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Yu Y, Chen R, Yi J, Huang K, Yu X, Zhang J, Song C. Non-invasive prediction of axillary lymph node dissection exemption in breast cancer patients post-neoadjuvant therapy: A radiomics and deep learning analysis on longitudinal DCE-MRI data. Breast 2024; 77:103786. [PMID: 39137488 PMCID: PMC11369401 DOI: 10.1016/j.breast.2024.103786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/15/2024] [Accepted: 08/08/2024] [Indexed: 08/15/2024] Open
Abstract
PURPOSE In breast cancer (BC) patients with clinical axillary lymph node metastasis (cN+) undergoing neoadjuvant therapy (NAT), precise axillary lymph node (ALN) assessment dictates therapeutic strategy. There is a critical demand for a precise method to assess the axillary lymph node (ALN) status in these patients. MATERIALS AND METHODS A retrospective analysis was conducted on 160 BC patients undergoing NAT at Fujian Medical University Union Hospital. We analyzed baseline and two-cycle reassessment dynamic contrast-enhanced MRI (DCE-MRI) images, extracting 3668 radiomic and 4096 deep learning features, and computing 1834 delta-radiomic and 2048 delta-deep learning features. Light Gradient Boosting Machine (LightGBM), Support Vector Machine (SVM), RandomForest, and Multilayer Perceptron (MLP) algorithms were employed to develop risk models and were evaluated using 10-fold cross-validation. RESULTS Of the patients, 61 (38.13 %) achieved ypN0 status post-NAT. Univariate and multivariable logistic regression analyses revealed molecular subtypes and Ki67 as pivotal predictors of achieving ypN0 post-NAT. The SVM-based "Data Amalgamation" model that integrates radiomic, deep learning features, and clinical data, exhibited an outstanding AUC of 0.986 (95 % CI: 0.954-1.000), surpassing other models. CONCLUSION Our study illuminates the challenges and opportunities inherent in breast cancer management post-NAT. By introducing a sophisticated, SVM-based "Data Amalgamation" model, we propose a way towards accurate, dynamic ALN assessments, offering potential for personalized therapeutic strategies in BC.
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Affiliation(s)
- Yushuai Yu
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, 350001, China; Department of Breast Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian Province, 350014, China
| | - Ruiliang Chen
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, 350001, China
| | - Jialu Yi
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, 350001, China
| | - Kaiyan Huang
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China
| | - Xin Yu
- Department of Breast Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian Province, 350014, China
| | - Jie Zhang
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, 350001, China.
| | - Chuangui Song
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, 350001, China; Department of Breast Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian Province, 350014, China.
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Detz D, Hanssen D, Whiting J, Sun W, Czerniecki B, Hoover S, Khakpour N, Kiluk J, Laronga C, Mallory M, Lee MC, Kruper L. Retrieval of the Clipped Axillary Lymph Node and Its Impact on Treatment Decisions. Cancers (Basel) 2024; 16:3001. [PMID: 39272859 PMCID: PMC11393888 DOI: 10.3390/cancers16173001] [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: 07/31/2024] [Revised: 08/22/2024] [Accepted: 08/27/2024] [Indexed: 09/15/2024] Open
Abstract
We examined clinically node-positive (cN+) breast cancer patients undergoing neoadjuvant chemotherapy and clipped lymph node (CLN) localization to determine the rate of CLN = non-sentinel lymph node (SLN), the factors associated with cN+ to pN0 conversion, and the treatment impact. We conducted a single institution review of cN+ patients receiving NAC from 2016 to 2022 with preoperative CLN localization (N = 81). Demographics, hormone receptor (HR) and HER2 status, time to surgery, staging, chemotherapy regimen, localization method, pathology, and adjuvant therapy were analyzed. Pathologic complete response (pCR) of the CLN was observed in 41 patients (50.6%): 18.8% HR+/HER2-, 75% HR+/HER2+, 75% HR-/HER2+, and 62.5% triple-negative breast cancer (p-value = 0.006). CLN = SLN in 68 (84%) patients, while CLN = non-SLN in 13 (16%). In 14 (17.3%) patients, the final treatment was altered based on +CLN status: 11 patients underwent axillary lymph node dissection (ALND), and 3 had systemic treatment changes. pCR rates varied, with the highest conversion rates observed in HER2+ disease and the lowest in HR+/HER2- disease. In 2 (2.5%) patients, adjuvant therapy changes were made based on a non-sentinel CLN, while in 97.5% of patients, a SLN biopsy alone represented the status of the axilla. This demonstrates that a +CLN often alters final plans and that, despite also being a SLN in most cases, a subset of patients will be undertreated by SLN biopsy alone.
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Affiliation(s)
- David Detz
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Diego Hanssen
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Junmin Whiting
- Department of Biostatistics & Bioinformatics, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Weihong Sun
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Brian Czerniecki
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Susan Hoover
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Nazanin Khakpour
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - John Kiluk
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Christine Laronga
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Melissa Mallory
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - M Catherine Lee
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Laura Kruper
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
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Cabıoğlu N, Karanlık H, Yılmaz R, Emiroğlu S, Tükenmez M, Bademler S, Şimşek DH, Kantarcı TR, Yirgin İK, Bayram A, Dursun M. Targeted axillary dissection reduces residual nodal disease in clinically node- positive breast cancer after neoadjuvant chemotherapy. World J Surg Oncol 2024; 22:178. [PMID: 38971793 PMCID: PMC11227135 DOI: 10.1186/s12957-024-03413-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/14/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Any advantage of performing targeted axillary dissection (TAD) compared to sentinel lymph node (SLN) biopsy (SLNB) is under debate in clinically node-positive (cN+) patients diagnosed with breast cancer. Our objective was to assess the feasibility of the removal of the clipped node (RCN) with TAD or without imaging-guided localisation by SLNB to reduce the residual axillary disease in completion axillary lymph node dissection (cALND) in cN+ breast cancer. METHODS A combined analysis of two prospective cohorts, including 253 patients who underwent SLNB with/without TAD and with/without ALND following NAC, was performed. Finally, 222 patients (cT1-3N1/ycN0M0) with a clipped lymph node that was radiologically visible were analyzed. RESULTS Overall, the clipped node was successfully identified in 246 patients (97.2%) by imaging. Of 222 patients, the clipped lymph nodes were non-SLNs in 44 patients (19.8%). Of patients in cohort B (n=129) with TAD, the clipped node was successfully removed by preoperative image-guided localisation, or the clipped lymph node was removed as the SLN as detected on preoperative SPECT-CT. Among patients with ypSLN(+) (n=109), no significant difference was found in non-SLN positivity at cALND between patients with TAD and RCN (41.7% vs. 46.9%, p=0.581). In the subgroup with TAD with axillary lymph node dissection (ALND; n=60), however, patients with a lymph node (LN) ratio (LNR) less than 50% and one metastatic LN in the TAD specimen were found to have significantly decreased non-SLN positivity compared to others (27.6% vs. 54.8%, p=0.032, and 22.2% vs. 50%, p=0.046). CONCLUSIONS TAD by imaging-guided localisation is feasible with excellent identification rates of the clipped node. This approach has also been found to reduce the additional non-SLN positivity rate to encourage omitting ALND in patients with a low metastatic burden undergoing TAD.
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Affiliation(s)
- Neslihan Cabıoğlu
- Department of Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye.
| | - Hasan Karanlık
- Department of Surgical Oncology, Istanbul University, Institute of Oncology, Istanbul, Türkiye
| | - Ravza Yılmaz
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Selman Emiroğlu
- Department of Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Mustafa Tükenmez
- Department of Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Süleyman Bademler
- Department of Surgical Oncology, Istanbul University, Institute of Oncology, Istanbul, Türkiye
| | - Duygu Has Şimşek
- Department of Nuclear Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Tarık Recep Kantarcı
- Department of Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - İnci Kızıldağ Yirgin
- Department of Radiology, Istanbul University, Institute of Oncology, Istanbul, Türkiye
| | - Aysel Bayram
- Department of Pathology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Memduh Dursun
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
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Chen X, Lu Z, Wang C, Lyu M, Qiao J, Sun X, Li L, Zhang C, Liu Z. Targeted axillary dissection after neoadjuvant chemotherapy for highly selective patients with initial cN1 breast cancer: A single-center prospective trial. Chin Med J (Engl) 2024; 137:1421-1430. [PMID: 38557731 PMCID: PMC11188870 DOI: 10.1097/cm9.0000000000003007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy is gradually accepted as the standard of care in breast cancer patients with down-staged axillary disease after neoadjuvant chemotherapy (NAC). However, it is still difficult to precisely define pre-NAC clinical node-positive (cN1) and post-NAC clinical node-negative (ycN0). This prospective single-center trial was designed to evaluate the feasibility and accuracy of standard targeted axillary dissection (TAD) after NAC in highly selective pre-NAC cN1 patients (not considering ultrasound-based axillary ycN staging). METHODS This prospective trial included patients with initial pre-NAC cT1-3N1M0 invasive breast cancer but with a rigorous definition of cN1 from the Affiliated Cancer Hospital of Zhengzhou University. When NAC was effective (including complete and partial responses) and preoperative axillary palpation was negative, preoperative ultrasound-based axillary staging was not considered, and all patients underwent TAD followed by axillary lymph node (LN) dissection. The detection rate (DR) and false-negative rate (FNR) of TAD were calculated. RESULTS A total of 82 patients were included, and 77 of them were eligible for data analysis. The DR for TAD was 94.8% (73/77). There were 26 patients with one abnormal LN at the time of diagnosis based on ultrasound, 45 patients with two, and 2 patients with three. One patient had one TAD LN, four patients had two TAD LNs, and 68 patients had three or more TAD LNs. Preoperative axillary palpation yielded negative results for all 73 patients who successfully underwent TAD. Preoperative ultrasound-based ycN0 and ycN+ conditions were detected for 52 and 21 cases, respectively. The FNR was 7.4% (2/27) for standard TAD (≥3 SLNs), which was lower than that of all successful TAD (≥1 SLN; 10.0%, 3/30). CONCLUSIONS In rigorously defined pre-NAC cN1 breast cancer patients, standard TAD is feasible for those with negative axillary palpation after NAC, and FNR is also less than 10%. REGISTRATION chictr.org.cn , ChiCTR2100049093.
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Affiliation(s)
- Xiuchun Chen
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Zhenduo Lu
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Chengzheng Wang
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Minhao Lyu
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Jianghua Qiao
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Xianfu Sun
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Lianfang Li
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Chongjian Zhang
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Zhenzhen Liu
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
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Varghese J, Patani N, Wazir U, Novintan S, Michell MJ, Malhotra A, Mokbel K, Mokbel K. Wire-Free Targeted Axillary Dissection: A Pooled Analysis of 1300+ Cases Post-Neoadjuvant Systemic Therapy in Node-Positive Early Breast Cancer. Cancers (Basel) 2024; 16:2172. [PMID: 38927878 PMCID: PMC11201777 DOI: 10.3390/cancers16122172] [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: 05/20/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Recent advances in neoadjuvant systemic therapy (NST) have significantly improved pathologic complete response rates in early breast cancer, challenging the role of axillary lymph node dissection in nose-positive patients. Targeted axillary dissection (TAD) integrates marked lymph node biopsy (MLNB) and tracer-guided sentinel lymph node biopsy (SLNB). The introduction of new wire-free localisation markers (LMs) has streamlined TAD and increased its adoption. The primary endpoints include the successful localisation and retrieval rates of LMs. The secondary endpoints include the pathological complete response (pCR), SLNB, and MLNB concordance, as well as false-negative rates. Seventeen studies encompassing 1358 TAD procedures in 1355 met the inclusion criteria. The localisation and retrieval rate of LMs were 97% and 99%. A concordance rate of 67% (95% CI: 64-70) between SLNB and MLNB was demonstrated. Notably, 49 days (range: 0-272) was the average LM deployment time to surgery. pCR was observed in 46% (95% CI: 43-49) of cases, with no significant procedure-related complications. Omitting MLNB or SLNB would have under-staged the axilla in 15.2% or 5.4% (p = 0.0001) of cases, respectively. MLNB inclusion in axillary staging post-NST for initially node-positive patients is crucial. The radiation-free Savi Scout, with its minimal MRI artefacts, is the preferred technology for TAD.
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Affiliation(s)
- Jajini Varghese
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Royal Free London NHS Trust, Pond Street, London NW3 2QG, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Neill Patani
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Umar Wazir
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
| | - Shonnelly Novintan
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- East Suffolk North Essex NHS Foundation Trust, Turner Road, Colchester CO4 5JL, UK
| | - Michael J. Michell
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Kings College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Anmol Malhotra
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Royal Free London NHS Trust, Pond Street, London NW3 2QG, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Kinan Mokbel
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Health and Care Profession Department, Faculty of Health and Life Sciences, University of Exeter Medical School, Exeter EX1 2HZ, UK
| | - Kefah Mokbel
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
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Alamoodi M, Wazir U, Venkataraman J, Almukbel R, Mokbel K. Assessing the Efficacy of Radioactive Iodine Seed Localisation in Targeted Axillary Dissection for Node-Positive Early Breast Cancer Patients Undergoing Neoadjuvant Systemic Therapy: A Systematic Review and Pooled Analysis. Diagnostics (Basel) 2024; 14:1175. [PMID: 38893701 PMCID: PMC11172271 DOI: 10.3390/diagnostics14111175] [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: 04/20/2024] [Revised: 05/24/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Targeted axillary dissection (TAD), employing marked lymph node biopsy (MLNB) alongside sentinel lymph node biopsy (SLNB), is increasingly recognised for its efficacy in reducing false negative rates (FNRs) in node-positive early breast cancer patients receiving neoadjuvant systemic therapy (NST). One such method, 125I radioactive seed localisation (RSL), involves implanting a seed into a biopsy-proven lymph node either pre- or post-NST. This systematic review and pooled analysis aimed to assess the performance of RSL in TAD among node-positive patients undergoing NST. Six studies, encompassing 574 TAD procedures, met the inclusion criteria. Results showed a 100% successful deployment rate, with a 97.6% successful localisation rate and a 99.8% retrieval rate. Additionally, there was a 60.0% concordance rate between SLNB and MLNB. The FNR of SLNB alone was significantly higher than it was for MLNB (18.8% versus 5.3%, respectively; p = 0.001). Pathological complete response (pCR) was observed in 44% of cases (248/564). On average, the interval from 125I seed deployment to surgery was 75.8 days (range: 0-272). These findings underscore the efficacy of RSL in TAD for node-positive patients undergoing NST, enabling precise axillary pCR identification and facilitating the safe omission of axillary lymph node dissection.
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Affiliation(s)
| | | | | | | | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK; (M.A.); (U.W.); (J.V.); (R.A.)
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7
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Tejedor L, Gómez-Modet S. Reducing axillary surgery in breast cancer. Cir Esp 2024; 102:220-224. [PMID: 37956715 DOI: 10.1016/j.cireng.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/23/2023] [Indexed: 11/15/2023]
Abstract
This article provides a brief account of the recent evolution of the highly controversial surgical management of the positive axilla in patients with breast cancer, an issue still open to disparate surgical procedures. This short review highlights the reports that supply the rationale for current trends in reducing the aggressiveness of this surgery and discusses the course of the trials still in progress pointing in the same direction, thus supporting the principle of not performing axillary lymph node dissection for staging purposes alone.
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Affiliation(s)
- L Tejedor
- Hospital Universitario Punta de Europa, Universidad de Cádiz, Spain.
| | - S Gómez-Modet
- Hospital Universitario Punta de Europa, Universidad de Cádiz, Spain
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8
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de Wild SR, Koppert LB, van Nijnatten TJA, Kooreman LFS, Vrancken Peeters MJTFD, Smidt ML, Simons JM. Systematic review of targeted axillary dissection in node-positive breast cancer treated with neoadjuvant systemic therapy: variation in type of marker and timing of placement. Br J Surg 2024; 111:znae071. [PMID: 38531689 PMCID: PMC10965400 DOI: 10.1093/bjs/znae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/15/2024] [Accepted: 03/02/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND In node-positive (cN+) breast cancer treated with neoadjuvant systemic therapy, combining sentinel lymph node biopsy and targeted lymph node excision, that is targeted axillary dissection, increases accuracy. Targeted axillary dissection procedures differ in terms of the targeted lymph node excision technique. This systematic review aimed to provide an overview of targeted axillary dissection procedures regarding definitive marker type and timing of placement: before neoadjuvant systemic therapy (1-step procedure) or after neoadjuvant systemic therapy adjacent to a clip placed before the neoadjuvant therapy (2-step procedure). METHODS PubMed and Embase were searched, to 4 July 2023, for RCTs, cohort studies, and case-control studies with at least 25 patients. Studies of targeted lymph node excision only (without sentinel lymph node biopsy), or where intraoperative localization of the targeted lymph node was not attempted, were excluded. For qualitative synthesis, studies were grouped by definitive marker and timing of placement. The targeted lymph node identification rate was reported. Study quality was assessed using a National Institutes of Health quality assessment tool. RESULTS Of 277 unique records, 51 studies with a total of 4512 patients were included. Six definitive markers were identified: wire, 125I-labelled seed, 99mTc, (electro)magnetic/radiofrequency markers, black ink, and a clip. Fifteen studies evaluated one-step procedures, with the identification rate of the targeted lymph node at surgery varying from 8 of 13 to 47 of 47. Forty-one studies evaluated two-step procedures, with the identification rate of the clipped targeted lymph node on imaging after neoadjuvant systemic therapy varying from 49 to 100%, and the identification rate of the targeted lymph node at surgery from 17 of 24 to 100%. Most studies (40 of 51) were rated as being of fair quality. CONCLUSION Various targeted axillary dissection procedures are used in clinical practice. Owing to study heterogeneity, the optimal targeted lymph node excision technique in terms of identification rate and feasibility could not be determined. Two-step procedures are at risk of not identifying the clipped targeted lymph node on imaging after neoadjuvant systemic therapy.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Thiemo J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Loes F S Kooreman
- Department of Pathology, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Janine M Simons
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
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9
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Engin A. Obesity-Associated Breast Cancer: Analysis of Risk Factors and Current Clinical Evaluation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1460:767-819. [PMID: 39287872 DOI: 10.1007/978-3-031-63657-8_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Several studies show that a significantly stronger association is obvious between increased body mass index (BMI) and higher breast cancer incidence. Additionally, obese and postmenopausal women are at higher risk of all-cause and breast cancer-specific mortality compared with non-obese women with breast cancer. In this context, increased levels of estrogens, excessive aromatization activity of the adipose tissue, overexpression of pro-inflammatory cytokines, insulin resistance, adipocyte-derived adipokines, hypercholesterolemia, and excessive oxidative stress contribute to the development of breast cancer in obese women. Genetic evaluation is an integral part of diagnosis and treatment for patients with breast cancer. Despite trimodality therapy, the four-year cumulative incidence of regional recurrence is significantly higher. Axillary lymph nodes as well as primary lesions have diagnostic, prognostic, and therapeutic significance for the management of breast cancer. In clinical setting, because of the obese population primary lesions and enlarged lymph nodes could be less palpable, the diagnosis may be challenging due to misinterpretation of physical findings. Thereby, a nomogram has been created as the "Breast Imaging Reporting and Data System" (BI-RADS) to increase agreement and decision-making consistency between mammography and ultrasonography (USG) experts. Additionally, the "breast density classification system," "artificial intelligence risk scores," ligand-targeted receptor probes," "digital breast tomosynthesis," "diffusion-weighted imaging," "18F-fluoro-2-deoxy-D-glucose positron emission tomography," and "dynamic contrast-enhanced magnetic resonance imaging (MRI)" are important techniques for the earlier detection of breast cancers and to reduce false-positive results. A high concordance between estrogen receptor (ER) and progesterone receptor (PR) status evaluated in preoperative percutaneous core needle biopsy and surgical specimens is demonstrated. Breast cancer surgery has become increasingly conservative; however, mastectomy may be combined with any axillary procedures, such as sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection whenever is required. As a rule, SLNB-guided axillary dissection in breast cancer patients who have clinically axillary lymph node-positive to node-negative conversion following neoadjuvant chemotherapy is recommended, because lymphedema is the most debilitating complication after any axillary surgery. There is no clear consensus on the optimal treatment of occult breast cancer, which is much discussed today. Similarly, the current trend in metastatic breast cancer is that the main palliative treatment option is systemic therapy.
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Affiliation(s)
- Atilla Engin
- Faculty of Medicine, Department of General Surgery, Gazi University, Besevler, Ankara, Turkey.
- Mustafa Kemal Mah. 2137. Sok. 8/14, 06520, Cankaya, Ankara, Turkey.
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10
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Copeland JE, Cherian CJ, Lyew MA. Technetium-99-Guided Axillary Lymph Node Identification: A Case Report of a Novel Technique for Targeted Lymph Node Excision Biopsy for Node Positive Breast Cancer After Neoadjuvant Chemotherapy. J Med Cases 2023; 14:419-425. [PMID: 38186556 PMCID: PMC10769653 DOI: 10.14740/jmc4172] [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: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024] Open
Abstract
Targeted axillary lymph node identification for breast cancer involves localization and removal of previously marked metastatic lymph nodes after the completion of neoadjuvant chemotherapy (NACT), when clinical and radiological complete responses of the axillary nodes are achieved. Traditionally, axillary lymph node dissection is performed for patients with node positive disease, but the high rates of pathological complete responses now seen after NACT have ushered in lower morbidity techniques such as sentinel lymph node excision biopsies, targeted axillary lymph node dissection and targeted axillary lymph node identification (clip node identification) in node positive disease which has converted to clinical/radiologically node negative. The latter two techniques often require the use of expensive seeds and advanced localization techniques. Here we describe the case of a 59-year-old woman who was diagnosed with node positive invasive breast cancer who was sequenced with NACT. We developed a novel technique, where technetium-99m was injected directly into a previously clipped metastatic axillary lymph node which was then localized with the Neoprobe gamma detection system intra-operatively and removed. This is a relatively low-cost technique that can be easily introduced in limited resourced health systems where radio-guided sentinel lymph node biopsies are already being performed.
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Affiliation(s)
- Jason E. Copeland
- Department of Surgery, Anaesthesia, Radiology and Emergency Medicine, University of the West Indies, Mona, Jamaica
- Department of General Surgery, Kingston Public Hospital, Kingston, Jamaica
- The Breast Health & Oncology Care Centre at the Andrews Memorial Hospital, Kingston, Jamaica
| | - Cherian J. Cherian
- Department of Surgery, Anaesthesia, Radiology and Emergency Medicine, University of the West Indies, Mona, Jamaica
- Department of General Surgery, Kingston Public Hospital, Kingston, Jamaica
- The Breast Health & Oncology Care Centre at the Andrews Memorial Hospital, Kingston, Jamaica
| | - Matthew A. Lyew
- Department of Surgery, Anaesthesia, Radiology and Emergency Medicine, University of the West Indies, Mona, Jamaica
- Department of General Surgery, Kingston Public Hospital, Kingston, Jamaica
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11
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Lee EG, Lee M, Jung SY, Han JH, Kim SK, Lee S. Questionnaire study of application about sentinel lymph node biopsy surgery in locally advanced breast cancer patients who received neoadjuvant chemotherapy. Front Oncol 2023; 13:1235938. [PMID: 37849812 PMCID: PMC10577222 DOI: 10.3389/fonc.2023.1235938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023] Open
Abstract
Background Nodal staging from sentinel lymph node (SLN) biopsy has become the standard procedure for early-stage breast cancer patients. SLN biopsy implementation after chemotherapy has previously been evaluated. This questionnaire study aimed to investigate the current trend of SLN biopsy after neoadjuvant chemotherapy (NAC) for locally advanced breast cancer. Methods and materials We conducted a web-based survey among breast surgeons who are members of the Korean Breast Cancer Society. The survey comprised 14 questions about axillary surgery after NAC. Results Of 135 respondents, 48.1% used a combined method of dye and radioactive isotope (RI). In the absence of SLN metastasis, 67.7% would perform only SLN biopsy, while 3% would perform ALN dissection. In case of SLN metastasis, the proportions of surgeons who would proceed with ALN dissection were 60.2% and 67.2% for less than two and more than three positive SLNs, respectively. Conclusion The present study confirmed the increasing tendency to adopt SLN biopsy for axillary staging in patients who achieved complete response with initial nodal metastasis. It could be expected that the mapping methods for patients receiving NAC have become diverse, including RI, vital dye, and indocyanine green fluorescence. The implementation of SLN biopsy after NAC will grow in the coming years due to an increasing demand of minimally invasive surgery.
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Affiliation(s)
- Eun-Gyeong Lee
- Department of Surgery, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Minjung Lee
- Department of Surgery, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - So-Youn Jung
- Department of Surgery, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Jai Hong Han
- Department of Surgery, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Seok-Ki Kim
- Department of Nuclear Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Seeyoun Lee
- Department of Surgery, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
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12
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Munck F, Jepsen P, Zeuthen P, Carstensen L, Hauerslev K, Paaskesen CK, Andersen IS, Høyer U, Lanng C, Gerlach MK, Vejborg I, Kroman NT, Tvedskov THF. Comparing Methods for Targeted Axillary Dissection in Breast Cancer Patients: A Nationwide, Retrospective Study. Ann Surg Oncol 2023; 30:6361-6369. [PMID: 37400618 PMCID: PMC10506928 DOI: 10.1245/s10434-023-13792-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/10/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Several techniques exist for performing targeted axillary dissection (TAD) after neoadjuvant chemotherapy with the removal of the sentinel node and a marked metastatic lymph node (LN). Two-step methods include coil-marking of the metastatic LN at diagnosis and re-marking with an intraoperatively identifiable marker before surgery. Because nondetection of the marked lymph node (MLN) warrants axillary clearance and many patients achieve axillary pathological complete response (ax-pCR), the success of TAD is crucial. We compare various two-step TAD methods in a Danish national cohort. METHODS We included patients who received two-step TAD between January 1, 2016 and August 31, 2021. Patients were identified from the Danish Breast Cancer Group database and cross-checked with locally accessible lists. Data were extracted from the patient's medical files. RESULTS We included 543 patients. In 79.4%, preoperative, ultrasound-guided re-marking was possible. Nonidentification of the coil-marked LN was more likely in patients with ax-pCR. The second markers used were hook-wire, iodine seeds, or ink marking on the axillary skin. Of patients with successful secondary marking, the MLN identification rate (IR) was 91%, and the sentinel node (SN) IR was 95%. Marking with iodine seeds was significantly more successful than ink marking with an odds ratio of 5.34 (95% confidence interval 1.62-17.60). The success rate of the complete TAD with the removal of MLN and SN was 82.3%. CONCLUSIONS With two-step TAD, nonidentification of the coiled LN before surgery is frequent, especially in patients with ax-pCR. Despite successful remarking, the IR of the MLN at surgery is inferior to one-step TAD.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark.
| | - Pernille Jepsen
- Department of Breast Surgery, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Pernille Zeuthen
- Department of Surgery and Plastic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | - Lena Carstensen
- Department of Surgery Esbjerg, Hospital of South West Jutland, Esbjerg, Denmark
| | - Katrine Hauerslev
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ute Høyer
- Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
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13
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Del Castillo A, Gomez-Modet S, Mata JM, Tejedor L. Targeted axillary dissection using Radioguided Occult Lesion Localization technique in the clinically negative marked lymph node after neoadjuvant treatment in breast cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1184-1188. [PMID: 36958951 DOI: 10.1016/j.ejso.2023.03.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/27/2022] [Accepted: 03/09/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE To be aware of the feasibility of targeted axillary dissection (TAD) injecting 99mTechnetium-labeled macroaggregated albumin (99mTc-MAA) preoperatively into the clipped lymph node of patients with axillary complete clinical response (ycN0), after neoadjuvant chemotherapy (NAC) for breast cancer. PATIENTS AND METHODS A retrospective observational study was performed on N1 patients with a clipped positive node and a clinically negative axilla (ycN0) after NAC in one center. The pretreatment positive lymph node was injected with 99mTc-MAA the day before surgery and identified intraoperatively with a radioguided occult lesion localization (ROLL) technique. Patients were subjected to a TAD with the intent of identifying the clipped node and other/s sentinel nodes through a standard sentinel lymph node biopsy (SLNB). RESULTS 54 patients and 55 axillary clipped nodes were included. The clip was intraoperatively encountered in every patient, accomplishing a 100% detection rate, although in one case no lymphatic tissue could be found in the intraoperative frozen section. An axillary lymph node dissection (ALND) was avoided in 62.9% of the cases (34/54). CONCLUSION The use of the ROLL technique is a highly valuable tool since it allows a 100% success rate in retrieving the marker (and a 98.1% rate in detecting the clipped lymph node) in ycN0 breast cancer patients.
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Affiliation(s)
- Ana Del Castillo
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - Susana Gomez-Modet
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - José María Mata
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - Luis Tejedor
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
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14
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Munck F, Andersen IS, Vejborg I, Gerlach MK, Lanng C, Kroman NT, Tvedskov THF. Targeted Axillary Dissection with 125I Seed Placement Before Neoadjuvant Chemotherapy in a Danish Multicenter Cohort. Ann Surg Oncol 2023; 30:4135-4142. [PMID: 37062781 PMCID: PMC10250439 DOI: 10.1245/s10434-023-13432-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/13/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Targeted axillary dissection (TAD), with marking of the metastatic lymph node before neoadjuvant chemotherapy (NACT), is increasingly used for breast cancer axillary staging. In the case of axillary pathological complete response (ax-pCR), axillary lymph node clearance can be omitted. Several marking methods exist, most using re-marking before surgery. Feasibility, learning curve, and identification rate (IR) vary. Marking with 125I seed before NACT makes re-marking at surgery redundant, possibly increasing feasibility and IR. Here, TAD with 125I seed placed before NACT is evaluated in a Danish multicenter cohort. METHODS Patients staged with 125I TAD in Denmark between 1 January 2016 and 31 August 2021 were included. Patients were identified in radioactivity-emitting implant registries at the radiology departments and from the Danish Breast Cancer Group database. Data were extracted from patients' medical records. Information on patient/tumor characteristics, 125I seed activity, marking period, TAD success, number of sentinel nodes (SNs), the histopathological status of excised nodes, and whether the marked lymph node (MLN) was an SN were registered. RESULTS 142 patients were included. The IR of the MLN was 99.3%, and the IR of the SLNB was 91.5%. TAD success was 91.5%. Minor challenges in marking or removal of the MLN were noted in three patients. In 72.3% of the patients, the MLN was a sentinel node. Overall, 40.8% had axillary pCR. CONCLUSION TAD with 125I seed marking before NACT is feasible without re-marking at surgery and with only minor surgical challenges. The IR is high. Staging with TAD spares 41% of breast cancer patients an axillary dissection.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark.
| | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
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15
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Clark BZ, Johnson RR, Berg WA, McAuliffe P, Bhargava R. Response in axillary lymph nodes to neoadjuvant chemotherapy for breast cancers: correlation with breast response, pathologic features, and accuracy of radioactive seed localization. Breast Cancer Res Treat 2023:10.1007/s10549-023-06983-3. [PMID: 37286892 DOI: 10.1007/s10549-023-06983-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/21/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVES This study examined the accuracy of radioactive seed localization (RSL) of lymph nodes (LNs) following neoadjuvant chemotherapy (NAC) for invasive breast carcinoma, recorded pathologic features of LNs following NAC, evaluated concordance of response between breast and LNs, and identified clinicopathologic factors associated with higher risk of residual lymph node involvement. METHODS Clinical records, imaging, and pathology reports and slides were retrospectively reviewed for 174 breast cancer patients who received NAC. Chi-square and Fisher's exact tests were used to compare differences in risk of residual lymph node disease. RESULTS Retrieval of biopsied pre-therapy positive LN was confirmed in 86/93 (88%) cases overall, and in 75/77 (97%) of cases utilizing RSL. Biopsy clip site was the best pathologic feature to confirm retrieval of a biopsied lymph node. Pre-therapy clinical N stage > 0, positive pre-therapy lymph node biopsy, estrogen and progesterone receptor positivity, Ki67 < 50%, HR + /HER2- tumors, and residual breast disease had higher likelihood of residual lymph node disease after NAC (p < 0.001). CONCLUSIONS RSL-guided LN excision improves retrieval of previously biopsied LNs following NAC. The pathologist can use histologic features to confirm retrieval of targeted LNs, and tumor characteristics can be used to predict a higher risk of residual LN involvement.
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Affiliation(s)
- Beth Z Clark
- Department of Pathology, UPMC Magee-Womens Hospital, 300 Halket St., Pittsburgh, PA, 15213, USA.
| | - Ronald R Johnson
- Department of Surgery, UPMC Magee-Womens Hospital, 300 Halket St., Pittsburgh, PA, 15213, USA
| | - Wendie A Berg
- Department of Radiology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, 300 Halket St., Pittsburgh, PA, 15213, USA
| | - Priscilla McAuliffe
- Department of Surgery, UPMC Magee-Womens Hospital, 300 Halket St., Pittsburgh, PA, 15213, USA
| | - Rohit Bhargava
- Department of Pathology, UPMC Magee-Womens Hospital, 300 Halket St., Pittsburgh, PA, 15213, USA
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16
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Gante I, Maldonado JP, Figueiredo Dias M. Marking Techniques for Targeted Axillary Dissection Among Patients With Node-Positive Breast Cancer Treated With Neoadjuvant Chemotherapy. Breast Cancer (Auckl) 2023; 17:11782234231176159. [PMID: 37255883 PMCID: PMC10226338 DOI: 10.1177/11782234231176159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/28/2023] [Indexed: 06/01/2023] Open
Abstract
Invasive breast cancer with axillary lymph node (LN) invasion is a continuing problem worldwide. The morbidity associated with axillary LN dissection along with the high rate of nodal downstaging after neoadjuvant chemotherapy (NACT) made the standard treatment shift towards less invasive surgery. Sentinel lymph node biopsy (SLNB) after NACT is associated with high false-negative rates (13%-14%). To overcome this problem, it was concluded that the positive nodes should first be indicated with image-detectable markers and then removed together with SLNB: targeted axillary dissection (TAD). This review aims to describe and evaluate the different marking techniques for TAD in patients with node-positive breast cancer treated with NACT, namely: clip placement and guidewire localization; clip placement and 125I-labelled radioactive seed localization; clip placement and skin mark; clip placement and intraoperative ultrasound; tattooing with a sterile black carbon suspension; magnetic seeds; radar and infrared light technology localization. Targeted axillary dissection techniques have shown false-negative rates below 9% and identification rates above 95%. The most studied technique is guidewire localization, as it is also the oldest one. However, according to data gathered from this review, some newer techniques have shown to be very promising due to their statistical results and management factors.
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Affiliation(s)
- Inês Gante
- Department of Gynecology, Coimbra
Hospital and Universitary Centre, Coimbra, Portugal
- Gynecologic University Clinic, Faculty
of Medicine, University of Coimbra, Coimbra, Portugal
- Area of Environment, Genetics and
Oncobiology (CIMAGO), Coimbra Institute for Clinical and Biomedical Research (iCBR),
Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - João Pedro Maldonado
- Gynecologic University Clinic, Faculty
of Medicine, University of Coimbra, Coimbra, Portugal
| | - Margarida Figueiredo Dias
- Department of Gynecology, Coimbra
Hospital and Universitary Centre, Coimbra, Portugal
- Gynecologic University Clinic, Faculty
of Medicine, University of Coimbra, Coimbra, Portugal
- Area of Environment, Genetics and
Oncobiology (CIMAGO), Coimbra Institute for Clinical and Biomedical Research (iCBR),
Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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17
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Hayward JH, Linden OE, Lewin AA, Weinstein SP, Bachorik AE, Balija TM, Kuzmiak CM, Paulis LV, Salkowski LR, Sanford MF, Scheel JR, Sharpe RE, Small W, Ulaner GA, Slanetz PJ. ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer: 2022 Update. J Am Coll Radiol 2023; 20:S125-S145. [PMID: 37236739 DOI: 10.1016/j.jacr.2023.02.016] [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: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Imaging plays a vital role in managing patients undergoing neoadjuvant chemotherapy, as treatment decisions rely heavily on accurate assessment of response to therapy. This document provides evidence-based guidelines for imaging breast cancer before, during, and after initiation of neoadjuvant chemotherapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Olivia E Linden
- Research Author, University of California, San Francisco, San Francisco, California
| | - Alana A Lewin
- Panel Chair, New York University Grossman School of Medicine, New York, New York
| | - Susan P Weinstein
- Panel Vice-Chair, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Tara M Balija
- Hackensack University Medical Center, Hackensack, New Jersey; American College of Surgeons
| | - Cherie M Kuzmiak
- University of North Carolina Hospital, Chapel Hill, North Carolina
| | | | - Lonie R Salkowski
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | | | | | | | - William Small
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, Illinois
| | - Gary A Ulaner
- Hoag Family Cancer Institute, Newport Beach, California, and University of Southern California, Los Angeles, California; Commission on Nuclear Medicine and Molecular Imaging
| | - Priscilla J Slanetz
- Specialty Chair, Boston University School of Medicine, Boston, Massachusetts
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18
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Di Paola V, Mazzotta G, Conti M, Palma S, Orsini F, Mola L, Ferrara F, Longo V, Bufi E, D'Angelo A, Panico C, Clauser P, Belli P, Manfredi R. Image-Guided Localization Techniques for Metastatic Axillary Lymph Nodes in Breast Cancer; What Radiologists Should Know. Cancers (Basel) 2023; 15:cancers15072130. [PMID: 37046791 PMCID: PMC10093304 DOI: 10.3390/cancers15072130] [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: 02/28/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/14/2023] Open
Abstract
Targeted axillary dissection (TAD) is an axillary staging technique after NACT that involves the removal of biopsy-proven metastatic lymph nodes in addition to sentinel lymph node biopsy (SLNB). This technique avoids the morbidity of traditional axillary lymph node dissection and has shown a lower false-negative rate than SLNB alone. Therefore, marking positive axillary lymph nodes before NACT is critical in order to locate and remove them in the subsequent surgery. Current localization methods include clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive tracer-based localizers, magnetic seeds, radar reflectors, and radiofrequency identification devices. The aim of this paper is to illustrate the management of axillary lymph nodes based on current guidelines and explain the features of axillary lymph node markers, with relative advantages and disadvantages.
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Affiliation(s)
- Valerio Di Paola
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiodiagnostica Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCSS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Giorgio Mazzotta
- Institute of Radiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Marco Conti
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiologia Toracica e Cardiovascolare, Fondazione Policlinico Universitario A. Gemelli IRCSS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Simone Palma
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiodiagnostica Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCSS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Federico Orsini
- Institute of Radiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Laura Mola
- Institute of Radiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Francesca Ferrara
- Institute of Radiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Valentina Longo
- Institute of Radiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Enida Bufi
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiologia Toracica e Cardiovascolare, Fondazione Policlinico Universitario A. Gemelli IRCSS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Anna D'Angelo
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiologia Toracica e Cardiovascolare, Fondazione Policlinico Universitario A. Gemelli IRCSS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Camilla Panico
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiologia Toracica e Cardiovascolare, Fondazione Policlinico Universitario A. Gemelli IRCSS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Paola Clauser
- Department of Biomedical Imaging and Image-Guided Radiotherapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Paolo Belli
- Institute of Radiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiologia Toracica e Cardiovascolare, Fondazione Policlinico Universitario A. Gemelli IRCSS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Riccardo Manfredi
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiodiagnostica Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCSS, Largo A. Gemelli 8, 00168 Rome, Italy
- Institute of Radiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
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19
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Chen JH, Canner JK, Myers K, Camp M. Concomitant Use of Biopsy Clips and Wire Localization in Invasive Breast Cancer is Associated With Successful Clip Retrieval. Clin Breast Cancer 2023; 23:e163-e172. [PMID: 36646538 DOI: 10.1016/j.clbc.2022.12.007] [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: 08/22/2022] [Revised: 12/11/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Surgical management of the axilla in patients with clinically node-positive breast cancer has shifted to less invasive surgical approaches, such as sentinel lymph node dissection (SLND) and targeted axillary dissection (TAD). Successful retrieval of the biopsy clip marking the lymph node of interest is crucial for assessment of pathologic response and locoregional disease control. METHODS We performed a retrospective review of patients ≥18 years old with invasive breast cancer and biopsy-proven axillary LN involvement, who underwent LN clip placement from January 2012 to July 2017 at Johns Hopkins Hospital. RESULTS Of the 128 eligible patients, the median age at diagnosis was 51.5 years (range, 23-92 years) with predominately stage T2-3 disease (54.7% T2, 42.2% T3), of ductal histology (76.6%), and located in the upper outer quadrant (42.2%). Among the 63.3% (81) of patients who received neoadjuvant systemic therapy, 43.2% (35) had a partial response and 30.9% (25) had a complete response. Axillary procedures performed consisted of 36.7% (47) SLND/TAD, 53.9% (69) ALND, and 9.4% (12) SLND/TAD with conversion to ALND. The clipped LN was successfully retrieved in 63.8% (30) of SLND/TADs, 39.1% (27) of ALNDs, and 58.3% (7) of SLND/TADs followed by ALND. Pre-operative node localization by wire and/or skin markings was performed for 16.4% (21) of patients. Among these, 90.5% (19) of clipped LNs were successfully retrieved, compared to 42.1% (45) retrieved in axillary procedures without preoperative node localization. CONCLUSION Use of preoperative targeted node localization improved rate of clipped LN retrieval across all three types of axillary procedures.
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Affiliation(s)
- Jennifer H Chen
- School of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Joe K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Kelly Myers
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Melissa Camp
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD.
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Tinterri C, Sagona A, Barbieri E, Di Maria Grimaldi S, Caraceni G, Ambrogi G, Jacobs F, Biondi E, Scardina L, Gentile D. Sentinel Lymph Node Biopsy in Breast Cancer Patients Undergoing Neo-Adjuvant Chemotherapy: Clinical Experience with Node-Negative and Node-Positive Disease Prior to Systemic Therapy. Cancers (Basel) 2023; 15:cancers15061719. [PMID: 36980605 PMCID: PMC10046076 DOI: 10.3390/cancers15061719] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/04/2023] [Accepted: 03/09/2023] [Indexed: 03/16/2023] Open
Abstract
Background: Sentinel lymph node biopsy (SLNB) has emerged as the standard procedure to replace axillary lymph node dissection (ALND) in breast cancer (BC) patients undergoing neo-adjuvant chemotherapy (NAC). SLNB is accepted in clinically node-negative (cN0) patients; however, its role in clinically node-positive (cN+) patients is debatable. Methods: We performed a retrospective analysis of BC patients undergoing NAC and SLNB. Our aim was to evaluate the clinical significance of SLNB in the setting of NAC. This was accomplished by comparing the characteristics and oncological outcomes between cN0 and cN+ patients prior to NAC and type of axillary surgery. Results: A total of 291 patients were included in the analysis: 131 were cN0 and 160 were cN+ who became ycN0 after NAC. At a median follow-up of 43 months, axillary recurrence occurred in three cN0 (2.3%) and two cN+ (1.3%) patients. However, there were no statistically significant differences in oncological outcomes (disease-free survival, distant disease-free survival, overall survival, and breast-cancer-specific survival) between cN0 and cN+ patients nor between patients treated with SLNB only or ALND. Conclusions: SLNB in the setting of NAC is an acceptable procedure with a general good prognosis and low axillary failure rates for both cN0 and cN+ patients.
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Affiliation(s)
- Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
| | - Andrea Sagona
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Erika Barbieri
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | | | - Giulia Caraceni
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Giacomo Ambrogi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
| | - Flavia Jacobs
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Ersilia Biondi
- Division of Breast Surgery, Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, 00168 Rome, Italy
| | - Lorenzo Scardina
- Division of Breast Surgery, Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, 00168 Rome, Italy
| | - Damiano Gentile
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Correspondence: ; Tel.: +39-0282243060
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Thompson JL, Wright GP. Contemporary approaches to the axilla in breast cancer. Am J Surg 2023; 225:583-587. [PMID: 36522219 DOI: 10.1016/j.amjsurg.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Over the past decade, axillary management in breast cancer has fundamentally shifted. The former notion that any degree of axillary nodal involvement warrants axillary lymph node dissection (ALND) has been challenged. Following publication of the ACOSOG Z0011 trial, national trends demonstrated significant reductions in ALND performance. Axillary radiotherapy in lieu of ALND is a consideration for select patients with a positive sentinel lymph node, while ongoing studies are investigating the role of adjuvant regional radiotherapy in women with positive nodes prior to neoadjuvant chemotherapy. Efforts toward de-escalation of axillary surgery continue to evolve, as do the indications for sentinel node biopsy omission in select subsets of patients. This review highlights the recent advances and neoteric approaches to local therapy of the axilla in breast cancer.
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Affiliation(s)
- Jessica L Thompson
- Spectrum Health Medical Group Comprehensive Breast Clinic, 145 Michigan Street NE, Suite 4400, Grand Rapids, MI, 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 15 Michigan Street NE, Grand Rapids, MI, 49503, USA.
| | - G Paul Wright
- Spectrum Health Medical Group Comprehensive Breast Clinic, 145 Michigan Street NE, Suite 4400, Grand Rapids, MI, 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 15 Michigan Street NE, Grand Rapids, MI, 49503, USA; Spectrum Health Medical Group, Division of Surgical Oncology, 145 Michigan Street NE, Suite 5500, Grand Rapids, MI, 49503, USA.
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Memişoğlu E, Sarı R. The effect of positron emission tomography/computed tomography in axillary surgery approach after neoadjuvant treatment in breast cancer. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:37-43. [PMID: 36629643 PMCID: PMC9937613 DOI: 10.1590/1806-9282.20220097] [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: 03/21/2022] [Accepted: 03/31/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The aim of this study was to determine the role of positron emission tomography/computed tomography in the decision to perform axillary surgery by comparing positron emission tomography/computed tomography findings with pathology consistency after neoadjuvant chemotherapy. METHODS Patients who were diagnosed for T1-4, cN1/2 breast cancer receiving neoadjuvant chemotherapy in our clinic between January 2016 and February 2021 were evaluated. Clinical and radiological responses, axillary surgery, and histopathological results after neoadjuvant chemotherapy were evaluated. RESULTS Axillary involvement was not detected in positron emission tomography/computed tomography after neoadjuvant chemotherapy in 140 (60.6%) of 231 node-positive patients. In total, 88 (62.8%) of these patients underwent sentinel lymph node biopsy, and axillary lymph node dissection was performed in 29 (33%) of these patients upon detection of 1 or 2 positive lymph nodes. The other 52 (37.1%) patients underwent direct axillary lymph node dissection, and no metastatic lymph nodes were detected in 33 (63.4%) patients. No metastatic lymph node was found pathologically in a total of 92 patients without involvement in positron emission tomography/computed tomography, and the negative predictive value was calculated as 65.7%. Axillary lymph node dissection was performed in 91 (39.4%) patients with axillary involvement in positron emission tomography/computed tomography after neoadjuvant chemotherapy. Metastatic lymph nodes were found pathologically in 83 of these patients, and the positive predictive value was calculated as 91.2%. CONCLUSION Positron emission tomography/computed tomography was found to be useful in the evaluation of clinical response, but it was not sufficient enough to predict a complete pathological response. When planning axillary surgery, axillary lymph node dissection should not be decided only with a positive positron emission tomography/computed tomography. Other radiological images should also be evaluated, and a positive sentinel lymph node biopsy should be the determinant of axillary lymph node dissection.
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Affiliation(s)
- Ecem Memişoğlu
- Kartal Dr. Lütfi Kirdar Şehir Hastanesi, Department of General Surgery – Istanbul, Turkey
| | - Ramazan Sarı
- Kartal Dr. Lütfi Kirdar Şehir Hastanesi, Department of General Surgery – Istanbul, Turkey
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Liu S, Du S, Gao S, Teng Y, Jin F, Zhang L. A delta-radiomic lymph node model using dynamic contrast enhanced MRI for the early prediction of axillary response after neoadjuvant chemotherapy in breast cancer patients. BMC Cancer 2023; 23:15. [PMID: 36604679 PMCID: PMC9817310 DOI: 10.1186/s12885-022-10496-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/29/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The objective of this paper is to explore the value of a delta-radiomic model of the axillary lymph node (ALN) using dynamic contrast-enhanced (DCE) MRI for early prediction of the axillary pathological complete response (pCR) of breast cancer patients after neoadjuvant chemotherapy (NAC). METHODS A total of 120 patients with ALN-positive breast cancer who underwent breast MRI before and after the first cycle of NAC between October 2018 and May 2021 were prospectively included in this study. Patients were divided into a training (n = 84) and validation (n = 36) cohort based on the temporal order of their treatments. Radiomic features were extracted from the largest slice of targeted ALN on DCE-MRI at pretreatment and after one cycle of NAC, and their changes (delta-) were calculated and recorded. Logistic regression was then applied to build radiomic models using the pretreatment (pre-), first-cycle(1st-), and changes (delta-) radiomic features separately. A clinical model was also built and combined with the radiomic models. The models were evaluated by discrimination, calibration, and clinical application and compared using DeLong test. RESULTS Among the three radiomic models, the ALN delta-radiomic model performed the best with AUCs of 0.851 (95% CI: 0.770-0.932) and 0.822 (95% CI: 0.685-0.958) in the training and validation cohorts, respectively. The clinical model yielded moderate AUCs of 0.742 (95% CI: 0.637-0.846) and 0.723 (95% CI: 0.550-0.896), respectively. After combining clinical features to the delta-radiomics model, the efficacy of the combined model (AUC = 0.932) in the training cohort was significantly higher than that of both the delta-radiomic model (Delong p = 0.017) and the clinical model (Delong p < 0.001) individually. Additionally, in the validation cohort, the combined model had the highest AUC (0.859) of any of the models we tested although this was not statistically different from any other individual model's validation AUC. Calibration and decision curves showed a good agreement and a high clinical benefit for the combined model. CONCLUSION This preliminary study indicates that ALN-based delta-radiomic model combined with clinical features is a promising strategy for the early prediction of downstaging ALN status after NAC. Future axillary MRI applications need to be further explored.
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Affiliation(s)
- Shasha Liu
- grid.412636.40000 0004 1757 9485Department of Radiology, The First Hospital of China Medical University, Shenyang, 110001 China
| | - Siyao Du
- grid.412636.40000 0004 1757 9485Department of Radiology, The First Hospital of China Medical University, Shenyang, 110001 China
| | - Si Gao
- grid.412636.40000 0004 1757 9485Department of Radiology, The First Hospital of China Medical University, Shenyang, 110001 China
| | - Yuee Teng
- grid.412636.40000 0004 1757 9485Departments of Medical Oncology and Thoracic Surgery, The First Hospital of China Medical University, Shenyang, 110001 China
| | - Feng Jin
- grid.412636.40000 0004 1757 9485Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, 110001 China
| | - Lina Zhang
- grid.412636.40000 0004 1757 9485Department of Radiology, The First Hospital of China Medical University, Shenyang, 110001 China
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Montagna G, Lee MK, Sevilimedu V, Barrio AV, Morrow M. Is Nodal Clipping Beneficial for Node-Positive Breast Cancer Patients Receiving Neoadjuvant Chemotherapy? Ann Surg Oncol 2022; 29:6133-6139. [PMID: 35902495 PMCID: PMC10109537 DOI: 10.1245/s10434-022-12240-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/06/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND In cN1 patients rendered cN0 with neoadjuvant chemotherapy, the false-negative rate of sentinel lymph node biopsy (SLNB) is < 10% when ≥ 3 sentinel lymph nodes (SLNs) are removed. The added value of nodal clipping in this scenario is unknown. Here we determine how often the clipped node is a sentinel node when ≥ 3 SLNs are retrieved. METHODS We identified cT1-3N1 patients treated between 02/2018 and 10/2021 with a clipped lymph node at presentation. SLNB was performed with a standardized approach of dual-tracer mapping and retrieval of ≥ 3 SLNs. Clipped nodes were not localized; SLNs were X-rayed intraoperatively to determine clip location. Axillary lymph node dissection (ALND) was performed for any residual disease or retrieval of < 3 SLNs. RESULTS Of 269 patients, 251 (93%) had ≥ 3 SLNs. Median age was 51 years; the majority (92%) had ductal histology; 46% were HR+/HER2-. The median number of SLNs removed was 4 (IQR 3,5). The clipped node was an SLN in 88% (220/251) of cases. Of the 31 where the clipped node was not, 13 had a positive SLN mandating ALND, and the clip was identified in the ALND specimen. In the remaining 18, where ≥ 3 negative SLNs were retrieved and an ALND was not performed, the clip was not retrieved, with no axillary failures in this group (median follow-up: 55 months). CONCLUSION When the SLNB procedure is optimized with dual tracer and retrieval of ≥ 3 SLNs, the clipped node is an SLN in the majority of cases, suggesting that failure to retrieve the clipped node should not be an indication for ALND.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Minna K Lee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Nakhlis F, Portnow L, Gombos E, Daylan AEC, Leone JP, Kantor O, Richardson ET, Ho A, Dunn SA, Ohri N. Multidisciplinary Considerations in the Management of Breast Cancer Patients Receiving Neoadjuvant Chemotherapy. Curr Probl Surg 2022; 59:101191. [DOI: 10.1016/j.cpsurg.2022.101191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Harrison B. Update on sentinel node pathology in breast cancer. Semin Diagn Pathol 2022; 39:355-366. [PMID: 35803776 DOI: 10.1053/j.semdp.2022.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
Abstract
Pathologic examination of the sentinel lymph nodes (SLNs) in patients with breast cancer has been impacted by the publication of practicing changing trials over the last decade. With evidence from the ACOSOG Z0011 trial to suggest that there is no significant benefit to axillary lymph node dissection (ALND) in early-stage breast cancer patients with up to 2 positive SLNs, the rate of ALND, and in turn, intraoperative evaluation of SLNs has significantly decreased. It is of limited clinical significance to pursue multiple levels and cytokeratin immunohistochemistry to detect occult small metastases, such as isolated tumor cells and micrometastases, in this setting. Patients treated with neoadjuvant therapy, who represent a population with more extensive disease and aggressive tumor biology, were not included in Z0011 and similar trials, and thus, the evidence cannot be extrapolated to them. Recent trials have supported the safety and accuracy of sentinel lymph node biopsy (SLNB) in these patients when clinically node negative at the time of surgery. ALND remains the standard of care for any amount of residual disease in the SLNs and intraoperative evaluation of SLNs is still of value for real time surgical decision making. Given the potential prognostic significance of residual small metastases in treated lymph nodes, as well as the decreased false negative rate with the use of cytokeratin immunohistochemistry (IHC), it may be reasonable to maintain a low threshold for the use of cytokeratin IHC in post-neoadjuvant cases. Further recommendations for patients treated with neoadjuvant therapy await outcomes data from ongoing clinical trials. This review will provide an evidence-based discussion of best practices in SLN evaluation.
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Affiliation(s)
- Beth Harrison
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, United States.
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27
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Song YX, Xu Z, Liang MX, Liu Z, Hou JC, Chen X, Xu D, Fei YJ, Tang JH. Diagnostic accuracy of de-escalated surgical procedure in axilla for node-positive breast cancer patients treated with neoadjuvant systemic therapy: A systematic review and meta-analysis. Cancer Med 2022; 11:4085-4103. [PMID: 35502768 DOI: 10.1002/cam4.4769] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/19/2022] [Accepted: 04/10/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND More initial clinical node-positive breast cancer patients achieve axillary pathological complete response (ax-pCR) after neoadjuvant systemic therapy (NST). Restaging axillary status and performing de-escalated surgical procedures to replace routine axillary lymph nodes dissection (ALND) is urgently needed. Targeted axillary lymph node biopsy (TLNB) is a novel de-escalated surgical strategy marking metastatic axillary nodes before NST and targeted dissection and biopsy intraoperatively to tailor individual axillary management. METHODS This study provided a systematic review and meta-analysis to evaluate the feasibility and diagnosis accuracy of TLNB. Prospective and retrospective clinical trials on TLNB were searched from Pubmed, Embase, and Cochrane. Identification rate (IFR), false-negative rate (FNR), negative predictive value (NPV), and rate of ax-pCR were the outcomes of this meta-analysis. RESULTS One thousand nine hundred and twenty patients attempted TLNB, with an overall IFR of 93.5% (95% confidence interval [CI] 90.1%-96.2%). IFR of three nodal marking methods, namely iodine seeds, clips, and carbon dye, was 95.6% (95% CI 91.2%-98.7%), 91.7% (95% CI 87.3%-95.4%), and 97.1% (95% CI 89.1%-100.0%), respectively. Of them, 847 patients received ALND, with an overall FNR of 5.5% (95% CI 3.3%-8.0%), and NPV ranged from 90.1% to 96.1%. Regression analysis showed that the overlap of targeted and sentinel biopsied nodes might associate with IFRs and FNRs. CONCLUSION TLNB is a novel, less invasive surgical approach to distinguish initial node-positive breast cancer that achieves negative axillary conversion after NST. It yields an excellent IFR with a low FNR and a high NPV. A combination of preoperative imaging, intraoperative TLNB with SLNB, and postoperative nodal radiotherapy might affect the future treatment paradigm of primary breast cancer with nodal metastases.
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Affiliation(s)
- Yu-Xin Song
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Xu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming-Xing Liang
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Liu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun-Chen Hou
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiu Chen
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Di Xu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yin-Jiao Fei
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jin-Hai Tang
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Lifrieri A, Fuzesi S, Desperito E, Taback B. When the clipped node goes missing, CT guided SAVI SCOUT placement: A novel approach for localizing soft tissue targets. Clin Imaging 2022; 85:115-117. [DOI: 10.1016/j.clinimag.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 11/03/2022]
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Prospective Evaluation of Radar-Localized Reflector-Directed Targeted Axillary Dissection in Node-Positive Breast Cancer Patients after Neoadjuvant Systemic Therapy. J Am Coll Surg 2022; 234:538-545. [PMID: 35290273 DOI: 10.1097/xcs.0000000000000098] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND This is a prospective, single-institution study to evaluate feasibility and accuracy of radar-localized reflector (RLR)-targeted axillary dissection (TAD) in node-positive breast cancer patients after neoadjuvant systemic therapy (NST). METHODS Patients with biopsy-proven T1-2, N1-3 disease were eligible. Before NST, a marker clip and/or RLR was placed into the positive node. After NST, RLR was inserted if not placed previously. All patients underwent RLR TAD followed by axillary lymph node dissection (ALND). Primary end points of the trial were feasibility of RLR TAD and false negative rate (FNR). RESULTS Between 2017 and 2021, 101 patients with N1-3 disease underwent NST. Five patients withdrew from the study, 1 was ineligible, and there were 9 technical failures, thus our final study cohort comprised 86 patients. RLR TAD was performed with probe guidance and confirmed with intraoperative specimen radiograph. After RLR TAD, ALND was performed. Median number of RLR TAD nodes removed was 2 (range 1-10), and the RLR TAD nodes remained positive in 56 patients. Median number of ALND nodes removed was 18 (range 4-46). Accounting for 9 technical failures, feasibility was 90%. All technical failures occurred with attempted placement of RLR after NST. Feasibility rate was 100% when RLR placement occurred at diagnosis. Of the evaluable 86 patients, RLR TAD accurately predicted axillary status in 83 patients, with FNR of 5.1%. CONCLUSION We demonstrate high accuracy of RLR TAD, especially when RLR is placed before NST. For patients who present with N1-3 disease, this is another step towards axillary surgery de-escalation strategies.
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Piltin MA, Boughey JC. Axillary Management: How Has Neoadjuvant Chemotherapy Changed Our Surgical Approach? CURRENT BREAST CANCER REPORTS 2022. [DOI: 10.1007/s12609-022-00442-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chavda J, Mishra A, Silodia A, Yadav SK, Sharma DB, Sharma D, Khandare M. Validation sentinel lymph node biopsy study in cN0 axilla using low-cost dual dye technique: potential solution for resource poor settings. Breast Cancer Res Treat 2022; 193:105-110. [PMID: 35246773 DOI: 10.1007/s10549-022-06556-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/22/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) using radio-pharmaceutical and a blue dye is gold standard for axillary staging in clinically node-negative breast cancer. High costs and limited availability of radio-pharmaceutical and/or gamma probe are major deterrents in performing SLNB in developing countries. In this study, we evaluated feasibility of SLN identification (SLN-IR) of fluorescein-guided (FG) SLNB in combination with methylene blue dye (MBD). METHODS This was a prospective cross-sectional non-randomized validation study in patients with clinically node-negative axilla. Patients underwent validation SLNB using fluorescein (and blue LED light) and MBD. Axillary dissection was performed irrespective of SLNB histology. SLIN-IR and False Negative Rate (FNR) were assessed for both groups. RESULTS The SLNs were identified in 29 (96.6%) pre-chemotherapy patients and 23 (82%) post Neoadjuvant Chemotherapy (NACT) patients. The median number of sentinel lymph nodes identified was 3 (range of 1-5) in pre-chemotherapy patients and 1 (range of 1-3) in post NACT patients. The SLN-IR using MBD was 90%, FD was 86.7% and combined MBD FD was 96.7% in pre-chemotherapy patients. The SLN-IR using MBD was 82%, FD was 71% and combined MBD FD was 82% in in post NACT patients. The false negative rate (FNR) in pre-chemotherapy group was 8.0% (MBD), 8.3% (FD) and 7.4% (MBD + FD). The FNR in post NACT group was 8.7% (MBD), 10% (FD) and 8.7% (MBD + FD). CONCLUSION This prospective validation study showed adequate SLN-IR and FNR using low-cost dual dyes in early breast cancer patients and can be used in low resource settings. However, SLNB in post NACT axilla though viable along with a satisfactory FNR, is associated with low identification rate and needs further evaluation.
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Affiliation(s)
- Jayesh Chavda
- Department of Surgery, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur, India
| | - Arpan Mishra
- Department of Surgery, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur, India
| | - Ashutosh Silodia
- Department of Surgery, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur, India
| | - Sanjay Kumar Yadav
- Department of Surgery, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur, India.
| | - Deepti Bala Sharma
- Department of Surgery, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur, India
| | - Dhananjaya Sharma
- Department of Surgery, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur, India
| | - Muktesh Khandare
- Department of Pathology, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur, India
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Rebollo Aguirre A, Fernández Fernández J, Sánchez Sánchez R, Mendoza Arnau I, Rivas Navas D, Martínez Meca S. Radioguided surgery with iodine-125 seeds in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2022; 41:71-77. [DOI: 10.1016/j.remnie.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/20/2021] [Indexed: 11/29/2022]
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Yang J, He T, Wu Y, Fu Z, Lv Q, Lu S, Wang X, Li H, Wang J, Chen J. Nanoparticle-assisted axillary staging: an alternative approach after neoadjuvant chemotherapy in patients with pretreatment node-positive breast cancers. Breast Cancer Res Treat 2022; 192:573-582. [PMID: 35129717 DOI: 10.1007/s10549-022-06539-x] [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: 11/17/2021] [Accepted: 01/29/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE In order to achieve an optimized method of axillary staging after neoadjuvant chemotherapy (NAC) in breast cancer patients with pretreatment positive axillary lymph nodes, we evaluated the feasibility and accuracy of nanoparticle-assisted axillary staging (NAAS) which combines carbon nanoparticles with standard sentinel lymph node biopsy (SLNB) with radioisotope and blue dye. METHODS Invasive breast cancer patients with pre-NAC positive axillary lymph nodes who converted to ycN0 and received surgeries from November 2020 to March 2021 were included. All patients underwent ipsilateral NAAS followed by axillary lymph node dissection. Detection rate (DR), false-negative rate (FNR), negative predictive value (NPV) and accuracy of axillary staging were calculated. RESULTS Eighty of 136 (58.8%) breast cancer patients converted to ycN0 after NAC and received NAAS. The DR, NPV and accuracy was 95.0%, 93.3% and 97.4% for NAAS, respectively. And the FNR was 4.2% (2/48) for NAAS, which was lower than that of standard dual-tracer SLNB (SD-SLNB) (9.5%, 4/42). Pretreatment clinical T4 classification was a risk factor for detection failure in NAAS (p = 0.016). When patients with pretreatment inflammatory breast cancers were excluded from analysis, FNR dropped to 2.2% (1/45) for NAAS. CONCLUSION NAAS revealed great performance in invasive breast cancer patients with pre-NAC positive axillary lymph nodes who converted to ycN0. The application of NAAS reached a better balance between more accurate axillary evaluation and less intervention. Trial registration Chictr.org.cn (ChiCTR2000039814). Registered Nov 11, 2020.
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Affiliation(s)
- Jiqiao Yang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China.,Clinical Research Center for Breast Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Tao He
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Yunhao Wu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Zhoukai Fu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Qing Lv
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Shan Lu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Xiaodong Wang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Hongjiang Li
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Jing Wang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Jie Chen
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China.
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Weiss A, King C, Grossmith S, Portnow L, Raza S, Nakhlis F, Dominici L, Barbie T, Minami C, Nimbkar S, Rhei E, Mittendorf EA, King TA. How Often Does Retrieval of a Clipped Lymph Node Change Adjuvant Therapy Recommendations? A Prospective, Consecutive, Patient Cohort Study. Ann Surg Oncol 2022; 29:3764-3771. [PMID: 35041097 DOI: 10.1245/s10434-022-11324-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/24/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prior studies examining sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) for cN1 patients have demonstrated that 20% of biopsied, clipped lymph nodes (cLNs) are nonsentinel lymph nodes (non-SLNs). Our goal was to determine how often the cLN was a non-SLN among both cN0 and cN1 patients and how often cLN pathology impacted management. METHODS Overall, 238 patients treated with NAC and surgery January 2019 to June 2020 were prospectively examined. Patients underwent routine axillary ultrasound, biopsy of suspicious nodes, and clip placement. Radioactive iodine-125 seed localization of the cLN was performed in cN1 patients only. Isolated tumor cells (ITCs) were considered node positive (ypN+) for both cN0 and cN1 cohorts. Chart review was performed to determine if cLNs were non-SLN and their ypN status. RESULTS Of 118 cN0 patients, 115 of 118 (97%) underwent successful SLNB, 33 of whom had a cLN present; 21 of 33 (64%) cLNs were non-SLNs. Overall, 9 of 118 (8%) were ypN+; no cLN was ypN+ without additional +SLNs. Of 120 cN1 patients, 104 of 120 (87%) converted to cN0, 98 of 104 (94%) of which had attempted SLNB, and 95 of 98 (97%) successfully mapped. The cLN was a non-SLN in 18 of 95 (19%). Overall, 58 of 104 (56%) cN1 patients were ypN+. One patient had a positive cLN in the absence of +SLNs. This patient underwent axillary lymph node dissection (ALND); adjuvant treatment recommendations were unchanged. CONCLUSIONS The cLN was a non-SLN in 19% of cN1 patients. cLN pathology did not impact adjuvant therapy recommendations, calling into question the utility of routinely clipping biopsied lymph nodes.
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Affiliation(s)
- Anna Weiss
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | - Claire King
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Samantha Grossmith
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Leah Portnow
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Sughra Raza
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Faina Nakhlis
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Laura Dominici
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Thanh Barbie
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Christina Minami
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Suniti Nimbkar
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Esther Rhei
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
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35
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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: 25] [Impact Index Per Article: 8.3] [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.
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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.
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36
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Pulappadi VP, Paul S, Hari S, Dhamija E, Manchanda S, Kataria K, Mathur S, Mani K, Gogia A, Deo S. Axillary ultrasonography combined with pre-operative wire localisation of clipped node in nodal restaging after neoadjuvant chemotherapy in node positive breast cancer patients: a pilot study. Br J Radiol 2021; 94:20210788. [PMID: 34491822 DOI: 10.1259/bjr.20210788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To evaluate the role of axillary ultrasonography (axUS) and ultrasound-guided pre-operative wire localisation of pre-treatment positive clipped node (CN) for prediction of nodal response to neoadjuvant chemotherapy (NACT) in node positive breast carcinoma patients. METHODS AND MATERIALS A prospective study was conducted between June 2018 and August 2020 after Ethics Committee approval. Breast carcinoma patients (cT1-cT4b) with palpable axillary nodes (cN1-cN3) and suitable for NACT were recruited after written informed consent. Single, most suspicious node was biopsied and clipped. Nodal response to NACT was assessed on axUS. Wire localisation of CN was performed prior to axillary lymph node dissection (ALND). Diagnostic performances of axUS and CN excision were assessed. RESULTS Of the 69 patients evaluated, 32 patients (mean age, 43.5 ± 11.8 years; females, 31/32 [97%]; pre-menopausal, 18/32 [56.3%]) with metastatic nodes who received NACT were included. Nodal pathological complete response rate was 34.4% (11/32) overall and 70% (7/10) in patients with ≤2 suspicious nodes on pre-NACT axUS. False-negative rates (FNRs) of axUS and CN excision were 4.8% and 28.6% respectively. Combination of post-NACT axUS and CN excision had an FNR of 4.8% overall and 0% in patients with ≤2 suspicious nodes on pre-NACT axUS. CONCLUSION Combination of AxUS and ultrasound-guided wire localisation of pre-treatment positive CN has high diagnostic accuracy for nodal restaging after NACT in node positive breast cancer patients. ADVANCES IN KNOWLEDGE Addition of axUS assessment to wire localisation of CN reduces its FNR for detecting residual metastasis after NACT.
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Affiliation(s)
- Vishnu Prasad Pulappadi
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shashi Paul
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Smriti Hari
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ekta Dhamija
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Smita Manchanda
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kamal Kataria
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Mathur
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Kalaivani Mani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Gogia
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Svs Deo
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
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37
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Baker JL, Haji F, Kusske AM, Fischer CP, Hoyt AC, Thompson CK, Lee MK, Attai D, DiNome ML. SAVI SCOUT® localization of metastatic axillary lymph node prior to neoadjuvant chemotherapy for targeted axillary dissection: a pilot study. Breast Cancer Res Treat 2021; 191:107-114. [PMID: 34652548 DOI: 10.1007/s10549-021-06416-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE In clinically node-positive breast cancer, axillary staging after neoadjuvant chemotherapy (NAC) is optimized with targeted axillary dissection (TAD), which includes removal of the biopsy-proven metastatic lymph node (LN) in addition to sentinel lymph nodes (SLN). Localization of the clipped node is currently performed post-NAC; however, technical limitations can make detection and localization of the treated LN challenging. We prospectively evaluated the feasibility of localizing the metastatic LN with a SAVI SCOUT® reflector (SAVI) prior to NAC for targeted removal at surgery. METHODS Twenty-five patients with stage 2/3 breast cancer underwent ultrasound-guided localization of the biopsy-proven LN with SAVI prior to NAC. After NAC, patients with clinical response underwent TAD. Primary outcome measures were rate of successful localization, days between insertion of SAVI and axillary surgery, frequency of retrieval of clipped node, and frequency of SAVI-LN as SLN. RESULTS After NAC, 23/25 (92%) had clinical axillary down-staging and underwent TAD. Two patients with persistent palpable axillary disease underwent ALND for initial staging. Axillary surgery was performed at an average of 141 days post-SAVI insertion and the SAVI was successfully retrieved in all cases. Among 23 patients undergoing TAD, the SAVI was retrieved within a LN in all patients, whereas clip migration was observed in two patients. The median SLN removed was 4, and SAVI-LN was SLN in 22/23 patients. Axillary pCR rate was 44%. CONCLUSION Localizing a metastatic LN with SAVI reflector prior to NAC for targeted removal at surgery is feasible and may provide technical and logistical advantages over axillary localization post-NAC. CLINICAL TRIAL REGISTRY Clinical trials.gov identifier: NCT03411070.
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Affiliation(s)
- Jennifer L Baker
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Farnaz Haji
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Amy M Kusske
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Cheryce P Fischer
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Anne C Hoyt
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Carlie K Thompson
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Minna K Lee
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Deanna Attai
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Maggie L DiNome
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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38
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Barrio AV, Montagna G, Mamtani A, Sevilimedu V, Edelweiss M, Capko D, Cody HS, El-Tamer M, Gemignani ML, Heerdt A, Kirstein L, Moo TA, Pilewskie M, Plitas G, Sacchini V, Sclafani L, Tadros A, Van Zee KJ, Morrow M. Nodal Recurrence in Patients With Node-Positive Breast Cancer Treated With Sentinel Node Biopsy Alone After Neoadjuvant Chemotherapy-A Rare Event. JAMA Oncol 2021; 7:1851-1855. [PMID: 34617979 DOI: 10.1001/jamaoncol.2021.4394] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Prospective trials have demonstrated sentinel lymph node (SLN) false-negative rates of less than 10% when 3 or more SLNs are retrieved in patients with clinically node-positive breast cancer rendered clinically node-negative with neoadjuvant chemotherapy (NAC). However, rates of nodal recurrence in such patients treated with SLN biopsy (SLNB) alone are unknown because axillary lymph node dissection (ALND) was performed in all patients, limiting adoption of this approach. Objective To evaluate nodal recurrence rates in a consecutive cohort of patients with clinically node-positive (cN1) breast cancer receiving NAC, followed by a negative SLNB using a standardized technique, and no further axillary surgery. Design, Setting, and Participants From November 2013 to February 2019, a cohort of consecutively identified patients with cT1 to cT3 biopsy-proven N1 breast cancer rendered cN0 by NAC underwent SLNB with dual tracer mapping and omission of ALND if 3 or more SLNs were identified and all were pathologically negative. Metastatic nodes were not routinely clipped, and localization of clipped nodes was not performed. The study was performed in a single tertiary cancer center. Intervention Omission of ALND in patients with cN1 breast cancer after NAC if 3 or more SLNs were pathologically negative. Main Outcome and Measures The primary outcome was the rate of nodal recurrence among patients with cN1 breast cancer treated with SLNB alone after NAC. Results Of 610 patients with cN1 breast cancer treated with NAC (median [IQR] age, 49 [40-58] years), 555 (91%) converted to cN0 and underwent SLNB; 234 (42%) had 3 or more negative SLNs and had SLNB alone. Median age was 49 years. Median tumor size was 3 cm; 144 (62%) were ERBB2 (formerly HER2)-positive, and 43 (18%) were triple negative. Most (212 [91%]) received doxorubicin-based NAC, 205 (88%) received adjuvant radiotherapy (RT), and 164 (70%) also received nodal RT. At a median follow-up of 40 months, there was 1 axillary nodal recurrence synchronous with local recurrence in a patient who refused RT. Among patients who received RT (n = 205), there were no nodal recurrences. Conclusions and Relevance This cohort study found that in patients with cN1 disease rendered cN0 with NAC, with 3 or more negative SLNs with SLNB alone, nodal recurrence rates were low, without routine nodal clipping. These findings potentially support omitting ALND in such patients.
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Affiliation(s)
- Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Varadan Sevilimedu
- Biostatistical Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcia Edelweiss
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Deborah Capko
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laurie Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa Sclafani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Audree Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Hartmann S, Stachs A, Kühn T, de Boniface J, Banys-Paluchowski M, Reimer T. Targeted Removal of Axillary Lymph Nodes After Carbon Marking in Patients with Breast Cancer Treated with Primary Chemotherapy. Geburtshilfe Frauenheilkd 2021; 81:1121-1127. [PMID: 34629491 PMCID: PMC8494517 DOI: 10.1055/a-1471-4234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/28/2021] [Indexed: 12/24/2022] Open
Abstract
In breast cancer patients who have received primary chemotherapy and then no longer have any suspicious lymph nodes clinically and/or on imaging, marking of initially suspicious axillary lymph nodes with targeted removal has recently been discussed and practised both in Germany and internationally as an alternative to complete axillary lymph node dissection. Tattooing of the suspicious lymph nodes with a highly purified carbon suspension is currently being investigated in clinical studies. Compared with other techniques, the advantages of this method are the high rate of intraoperative lymph node detection, avoidance of an immediately preoperative localisation procedure and the low costs. The practical aspects of lymph node tattooing and the current data regarding this method will be described.
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Affiliation(s)
- Steffi Hartmann
- Universitätsklinikum Rostock, Klinik für Gynäkologie und Geburtshilfe, Rostock, Germany
| | - Angrit Stachs
- Universitätsklinikum Rostock, Klinik für Gynäkologie und Geburtshilfe, Rostock, Germany
| | - Thorsten Kühn
- Klinikum Esslingen, Klinik für Gynäkologie und Geburtshilfe, Esslingen, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
| | - Maggie Banys-Paluchowski
- Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Klinik für Gynäkologie und Geburtshilfe, Lübeck, Germany
- Medizinische Fakultät der Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Toralf Reimer
- Universitätsklinikum Rostock, Klinik für Gynäkologie und Geburtshilfe, Rostock, Germany
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40
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Līcīte B, Irmejs A, Maksimenko J, Loža P, Trofimovičs G, Miklaševičs E, Nazarovs J, Romanovska M, Deičmane J, Irmejs R, Purkalne G, Gardovskis J. Ultrasound guided needle biopsy of axilla to evaluate nodal metastasis after preoperative systemic therapy in cohort of 106 breast cancers enriched with BRCA1/2 pathogenic variant carriers. Hered Cancer Clin Pract 2021; 19:30. [PMID: 34233740 PMCID: PMC8262039 DOI: 10.1186/s13053-021-00187-w] [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: 02/03/2021] [Accepted: 06/18/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Aim of the study is to evaluate the role of ultrasound guided fine needle aspiration cytology (FNAC) in the restaging of node positive breast cancer after preoperative systemic therapy (PST). METHODS From January 2016 - October 2020 106 node positive stage IIA-IIIC breast cancer cases undergoing PST were included in the study. 18 (17 %) were carriers of pathogenic variant in BRCA1/2. After PST restaging of axilla was performed with ultrasound and FNAC of the marked and/or the most suspicious axillary node. In 72/106 cases axilla conserving surgery and in 34/106 cases axillary lymph node dissection (ALND) was performed. RESULTS False Positive Rate (FPR) of FNAC after PST in whole cohort and BRCA1/2 positive subgroup is 8 and 0 % and False Negative Rate (FNR) - 43 and 18 % respectively. Overall Sensitivity - 55 %, specificity- 93 %, accuracy 70 %. CONCLUSION FNAC after PST has low FPR and is useful to predict residual axillary disease and to streamline surgical decision making regarding ALND both in BRCA1/2 positive and negative subgroups. FNR is high in overall cohort and FNAC alone are not able to predict ypCR and omission of further axillary surgery. However, FNAC performance in BRCA1/2 positive subgroup is more promising and further research with larger number of cases is necessary to confirm the results.
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Affiliation(s)
- Baiba Līcīte
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia.
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia.
| | - Arvīds Irmejs
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jeļena Maksimenko
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Pēteris Loža
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Genādijs Trofimovičs
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Edvīns Miklaševičs
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jurijs Nazarovs
- Department of Pathology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Māra Romanovska
- Department of Pathology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Justīne Deičmane
- Department of Radiology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Reinis Irmejs
- St John's College, University of Cambridge, Cambridge, England
| | - Gunta Purkalne
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Oncology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jānis Gardovskis
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
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Balija TM, Braz D, Hyman S, Montgomery LL. Early reflector localization improves the accuracy of localization and excision of a previously positive axillary lymph node following neoadjuvant chemotherapy in patients with breast cancer. Breast Cancer Res Treat 2021; 189:121-130. [PMID: 34159474 DOI: 10.1007/s10549-021-06281-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/31/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Clipped axillary lymph node (CALN) localization after neoadjuvant chemotherapy (NAC) for axillary node positive breast cancer can be difficult due to significant shrinkage or disappearance of the CALN after NAC. This study compares wire localization to a radar-based localization system utilizing a reflector that can be placed before or during NAC, in the months before definitive surgery, to facilitate accurate localization and excision of the CALN. METHODS Between 2016 and 2019, women with T0-4 N1-3 M0 breast cancer who underwent NAC followed by axillary surgery with planned excision of a biopsy positive or clinically suspicious axillary node via wire or reflector localization were identified. A retrospective chart review was performed comparing successful localization and CALN retrieval by each localization technique. RESULTS Ninety-nine patients met inclusion criteria. Forty-two patients underwent wire localization while 57 patients underwent reflector localization of the CALN. Successful identification of the CALN by wire or reflector was equivalent (83.3% vs 84.2%, respectively). Twenty-two reflectors placed before or during early/mid NAC (early placement) had 100% successful CALN localization and retrieval in the OR. Placement of wire or reflector localization devices within 8 weeks of surgery (late placement) only resulted in 79.2% localization success (p = .02). CONCLUSION This study suggests a benefit of axillary lymph node reflector placement in the early NAC setting. Early reflector placement allows for more accurate excision of the CALN during axillary surgery after NAC as compared to placement of localization wires or reflectors in the few weeks prior to surgery.
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Affiliation(s)
- Tara M Balija
- Department of Surgery, Division of Breast Surgery, Hackensack Meridian School of Medicine, 20 Prospect Avenue, Suite 402, Hackensack, NJ, 07601, USA.
| | - Devin Braz
- Department of Surgery, Division of Breast Surgery, Hackensack Meridian School of Medicine, 20 Prospect Avenue, Suite 402, Hackensack, NJ, 07601, USA
| | - Sara Hyman
- Department of Surgery, Division of Breast Surgery, Hackensack Meridian School of Medicine, 20 Prospect Avenue, Suite 402, Hackensack, NJ, 07601, USA
| | - Leslie L Montgomery
- Department of Surgery, Division of Breast Surgery, Hackensack Meridian School of Medicine, 20 Prospect Avenue, Suite 402, Hackensack, NJ, 07601, USA
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van der Noordaa MEM, van Duijnhoven FH, Cuijpers FNE, van Werkhoven E, Wiersma TG, Elkhuizen PHM, Winter-Warnars G, Dezentje V, Sonke GS, Groen EJ, Stokkel M, Vrancken Peeters MTFD. Toward omitting sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with clinically node-negative breast cancer. Br J Surg 2021; 108:667-674. [PMID: 34157085 DOI: 10.1002/bjs.12026] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The nodal positivity rate after neoadjuvant chemotherapy (ypN+) in patients with clinically node-negative (cN0) breast cancer is low, especially in those with a pathological complete response of the breast. The aim of this study was to identify characteristics known before surgery that are associated with achieving ypN0 in patients with cN0 disease. These characteristics could be used to select patients in whom sentinel lymph node biopsy may be omitted after neoadjuvant chemotherapy. METHODS This cohort study included patients with cT1-3 cN0 breast cancer treated with neoadjuvant chemotherapy followed by breast surgery and sentinel node biopsy between 2013 and 2018. cN0 was defined by the absence of suspicious nodes on ultrasound imaging and PET/CT, or absence of tumour cells at fine-needle aspiration. Univariable and multivariable logistic regression analyses were performed to determine predictors of ypN0. RESULTS Overall, 259 of 303 patients (85.5 per cent) achieved ypN0, with high rates among those with a radiological complete response (rCR) on breast MRI (95·5 per cent). Some 82 per cent of patients with hormone receptor-positive disease, 98 per cent of those with triple-negative breast cancer (TNBC) and all patients with human epidermal growth factor receptor 2 (HER2)-positive disease who had a rCR achieved ypN0. Multivariable regression analysis showed that HER2-positive (odds ratio (OR) 5·77, 95 per cent c.i. 1·91 to 23·13) and TNBC subtype (OR 11·65, 2·86 to 106·89) were associated with ypN0 status. In addition, there was a trend toward ypN0 in patients with a breast rCR (OR 2·39, 0·95 to 6·77). CONCLUSION The probability of nodal positivity after neoadjuvant chemotherapy was less than 3 per cent in patients with TNBC or HER2-positive disease who achieved a breast rCR on MRI. These patients could be included in trials investigating the omission of sentinel node biopsy after neoadjuvant chemotherapy.
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Affiliation(s)
- M E M van der Noordaa
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - F H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - F N E Cuijpers
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - E van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - T G Wiersma
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - P H M Elkhuizen
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - G Winter-Warnars
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - V Dezentje
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - G S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - E J Groen
- Department of Pathology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - M Stokkel
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - M T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
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Guergan S, Hoopmann U, Roehm C, Boeer B, Fugunt R, Helms G, Seller A, Marx M, Oberlechner E, Hartkopf A, Preibsch H, Brucker S, Wallwiener D, Hahn M, Gruber IV. Evaluation of sonographic detectability of different markers within an in vitro simulation model of the axilla. Arch Gynecol Obstet 2021; 304:839-848. [PMID: 34142225 PMCID: PMC8325667 DOI: 10.1007/s00404-021-06085-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Clip-marking of axillary lymph nodes with initial biopsy-confirmed metastasis is required for targeted axillary dissection (TAD), which includes sentinel lymph node dissection (SLND) and selective localization and removal of the clipped targeted lymph node. There have been several studies which examined the feasibility of TAD in routine clinical use. In this context, the optimal clip visualisation was noted as one of the crucial limiting factors. We, therefore, evaluated the sonographic detectability of 10 different commercially available markers within an in vitro model simulating the anatomical composition of the axilla. METHODS In this standardised model consisting of porcine fat with 30 mm thickness, the visibility of a total of ten markers was analysed in all 3 planes (parallel, diagonal, orthograde) with wire guidance and then classified into either "visibility good", "visibility moderate" or "visibility poor" with regard to the alignment of the transducer. Additionally, "real-life conditions" were simulated, in which the markers were searched without any wires guidance. RESULTS It was observed that, while not all markers are detectable in fatty tissue, markers with spherical shape (non-embedded Inconel or Nitinol) or rectangular-shaped Titanium markers with embedded material have a clear advantage. 3D-shaped markers can always be detected in all three axes, which is of particular importance in the axilla with its pyramid shape and fatty tissue. CONCLUSION The shape and the embedding of the material play a crucial role for visibility and efficacy of the marker, as reliable marking of suspicious and pathological axillary lymph nodes is essential for TAD.
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Affiliation(s)
- Selin Guergan
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Uta Hoopmann
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Carmen Roehm
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Bettina Boeer
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Regina Fugunt
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Gisela Helms
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Anna Seller
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Mario Marx
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany.,Department of Plastic, Reconstructive and Breast Surgery, Elblandklinikum Radebeul, Radebeul, Germany
| | - Ernst Oberlechner
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Andreas Hartkopf
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Heike Preibsch
- Diagnostic and Interventional Radiology, University of Tübingen, Tübingen, Germany
| | - Sara Brucker
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Diethelm Wallwiener
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Markus Hahn
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Ines Verena Gruber
- Department for Women's Health, University of Tübingen, Calwerstraße 7, 72076, Tübingen, Germany.
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Breast and axillary surgery in malignant breast disease: a review focused on literature of 2018 and 2019. Curr Opin Obstet Gynecol 2021; 32:91-99. [PMID: 31833973 DOI: 10.1097/gco.0000000000000593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW There have been fundamental changes in the surgical approach to breast cancer management over the last decades. The primary objective of achieving locoregional control, however, remains unchanged. RECENT FINDINGS In addition to strategies optimizing systemic treatment and radiotherapy, current discussions focus on improving the surgical approach to breast cancer. Especially in view of the increasingly pivotal role of neoadjuvant chemotherapy NAT/NAC (NACT), gauging the extent of tissue removal in the breast and the width of resection margins in breast-conserving surgery is highly important, as is the extent of axillary surgery. Although sentinel lymph node (SLN)-positive patients always underwent axillary lymph node dissection in the past, this paradigm has been challenged in recent years. Targeted axillary dissection (TAD) has emerged as a new staging option in biopsy-proven node-positive patients who convert to clinical node negativity (cN0) after NACT. TAD combines the removal of the SLN and of the target lymph node marked prior to NACT. The accuracy of axillary staging both before and after NACT plays an important role for prognostication and multidisciplinary treatment plans, while its extent has significant effects on patients' arm morbidity and quality of life. SUMMARY The current review focuses on recent evidence regarding surgical management of the breast and axilla in patients with primary breast cancer based on a PubMed and EMBASE literature search for publication years 2018 and 2019.
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Gurleyik G, Aksu SA, Aker F, Tekyol KK, Tanrikulu E, Gurleyik E. Targeted axillary biopsy and sentinel lymph node biopsy for axillary restaging after neoadjuvant chemotherapy. Ann Surg Treat Res 2021; 100:305-312. [PMID: 34136426 PMCID: PMC8176200 DOI: 10.4174/astr.2021.100.6.305] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/26/2021] [Accepted: 03/23/2021] [Indexed: 01/09/2023] Open
Abstract
Purpose Accurate restaging of the axilla after neoadjuvant chemotherapy (NAC) is an important issue to ensure deescalating axillary surgery in patients with initial metastatic nodes. We aimed to present our results of targeted axillary biopsy (TAB) combined with sentinel lymph node biopsy (SLNB) for axillary restaging after NAC. Methods In 64 breast cancer patients who underwent NAC, biopsy-proven positive nodes were marked with clips before NAC, and ultrasound-guided wire localization of clip-marked nodes was performed after NAC. Patients underwent TAB and SLNB for post-NAC axilla restaging. Results Identification rates of post-NAC TAB and SLNB were 98.4% and 87.5%, respectively (P = 0.033). Histopathology revealed a nodal pathologic complete response (pCR) rate of 47% in which axillary lymph node dissection (ALND) was avoided. TAB alone and SLNB alone detected residual disease in 29 (85.3%) and 20 (58.8%) patients (P = 0.029), respectively. Whereas rates of up to 97% had been achieved with a combination of TAB and SLNB. The pCR rates after NAC were 64.3% for human epidermal growth factor receptor 2 positive and triple-negative tumors and 13.6% in luminal tumors (P = 0.0002). Conclusion Pathologic analysis following TAB combined with SLNB revealed the pCR rates to NAC in a considerable number of patients that provided de-escalation of axillary surgery. A combination of SLNB and TAB was found to be an accurate procedure in establishing residual nodal disease. This combined procedure in patients with initially positive nodes was a reliable method for post-NAC axillary restaging.
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Affiliation(s)
- Gunay Gurleyik
- Department of Surgery, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Sibel Aydin Aksu
- Department of Radiology, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Fügen Aker
- Department of Pathology, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Kubra Kaytaz Tekyol
- Department of Surgery, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Eda Tanrikulu
- Department of Surgery, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Emin Gurleyik
- Department of Surgery, Duzce University Medical Faculty, Duzce, Turkey
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Hartmann S, Stachs A, Schultek G, Gerber B, Reimer T. The Clinical Relevance of Target Lymph Node Biopsy after Primary Systemic Therapy in Initially Node-Positive Breast Cancer Patients. Cancers (Basel) 2021; 13:cancers13112620. [PMID: 34073547 PMCID: PMC8198475 DOI: 10.3390/cancers13112620] [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: 04/23/2021] [Revised: 05/16/2021] [Accepted: 05/23/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Currently, the optimal axillary surgical approach for breast cancer patients with initial node-positive disease and conversion to clinically node-negative status after primary systemic therapy is unclear. The aim of our study was to evaluate the clinical impact of removing the initially most suspicious, labeled axillary lymph node in addition to the sentinel lymph node. Metastatic target lymph nodes were found in five out of 63 patients (7.9%), while the sentinel lymph node was either tumor-free or not detected. The removal of the target lymph node influenced the adjuvant systemic therapy in only one case (1.6%). However, complete axillary dissection was indicated in all five cases. Furthermore, with fewer than three sentinel lymph nodes removed, the target lymph node reduced the false-negative rate to less than 10%. We therefore conclude that although the target lymph node has a minor impact on adjuvant systemic therapy, it is relevant for surgical axillary management. Abstract Purpose: To assess the impact of the removal of the target lymph node (TLN) on therapy after the completion of primary systemic therapy (PST) in initially node-positive breast cancer patients. Methods: Pooled data analysis of participants of the prospective CLIP- and TATTOO-study at the University of Rostock was performed. Results: A total of 75 patients were included; 63 of them (84.0%) converted to clinically node-negative after PST. Both TLN and sentinel lymph node (SLN) were identified in 41 patients (51.2%). In five out of 63 patients (7.9%), the TLN was metastatic after PST and the SLN was either tumor-free or not detected. Axillary lymph node dissection (ALND) was conducted in all five patients. In one patient, systemic therapy recommendation was influenced by the TLN; adjuvant radiotherapy was influenced by the TLN in zero patients. For patients with fewer than three removed SLNs, the FNR was 28.6% for the SLN biopsy alone and 7.1% for targeted axillary dissection (TAD). Conclusions: Removal of the TLN in addition to the SLN after PST has only minimal impact on the type of adjuvant systemic therapy and radiotherapy. However, the extent of axillary surgery was relevantly affected and FNR was improved by TAD.
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Arjmandi F, Mootz A, Farr D, Reddy S, Dogan B. New horizons in imaging and surgical assessment of breast cancer lymph node metastasis. Breast Cancer Res Treat 2021; 187:311-322. [PMID: 33982209 DOI: 10.1007/s10549-021-06248-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 04/29/2021] [Indexed: 01/09/2023]
Abstract
Axillary nodal status is one of the most important prognostic factors in breast cancer. While sentinel lymph node biopsy (SLNB) is a safe and validated procedure for clinically node-negative patients, axillary management of clinically node-positive patients has been more controversial. Patients with clinically detected axillary metastases often benefit from neoadjuvant chemotherapy (NAC). Those who convert to node-negative disease following NAC are important to identify, since they can often be spared significant morbidity from axillary dissection. SLNB has shown widely varying false-negative rates (FNR) but with the use of dual mapping and surgical biopsy of 3 or more nodes, it is considered an acceptable method to stage the axilla in clinically node-positive patients who receive NAC. Various methods including targeted axillary dissection (TAD) have been shown to decrease the FNR of SLNB. We will review appropriate methods to identify a metastatic node and subsequent ultrasound-guided biopsy with tissue marking techniques. We underscore key points in monitoring axillary response, techniques to accurately localize the biopsied and clipped known metastatic node for surgical excision and the effect of various methods in reducing the FNR of SLNB, including the emerging concept of TAD on patient care.
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Affiliation(s)
- Firouzeh Arjmandi
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA.
| | - Ann Mootz
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA
| | - Deborah Farr
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA
| | - Sangeetha Reddy
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA
| | - Basak Dogan
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA
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Hartmann S, Stachs A, Gerber B, Knauerhase H, Kamin F, Kundt G, Reimer T. Lost clips after targeted lymph node biopsy in breast cancer patients: Follow-up of the CLIP-study. Eur J Surg Oncol 2021; 47:1907-1912. [PMID: 33962833 DOI: 10.1016/j.ejso.2021.04.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/18/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Clipping and selective removal of axillary lymph nodes in breast cancer patients presenting with initially node-positive disease and achieving a nodal downstaging after primary systemic therapy is a less invasive method for axillary staging. An imaging guided localization and successful extirpation of these clipped lymph nodes is not possible in all patients. To date no follow-up data regarding patients with lost clips are available. MATERIAL AND METHODS The oncological outcome of all participants of the CLIP-study and the results of postoperative axillary imaging in those patients with unproven clip resection are presented. RESULTS A total of thirty patients were included into the pilot study. In ten of these patients (33%) the removal of the clipped axillary lymph node could not be verified by intraoperative radiograph. Postoperative imaging did not find lost clips in eight of these ten patients (80%). The lost clip was detected in two patients after surgery (20%), by mammography in one patient during routine follow-up and by computed tomography scan in one patient before radiotherapy. After a median follow-up of 40 months, 26 (87%) patients were still alive. Seven patients (23%) developed distant recurrent disease. No local or axillary recurrences were observed. CONCLUSION Lost clips were detected by postoperative imaging only in a minority of patients. The impact of lost clips on axillary recurrences in breast cancer patients is still unclear and should be further clarified in larger, multicentric trials.
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Affiliation(s)
- Steffi Hartmann
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany.
| | - Angrit Stachs
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Bernd Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Hellen Knauerhase
- Department of Radiotherapy and Radiation Oncology, University of Rostock, Rostock, Germany
| | - Frank Kamin
- Department of Pathology, Klinikum Südstadt, Rostock, Germany
| | - Günther Kundt
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, University of Rostock, Rostock, Germany
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
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Beniey M, Boulva K, Rodriguez-Qizilbash S, Kaviani A, Younan R, Patocskai E. Targeted Axillary Dissection in Node-Positive Breast Cancer: A Retrospective Study and Cost Analysis. Cureus 2021; 13:e14610. [PMID: 34040910 PMCID: PMC8139537 DOI: 10.7759/cureus.14610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Targeted axillary dissection (TAD) is a novel technique in the field of surgical oncology. During TAD, patients with node-positive breast cancer who clinically responded to neoadjuvant chemotherapy undergo resection of a previously proven metastatic node together with sentinel lymph node dissection (SLND). We aimed to assess the success rates of seed insertion and seed retrieval in the Canadian setting, as well as hospital costs of the procedure. Methods Patients converted to clinically node-negative status post-neoadjuvant chemotherapy underwent TAD. Before surgery, an iodine-125 radioactive seed was inserted in the previously proven metastatic node. The seed node was resected together with an SLND. Axillary lymph node dissection (ALND) was performed in all patients with residual metastases. Results Radioactive seeds were successfully inserted in 34/35 patients. In 34 patients, the targeted node was successfully resected with the radioactive probe during TAD. In one patient, the seed was retrieved inferiorly in the axilla during surgery. There was no adverse event. In total, 50% (17/34) of patients had no residual metastases and were able to avoid ALND. Eight out of 17 patients who underwent ALND did not have any residual disease in their specimen. The mean cost of TAD was 25% superior to the mean cost of ALND (p = 0.02). However, the mean total cost of the hospital stay for TAD was 20% superior to the mean cost of ALND (p = 0.11). The mean cost of TAD was 4,322 Can$ (Canadian dollars), similar to the mean cost of both ALND and SLND performed during the same procedure (4,479 Can$). Conclusions TAD was successful in 97% of patients. Despite increased procedural costs, with a lesser impact on total hospital stay costs, TAD was beneficial in 50% of patients. These patients avoided the unnecessary morbidity associated with ALND.
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Affiliation(s)
- Michèle Beniey
- Department of General Surgery, Université de Montréal, Montreal, CAN
| | - Kerianne Boulva
- Department of Surgical Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | | | - Ahmad Kaviani
- Department of Surgical Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Rami Younan
- Department of Surgical Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Erica Patocskai
- Department of Surgical Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
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Rebollo Aguirre AC, Fernández Fernández J, Sánchez Sánchez R, Mendoza Arnau I, Rivas Navas DJ, Martínez Meca S. Radioguided surgery with iodine-125 seeds in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2021; 41:S2253-654X(21)00067-6. [PMID: 33863696 DOI: 10.1016/j.remn.2021.02.017] [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: 01/29/2021] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the use of radioactive iodine-125 seed (RIS) in breast and/or axillary surgery, in patients with breast cancer treated with neoadjuvant chemotherapy (NAC). MATERIAL AND METHODS Prospective study between January 2016 and June 2020. 80 women T1-3,N0-2,M0: 30 RIS marking the breast tumor, 36 both the tumor and the biopsied positive axillary node, and 14 only the axilla. Age: 54.7±11.4 years. Tumor size: 34.1±14.6mm. Histological type: invasive ductal carcinoma 90.0%. Molecular subtypes: luminal-A 23.8%, luminal-B/HER2- 33.7%, luminal-B/HER2+ 18.8%, HER2+ 7.5%, basal-like 16,2%. RESULTS Of the 66 patients with RIS marking of the tumor (51 pre-NAC, 15 post-NAC), 92.1% had tumor-free surgical margins, with a specimen volume of 126.7±111.2 cm3. Of the 5 second local excisions, in 3 the resection margin was involved (1 mastectomy). Of the 50 patients N1 with RIS marking (MLN), 44 pre-NAC and 6 post-NAC, MLN was identified in 97.2%: negative 23, positive 26. In 45/50 patients, sentinel node biopsy (SNB) was performed and it was identified in 93.3%: negative 26, positive 16. In 1 case RIS was not placed correctly and SNB was not identified due to non-migration. In 61.9% of the patients, MLN was among the SNB identified in the surgery. In 5 patients with mismatched SNB and MLN, the pathological result of the SNB was negative and the MLN was positive. Axillary lymph node dissection was performed in 53.8% of the patients. CONCLUSION RIS allow to perform breast-conserving surgery and improve detection of residual axillary disease in patients treated with NAC.
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Affiliation(s)
- A C Rebollo Aguirre
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España.
| | - J Fernández Fernández
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - R Sánchez Sánchez
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - I Mendoza Arnau
- Servicio de Radiodiagnóstico. Hospital Universitario Virgen de las Nieves, Granada, España
| | - D J Rivas Navas
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - S Martínez Meca
- Servicio de Radiodiagnóstico. Hospital Universitario Virgen de las Nieves, Granada, España
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