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Whitrock JN, Carter MM, Leonard LD, Lewis JD, Shaughnessy EA, Heelan AA. Axillary management in breast cancer after neoadjuvant chemotherapy in the modern era: A national cancer database analysis. Surgery 2024; 175:687-694. [PMID: 37880050 DOI: 10.1016/j.surg.2023.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/27/2023] [Accepted: 08/08/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Axillary management for node-positive breast cancer continues to evolve. Data further supporting targeted axillary dissection after neoadjuvant chemotherapy was published in 2016 and may have induced changes in practice. METHODS Patients included in the National Cancer Database from 2014 to 2017 with clinical T1 to T4 and node-positive disease who underwent neoadjuvant chemotherapy before surgical axillary management were evaluated. Patients were divided into the following 3 groups: selective axillary dissection, minimal axillary dissection, and maximal axillary dissection, according to surgical axillary management and pathological node status. RESULTS Patients who underwent selective axillary dissection were younger (52.4 years ± 12.4, P < .0001) compared to maximal axillary dissection (55.1 ± 12.7) and minimal axillary dissection (54.6 ± 12.7). Patients with higher clinical stage more frequently underwent maximal axillary dissection, and those with lower tumor grade more frequently underwent minimal axillary dissection (P < .0001). Community cancer programs were more likely to perform maximal axillary dissection compared to all other types of programs and had the slowest rate of adoption of selective axillary dissection. Integrated Network Cancer Programs had the lowest proportion of maximal axillary dissection performed and the highest proportion of selective axillary dissection. Uninsured patients were more likely to receive maximal axillary dissection, and those with private insurance were more likely to undergo selective axillary dissection (P < .0001). Selective axillary dissection rates increased from 29.8% of procedures in 2016 to 41.5% in 2017, and MaxAD rates decreased from 62.4% in 2016 to 47.9% in 2017. CONCLUSION Utilization of selective axillary dissection has increased since 2016; however, discrepancies in surgical axillary management after neoadjuvant chemotherapy still exist.
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Affiliation(s)
- Jenna N Whitrock
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Michela M Carter
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Laura D Leonard
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jaime D Lewis
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Elizabeth A Shaughnessy
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Alicia A Heelan
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH.
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2
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Pantiora E, Eriksson S, Wärnberg F, Karakatsanis A. Magnetically guided surgery after primary systemic therapy for breast cancer: implications for enhanced axillary mapping. Br J Surg 2024; 111:znae008. [PMID: 38325801 PMCID: PMC10849829 DOI: 10.1093/bjs/znae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/06/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Superparamagnetic iron nanoparticles perform comparably to radioisotope ± blue dye for sentinel lymph node detection in breast cancer, even when injected up to 8 weeks before surgery. Using superparamagnetic iron nanoparticles for sentinel lymph node detection after primary systemic therapy, and the maximum time frame of superparamagnetic iron nanoparticle administration have not been investigated. METHODS This cohort study included cN0/1-to-ycN0 patients undergoing sentinel lymph node detection or targeted axillary dissection. All patients received superparamagnetic iron nanoparticles either before primary systemic therapy or before surgery, and radioisotope on the day of surgery. RESULTS For 113 patients analysed, superparamagnetic iron nanoparticles were injected a median of 3 (range 0-248) days before surgery, with a 97.4% detection rate compared with 91.2% for radioisotope (P = 0.057). Concordance for radioisotope was 97.1% and this was not affected by timing of superparamagnetic iron nanoparticle injection (Kendall's tau 0.027; P = 0.746). The median sentinel lymph node yield was 3 (interquartile range (i.q.r.) 2-3) for superparamagnetic iron nanoparticles and 2 (i.q.r. 2-3) for radioisotope (P < 0.001). In targeted axillary dissection, detection was 100% for superparamagnetic iron nanoparticles and 81.8% for radioisotope (P = 0.124). The index node was magnetic in 93.9% and radioactive in 66.7% (P = 0.007), an outcome that was not affected by any factors. For patients with metastases, superparamagnetic iron nanoparticle detection was 100% and radioisotope-based detection was 84.2% (P = 0.083), with superparamagnetic iron nanoparticles detecting more metastatic sentinel lymph nodes (median of 1 (i.q.r. 1-2) for superparamagnetic iron nanoparticles compared with a median of 1 (i.q.r. 0-1) for radioisotope; P = 0.005). CONCLUSION Injection before primary systemic therapy is feasible and does not affect concordance with radioisotope. Superparamagnetic iron nanoparticles perform comparably to radioisotope, but detect more sentinel lymph nodes and have a higher rate of detection of metastatic sentinel lymph nodes.
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Affiliation(s)
- Eirini Pantiora
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Section for Breast Surgery, Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Staffan Eriksson
- Centre for Clinical Research, Department of Surgical Sciences, Uppsala University, Västerås, Sweden
- Section for Breast Surgery, Department of Surgery, Västmanlands County Hospital, Västerås, Sweden
| | - Fredrik Wärnberg
- Sahlgrenska Centre for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Karakatsanis
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Section for Breast Surgery, Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
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Slavu IM, Tulin A, Filipoiu F, Dogaru A, Munteanu O, Anca Monica OM, Tulin R, Ursut B. Axillary Lymphadenectomy: Safe Dissection Through a Correct Technique. Cureus 2024; 16:e52434. [PMID: 38371030 PMCID: PMC10870804 DOI: 10.7759/cureus.52434] [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] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
The primary treatment of breast cancer in sentinel-positive ganglia includes axillary lymphatic nodal dissection. The LAD (lymphatic axillary dissection) has decreased in overall numbers but due to the increasing incidence of breast cancer, it is practised on a daily basis, even though there is a myriad of complications such as numbness of the upper limb and chest wall, movement restriction of the upper limb, and chronic pain which appear due to trauma to the nerves which pass through the axilla. However, the utility in the overall survival or DFS (disease-free survival) of the patient is unquestionable. In our study, through the dissection of cadavers, we exposed the vital structures and the anatomical relations of this region. We aimed to offer a map or technique for the surgeon to follow to decrease the overall morbidity of this procedure.
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Affiliation(s)
- Iulian M Slavu
- Anatomy, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Adrian Tulin
- General Surgery, Agrippa Ionescu Emergency Hospital, Bucharest, ROU
| | - Florin Filipoiu
- Anatomy, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Alexandru Dogaru
- General Surgery, Agrippa Ionescu Emergency Hospital, Bucharest, ROU
| | - Octavian Munteanu
- Obstetrics and Gynaecology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | | | - Raluca Tulin
- Anatomy and Embryology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Endocrinology, Agrippa Ionescu Emergency Hospital, Bucharest, ROU
| | - Bogdan Ursut
- General Surgery, Agrippa Ionescu Emergency Hospital, Bucharest, ROU
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Galaychuk I. REPEATED BREAST-CONSERVING SURGERIES AS REFLECTION OF THE EVOLUTION IN BREAST CANCER TREATMENT (CASE REPORT WITH LITERATURE REVIEW). Exp Oncol 2023; 45:386-392. [PMID: 38186016 DOI: 10.15407/exp-oncology.2023.03.386] [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: 12/28/2023] [Indexed: 01/09/2024]
Abstract
The clinical case of a patient with multicentric breast cancer who underwent organ-sparing surgery after neoadjuvant chemo-radiation therapy is presented. An ipsilateral cancer recurrence was diagnosed 8 years after the first operation. The repeated organ-sparing surgery (lumpectomy) was done with a good cosmetic result and without disease progression during 1-year follow-up. The literature review shows that neoadjuvant systemic therapy accounting for molecular subtypes of cancer has radically changed breast cancer surgeries. The evolution of surgical approaches in stage I-II breast cancer patients consists in the de-escalation of surgery from mastectomy to organsparing or oncoplastic surgery, minimally directed surgery, and repeated breast-conserving surgery. De-escalation of surgical interventions in the area of the regional lymphatic collector consists in the transition from total axillary lymphatic dissection to sentinel lymph node biopsy or targeted removal of metastatic lymph nodes. The repeated breast-conserving surgery can be safely performed for ipsilateral recurrence in patients with all molecular subtypes of breast cancer.
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Affiliation(s)
- I Galaychuk
- I. Horbachevsky National Medical University, Ternopil, Ukraine
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5
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Woodfin AA, Caudle AS. Evidence-Based Strategies to Minimize the Likelihood of Axillary Lymph Node Dissection in Clinically Node-Positive Patients Following Neoadjuvant Chemotherapy. Surg Oncol Clin N Am 2023; 32:693-703. [PMID: 37714637 DOI: 10.1016/j.soc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
De-escalation of axillary management after neoadjuvant chemotherapy in clinically node-positive patients is feasible. The current literature shows this may be accomplished by sentinel lymph node biopsy (SLNB) with the use of dual tracer and removal of at least 2 sentinel lymph nodes, or by targeted axillary dissection (TAD). The accuracy of TAD has been consistently shown as better than that of SLNB. However, these techniques should only be offered to select patients without extensive axillary disease, understanding that long-term outcomes of minimal axillary surgery in this population are limited at this time.
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Affiliation(s)
- Ashley A Woodfin
- MD Anderson Cancer Center, Breast Surgical Oncology, 1515 Holcombe Boulevard, Houston TX 77030, USA
| | - Abigail S Caudle
- MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston TX 77030-4009, USA.
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6
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Ferrarazzo G, Nieri A, Firpo E, Rattaro A, Mignone A, Guasone F, Manzara A, Perniciaro G, Spinaci S. The Role of Sentinel Lymph Node Biopsy in Breast Cancer Patients Who Become Clinically Node-Negative Following Neo-Adjuvant Chemotherapy: A Literature Review. Curr Oncol 2023; 30:8703-8719. [PMID: 37887530 PMCID: PMC10605278 DOI: 10.3390/curroncol30100630] [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: 08/19/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND In clinically node-positive (cN+) breast cancer (BC) patients who become clinically node-negative (cN0) following neoadjuvant chemotherapy (NACT), sentinel lymph node biopsy (SLNB) after lymphatic mapping with lymphoscintigraphy is not widely accepted; therefore, it has become a topic of international debate. OBJECTIVE Our literature review aims to evaluate the current use of this surgical practice in a clinical setting and focuses on several studies published in the last six years which have contributed to the assessment of the feasibility and accuracy of this practice, highlighting its importance and oncological safety. We have considered the advantages and disadvantages of this technique compared to other suggested methods and strategies. We also evaluated the role of local irradiation therapy after SLNB and state-of-the-art SLN mapping in patients subjected to NACT. METHODS A comprehensive search of PubMed and Cochrane was conducted. All studies published in English from 2018 to August 2023 were evaluated. RESULTS Breast units are moving towards a de-escalation of axillary surgery, even in the NACT setting. The effects of these procedures on local irradiation are not very clear. Several studies have evaluated the oncological outcome of SLNB procedures. However, none of the alternative techniques proposed to lower the false negative rate (FNR) of SLNB are significant in terms of prognosis. CONCLUSIONS Based on these results, we can state that lymphatic mapping with SLNB in cN+ BC patients who become clinically node-negative (ycN0) following NACT is a safe procedure, with a good prognosis and low axillary failure rates.
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Affiliation(s)
- Giulia Ferrarazzo
- Nuclear Medicine, Ospedale Villa Scassi ASL3, 16149 Genova, Italy; (A.M.); (A.M.)
| | - Alberto Nieri
- Nuclear Medicine Unit, Oncological Medical and Specialist Department, University Hospital of Ferrara, 44124 Cona, Italy;
| | - Emma Firpo
- Breast Surgery, Department of Surgery, Ospedale Villa Scassi ASL3, 16149 Genova, Italy; (E.F.); (A.R.); (F.G.)
| | - Andrea Rattaro
- Breast Surgery, Department of Surgery, Ospedale Villa Scassi ASL3, 16149 Genova, Italy; (E.F.); (A.R.); (F.G.)
| | - Alessandro Mignone
- Nuclear Medicine, Ospedale Villa Scassi ASL3, 16149 Genova, Italy; (A.M.); (A.M.)
| | - Flavio Guasone
- Breast Surgery, Department of Surgery, Ospedale Villa Scassi ASL3, 16149 Genova, Italy; (E.F.); (A.R.); (F.G.)
| | - Augusto Manzara
- Nuclear Medicine, Ospedale Villa Scassi ASL3, 16149 Genova, Italy; (A.M.); (A.M.)
| | - Giuseppe Perniciaro
- Division of Plastic and Reconstructive Surgery, Burn Unit, Ospedale Villa Scassi ASL3, 16149 Genova, Italy;
| | - Stefano Spinaci
- Breast Unit, Department of Surgery, Ospedale Villa Scassi ASL3, 16149 Genova, Italy;
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7
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Ryan JF, Lesniak DM, Cordeiro E, Campbell SM, Rajaee AN. Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist. Ann Surg Oncol 2023; 30:4695-4713. [PMID: 37036590 DOI: 10.1245/s10434-023-13472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist. METHODS A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis. RESULTS A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies). CONCLUSIONS On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - David M Lesniak
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Erin Cordeiro
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - A Nikoo Rajaee
- Department of Surgery, University of Alberta, Edmonton, Canada.
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8
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Munoz P, Corral S, Martínez-Regueira F, Paz A, Muñoz-Madero V, Mena A, Cabañas J, Rivas S. Axillary staging and management of cN + breast cancer patients treated with neoadjuvant chemotherapy: results of a survey among breast cancer surgeons in Spain. CLINICAL & TRANSLATIONAL ONCOLOGY : OFFICIAL PUBLICATION OF THE FEDERATION OF SPANISH ONCOLOGY SOCIETIES AND OF THE NATIONAL CANCER INSTITUTE OF MEXICO 2022; 25:1463-1471. [PMID: 36586064 DOI: 10.1007/s12094-022-03049-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/12/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Given the high rate of complete nodal response, the role of axillary lymph node dissection on staging the axilla has been questioned. This survey, addressed to breast cancer surgeons in Spain, has the objective of assessing current clinical trends on axillary staging of cN + patients treated with NAC. METHODS An online survey was conducted among breast surgeons from the Spanish Society of Surgery (AEC), Spanish Surgical Oncology Society (SEOQ), Spanish Breast Cancer Surgeons Society (AECIMA) and Spanish Gynecology and Obstetrics Society (SEGO). It was structured in 5 sections: general information and clinical practice, knowledge of clinical trials, diagnosis work-up and nodal marking, axillary staging, and axillary treatment. RESULTS 150 breast cancer surgeons completed the full survey (96.7%). 81.8% of respondents performed SLNB or targeted axillary dissection in cN1 patients treated with NAC. Radiological axillary response was the preferred parameter guiding the surgical strategy. The excision of the clipped node (92.0%), use of dual tracer (73.2%), and axillary US (65.9%) after treatment were the most important variables considered by respondents, to increase the accuracy of SLNB in cN + patients. CONCLUSION This survey confirms a trend toward a less invasive approach for axillary staging in cN + patients treated with NAC among breast cancer surgeons in Spain. While there is widespread agreement in less invasive approaches to axillary staging, there is, however, a lack of consensus around treatment strategy. Further, it shows a wide heterogeneity in their clinical practice. This study highlights the need for clear evidence concerning less invasive staging procedures and their oncological safety, to ensure consistent recommendations in surgical practice.
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Affiliation(s)
- Paula Munoz
- General and Digestive Surgery, Hospital Quironsalud Torrevieja, Torrevieja, Alicante, Spain.
| | - Sara Corral
- General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Alejandro Paz
- General and Digestive Surgery, Hospital Quironsalud Torrevieja, Torrevieja, Alicante, Spain
| | - Vicente Muñoz-Madero
- General and Digestive Surgery, Hospital Quironsalud Torrevieja, Torrevieja, Alicante, Spain
| | - Antonio Mena
- General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Jacobo Cabañas
- General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Sonia Rivas
- General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Gwark S, Kim HJ, Kim J, Chung IY, Kim HJ, Ko BS, Lee JW, Son BH, Ahn SH, Lee SB. Survival After Breast-Conserving Surgery Compared with that After Mastectomy in Breast Cancer Patients Receiving Neoadjuvant Chemotherapy. Ann Surg Oncol 2022; 30:2845-2853. [PMID: 36577865 DOI: 10.1245/s10434-022-12993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 12/04/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Breast-conserving surgery (BCS) plus radiotherapy (BCS + RT) has been shown to improve survival compared with mastectomy in patients with early breast cancer; however, whether this superiority is maintained in breast cancer patients receiving neoadjuvant chemotherapy (NCT) is unclear. We evaluated and compared the survival outcomes after BCS + RT and mastectomy in Korean women with breast cancer treated with NCT. METHODS We evaluated 1641 patients who received NCT before surgery (BCS or mastectomy). We performed propensity score matching to minimize potential bias due to factors other than the surgical method and compared the 5-year, disease-free survival (DFS), distant metastasis-free survival (DMFS), and overall survival (OS) rates before and after exact matching. RESULTS Among the 1641 patients, 839 (51.1%) underwent BCS + RT and 802 (48.9%) underwent mastectomy. Patients who underwent mastectomy had larger tumors and more frequently had positive nodes. For BCS+RT and mastectomy, the unadjusted 5-year DFS, 5-year DMFS, and 5-year OS rates were 87.0% and 73.1%, 89.5% and 77.0%, and 91.8% and 81.0%, respectively (all p < 0.05 = 0.000). After PSM, 5-year DFS, 5-year DMFS, and 5-year OS rates for BCS + RT and mastectomy were 87.6% and 69.1%, 89.7% and 76.0%, and 89.1% and 75.7%, respectively (all p < 0.05). In both unadjusted and adjusted analyses accounting for various confounding factors, BCS + RT was significantly associated with improved DFS (p < 0.05), DMFS (p < 0.05), and OS (p < 0.05) rates compared with mastectomy. CONCLUSIONS BCS + RT does not impair DFS and OS in patients treated with NCT. Tumor biology and treatment response are significant prognostic indicators. Our results suggest that BCS + RT may be preferred in most breast cancer patients when both BCS and mastectomy are suitable.
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Affiliation(s)
- Sungchan Gwark
- Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Hwa Jung Kim
- Department of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jisun Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Il Yong Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Jeong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Beom Seok Ko
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Won Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Ho Son
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sei Hyun Ahn
- Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Sae Byul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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10
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Galimberti V, Ribeiro Fontana SK, Vicini E, Morigi C, Sargenti M, Corso G, Magnoni F, Intra M, Veronesi P. "This house believes that: Sentinel node biopsy alone is better than TAD after NACT for cN+ patients". Breast 2022; 67:21-25. [PMID: 36566690 PMCID: PMC9803818 DOI: 10.1016/j.breast.2022.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
The increased use of neoadjuvant chemotherapy (NACT) has changed the approach to breast surgery. NACT allows de-escalation of surgery by both increasing breast conservation rates (up to 40%), the initial goal of this chemotherapy, and in particular it permits reduces axillary surgery. Furthermore, in relation to the molecular characteristics of the tumor we can have a pathological complete response (pCR) ranging from 20 to 80%. In clinically node positive (cN+) patients who converted to clinically node-negative (cN0) various prospective studies have demonstrated that the false negative rate (FNR) of the sentinel node biopsy (SNB) were higher than the acceptable 10% and strategies to reduce the FNR in cN + patients are being investigated. But all the effort to reduce the FNR does not have clinical prognostic significance. This has already been demonstrated in the literature in different randomized trials with long term follow up. The 10-year follow-up of our study confirmed our preliminary data that the use of standard SNB without the use of clip is acceptable in cN1/2 patients who become cN0 after NAT and will not translate into a worse outcome. In fact, the axillary recurrences were less than 2%. Similar positive data with different follow up were also confirmed by other studies that used SNB alone without TAD. All these studies, with encouraging results on the follow up, confirm that SN surgery alone for selected patients who have an excellent response to NACT is rationale and not oncologically inferior to AD during a short- and long-term follow-up.
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Affiliation(s)
- Viviana Galimberti
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy.
| | | | - Elisa Vicini
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Consuelo Morigi
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Manuela Sargenti
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Giovanni Corso
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy,University of Milan School of Medicine, Milan, Italy
| | - Francesca Magnoni
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy,University of Milan School of Medicine, Milan, Italy
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11
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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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12
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Gwark S, Ahn HS, Yeom J, Yu J, Oh Y, Jeong JH, Ahn JH, Jung KH, Kim SB, Lee HJ, Gong G, Lee SB, Chung IY, Kim HJ, Ko BS, Lee JW, Son BH, Ahn SH, Kim K, Kim J. Plasma Proteome Signature to Predict the Outcome of Breast Cancer Patients Receiving Neoadjuvant Chemotherapy. Cancers (Basel) 2021; 13:6267. [PMID: 34944885 PMCID: PMC8699627 DOI: 10.3390/cancers13246267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 12/31/2022] Open
Abstract
The plasma proteome of 51 non-metastatic breast cancer patients receiving neoadjuvant chemotherapy (NCT) was prospectively analyzed by high-resolution mass spectrometry coupled with nano-flow liquid chromatography using blood drawn at the time of diagnosis. Plasma proteins were identified as potential biomarkers, and their correlation with clinicopathological variables and survival outcomes was analyzed. Of 51 patients, 20 (39.2%) were HR+/HER2-, five (9.8%) were HR+/HER2+, five (9.8%) were HER2+, and 21 (41.2%) were triple-negative subtype. During a median follow-up of 52.0 months, there were 15 relapses (29.4%) and eight deaths (15.7%). Four potential biomarkers were identified among differentially expressed proteins: APOC3 had higher plasma concentrations in the pathological complete response (pCR) group, whereas MBL2, ENG, and P4HB were higher in the non-pCR group. Proteins statistically significantly associated with survival and capable of differentiating low- and high-risk groups were MBL2 and P4HB for disease-free survival, P4HB for overall survival, and MBL2 for distant metastasis-free survival (DMFS). In the multivariate analysis, only MBL2 was a consistent risk factor for DMFS (HR: 9.65, 95% CI 2.10-44.31). The results demonstrate that the proteomes from non-invasive sampling correlate with pCR and survival in breast cancer patients receiving NCT. Further investigation may clarify the role of these proteins in predicting prognosis and thus their therapeutic potential for the prevention of recurrence.
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Affiliation(s)
- Sungchan Gwark
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul 07985, Korea;
| | - Hee-Sung Ahn
- Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Korea; (H.-S.A.); (J.Y.); (Y.O.)
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Korea;
| | - Jeonghun Yeom
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Korea;
| | - Jiyoung Yu
- Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Korea; (H.-S.A.); (J.Y.); (Y.O.)
| | - Yumi Oh
- Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Korea; (H.-S.A.); (J.Y.); (Y.O.)
- Department of Biomedical Sciences, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.J.); (J.-H.A.); (K.H.J.); (S.-B.K.)
| | - Jin-Hee Ahn
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.J.); (J.-H.A.); (K.H.J.); (S.-B.K.)
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.J.); (J.-H.A.); (K.H.J.); (S.-B.K.)
| | - Sung-Bae Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.J.); (J.-H.A.); (K.H.J.); (S.-B.K.)
| | - Hee Jin Lee
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (H.J.L.); (G.G.)
| | - Gyungyub Gong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (H.J.L.); (G.G.)
| | - Sae Byul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.B.L.); (I.Y.C.); (H.J.K.); (B.S.K.); (J.W.L.); (B.H.S.); (S.H.A.)
| | - Il Yong Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.B.L.); (I.Y.C.); (H.J.K.); (B.S.K.); (J.W.L.); (B.H.S.); (S.H.A.)
| | - Hee Jeong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.B.L.); (I.Y.C.); (H.J.K.); (B.S.K.); (J.W.L.); (B.H.S.); (S.H.A.)
| | - Beom Seok Ko
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.B.L.); (I.Y.C.); (H.J.K.); (B.S.K.); (J.W.L.); (B.H.S.); (S.H.A.)
| | - Jong Won Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.B.L.); (I.Y.C.); (H.J.K.); (B.S.K.); (J.W.L.); (B.H.S.); (S.H.A.)
| | - Byung Ho Son
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.B.L.); (I.Y.C.); (H.J.K.); (B.S.K.); (J.W.L.); (B.H.S.); (S.H.A.)
| | - Sei Hyun Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.B.L.); (I.Y.C.); (H.J.K.); (B.S.K.); (J.W.L.); (B.H.S.); (S.H.A.)
| | - Kyunggon Kim
- Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Korea; (H.-S.A.); (J.Y.); (Y.O.)
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Korea;
- Department of Biomedical Sciences, University of Ulsan College of Medicine, Seoul 05505, Korea
- Clinical Proteomics Core Laboratory, Convergence Medicine Research Center, Asan Medical Center, Seoul 05505, Korea
- Bio-Medical Institute of Technology, Asan Medical Center, Seoul 05505, Korea
| | - Jisun Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.B.L.); (I.Y.C.); (H.J.K.); (B.S.K.); (J.W.L.); (B.H.S.); (S.H.A.)
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Rauch GM, Kuerer HM, Jochelson MS. To Look or Not to Look? Yes to Nodal Ultrasound! JOURNAL OF BREAST IMAGING 2021; 3:659-665. [PMID: 38424935 DOI: 10.1093/jbi/wbab079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Indexed: 03/02/2024]
Abstract
Knowledge of axillary nodal status is highly important for correct staging and treatment planning in patients with breast cancer. Axillary US is a recognized highly specific and cost-effective tool for assessing nodal status and guiding appropriate treatment. Axillary US imaging with US-guided biopsy is routinely performed throughout the world. However, because of recent developments in the surgical management of the axilla in patients with newly diagnosed breast cancer (American College of Surgeons Oncology Group [ACOSOG] Z0011 trial) and in patients with breast cancer receiving neoadjuvant systemic therapy (ACOSOG Z1071, SENTinel NeoAdjuvant [SENTINA] and Sentinel Node biopsy aFter NeoAdjuvant Chemotherapy [SN FNAC] trials), some have questioned the utility of axillary US for nodal staging. Here, we review the evidence to date supporting the additional value of axillary US for patients with breast cancer. Nodal US in patients with newly diagnosed breast cancer is useful for staging; in a significant proportion of patients, nodal US identifies additional axillary level II or level III nodal disease, which allows for appropriate treatment of disease. Furthermore, ongoing clinical trials may show that axillary surgery can be omitted in patients with negative findings on axillary US. In patients with lymph node-positive disease undergoing neoadjuvant systemic therapy, nodal US can guide the approach to axillary surgery. A more personalized patient approach, taking into the account tumor biology, among other factors, may help to mitigate the controversy surrounding the role of axillary US in breast cancer patients.
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Affiliation(s)
- Gaiane M Rauch
- The University of Texas MD Anderson Cancer Center, Departments of Abdominal and Breast Imaging, Houston, TX, USA
| | - Henry M Kuerer
- The University of Texas MD Anderson Cancer Center, Department of Breast Surgical Oncology, Houston, TX, USA
| | - Maxine S Jochelson
- Memorial Sloan Kettering Cancer Center, Department of Diagnostic Radiology, New York City, NY, USA
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14
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Moo TA, Pawloski KR, Flynn J, Edelweiss M, Le T, Tadros A, Barrio AV, Morrow M. Is Residual Nodal Disease at Axillary Dissection Associated with Tumor Subtype in Patients with Low Volume Sentinel Node Metastasis After Neoadjuvant Chemotherapy? Ann Surg Oncol 2021; 28:6044-6050. [PMID: 33876362 DOI: 10.1245/s10434-021-09910-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/11/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In patients with a positive sentinel lymph node (SLN) after neoadjuvant chemotherapy (NAC), the likelihood of residual nodal disease at axillary dissection (ALND) is high. Whether non-SLN metastasis frequency varies based on tumor subtype and SLN metastasis size is uncertain. We examined the association between tumor subtype and frequency of non-SLN metastases in patients with SLN micro- vs macrometastases after NAC. METHODS Patients with invasive breast cancer and a positive SLN biopsy after NAC between July 2008 and July 2019 were identified. Associations between tumor subtype, SLN disease volume, and frequency of non-SLN metastases were examined. RESULTS Among 273 patients with ≥ 1 positive SLN and a completion ALND, mean age was 51 years, 87% of tumors were ductal, 80% were clinically node-positive at presentation, and 85% were cT2-3. The frequency of non-SLN metastases was non-significantly higher in HR+/HER2- (61%) vs. HER2+ (52%) and triple negative tumors (45%) (p = 0.09). Frequency of SLN micrometastasis was 9% for triple negative tumors compared with 17% for HR+/HER2- and 34% for HER2+ tumors (p = 0.015). Size of SLN metastasis (micro- vs. macrometastases) was not associated with non-SLN metastasis frequency or number within any subtype. CONCLUSIONS In patients with a positive SLN after NAC, the likelihood of non-SLN metastasis at ALND was high across all tumor subtypes and did not vary significantly for SLN micro- versus macrometastases. ALND is recommended for SLN micro- and macrometastases after NAC, irrespective of tumor subtype.
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Affiliation(s)
- Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jessica Flynn
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marcia Edelweiss
- Diagnostic Cytology and Breast Pathology Services, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tiana Le
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree Tadros
- Breast Service, Department of Surgery, 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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15
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Gwark S, Ahn SH, Noh WC, Lee ES, Jung Y, Kim LS, Han W, Nam SJ, Gong G, Kim SO, Kim HJ. Patient-Reported Outcomes From Phase III Neoadjuvant Systemic Trial Comparing Neoadjuvant Chemotherapy With Neoadjuvant Endocrine Therapy in Pre-Menopausal Patients With Estrogen Receptor-Positive and HER2-Negative, Lymph Node-Positive Breast Cancer. Front Oncol 2021; 11:608207. [PMID: 34277393 PMCID: PMC8284076 DOI: 10.3389/fonc.2021.608207] [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: 09/19/2020] [Accepted: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
We aimed to evaluate the patient-reported outcomes (PROs) in a prospective phase III clinical trial, comparing neoadjuvant endocrine therapy (NET) with conventional neoadjuvant chemotherapy (NCT) in patients with hormone status positive, lymph node-positive premenopausal breast cancer (NCT01622361). The patients were randomized prospectively to either 24 weeks of NCT with adriamycin plus cyclophosphamide followed by taxane or NET with gonadotropin-releasing hormone agonist and tamoxifen. The patients were examined at the surgery unit of a large tertiary care hospital with a comprehensive cancer center. PROs were assessed on the first day of the trial (day 1, baseline) and at the end of treatment, using the breast cancer module of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 23 (EORTC QLQ BR23). One hundred and eighty-seven patients were randomly assigned to chemotherapy (n=95) or endocrine therapy (n=92), and 174 patients completed 24 weeks of the neoadjuvant treatment period (n=87, in each group). Baseline scores were similar between the groups. After treatment, there were no statistically significant differences in the function scales, including body image, sexual functioning, and sexual enjoyment between the groups, although the endocrine treatment group showed a significant improvement in the future perspective (hazard ratio, 8.3; 95% confidence interval, 1.72-18.38; P = 0.021). Similarly, there were no statistically significant differences in the symptom scales between the groups, including adverse effects of systemic therapy, breast symptoms, arm symptoms, and upset about hair loss. In conclusion, overall PROs were similar in both treatment groups, except for "future perspective," which was significantly better in the NET group than in the NCT group. CLINICAL TRIAL REGISTRATION ClinicalTrials.Gov, identifier NCT01622361.
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Affiliation(s)
- Sungchan Gwark
- Department of Surgery, College of Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Sei Hyun Ahn
- Department of Surgery, College of Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Woo Chul Noh
- Department of Surgery, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Eun Sook Lee
- Department of Surgery, Center for Breast Cancer, Research and Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Yongsik Jung
- Department of Surgery, School of Medicine, Ajou University, Suwon, South Korea
| | - Lee Su Kim
- Division of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Hallym University, Anyang, South Korea
| | - Wonshik Han
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, Seoul, South Korea
| | - Seok Jin Nam
- Department of Surgery, School of Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
| | - Gyungyub Gong
- Department of Pathology, College of Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, South Korea
| | - Hee Jeong Kim
- Department of Surgery, College of Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
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16
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Samiei S, Simons JM, Engelen SME, Beets-Tan RGH, Classe JM, Smidt ML. Axillary Pathologic Complete Response After Neoadjuvant Systemic Therapy by Breast Cancer Subtype in Patients With Initially Clinically Node-Positive Disease: A Systematic Review and Meta-analysis. JAMA Surg 2021; 156:e210891. [PMID: 33881478 PMCID: PMC8060891 DOI: 10.1001/jamasurg.2021.0891] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/16/2021] [Indexed: 12/18/2022]
Abstract
Importance An overview of rates of axillary pathologic complete response (pCR) for all breast cancer subtypes, both for patients with and without pathologically proven clinically node-positive disease, is lacking. Objective To provide pooled data of all studies in the neoadjuvant setting on axillary pCR rates for different breast cancer subtypes in patients with initially clinically node-positive disease. Data Sources The electronic databases Embase and PubMed were used to conduct a systematic literature search on July 16, 2020. The references of the included studies were manually checked to identify other eligible studies. Study Selection Studies in the neoadjuvant therapy setting were identified regarding axillary pCR for different breast cancer subtypes in patients with initially clinically node-positive disease (ie, defined as node-positive before the initiation of neoadjuvant systemic therapy). Data Extraction and Synthesis Two reviewers independently selected eligible studies according to the inclusion criteria and extracted all data. All discrepant results were resolved during a consensus meeting. To identify the different subtypes, the subtype definitions as reported by the included articles were used. The random-effects model was used to calculate the overall pooled estimate of axillary pCR for each breast cancer subtype. Main Outcomes and Measures The main outcome of this study was the rate of axillary pCR and residual axillary lymph node disease after neoadjuvant systemic therapy for different breast cancer subtypes, differentiating studies with and without patients with pathologically proven clinically node-positive disease. Results This pooled analysis included 33 unique studies with 57 531 unique patients and showed the following axillary pCR rates for each of the 7 reported subtypes in decreasing order: 60% for hormone receptor (HR)-negative/ERBB2 (formerly HER2)-positive, 59% for ERBB2-positive (HR-negative or HR-positive), 48% for triple-negative, 45% for HR-positive/ERBB2-positive, 35% for luminal B, 18% for HR-positive/ERBB2-negative, and 13% for luminal A breast cancer. No major differences were found in the axillary pCR rates per subtype by analyzing separately the studies of patients with and without pathologically proven clinically node-positive disease before neoadjuvant systemic therapy. Conclusions and Relevance The HR-negative/ERBB2-positive subtype was associated with the highest axillary pCR rate. These data may help estimate axillary treatment response in the neoadjuvant setting and thus select patients for more or less invasive axillary procedures.
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Affiliation(s)
- Sanaz Samiei
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- GROW–School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Janine M. Simons
- GROW–School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Sanne M. E. Engelen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Regina G. H. Beets-Tan
- GROW–School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
- Department of Radiology, the Netherlands Cancer Institute, Amsterdam
| | - Jean-Marc Classe
- Department of Surgical Oncology, Institut de Cancérologie de l’Ouest, Saint-Herblain, Loire Atlantique, France
| | - Marjolein L. Smidt
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- GROW–School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
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Chun JW, Kim J, Chung IIY, Ko BS, Kim HJ, Lee JW, Son BH, Ahn SH, Lee SB. Comparison of survival outcomes for axillary surgery extent based on intraoperative sentinel lymph node biopsy result after neoadjuvant chemotherapy for breast cancer. Breast Cancer Res Treat 2021; 187:647-655. [PMID: 33966181 DOI: 10.1007/s10549-021-06249-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/29/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the survival difference between limited axillary surgery and full axillary lymph node dissection (ALND) in patients with 1-3 positive sentinel lymph node biopsies (SLNBs) after neoadjuvant chemotherapy (NAC). METHOD We retrospectively analyzed data from 676 patients who underwent surgery between 2007 and 2017 with cT1-4, cN0-3, cM0 breast cancer at the time of diagnosis and 1-3 positive SLNBs after NAC. The patients received either SLNB only or completed level I or II ALND based on SLNB results. After propensity score matching, 483 patients who had undergone SLNB only (n = 188) and ALND (n = 295) were included. We examined overall survival, axillary recurrence-free survival, regional recurrence-free survival, and distant metastasis-free survival and compared them between the subgroups. RESULT At a median follow-up of 59.4 months, no significant statistical difference was observed in overall survival, axillary recurrence-free survival, regional recurrence-free survival, and distant metastasis-free survival between SLNB only and ALND. No significant differences were observed in the 5-year axillary recurrence-free survival (93.1% vs. 94.0%, hazard ratio [HR] = 0.94, 95% confidence interval [CI] = 0.43-2.05, p = 0.876) and 5-year overall survival (97.7% vs. 97.3%, HR = 1.65, 95% CI = 0.58-4.65, p = 0.347) between the two groups. CONCLUSION Our analysis suggests that SLNB alone may be a possible option for patients with 1-3 sentinel node-positive breast cancer following NAC without significant compromise of recurrence or overall survival.
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Affiliation(s)
- Jung Whan Chun
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jisun Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - I I Yong Chung
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Beom Seok Ko
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Hee Jeong Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jong Won Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Byung Ho Son
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Sei-Hyun Ahn
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Sae Byul Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
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18
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Chun JW, Kim J, Chung IY, Ko BS, Kim HJ, Lee JW, Son BH, Ahn SH, Lee SB. Sentinel node biopsy alone for breast cancer patients with residual nodal disease after neoadjuvant chemotherapy. Sci Rep 2021; 11:9056. [PMID: 33907236 PMCID: PMC8079673 DOI: 10.1038/s41598-021-88442-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
For residual N1 nodal disease following neoadjuvant chemotherapy (NAC) for patients with breast cancer, the optimal local therapy for axilla is an evolving area. We analyzed the long-term results of these patients according to axillary surgical methods using propensity score matching (PSM) to clarify whether omission of axillary lymph node dissection (ALND) is oncologically safe. This was a single institution retrospective study of patients with ypN1 from Asan Medical Center (AMC). We included 324 patients who had undergone axillary surgery with either sentinel lymph node biopsy (SLNB) only or ALND. The patients received NAC at AMC between 2008 and 2013. General indications for ALND included prominent nodes detected clinically before NAC, evident macrometastasis on multiple nodes during SLNB. Patients who had either micrometastasis or macrometastasis in 1 or 2 node(s) were included. SLNB was performed for patients with good responders to NAC with limited nodal burden. Patients were matched for baseline characteristics. After matching, we included 98 patients in each SLNB only group and ALND group respectively. We compared axillary recurrence-free survival (ARFS), distant metastasis-free survival (DMFS), overall survival (OS), and breast cancer-free survival (BCSS) according to the surgical method. The median follow-up period was 71 months. Univariate and multivariate analyses revealed no statistically significant differences between the two groups for ARFS, DMFS, OS, and BCSS. After the propensity score matching, no significant statistical differences were observed in 5-year ARFS, DMFS, OS, and BCSS between the SLNB only group and ALND group. SLNB might be a possible option for ALND in patients with breast cancer who have limited axillary node metastasis after NAC without compromising survival outcomes.
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Affiliation(s)
- Jung Whan Chun
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jisun Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Il Yong Chung
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Beom Seok Ko
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Hee Jeong Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jong Won Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Byung Ho Son
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Sei-Hyun Ahn
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Sae Byul Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
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19
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Diagnostic Performance of Noninvasive Imaging for Assessment of Axillary Response After Neoadjuvant Systemic Therapy in Clinically Node-positive Breast Cancer: A Systematic Review and Meta-analysis. Ann Surg 2021; 273:694-700. [PMID: 33201095 DOI: 10.1097/sla.0000000000004356] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The purpose of this study was to perform a systematic review and meta-analysis to determine the diagnostic performance of current noninvasive imaging modalities for assessment of axillary response after neoadjuvant systemic therapy (NST) in clinically node-positive breast cancer patients. SUMMARY OF BACKGROUND DATA NST can lead to downstaging of axillary lymph node disease. Imaging can potentially provide information about the axillary response to NST and, consequently, tailor the surgical management. METHODS PubMed and Embase were searched for studies that compared noninvasive imaging after NST with axillary surgery outcome to identify axillary response in patients with initial pathologically proven axillary lymph node metastasis. Two reviewers independently screened the studies and extracted the data. A meta-analysis was performed by computing the pooled sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS Thirteen studies describing 2380 patients were included for final analysis. Of these patients, 1322 had undergone axillary ultrasound, 849 breast MRI, and 209 whole-body 18F-FDG PET-CT. The overall axillary pathologic complete response rate was 39.5% (941/2380). For axillary ultrasound, the pooled sensitivity, specificity, PPV, and NPV were 65%, 69%, 77%, 50%, respectively. For breast MRI, the pooled sensitivity, specificity, PPV, and NPV were 60%, 76%, 78%, 58%, respectively. For whole-body 18F-FDG PET-CT, the pooled sensitivity, specificity, PPV, and NPV were 38%, 86%, 78%, 49%, respectively. CONCLUSIONS The diagnostic performance of current noninvasive imaging modalities is limited to accurately assess axillary response after NST in clinically node-positive breast cancer patients.
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20
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Montagna G, Tong Y, Ritter M, Levi J, Weber WP, Chen X, Shen K. Predictors of Nodal Pathological Complete Response in Asian Women with Stage II-III Node-Positive Breast Cancer. Oncology 2021; 99:359-364. [PMID: 33735903 DOI: 10.1159/000513454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) is increasingly used to treat node-positive (N+) breast cancer. Predictors of nodal pathological complete response (pCR) in Asian women are poorly described and there is variety in the management of the axilla after NAC. We evaluated predictors of nodal pCR and axillary management in a cohort of Asian N+ patients. METHODS Consecutive biopsy-proven N+ breast cancer patients treated with NAC were identified from the Shanghai Ruijin Hospital in China. Axillary lymph node dissection was performed on all patients, irrespective of the nodal response to NAC. RESULTS A total of 323 patients were included. Nodal pCR was achieved in 105 patients (33%), 15% of HR+/HER2- tumors, 38% of HR+/HER2+ tumors, 49% of HR-/HER2+ tumors, and 42% of HR-/HER2-tumors (p < 0.001). Factors associated with nodal pCR were (1) receptor status (HR+/HER2- [referent]: OR 3.42, 95% CI 1.43-8.16, p = 0.006 for HR+/HER2+; OR 4.19, 95% CI 1.85-9.50, p = 0.001 for HR-/HER2+; and OR 2.94, 95% CI 1.11-7.74, p = 0.029 for HR-/HER2-), (2) breast pCR (no pCR [referent]: OR 15.22, 95% CI 6.29-36.79, p < 0.001), and (3) absence of lymphovascular invasion (LVI [referent]: OR 9.04, 95% CI 2.09-39.18, p = 0.003). CONCLUSION This study confirmed expected predictors of nodal pCR in Asian women and the benefit of NAC in downstaging the axilla independently of ethnicity.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Breast Center, University Hospital of Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Yiwei Tong
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mathilde Ritter
- Breast Center, University Hospital of Basel, Basel, Switzerland
| | - Jeremy Levi
- Biometrical Practice BIOP, Basel, Switzerland
| | - Walter P Weber
- Breast Center, University Hospital of Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Xiaosong Chen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,
| | - Kunwei Shen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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21
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Kantor O, Chang C, Yao K, Boughey J, Roland C, Francescatti AB, Blair S, Dickson Witmer D, Hunt KK, Nelson H, Weiss A, Oseni T. Uptake of Breast Cancer Clinical Trials at Minority Serving Cancer Centers. Ann Surg Oncol 2021; 28:4995-5004. [PMID: 33423122 DOI: 10.1245/s10434-020-09533-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Most minorities receive cancer care at minority-serving hospitals (MSHs) that have been associated with disparate treatment between Black and White patients. OBJECTIVE Our aim was to examine the uptake of clinical trials that have changed axillary management in breast cancer patients at MSH and non-MSH cancer centers. METHODS The National Cancer Database was used to identify patients eligible for the American College of Surgeons Oncology Group Z0011 and Z1071 trials, and mastectomy patients fulfilling the European AMAROS trial. Uptake of trial results (omission of axillary lymph node dissection) was analyzed between patients treated at MSHs and non-MSHs and adjusted for patient, tumor, and facility factors. MSHs were defined as the top decile of hospitals according to the proportion of Black and Hispanic patients treated. RESULTS Of 7167 patients eligible for Z0011, 4546 for Z0171, and 9433 for AMAROS from 2015 to 2016, clinical trial uptake was seen in 1195 (74.6%) MSH and 4056 (72.9%) non-MSH patients (p = 0.173) for Z0011, 588 (41.9%) MSH and 1366 (43.5%) non-MSH patients for Z1071 (p = 0.302), and 272 (11.7%) MSH and 996 (14.0%) non-MSH patients (p = 0.005) for AMAROS. On adjusted analyses, MSH status was not significant for uptake of any of the three trials. Black race, socioeconomic status, and insurance were not associated with clinical trial uptake. CONCLUSION The uptake of three landmark clinical trials of axillary management in breast cancer was not different at MSH and non-MSH centers despite adjustment for social determinants of health. At the Commission on Cancer-accredited centers in this analysis, MSH status did not affect the uptake of evidence-based care.
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Affiliation(s)
- Olga Kantor
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Cecilia Chang
- Research Institute, NorthShore University HealthSystem, Evanston, IL, USA
| | - Katharine Yao
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.,American College of Surgeons Cancer Programs, Chicago, IL, USA
| | - Judy Boughey
- American College of Surgeons Cancer Programs, Chicago, IL, USA.,Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Christina Roland
- American College of Surgeons Cancer Programs, Chicago, IL, USA.,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sarah Blair
- American College of Surgeons Cancer Programs, Chicago, IL, USA.,Department of Surgery, University of San Diego, San Diego, CA, USA
| | - Diana Dickson Witmer
- American College of Surgeons Cancer Programs, Chicago, IL, USA.,Department of Surgery, Helen F Graham Cancer Center and Research Institute, Newark, DE, USA
| | - Kelly K Hunt
- American College of Surgeons Cancer Programs, Chicago, IL, USA.,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heidi Nelson
- American College of Surgeons Cancer Programs, Chicago, IL, USA.,Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anna Weiss
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber Cancer Institute, Boston, MA, USA.,American College of Surgeons Cancer Programs, Chicago, IL, USA
| | - Tawakalitu Oseni
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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22
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Simons JM, Scoggins ME, Kuerer HM, Krishnamurthy S, Yang WT, Sahin AA, Shen Y, Lin H, Bedrosian I, Mittendorf EA, Thompson A, Lane DL, Hunt KK, Caudle AS. Prospective Registry Trial Assessing the Use of Magnetic Seeds to Locate Clipped Nodes After Neoadjuvant Chemotherapy for Breast Cancer Patients. Ann Surg Oncol 2021; 28:4277-4283. [PMID: 33417121 DOI: 10.1245/s10434-020-09542-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/14/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Targeted axillary dissection (TAD) involves locating and removing both clipped nodes and sentinel nodes for assessment of the axillary response to neoadjuvant chemotherapy (NAC) by clinically node-positive breast cancer patients. Initial reports described radioactive seeds used for localization, which makes the technique difficult to implement in some settings. This trial was performed to determine whether magnetic seeds can be used to locate clipped axillary lymph nodes for removal. METHODS This prospective registry trial enrolled patients who had biopsy-proven node-positive disease with a clip placed in the node and treatment with NAC. A magnetic seed was placed under ultrasound guidance in the clipped node after NAC. All the patients underwent TAD. RESULTS Magnetic seeds were placed in 50 patients by 17 breast radiologists. All the patients had successful seed placement at the first attempt (mean time for localization was 6.1 min; range 1-30 min). The final position of the magnetic seed was within the node (n = 44, 88%), in the cortex (n = 3, 6%), less than 3 mm from the node (n = 2, 4%), or by the clip when the node could not be adequately visualized (n = 1, 2%). The magnetic seed was retrieved at surgery from all the patients. In 49 (98%) of the 50 cases, the clip and magnetic seed were retrieved from the same node. Surgeons rated the transcutaneous and intraoperative localization as easy for 43 (86%) of the 50 cases. No device-related adverse events occurred. CONCLUSIONS Localization and selective removal of clipped nodes can be accomplished safely and effectively using magnetic seeds.
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Affiliation(s)
- Janine M Simons
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Surgery, Maastricht University, Maastricht, The Netherlands
| | - Marion E Scoggins
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Savitri Krishnamurthy
- Department of Anatomic Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei T Yang
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aysegul A Sahin
- Department of Anatomic Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth A Mittendorf
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Division of Breast Surgery, Department of Surgery, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Alastair Thompson
- Department of Surgery, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Deanna L Lane
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abigail S Caudle
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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23
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Montagna G, Corso G, Di Micco R, Van Den Rul N, Rocco N. Axillary management after neoadjuvant treatment. MINERVA CHIR 2020; 75:400-407. [PMID: 33345526 DOI: 10.23736/s0026-4733.20.08600-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since its introduction nearly 30 years ago, sentinel lymph node biopsy (SLNB) has become the standard technique to stage the axilla for the great majority of patients with early breast cancer. While the accuracy of SLNB in clinically node-negative patients who undergo neoadjuvant chemotherapy (NAC) is similar to the upfront surgery setting, modifications of the technique to improve the false negative rate are necessary in node-positive patients at presentation. Currently, patients who present with matted nodes, cN1 patients who fail to downstage to cN0 with NAC and those with pathological residual disease have an indication to undergo axillary lymph node dissection. Ongoing trials will confirm if extensive nodal irradiation can replace surgery in patients with residual nodal disease after NAC and if nodal radiotherapy can be omitted in patients who achieve nodal pathological complete response. The aim of this review was to focus on the open questions on the management of the axilla after NAC.
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Affiliation(s)
- Giacomo Montagna
- Breast Unit, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA - .,Breast Center, University Hospital of Basel, Basel, Switzerland -
| | - Giovanni Corso
- Division of Breast Surgery, IRCCS European Institute of Oncology, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Rosa Di Micco
- Breast Surgery Unit, IRCCS San Raffaele Hospital, Milan, Italy.,Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | | | - Nicola Rocco
- Group for Reconstructive and Therapeutic Advancements (GRETA) Milan-Naples-Catania, Milan, Italy
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24
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Wong SM, Boileau JF. ASO Author Reflections: Low Rates of Axillary Recurrence in Clinically Node-Positive Breast Cancer Patients Undergoing Sentinel Lymph Node Biopsy Alone Following Pathologic Response to Neoadjuvant Chemotherapy. Ann Surg Oncol 2020; 28:2630-2631. [PMID: 33123855 DOI: 10.1245/s10434-020-09259-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Stephanie M Wong
- Department of Surgical Oncology, McGill University Medical School, Montreal, QC, Canada. .,Segal Cancer Centre, Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada.
| | - Jean Francois Boileau
- Department of Surgical Oncology, McGill University Medical School, Montreal, QC, Canada.,Segal Cancer Centre, Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
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25
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Laws A, Specht MC. Leveraging Neoadjuvant Chemotherapy to Minimize the Burden of Axillary Surgery: a Review of Current Strategies and Surgical Techniques. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00388-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Wong SM, Basik M, Florianova L, Margolese R, Dumitra S, Muanza T, Carbonneau A, Ferrario C, Boileau JF. Oncologic Safety of Sentinel Lymph Node Biopsy Alone After Neoadjuvant Chemotherapy for Breast Cancer. Ann Surg Oncol 2020; 28:2621-2629. [PMID: 33095362 DOI: 10.1245/s10434-020-09211-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/12/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The oncologic safety of sentinel lymph node biopsy (SLNB) alone for clinically node-positive (cN1-2) patients who convert to pathologic node-negativity (ypN0) after neoadjuvant chemotherapy (NAC) is not well established. METHODS This study retrospectively identified 244 consecutive patients with a diagnosis of cT1-3cN0-2 breast cancer who underwent NAC followed by SLNB at the authors' institution between 2013 and 2018. The patients were categorized as clinically node-negative (cN0) or cN1-2 before the onset of NAC, and the Kaplan-Meier method was used to compare locoregional and distant recurrence rates after SLNB alone for ypN0 patients. RESULTS Among 244 patients who underwent NAC followed by surgery with SLNB for axillary staging, 112 (45.9%) were cN0 at presentation, whereas 132 (54.5%) had biopsy-proven cN1-2 disease and converted to cN0 after treatment. Of the patients presenting with cN0 disease, 102 (91.1%) were ypN0 on SLNB pathology compared with 60 cN1/2 patients (45.5%; p < 0.001). Regional nodal irradiation was administered to 5% of the cN0/ypN0 patients compared with 70.7% of the cN1-2/ypN0 patients (p < 0.001). Overall, 211 patients were treated with SLNB alone and had a median follow-up period of 36 months (interquartile range [IQR], 24-53 months). For 101 cN0/ypN0 patients who underwent SLNB alone, the 5-year local and regional recurrence rates were respectively 5.7% (95% confidence interval [CI], 2.4-13.8) and 1% (95% CI 0.1-7.0). For 58 cN1-2/ypN0 patients who underwent SLNB alone, the 5-year local and regional recurrence rates were respectively 4.1% (95% CI 1.0-15.5) and 0%, with no axillary recurrences noted. CONCLUSION For ypN0 patients, SLNB alone after NAC is associated with low and acceptable short-term axillary recurrence rates. Additional follow-up data from prospective clinical trials are needed to confirm long-term oncologic safety and define optimal local therapy recommendations.
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Affiliation(s)
- Stephanie M Wong
- Department of Surgical Oncology, McGill University Medical School, Montreal, QC, Canada.,Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada
| | - Mark Basik
- Department of Surgical Oncology, McGill University Medical School, Montreal, QC, Canada.,Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada.,Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Livia Florianova
- Department of Pathology, McGill University Medical School, Montreal, QC, Canada
| | - Richard Margolese
- Department of Surgical Oncology, McGill University Medical School, Montreal, QC, Canada.,Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Sinziana Dumitra
- Department of Surgical Oncology, McGill University Medical School, Montreal, QC, Canada.,Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Thierry Muanza
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada.,Department of Oncology, McGill University Medical School, Montreal, QC, Canada.,Department of Radiation Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Annie Carbonneau
- Department of Radiation Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Cristiano Ferrario
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada.,Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Jean Francois Boileau
- Department of Surgical Oncology, McGill University Medical School, Montreal, QC, Canada.
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27
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Analysis of the serial circulating tumor cell count during neoadjuvant chemotherapy in breast cancer patients. Sci Rep 2020; 10:17466. [PMID: 33060768 PMCID: PMC7562710 DOI: 10.1038/s41598-020-74577-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 09/23/2020] [Indexed: 12/16/2022] Open
Abstract
We evaluated the prognostic implications of the circulating tumor cell (CTC) count in non-metastatic, HER2-negative breast cancer patients who failed to achieve pathologic complete response (pCR) after neoadjuvant chemotherapy (NCT). A total of 173, non-metastatic breast cancer patients treated with NCT were prospectively enrolled. CTCs were obtained from blood drawn pre-NCT and post-NCT using a SMART BIOPSY SYSTEM isolation kit (Cytogen Inc., Seoul, Korea) with immunofluorescence staining. Excluding 26 HER2-positive patients, Relapse-free survival (RFS) and overall survival (OS) related to the CTC count and the association of the CTC count with the treatment response to given therapy were analyzed in 147 HER2-negative patients. Among 147 HER2-negative patients, 28 relapses (19.0%) and 13 deaths (8.8%, all breast cancer-specific) were observed during a median follow-up of 37.3 months. One hundred and seven patients (72.8%) were hormone receptor-positive, and 40 patients (27.2%) had triple-negative breast cancer (TNBC). One or more CTCs were identified in 88 of the 147 patients (59.9%) before NCT and 77 of the 134 patients (52.4%) after NCT. In the entire HER2-negative patient cohort, the initial nodal status was the most significant factor influencing RFS and OS. In TNBC, 11 patients (27.5%) achieved pCR and patients that failed to achieve pCR with ≥ 5 CTCs after NCT, showed worse RFS (HR, 10.66; 95% CI, 1.80–63.07; p = 0.009) and OS (HR, 14.00; 95% CI, 1.26–155.53; p = 0.032). The patients with residual tumor and a high number of the CTCs after NCT displayed the worse outcome. These findings could provide justification to launch a future, well designed trial with longer follow-up data to obtain regulatory approval for clinical use of the assay, especially for the ER-positive, HER2-negative breast cancer subset.
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28
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Piltin MA, Hoskin TL, Day CN, Davis J, Boughey JC. Oncologic Outcomes of Sentinel Lymph Node Surgery After Neoadjuvant Chemotherapy for Node-Positive Breast Cancer. Ann Surg Oncol 2020; 27:4795-4801. [PMID: 32779055 DOI: 10.1245/s10434-020-08900-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/30/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy (NAC) has been well studied. However, outcomes data addressing the oncologic safety of this technique are sparse. This study aimed to evaluate use of SLN surgery versus axillary lymph node dissection (ALND) for clinically node-positive patients treated with NAC and to report outcomes. METHODS The study identified patients at the authors' institution with biopsy proven clinically node-positive (cN1-cN3) breast cancer undergoing axillary surgery after NAC from 2009 to 2019. Practice patterns and outcomes were evaluated. RESULTS Of 602 patients, 52.3% underwent SLN surgery. Use of SLN surgery increased significantly over time, reaching 75.3% during 2015-2019. For 52.5% of the patients who had an SLN identified, ALND was not used. Use of ALND (± SLN surgery) decreased from 100% in 2009 to 57.2% in 2015-2019. The nodal positivity rate of patients who proceeded directly to ALND was 64.5% (185/287), increasing significantly over time. Factors significantly associated with performing SLN surgery on multivariable analysis were lower presenting clinical T category, lower presenting clinical N category (cN1 vs cN2-3) and HER2-positive status. During the median 34-month follow-up period, 17 regional recurrences were observed (16/443 with ALND; 1/159 with SLN surgery alone), for a 2-year freedom-from-regional-recurrence rate of 99.1% among the SLN surgery patients and 96.4% among the ALND patients (p = 0.10). CONCLUSIONS For cN1-3 breast cancer treated with NAC, SLN surgery has been incorporated into clinical practice at the authors' institution. In this study, selection for SLN surgery was based on clinical factors and tumor biology. More than half of the patients who were selected for SLN surgery were spared ALND, with a low nodal failure rate and no recurrence-free survival disadvantage at 2 years.
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Affiliation(s)
- Mara A Piltin
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Health Science Research and Clinical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Health Science Research and Clinical Statistics, Mayo Clinic, Rochester, MN, USA
| | - John Davis
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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29
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Postlewait LM, Lucci A. ASO Author Reflection: Axillary Dissection for Negative Lymph Nodes in Inflammatory Breast Cancer-Need for Clinical Trials to Reassess Standard of Care. Ann Surg Oncol 2020; 27:676-677. [PMID: 32737697 DOI: 10.1245/s10434-020-08952-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Lauren M Postlewait
- Department of Breast Surgical Oncology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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30
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Almahariq MF, Levitin R, Quinn TJ, Chen PY, Dekhne N, Kiran S, Desai A, Benitez P, Jawad MS, Gustafson GS, Dilworth JT. Omission of Axillary Lymph Node Dissection is Associated with Inferior Survival in Breast Cancer Patients with Residual N1 Nodal Disease Following Neoadjuvant Chemotherapy. Ann Surg Oncol 2020; 28:930-940. [PMID: 32712895 DOI: 10.1245/s10434-020-08928-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/07/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The appropriateness of substituting sentinel lymph node dissection (SLND) and regional nodal irradiation (RNI) for axillary lymph node dissection (ALND) in patients with residual lymph node (LN) disease following neoadjuvant chemotherapy (NAC) is unknown. We used the National Cancer Database (NCDB) to compare survival following SLND and ALND in breast cancer patients with residual LN disease. METHODS We analyzed NCDB patients, treated between 2006 and 2014, with cT1-3, cN1, cM0 breast cancer and residual disease in 1-3 axillary LNs (ypN1) following NAC. Patients were grouped into those who received SLND (defined as removal of ≤ 4 LNs) and RNI, or ALND and RNI. Patients were matched for all patient, tumor, and treatment characteristics. RESULTS We identified 1313 eligible patients in the ALND group and 304 patients in the SLND group. For the matched cohorts, SLND was associated with significantly lower survival in both univariate and doubly robust multivariable analyses (MVA) (HR 1.7, 95% CI 1.3-2.2, P < 0.001 for MVA), with estimated 5-year OS of 71%, compared with 77% in the ALND group (P = 0.01). Exploratory subgroup analyses showed that SLND was comparable with ALND in patients with luminal A or B tumors with a single metastatic LN (HR 1.03, 95% CI 0.59-1.8, (P = 0.91). CONCLUSIONS Our analysis suggests that, while an ALND may not be needed for patients with limited residual nodal burden and biologically favorable tumors, SLND should not be routinely substituted for ALND in patients with ypN1 disease following NAC until its efficacy is confirmed by prospective trials.
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Affiliation(s)
| | - Ronald Levitin
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA
| | - Nayana Dekhne
- Department of Surgery, Beaumont Health, Royal Oak, MI, USA
| | - Sayee Kiran
- Department of Surgery, Beaumont Health, Royal Oak, MI, USA
| | - Amita Desai
- Department of Surgery, Beaumont Health, Royal Oak, MI, USA
| | - Pamela Benitez
- Department of Surgery, Beaumont Health, Royal Oak, MI, USA
| | - Maha S Jawad
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA
| | | | - Joshua T Dilworth
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA.
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Postlewait LM, Teshome M, DeSnyder SM, Lim B, Kuerer HM, Bedrosian I, Woodward WA, Ueno NT, Lucci A. Factors Associated with Pathological Node Negativity in Inflammatory Breast Cancer: Are There Patients Who May be Candidates for a De-Escalation of Axillary Surgery? Ann Surg Oncol 2020; 27:4603-4612. [PMID: 32710271 DOI: 10.1245/s10434-020-08891-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/09/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Modified radical mastectomy (MRM), which includes axillary dissection, is the standard of care for inflammatory breast cancer (IBC). While more limited axillary staging after neoadjuvant chemotherapy (NAC) in clinically node-positive non-IBC has been increasingly adopted, the impact of these techniques in IBC is not clear. To inform patient selection for further study of limited axillary surgery, we aimed to describe the frequency and factors associated with pathological node-negativity (ypN0) in IBC. METHODS Patients with IBC who received NAC and MRM were identified from a prospective institutional database (2004-2019). Binary logistic regression analyses were conducted to identify factors associated with ypN0. RESULTS Of 453 patients, 189 (41.7%) had a post-NAC clinical nodal stage (ycN stage) of N0 (ycN1: 150, 33.1%; ycN2: 4, 0.9%; ycN3: 47, 10.4%; unknown: 63, 13.9%); 156 (34%) were ypN0. On multivariable analysis, higher tumor grade was not associated with ypN0 (odds ratio [OR] 1.59, 95% confidence interval [CI] 0.90-2.81, p =0.11). Compared with hormone receptor (HR)-negative/human epidermal growth factor receptor 2 (HER2)-negative tumors (n =113, 24.9%), HR-positive/HER2-negative tumors (n =169, 37.3%) had a trend toward less ypN0 (OR 0.55, 95% CI 0.29-1.02, p =0.06); HR-positive/HER2-positive tumors (n =79, 17.4%) were similar to HR-negative/HER2-negative tumors (OR 0.72, 95% CI 0.35-1.48, p =0.37); and HR-negative/HER2-positive tumors (n =92, 20.3%) were associated with increased ypN0 (OR 4.82, 95% CI 2.41-9.63, p <0.001). As ycN stage increased, the likelihood of ypN0 decreased compared with ycN0 patients (ycN1/2: OR 0.54, 95% CI 0.32-0.89, p =0.02; ycN3: OR 0.29, 95% CI 0.13-0.67, p =0.004). CONCLUSIONS One-third of patients with IBC who received NAC and MRM had pathologically negative nodes. Factors associated with ypN0 included ycN0 status and HR-negative/HER2-positive subtype. Large, prospective studies are needed to investigate the feasibility of alternative nodal evaluation strategies in IBC, with consideration to these subgroups.
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Affiliation(s)
- Lauren M Postlewait
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah M DeSnyder
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bora Lim
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy A Woodward
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Division of Radiation Oncology, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naoto T Ueno
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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32
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Use of Intraoperative Radioguidance in Recurrent Merkel Carcinoma. Case Rep Surg 2020; 2020:1789185. [PMID: 32637182 PMCID: PMC7321529 DOI: 10.1155/2020/1789185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/17/2020] [Indexed: 11/17/2022] Open
Abstract
Merkel cell carcinoma is a rapidly progressive nonmelanoma skin cancer with a high risk of recurrence. When recurrence occurs, it is associated with poor prognosis and there is a lack of guidelines for the management of such cases. This article describes a challenging case in which the innovative use of iodine-125 radioactive seeds permitted us to precisely identify and resect two nonpalpable recurrent nodules. The safety and accuracy of the surgical procedure were compromised by the presence of scar tissue following two past resections and two courses of radiotherapy. Radioactive seed localization is a well-known procedure in breast cancer, demonstrating potential for an extended application in other cancer types and in complex clinical situations.
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Montagna G, Mamtani A, Knezevic A, Brogi E, Barrio AV, Morrow M. Selecting Node-Positive Patients for Axillary Downstaging with Neoadjuvant Chemotherapy. Ann Surg Oncol 2020; 27:4515-4522. [PMID: 32488513 DOI: 10.1245/s10434-020-08650-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Axillary lymph node dissection (ALND) can be avoided in node-positive patients who receive neoadjuvant chemotherapy (NAC) if three or more negative sentinel lymph nodes (SLNs) are retrieved. We evaluate how often node-positive patients avoid ALND with NAC, and identify predictors of identification of three or more SLNs and of nodal pathological complete response (pCR). METHODS From November 2013 to July 2019, all patients with cT1-3, biopsy-proven N1 tumors who converted to cN0 after NAC received SLN biopsy (SLNB) with dual mapping and were identified from a prospectively maintained database. RESULTS 630 consecutive N1 patients were eligible for axillary downstaging with NAC; 573 (91%) converted to cN0 and had SLNB, and 531 patients (93%) had three or more SLNs identified. Lymphovascular invasion (LVI; odds ratio [OR] 0.46, 95% confidence interval [CI] 0.24-0.87; p = 0.02) and increasing body mass index (BMI; OR 0.77, 95% CI 0.62-0.96 per 5-unit increase; p = 0.02) were significantly associated with failure to identify three or more SLNs. 255/573 (46%) patients achieved nodal pCR; 237 (41%) had adequate mapping. Factors associated with ALND avoidance included high grade (OR 2.51, 95% CI 1.6-3.94, p = 0.001) and receptor status (HR+/HER2- [referent]: OR 1.99, 95% CI 1.15-3.46 [p = 0.01] for HR-/HER2-, OR 3.93, 95% CI 2.40-6.44 [p < 0.001] for HR+/HER2+, and OR 8.24, 95% CI 4.16-16.3 [p < 0.001] for HR-/HER2+). LVI was associated with a lower likelihood of avoiding ALND (OR 0.28, 95% CI 0.18-0.43; p < 0.001). CONCLUSIONS ALND was avoided in 41% of cN1 patients after NAC. Increased BMI and LVI were associated with lower retrieval rates of three or more SLNs. ALND avoidance rates varied with receptor status, grade, and LVI. These factors help select patients most likely to avoid ALND.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea Knezevic
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edi Brogi
- Department of Pathology, 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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van Munster JJCM, Zamanipoor Najafabadi AH, de Boer NP, Peul WC, van den Hout WB, van Benthem PPG. Impact of surgical intervention trials on healthcare: A systematic review of assessment methods, healthcare outcomes, and determinants. PLoS One 2020; 15:e0233318. [PMID: 32442235 PMCID: PMC7244162 DOI: 10.1371/journal.pone.0233318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/01/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Frameworks used in research impact evaluation studies vary widely and it remains unclear which methods are most appropriate for evaluating research impact in the field of surgical research. Therefore, we aimed to identify and review the methods used to assess the impact of surgical intervention trials on healthcare and to identify determinants for surgical impact. METHODS We searched journal databases up to March 10, 2020 for papers assessing the impact of surgical effectiveness trials on healthcare. Two researchers independently screened the papers for eligibility and performed a Risk of Bias assessment. Characteristics of both impact papers and trial papers were summarized. Univariate analyses were performed to identify determinants for finding research impact, which was defined as a change in healthcare practice. RESULTS Sixty-one impact assessments were performed in 37 included impact papers. Some surgical trial papers were evaluated in more than one impact paper, which provides a total of 38 evaluated trial papers. Most impact papers were published after 2010 (n = 29). Medical records (n = 10), administrative databases (n = 22), and physician's opinion through surveys (n = 5) were used for data collection. Those data were analyzed purely descriptively (n = 3), comparing data before and after publication (n = 29), or through time series analyses (n = 5). Significant healthcare impact was observed 49 times and more often in more recent publications. Having impact was positively associated with using medical records or administrative databases (ref.: surveys), a longer timeframe for impact evaluation and more months between the publication of the trial paper and the impact paper, data collection in North America (ref.: Europe), no economic evaluation of the intervention, finding no significant difference in surgical outcomes, and suggesting de-implementation in the original trial paper. CONCLUSIONS AND IMPLICATIONS Research impact evaluation receives growing interest, but still a small number of impact papers per year was identified. The analysis showed that characteristics of both surgical trial papers and impact papers were associated with finding research impact. We advise to collect data from either medical records or administrative databases, with an evaluation time frame of at least 4 years since trial publication.
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Affiliation(s)
- Juliëtte J. C. M. van Munster
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Amir H. Zamanipoor Najafabadi
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Nick P. de Boer
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
| | - Wilco C. Peul
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Wilbert B. van den Hout
- Department of Biomedical Data Science–Medical Decision Making, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Peter Paul G. van Benthem
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
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Zhang K, Zhu Q, Sheng D, Li J, Chang C. A New Model Incorporating Axillary Ultrasound After Neoadjuvant Chemotherapy to Predict Non-Sentinel Lymph Node Metastasis in Invasive Breast Cancer. Cancer Manag Res 2020; 12:965-972. [PMID: 32104078 PMCID: PMC7020912 DOI: 10.2147/cmar.s239921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/29/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose Few models with good discriminative power have been introduced to predict the risk of non-sentinel lymph node (non-SLN) metastasis in breast cancer after neoadjuvant chemotherapy (NAC). We aimed to develop a new and simple model for predicting the probability of non-SLN metastasis in breast cancer and facilitate the selection of patients who could avoid unnecessary axillary lymph node dissection following NAC. Patients and Methods A total of 298 patients diagnosed with invasive breast cancer, who underwent SLN biopsy after completing NAC and subsequently breast surgery, were included and classified into the training set (n=228) and testing set (n=70). Univariate and multivariate analyses were used to select factors that could be determined prior to breast surgery and significantly correlated with non-SLN metastasis in the training set. A logistic regression model was developed based on these factors and validated in the testing set. Results Nodal status before NAC, post-NAC axillary ultrasound status, SLN number, and SLN metastasis number were independent predictors of non-SLN metastases in breast cancer after NAC. A predictive model based on these factors yielded an area under the curve of 0.838 (95% confidence interval: 0.774-0.902, p< 0.001) in the training set. When applied to the testing set, this model yielded an area under the curve of 0.808 (95% confidence interval: 0.609-1.000, p= 0.003). Conclusion A new and simple model, which incorporated factors that could be determined prior to breast surgery, was developed to predict non-SLN metastasis in invasive breast cancer following NAC. Although this model performed excellently in internal validation, it requires external validation before it can be widely utilized in the clinical setting.
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Affiliation(s)
- Kai Zhang
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Qian Zhu
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Danli Sheng
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Jiawei Li
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Cai Chang
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
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Simons J, Maaskant-Braat A, Luiten E, Leidenius M, van Nijnatten T, Boelens P, Koppert L, van der Pol C, van de Velde C, Audisio R, Smidt M. Patterns of axillary staging and management in clinically node positive breast cancer patients treated with neoadjuvant systemic therapy: Results of a survey amongst breast cancer specialists. Eur J Surg Oncol 2020; 46:53-58. [DOI: 10.1016/j.ejso.2019.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/03/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022] Open
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Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer: A Systematic Review and Meta-analysis. Ann Surg 2019; 269:432-442. [PMID: 30312200 PMCID: PMC6369968 DOI: 10.1097/sla.0000000000003075] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective: The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND. Summary of Background Data: Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity. Methods: PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV). Results: Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%. Conclusion: Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.
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Weiss A, Lopez NE, Ward EP, Lee KC, Caudle AS, Dickson-Witmer D, Chang C, Kelly K, Martin LW, Jacobs LK, Hunt KK, Yao K, Blair SL. Challenges in Clinical Trial Implementation: Results from a Survey of the National Accreditation Program of Breast Centers (NAPBC). Ann Surg Oncol 2019; 26:4364-4371. [PMID: 31625045 DOI: 10.1245/s10434-019-07807-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although the results of clinical trials often guide best practices, changing clinical practice based on clinical trial results can be challenging. The objective of this study was to examine provider-reported barriers to adopting best clinical practices according to clinical trial data. METHODS A cross-sectional survey was conducted of providers from the National Accreditation Program for Breast Centers about barriers that prevent the incorporation of trial findings. Descriptive analyses and multivariable analyses were performed to determine provider characteristics that were significantly associated with reported barriers. RESULTS Overall, 383 institutions participated (63.5% response rate), with a total of 1226 physicians responding to the survey (80% response rate). Providers identified national guidelines and meetings as the most compelling way to receive practice-changing information. They reported the following internal barriers to trial implementation: patient preference (45%), strongly held beliefs by partners/colleagues (37%), and insufficient time to discuss new practices (30%). External barriers preventing trial implementation included a lack of agreement from multidisciplinary tumor boards (32%), fear of reimbursement loss (23%), and resistance from clinical staff (20%). Reported barriers differed by provider specialty, with plastic surgeons and radiation oncologists reporting that strongly held beliefs by partners/colleagues and disagreement from multidisciplinary tumor boards were the most significant factors preventing clinical trial implementation. CONCLUSIONS Physician beliefs and patient preferences are the most frequently reported barriers to clinical trial implementation. Tactics to better educate providers about how to explain new clinical trial data to their patients and colleagues are needed.
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Affiliation(s)
- Anna Weiss
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, MA, USA. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | - Nicole E Lopez
- Department of Surgery, University of California - San Diego, San Diego, CA, USA
| | - Erin P Ward
- Department of Surgery, University of California - San Diego, San Diego, CA, USA
| | - Katherine C Lee
- Department of Surgery, University of California - San Diego, San Diego, CA, USA
| | - Abigail S Caudle
- Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana Dickson-Witmer
- Department of Surgery, Helen F. Graham Cancer Center and Research Institute, Newark, DE, USA
| | - Cecilia Chang
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Kaitlyn Kelly
- Department of Surgery, University of California - San Diego, San Diego, CA, USA
| | | | - Lisa Kay Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly K Hunt
- Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine Yao
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Sarah L Blair
- Department of Surgery, University of California - San Diego, San Diego, CA, USA
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Simons JM, van Pelt MLMA, Marinelli AWKS, Straver ME, Zeillemaker AM, Pereira Arias-Bouda LM, van Nijnatten TJA, Koppert LB, Hunt KK, Smidt ML, Luiten EJT, van der Pol CC. Excision of both pretreatment marked positive nodes and sentinel nodes improves axillary staging after neoadjuvant systemic therapy in breast cancer. Br J Surg 2019; 106:1632-1639. [PMID: 31593294 PMCID: PMC6856822 DOI: 10.1002/bjs.11320] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/10/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Marking the axilla with radioactive iodine seed and sentinel lymph node (SLN) biopsy have been proposed for axillary staging after neoadjuvant systemic therapy in clinically node-positive breast cancer. This study evaluated the identification rate and detection of residual disease with combined excision of pretreatment-positive marked lymph nodes (MLNs) together with SLNs. METHODS This was a multicentre retrospective analysis of patients with clinically node-positive breast cancer undergoing neoadjuvant systemic therapy and the combination procedure (with or without axillary lymph node dissection). The identification rate and detection of axillary residual disease were calculated for the combination procedure, and for MLNs and SLNs separately. RESULTS At least one MLN and/or SLN(s) were identified by the combination procedure in 138 of 139 patients (identification rate 99·3 per cent). The identification rate was 92·8 per cent for MLNs alone and 87·8 per cent for SLNs alone. In 88 of 139 patients (63·3 per cent) residual axillary disease was detected by the combination procedure. Residual disease was shown only in the MLN in 20 of 88 patients (23 per cent) and only in the SLN in ten of 88 (11 per cent), whereas both the MLN and SLN contained residual disease in the remainder (58 of 88, 66 per cent). CONCLUSION Excision of the pretreatment-positive MLN together with SLNs after neoadjuvant systemic therapy in patients with clinically node-positive disease resulted in a higher identification rate and improved detection of residual axillary disease.
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Affiliation(s)
- J M Simons
- Department of Surgical Oncology, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands.,Department of Surgical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M L M A van Pelt
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A W K S Marinelli
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - M E Straver
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A M Zeillemaker
- Department of Surgical Oncology, Alrijne Hospital, Leiderdorp, the Netherlands
| | - L M Pereira Arias-Bouda
- Department of Nuclear Medicine, Alrijne Hospital, Leiderdorp, the Netherlands.,Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - L B Koppert
- Department of Surgical Oncology, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - K K Hunt
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M L Smidt
- Department of Surgical Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - E J T Luiten
- Department of Surgical Oncology, Amphia Hospital, Breda, the Netherlands
| | - C C van der Pol
- Department of Surgical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Surgical Oncology, Alrijne Hospital, Leiderdorp, the Netherlands
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Beniey M, Boulva K, Kaviani A, Patocskai E. Novel Uses of Radioactive Seeds in Surgical Oncology: A Case Series. Cureus 2019; 11:e5706. [PMID: 31720174 PMCID: PMC6823086 DOI: 10.7759/cureus.5706] [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] [Indexed: 11/05/2022] Open
Abstract
The localization of nonpalpable axillary metastatic lymph nodes has been achieved using several techniques in the past. Amongst these techniques, the use of radioactive iodine seeds is increasingly spread, and was initially reserved to breast-conserving surgery. Many studies have assessed the use of radioactive seed localization for the surgical management of breast cancer patients diagnosed with lymph node metastases. However, few articles have reported their utilization in other cancer subtypes and in complex clinical situations. This case series describes the innovative use of radioactive seeds in the axilla in five patients, including one case of squamous cell carcinoma skin cancer, one case of malignant melanoma, and three cases of invasive breast cancer.
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Affiliation(s)
- Michèle Beniey
- Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Kerianne Boulva
- Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Ahmad Kaviani
- Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Erica Patocskai
- Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
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Christin OL, Kuten J, Even-Sapir E, Klausner J, Menes TS. Node positive breast cancer: Concordance between baseline PET/CT and sentinel node assessment after neoadjuvant therapy. Surg Oncol 2019; 30:1-5. [PMID: 31500769 DOI: 10.1016/j.suronc.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/30/2019] [Accepted: 05/13/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Sentinel node biopsy for axillary staging in node positive patients after neoadjuvant treatment is controversial, mainly due to high false negative rates. We examined the concordance between the location of the hot nodes identified on PET-CT at presentation with the location of the sentinel nodes. MATERAILS AND METHODS Fifty-eight breast cancer patients undergoing neoadjuvant treatment between January 2013 and September 2018 who had positive regional lymph nodes on PET/CT, and a SPECT/CT lymphoscintigraphy completed before sentinel node biopsy were included. Patient, tumor and treatment characteristics were collected. Images of PET/CT were compared to images of SPECT/CT lymphoscintigraphy post treatment and concordance between location of the hot nodes on PET/CT with the sentinel nodes visualized on SPECT/CT was assessed. Association between patient, tumor and treatment characteristics and concordance between the sentinel node and the hot nodes was determined. RESULTS Sentinel nodes were identified in 53 (91%) of the cases in surgery. In 25 (43%) patients, axillary nodes were positive after treatment. In 16 (28%; 95% CI 18, 40) the sentinel node was not one of the hot nodes seen on PET/CT at presentation. Twenty-three (40%) patients had excision of additional axillary nodes. In two patients with non-concordant sentinel nodes, the sentinel node was falsely negative. CONCLUSIONS In node positive patients who undergo neoadjuvant treatment, the sentinel node visualized on lymphatic mapping is not necessarily one of the hot nodes identified on PET/CT at presentation. These findings underline the importance of marking the pathologically proven lymph node and excising it as well as the sentinel nodes after treatment.
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Affiliation(s)
| | - Jonathan Kuten
- Department of Nuclear Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Einat Even-Sapir
- Department of Nuclear Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; (c)Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joseph Klausner
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; (c)Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tehillah S Menes
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; (c)Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Boughey JC. Identifying Residual Nodal Disease in Sentinel Lymph Node Surgery After Neoadjuvant Chemotherapy for Breast Cancer. Ann Surg Oncol 2019; 26:3794-3797. [PMID: 31429022 DOI: 10.1245/s10434-019-07733-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Indexed: 11/18/2022]
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Wong SM, Weiss A, Mittendorf EA, King TA, Golshan M. Surgical Management of the Axilla in Clinically Node-Positive Patients Receiving Neoadjuvant Chemotherapy: A National Cancer Database Analysis. Ann Surg Oncol 2019; 26:3517-3525. [PMID: 31342389 DOI: 10.1245/s10434-019-07583-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The feasibility of sentinel lymph node biopsy (SLNB) in patients with clinically node-positive (cN+) disease who convert to clinically node-negative (cN0) disease following neoadjuvant chemotherapy (NAC) has been evaluated in several large clinical trials, but it remains unclear whether the approach has been broadly adopted in the United States. METHODS The National Cancer Database was used to identify women diagnosed with cN+ breast cancer who received NAC followed by surgery between 2012 and 2015. Trends in axillary surgery were evaluated and multivariable logistic regression analyses performed to determine factors associated with receipt of SLNB. RESULTS Of 12,965 women cN+ at baseline, the use of SLNB increased from 31.8% in 2012 to 49% in 2015 (p < 0.001). Using axillary pCR as a surrogate for patients who convert to cN0 following NAC, among 5127 (39.5%) ypN0 patients, SLNB increased from 38.2 to 58.4% over the study period (p < 0.001), resulting in avoidance of axillary dissection in 42.2% of ypN0 patients by 2015. In adjusted analyses, factors significantly associated with SLNB attempt included cN1 disease, age < 45 years, treatment facility type, triple-negative and HER2-positive subtypes, and year of diagnosis. In women with residual isolated tumor cells (ITCs), micrometastases, and ypN1 disease, SLNB was the only axillary procedure performed in 36.9%, 23.6%, and 13.0% of cases. CONCLUSIONS The use of SLNB in cN+ patients receiving NAC increased significantly between 2012 and 2015. SLNB alone was performed in more than 10% of patients with ypN1 disease, 20% with micrometastases, and 35% with ITCs; the oncologic safety of omitting axillary dissection in these patients requires further evaluation.
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Affiliation(s)
- Stephanie M Wong
- 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
| | - Anna Weiss
- 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
| | - Elizabeth A Mittendorf
- 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
| | - 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
| | - Mehra Golshan
- 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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Srour MK, Tseng J, Luu M, Alban RF, Giuliano AE, Chung A. Patterns in the Use of Axillary Operations for Patients with Node-Positive Breast Cancer After Neoadjuvant Chemotherapy: A National Cancer Database (NCDB) Analysis. Ann Surg Oncol 2019; 26:3305-3311. [DOI: 10.1245/s10434-019-07540-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Indexed: 11/18/2022]
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Hamdy O. Neoadjuvant Therapy Should Be the Standard of Care for Every Node Positive Breast Cancer Patient. J Breast Cancer 2019; 22:149-152. [PMID: 30941242 PMCID: PMC6438838 DOI: 10.4048/jbc.2019.22.e3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Omar Hamdy
- Surgical Oncology Unit, Oncology Center, Mansoura University, Mansoura, Egypt
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Caudle AS, Kuerer HM, Krishnamurthy S, Shin K, Hobbs BP, Ma J, Mittendorf EA, Washington AC, DeSnyder SM, Black DM, Hunt KK, Yang WT. Feasibility of fine-needle aspiration for assessing responses to chemotherapy in metastatic nodes marked with clips in breast cancer: A prospective registry study. Cancer 2018; 125:365-373. [PMID: 30359480 DOI: 10.1002/cncr.31825] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/13/2018] [Accepted: 10/01/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Clips are often placed to mark axillary nodes with biopsy-confirmed metastases in patients with breast cancer. The evaluation of clipped nodes after chemotherapy can identify patients who have eradication of nodal disease. The goal of this study was to determine whether preoperative fine-needle aspiration (FNA) of clipped nodes after neoadjuvant chemotherapy (NAC) could predict the presence of residual disease. METHODS This prospective registry study enrolled 50 patients with a clip placed to mark nodes with biopsy-confirmed metastases who had completed NAC. Participants underwent FNA of the clipped node before seed-localized lymph node excision. FNA pathology was compared with surgical pathology. RESULTS There were 36 patients (72%) with residual disease on surgical pathology: 3 (8%) had a nondiagnostic aspirate, carcinoma was seen in 14 (39%), and 19 (53%) had a false-negative result. The sensitivity of FNA was 42.4%, its specificity was 100%, and its negative predictive value was 40.6%. In a univariate analysis, the odds of a true-positive result increased significantly with the mean initial size of the clipped node (odds ratio [OR], 4.3; P = .004) and the size of the metastatic focus after NAC (OR, 1.3; P = 0.003), whereas normalization of nodes after chemotherapy (OR, 0.1) and a lack of response on ultrasound (OR, 0.11) were associated with a false-negative result (P = .01). CONCLUSIONS FNA of marked nodes after chemotherapy has a high false-negative rate. This highlights the need for surgical staging of the axilla after NAC to assess the response.
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Affiliation(s)
- Abigail S Caudle
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Savitri Krishnamurthy
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kyungmin Shin
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Junsheng Ma
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth A Mittendorf
- Department of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Ashley C Washington
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah M DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dalliah M Black
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wei T Yang
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
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47
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Park KU, Caudle A. Management of the Axilla in the Patient with Breast Cancer. Surg Clin North Am 2018; 98:747-760. [DOI: 10.1016/j.suc.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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48
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Caudle AS. Intraoperative Pathologic Evaluation with Targeted Axillary Dissection. Ann Surg Oncol 2018; 25:3112-3114. [DOI: 10.1245/s10434-018-6666-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Indexed: 11/18/2022]
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49
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Corso G, De Scalzi AM, Vicini E, Morigi C, Veronesi P, Galimberti V. Sentinel lymph node biopsy management after neoadjuvant treatment for breast cancer care. Future Oncol 2018; 14:1423-1426. [DOI: 10.2217/fon-2018-0132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Giovanni Corso
- Division of Breast Cancer Surgery, European Institute of Oncology, via G. Ripamonti 435, 20141 Milano, Italy
| | | | - Elisa Vicini
- Division of Breast Cancer Surgery, European Institute of Oncology, via G. Ripamonti 435, 20141 Milano, Italy
| | - Consuelo Morigi
- Division of Breast Cancer Surgery, European Institute of Oncology, via G. Ripamonti 435, 20141 Milano, Italy
| | - Paolo Veronesi
- Division of Breast Cancer Surgery, European Institute of Oncology, via G. Ripamonti 435, 20141 Milano, Italy
- Faculty of Medicine, University of Milan, Milano, Italy
| | - Viviana Galimberti
- Division of Breast Cancer Surgery, European Institute of Oncology, via G. Ripamonti 435, 20141 Milano, Italy
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50
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Breast cancer metastasis through the lympho-vascular system. Clin Exp Metastasis 2018; 35:443-454. [PMID: 29796854 DOI: 10.1007/s10585-018-9902-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/13/2018] [Indexed: 12/21/2022]
Abstract
Breast cancer metastasizes through the lymphovascular system to the regional lymph nodes in the axilla and to both visceral and non-visceral sites. Renewed interest in the route by which tumor cells gain access to blood and lymphatic capillaries are the subject of research at mechanical, anatomic, pathologic, genetic, epidemiologic and molecular levels. Two papers presented at the 7th International Symposium on Cancer Metastasis in San Francisco showed tumor cells entering the systemic circulation through the sentinel lymph node. This information challenges the current paradigm where clinicians believe that access is gained through intra- and peri-tumoral blood vessels and that metastasis to axillary lymph nodes is an interesting epi-phenomenon. The sentinel lymph node era has changed the modern surgical approach to the axilla and the basis of this change is summarized in this paper. A new approach to the management of axillary metastases after systemic therapy relies on determining whether there is a complete pathologic response; if no tumor is found in the previously biopsied node, a complete axillary lymph node dissection may be avoided. African American women seem to inherit a trait from West African ancestors and tend to develop more lethal types of breast cancer. These tumors may have a molecular machinery that enhances their ability to metastasize to visceral sites and future research may unearth the mechanisms for this phenomenon.
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