uppsala, Sweden.,Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - S Emdin
- Department of Surgery, Clinical Sciences, Umeå University, Umeå, Sweden
| | - L Lofgren
- Department of Surgery, St Göran's Hospital, Stockholm, Sweden
| | - M Nordander
- Department of Surgery, Clinical Sciences, Lund University, Lund, Sweden
| | - E Niméus
- Department of Surgery, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - L-G Arnesson
- Department of Surgery, Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
14
|
Ebner F, Wöckel A, Schwentner L, Blettner M, Janni W, Kreienberg R, Wischnewsky M. Does the number of removed axillary lymphnodes in high risk breast cancer patients influence the survival? BMC Cancer 2019; 19:90. [PMID: 30658597 PMCID: PMC6339270 DOI: 10.1186/s12885-019-5292-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
Background The decision making process for axillary dissection has changed in recent years for patients with early breast cancer and positive sentinel lymph nodes (LN). The question now arises, what is the optimal surgical treatment for patients with positive axillary LN (pN+). This article tries to answer the following questions:Is there a survival benefit for breast cancer patients with 3 or more positive LN (pN3+) and with more than 10 removed LN? Is there a survival benefit for high risk breast cancer patients (triple negative or Her2 + breast cancer) and with 3 or more positive LN (pN3+) with more than 10 removed LN? In pN + patients is the prognostic value of the lymph node ratio (LNR) of pN+/pN removed impaired if 10 or less LN are removed?
Methods A retrospective database analysis of the multi center cohort database BRENDA (breast cancer under evidence based guidelines) with data from 9625 patients from 17 breast centers was carried out. Guideline adherence was defined by the 2008 German National consensus guidelines. Results 2992 out of 9625 patients had histological confirmed positive lymph nodes. The most important factors for survival were intrinsic sub types, tumor size and guideline adherent chemo- and hormonal treatment (and age at diagnosis for overall survival (OAS)). Uni-and multivariable analyses for recurrence free survival (RFS) and OAS showed no significant survival benefit when removing more than 10 lymph nodes even for high-risk patients. The mean and median of LNR were significantly higher in the pN+ patients with ≤10 excised LN compared to patients with > 10 excised LN. LNR was in both, uni-and multivariable, analysis a highly significant prognostic factor for RFS and OAS in both subgroups of pN + patients with less respective more than 10 excised LN. Multivariable COX regression analysis was adjusted by age, tumor size, intrinsic sub types and guideline adherent adjuvant systemic therapy. Conclusion The removal of more than 10 LN did not result in a significant survival benefit even in high risk pN + breast cancer patients.
Collapse
Affiliation(s)
- Florian Ebner
- University Ulm, Germany, Prittwitzstraße 43, 89075, Ulm, Germany. .,HELIOS-Amper Klinikum, Germany, Krankenhausstr. 15, 85221, Dachau, Germany.
| | - Achim Wöckel
- Department of Gynaecology and Obstetrics, University Würzburg, Germany, Josef-Schneider-Str. 4 · Haus C15, 97080, Würzburg, Germany
| | - Lukas Schwentner
- University Ulm, Germany, Prittwitzstraße 43, 89075, Ulm, Germany
| | - Maria Blettner
- Institut für Medizinische Biometrie, Epidemiologieund Informatik (IMBEI), Universität Mainz, Germany, Obere Zahlbacher Straße 69, 55131, Mainz, Germany
| | - Wolfgang Janni
- University Ulm, Germany, Prittwitzstraße 43, 89075, Ulm, Germany
| | - Rolf Kreienberg
- University Ulm, Germany, Prittwitzstraße 43, 89075, Ulm, Germany
| | - Manfred Wischnewsky
- Department of Mathematics and Computer Science, University Bremen, Germany, Universitätsallee, 28359, Bremen, Germany
| |
Collapse
|
15
|
Castaneda CA, Rebaza P, Castillo M, Gomez HL, De La Cruz M, Calderon G, Dunstan J, Cotrina JM, Abugattas J, Vidaurre T. Critical review of axillary recurrence in early breast cancer. Crit Rev Oncol Hematol 2018; 129:146-152. [PMID: 30097233 DOI: 10.1016/j.critrevonc.2018.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 05/20/2018] [Accepted: 06/18/2018] [Indexed: 01/07/2023] Open
Abstract
Around 2% of early breast cancer cases treated with axillary lymph node dissection (ALND) underwent axillary recurrence (AR) and it has a deleterious effect in prognosis. Different scenarios have incorporated Sentinel Lymph Node (SLN) Biopsy (SLNB) instead of ALND as part of the standard treatment and more effective systemic treatment has also been incorporated in routine management after first curative surgery and after regional recurrence. However, there is concern about the effect of SLNB alone over AR risk and how to predict and treat AR. SLN biopsy (SLNB) has been largely accepted as a valid option for SLN-negative cases, and recent prospective studies have demonstrated that it is also safe for some SLN-positive cases and both scenarios carry low AR rates. Different studies have identified clinicopathological factors related to aggressiveness as well as high-risk molecular signatures can predict the development of locoregional recurrence. Other publications have evaluated factors affecting prognosis after AR and find that time between initial treatment and AR as well as tumor aggressive behavior influence patient survival. Retrospective and prospective studies indicate that treatment of AR should include local and systemic treatment for a limited time.
Collapse
Affiliation(s)
- Carlos A Castaneda
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru.
| | - Pamela Rebaza
- Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Miluska Castillo
- Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Henry L Gomez
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Miguel De La Cruz
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Gabriela Calderon
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jorge Dunstan
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jose Manuel Cotrina
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Julio Abugattas
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Tatiana Vidaurre
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| |
Collapse
|
16
|
|
17
|
Poodt IGM, Schipper RJ, Vugts G, Woensdregt K, van der Sangen M, Voogd AC, Nieuwenhuijzen GAP. The rationale for and long-term outcome of incomplete axillary staging in elderly women with primary breast cancer. Eur J Surg Oncol 2018; 44:1714-1719. [PMID: 30082177 DOI: 10.1016/j.ejso.2018.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/26/2018] [Accepted: 07/08/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The proportion of elderly women diagnosed with breast cancer is rising. Standard treatment, including axillary staging, is often not given to these patients. This study aimed to investigate reasons to omit any surgical axillary staging or to refrain from completion axillary lymph node dissection (cALND) after positive-sentinel lymph node biopsy (SLNB); so-called "incomplete staging". Furthermore, the impact of incomplete staging on regional control and survival in patients aged 75 or older was evaluated. METHODS A retrospective cohort study was conducted including all primary breast cancer patients aged 75 or older, diagnosed between 2001 and 2008, and documented by the Netherlands Cancer Registry (NCR). Patients with incomplete staging were compared to patients with complete axillary staging. Survival analyses were used to determine the risk of local, regional and distant recurrence and overall survival. RESULTS In total, 1467 of 2116 (69%) patients were considered eligible, of whom 258 (17.2%) had incomplete axillary staging. For 93 patients, diagnosed in 6 of the 10 hospitals in the NCR-area, examination of clinical records revealed that age, comorbidities and patient preferences were the main reason for omitting complete axillary staging. The 10-year axillary recurrence rate in these 93 patients was 5.2% (95% CI, 0.03-10.1). Of the 77 patients who had died, 64 (83%) died of non-breast-cancer-related causes. No significant difference in overall survival was observed between patients with or without complete axillary staging. CONCLUSION This study demonstrates that the omission of complete axillary staging is common in selected elderly breast cancer patients with ≥2 comorbidities, with no apparent impact on regional control and 10-year overall survival.
Collapse
Affiliation(s)
- Ingrid G M Poodt
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands.
| | | | - Guusje Vugts
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
| | - Karlijn Woensdregt
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Adri C Voogd
- Department of Epidemiology, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands; GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | |
Collapse
|
18
|
Chen Y, Zhang Y, Yang W, Li X, Zhu L, Chen K, Chen X. Accuracy of a nomogram to predict the survival benefit of surgical axillary staging in T1 breast cancer patients. Medicine (Baltimore) 2018; 97:e11273. [PMID: 29953003 PMCID: PMC6039583 DOI: 10.1097/md.0000000000011273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
T1 breast cancer patients have favorable clinical outcomes, so that whether axillary stating (AS) surgery can be omitted in these patients is still unclear. This retrospective cohort study developed a nomogram to predict the cancer-specific survival (CSS) of T1 breast cancer patients with and without AS and estimate the survival benefit of AS in these patients.We used surveillance, epidemiology, and end results (SEER) database to identify 232,195 breast cancer patients with T1 tumors diagnosed between 1990 and 2008. In the training cohort, we used the Kaplan-Meier method and the competing risk analysis, with non-CSS as the competing risk, to screen for prognostic factors for CSS. A nomogram to predict the CSS, with receiving AS or not as one of the predictors, was developed and externally validated, using the C-index and calibration plots. The survival benefit of AS can be estimated by the difference of 2 predicted CSS, when the patient was considered as having and not having AS.With a median follow-up of 109 months, the CSS of the study population were 96.3%, 92.3%, and 88.5% at 5, 10, and 15 years, respectively. Significant predictors for CSS identified in the training cohort were used to develop a nomogram, which was validated internally [C-index = 0.707, 95% confidence interval (95% CI) 0.702-0.712] and externally (C-index = 0.704, 95% CI 0.698-0.710). The nomogram was well calibrated. With this nomogram, AS was predicted to have less than 2% benefit of 5-, 10-, and 15-year CSS in 60.6% (140,599/232,195), 15.5% (36,074/232,195), and 8.6% (20,043/232,195) of the entire study population, respectively.The new nomogram can accurately predict the CSS of T1 breast cancer patients, and also be able to estimate the survival benefit of AS in these patients. Prospective studies are needed to confirm our findings.
Collapse
Affiliation(s)
- Yuxia Chen
- Galactphore Department, Maoming People's Hospital, Maoming
| | - Yuanqi Zhang
- Department of Breast Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang
| | - Weixiong Yang
- Galactphore Department, Maoming People's Hospital, Maoming
| | - Xiaoping Li
- General Surgery Department, Jiangmen Central Hospital, Jiangmen
| | - Liling Zhu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Kai Chen
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiang Chen
- General Surgery Department, Baoshan Traditional Chinese Medicine-Integrated Hospital of Shanghai, Shanghai
| |
Collapse
|
19
|
Gennaro M, Di Cosimo S, Ardoino I, Veneroni S, Mariani L, Agresti R, Daidone MG, de Braud F, Apolone G, Biganzoli E, Demicheli R. Dynamics of the hazard for distant metastases after ipsilateral breast tumor recurrence according to estrogen receptor status: An analysis of 2851 patients. Breast 2018; 40:131-135. [PMID: 29772517 DOI: 10.1016/j.breast.2018.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/23/2018] [Accepted: 05/07/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Breast cancer (BC) patients with ipsilateral breast tumor recurrence (IBTR) are at high risk of developing distant metastases (DM). We aimed to evaluate the risk pattern of developing DM, with respect to the occurrence of IBTR, in a large series of patients homogeneously treated by conservative surgery (QUART) with a considerably long follow-up. METHODS Piecewise exponential model was used to investigate DM dynamics conditioning on known prognostic factors and IBTR occurrence as time dependent covariate. The model was extended to account for the timescale induced by IBTR, namely the time elapsed since IBTR to the endpoint. RESULTS Among 2851 BCE patients receiving QUART, 209 were assessable for IBTR. After a median follow-up of 129 months, 588 patients presented DM (CCI = 27.3%) as first event and 92 (CCI = 48.8%) following IBTR. Primary tumor size and nodal status confirmed their prognostic value. The hazard for DM was early and high in Estrogen Receptor (ER) negative BC patients; while it was initially low but increases during follow-up in ER positive cases. Patients experiencing IBTR showed DM dynamic similar to that following primary tumor, with a sudden increased risk within 24 months from surgery, regardless the time elapsed since QUART. CONCLUSION BC patients experiencing IBTR showed a sudden and sustained risk of DM following surgery. Our findings are consistent with the hypothesis that IBTR occurrence might act as a "time resector" for risk of DM, and provide a rationale for proper surveillance guidelines and systemic therapy for optimizing BC recurrence and appropriate choice of treatment.
Collapse
Affiliation(s)
- Massimiliano Gennaro
- Department of Surgery, Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Serena Di Cosimo
- Department of Applied Research and Technological Development, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ilaria Ardoino
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy.
| | - Silvia Veneroni
- Department of Applied Research and Technological Development, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Mariani
- Medical Statistics, Biometry and Bioinformatics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Roberto Agresti
- Department of Surgery, Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maria Grazia Daidone
- Department of Applied Research and Technological Development, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo de Braud
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giovanni Apolone
- Scientific Directorate, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elia Biganzoli
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy; Medical Statistics, Biometry and Bioinformatics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Romano Demicheli
- Scientific Directorate, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| |
Collapse
|
20
|
|
21
|
Abstract
Management of the axilla in early breast cancer patients has significantly evolved in the last several decades. With the arrival of the sentinel lymph node biopsy, surgical practice for axillary staging in patients with early breast cancer has become gradually less invasive and formal axillary lymph node dissection has been confined to selected patients. Over the last two decades, evidence from randomized clinical trials have allowed for the de-escalation of axillary surgery in the management of early stage breast cancer. Advances in the staging and treatment of the axilla constitute a key component in determining initial surgical planning and therapeutic strategies in the treatment of early breast cancer. This chapter provides an updated review on the history, evolution, and current practices for axillary management in patients with early breast cancer, with particular attention to the surgical recommendations and controversial scenarios of the evolving management of the axilla.
Collapse
Affiliation(s)
- Monica G Valero
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Breast Oncology Program, Susan F. Smith Center for Women's Cancer, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| |
Collapse
|
22
|
De-escalation of axillary surgery in early breast cancer. Lancet Oncol 2017; 17:e430-e441. [PMID: 27733269 DOI: 10.1016/s1470-2045(16)30311-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 12/15/2022]
Abstract
With the advent of sentinel lymph node biopsy, surgical methods for accurately staging the axilla in patients with early-stage breast cancer have become progressively less extensive, with formal axillary lymph node dissection confined to a dwindling group of patients. Although details of methods for sentinel lymph node biopsy have yet to be standardised, this technique is now widely practised and accepted as standard of care worldwide. In the past 5 years, attention has focused on minimisation of surgical morbidity by restricting further axillary surgery or considering radiotherapy in patients with a small tumour burden in their sentinel nodes. This change in approach to patients with positive sentinel lymph node biopsies has increased the complexity of axillary management, and any policy of de-escalation and avoidance of morbidity must not compromise patient outcomes. This trend for de-escalation has accompanied a shift in understanding of how any residual tumour burden can be adequately managed without surgical extirpation and reliance on effective adjuvant therapies. Indications for omission of completion axillary lymph node dissection in patients with two or fewer nodes containing macrometastases demand further clarification, together with the roles of preoperative imaging in defining axillary nodal burden, deselection of patients for sentinel lymph node biopsy, and provision of radiotherapy. Downstaging of biopsy-proven node-positive patients with neoadjuvant chemotherapy could safely permit sentinel lymph node biopsy alone when the index node has been successfully retrieved at surgery, while nodal deposits of any size continue to mandate completion axillary lymph node dissection. Developments in molecular imaging technologies and percutaneous biopsy techniques could potentially render sentinel lymph node biopsy redundant in the future.
Collapse
|
23
|
Ozmen T, Huff Vinyard A, Avisar E. Management of the Positive Axilla in 2017. Cureus 2017; 9:e1216. [PMID: 28589065 PMCID: PMC5453747 DOI: 10.7759/cureus.1216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/02/2017] [Indexed: 02/06/2023] Open
Abstract
The role of surgery in breast cancer treatment and axillary staging is changing. It is not very far from today, when axillary dissection was the standard treatment and staging procedure for all stages of breast cancer. Today, we are on the edge of omitting axillary dissection even in patients with the axillary disease. In this review, we walked through the changes in axillary management throughout the past hundred years.
Collapse
Affiliation(s)
- Tolga Ozmen
- Surgical Oncology, University of Miami, Miller School of Medicine
| | | | - Eli Avisar
- Department of Surgery, University of Miami, Miller School of Medicine
| |
Collapse
|
24
|
Avisar E, Ozmen T. Management of the positive axilla in 2017. Breast Cancer Res Treat 2017; 163:413-415. [DOI: 10.1007/s10549-017-4227-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 03/29/2017] [Indexed: 10/19/2022]
|
25
|
Reimer T, Stachs A, Nekljudova V, Loibl S, Hartmann S, Wolter K, Hildebrandt G, Gerber B. Restricted Axillary Staging in Clinically and Sonographically Node-Negative Early Invasive Breast Cancer (c/iT1-2) in the Context of Breast Conserving Therapy: First Results Following Commencement of the Intergroup-Sentinel-Mamma (INSEMA) Trial. Geburtshilfe Frauenheilkd 2017; 77:149-157. [PMID: 28331237 DOI: 10.1055/s-0042-122853] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Axillary lymph node status remains an important prognostic factor in early breast cancer. It is regarded as an indicator for (neo)adjuvant systemic treatment and postoperative radiotherapy of the regional lymphatics. Commenced in September 2015, the INSEMA trial is investigating whether operative determination of nodal status as part of breast conserving therapy (BCT) for early stage breast cancer (c/iT1-2 c/iN0) can be avoided without reducing oncological safety. After inclusion of 1001 patients there was general acceptance of the complex study design by patients and study doctors so that recruitment for the first randomisation (axillary sentinel lymph node biopsy [SLNB]: yes or no) achieved predicted case numbers. The second randomisation however (SLNB alone versus complete axillary dissection when one or two macrometastases are present at SLNB) recruited fewer cases than expected for the following three reasons: a) the 13 % rate of one or two macrometastases after SLNB in the INSEMA trial collective was lower than expected; b) around 20 % of patients refused the second randomisation; c) there was delayed inclusion of the Austrian study centres, which only recruited for the second randomisation. Lack of knowledge of nodal status when SLNB is avoided represents a new challenge for the postoperative tumour board. In particular decisions on chemotherapy for luminal-like tumours and irradiation of the lymphatics (excluding axilla) must be guided by tumour biological parameters. The INSEMA trial does not provide answers to some important questions, e.g. it remains unclear whether patients without SLNB can be offered partial breast irradiation alone in low-risk situations and whether SLNB can also be avoided in patients with stage T1-2 tumours who have a mastectomy indication.
Collapse
Affiliation(s)
- T Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - A Stachs
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | | | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
| | - S Hartmann
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - K Wolter
- Department of Radiotherapy, University of Rostock, Rostock, Germany
| | - G Hildebrandt
- Department of Radiotherapy, University of Rostock, Rostock, Germany
| | - B Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| |
Collapse
|
26
|
Boughey JC, Haffty BG, Habermann EB, Hoskin TL, Goetz MP. Has the Time Come to Stop Surgical Staging of the Axilla for All Women Age 70 Years or Older with Hormone Receptor-Positive Breast Cancer? Ann Surg Oncol 2017; 24:614-617. [PMID: 28054190 DOI: 10.1245/s10434-016-5740-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Indexed: 11/18/2022]
Affiliation(s)
| | - Bruce G Haffty
- Department of Surgery, Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Health Care Policy and Research and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
27
|
O'Connell R, Rusby J, Stamp G, Conway A, Roche N, Barry P, Khabra K, Bonomi R, Rapisarda I, della Rovere G. Long term results of treatment of breast cancer without axillary surgery – Predicting a SOUND approach? Eur J Surg Oncol 2016; 42:942-8. [DOI: 10.1016/j.ejso.2016.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/29/2016] [Indexed: 12/01/2022] Open
|
28
|
Y.L. JT, McGowan K, Cooley G, McLaughlin R, Sugrue M. The role of ultrasound guided core biopsy of axillary nodes in predicting macrometastases and avoiding overtreatment outside ACOSOG Z0011 parameters. Breast 2015; 24:57-61. [DOI: 10.1016/j.breast.2014.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/19/2014] [Accepted: 11/15/2014] [Indexed: 10/24/2022] Open
|