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Aragón-Sánchez S, Sánchez-Bayona R, López-Marín L, Ciruelos-Gil E, Parrilla-Rubio L, Zaragoza-Ballester P, Galindo-Izquierdo A, García-Chapinal B, Álvaro-Valiente L, Oliver-Pérez MR. De-escalating axillary management after neoadjuvant chemotherapy in breast cancer: The ratio of positive sentinel lymph nodes matters. Surg Oncol 2024; 54:102062. [PMID: 38531288 DOI: 10.1016/j.suronc.2024.102062] [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: 09/17/2023] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND De-escalation of axillary surgery in breast cancer (BC) patients diminishes sequelae without compromising cancer outcomes. Surgical management of the axilla is challenging after neoadjuvant treatment. We aimed to identify the factors associated with residual axillary disease amenable to lymphadenectomy in patients with positive sentinel lymph node biopsy (SLNB). METHODS We conducted a retrospective observational study in Hospital 12 de Octubre (Spain). We included BC patients with positive SLNB who underwent axillary dissection after neoadjuvant chemotherapy. Univariate and multivariate logistic regression models were performed to identify independent predictors of residual axillary disease. We estimated the ratio of positive nodes in SLNB and assessed the diagnostic validity of this ratio in relation to residual axillary disease. RESULTS We included 103 patients in the study. Residual axillary disease was identified in 54 patients (52.4%). Clinically node positive status at diagnosis (OR = 18.3, 95%CI: 4.0-83.6) and a ratio of positive nodes in SLNB ≥0.5 (OR = 6.5, 95%CI 41.7-23.7) were associated with residual axillary disease. The sensitivity and negative predictive value of a ratio of positive nodes in SLNB ≥0.5 were 87% (95%CI 75.1%-94.6%) and 75% (95%CI 55.1%-89.3%), respectively. CONCLUSIONS In our study, for patients with positive SLNB after neoadjuvant chemotherapy, stage N+ at diagnosis and a ratio of positive nodes in SLNB ≥0.5 were independent risk factors of positive residual axillary disease. This ratio is a feasible measure with a good diagnostic validity for residual axillary disease and could be used as a guiding factor in the surgical management of these patients.
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Affiliation(s)
- S Aragón-Sánchez
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain
| | - R Sánchez-Bayona
- Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain; Department of Medical Oncology. University Hospital 12 de Octubre. Madrid, Spain.
| | - L López-Marín
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain
| | - E Ciruelos-Gil
- Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain; Department of Medical Oncology. University Hospital 12 de Octubre. Madrid, Spain
| | - L Parrilla-Rubio
- Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain; Department of Pathology. University Hospital 12 de Octubre. Madrid, Spain
| | | | - A Galindo-Izquierdo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain; Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
| | - B García-Chapinal
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain
| | - L Álvaro-Valiente
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain
| | - M R Oliver-Pérez
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain
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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Montagna G, Mrdutt MM, Sun SX, Hlavin C, Diego EJ, Wong SM, Barrio AV, van den Bruele AB, Cabioglu N, Sevilimedu V, Rosenberger LH, Hwang ES, Ingham A, Papassotiropoulos B, Nguyen-Sträuli BD, Kurzeder C, Aybar DD, Vorburger D, Matlac DM, Ostapenko E, Riedel F, Fitzal F, Meani F, Fick F, Sagasser J, Heil J, Karanlık H, Dedes KJ, Romics L, Banys-Paluchowski M, Muslumanoglu M, Perez MDRC, Díaz MC, Heidinger M, Fehr MK, Reinisch M, Tukenmez M, Maggi N, Rocco N, Ditsch N, Gentilini OD, Paulinelli RR, Zarhi SS, Kuemmel S, Bruzas S, di Lascio S, Parissenti TK, Hoskin TL, Güth U, Ovalle V, Tausch C, Kuerer HM, Caudle AS, Boileau JF, Boughey JC, Kühn T, Morrow M, Weber WP. Omission of Axillary Dissection Following Nodal Downstaging With Neoadjuvant Chemotherapy. JAMA Oncol 2024; 10:793-798. [PMID: 38662396 PMCID: PMC11046400 DOI: 10.1001/jamaoncol.2024.0578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/07/2023] [Indexed: 04/26/2024]
Abstract
Importance Data on oncological outcomes after omission of axillary lymph node dissection (ALND) in patients with breast cancer that downstages from node positive to negative with neoadjuvant chemotherapy are sparse. Additionally, the best axillary surgical staging technique in this scenario is unknown. Objective To investigate oncological outcomes after sentinel lymph node biopsy (SLNB) with dual-tracer mapping or targeted axillary dissection (TAD), which combines SLNB with localization and retrieval of the clipped lymph node. Design, Setting, and Participants In this multicenter retrospective cohort study that was conducted at 25 centers in 11 countries, 1144 patients with consecutive stage II to III biopsy-proven node-positive breast cancer were included between April 2013 and December 2020. The cumulative incidence rates of axillary, locoregional, and any invasive (locoregional or distant) recurrence were determined by competing risk analysis. Exposure Omission of ALND after SLNB or TAD. Main Outcomes and Measures The primary end points were the 3-year and 5-year rates of any axillary recurrence. Secondary end points included locoregional recurrence, any invasive (locoregional and distant) recurrence, and the number of lymph nodes removed. Results A total of 1144 patients (median [IQR] age, 50 [41-59] years; 78 [6.8%] Asian, 105 [9.2%] Black, 102 [8.9%] Hispanic, and 816 [71.0%] White individuals; 666 SLNB [58.2%] and 478 TAD [41.8%]) were included. A total of 1060 patients (93%) had N1 disease, 619 (54%) had ERBB2 (formerly HER2)-positive illness, and 758 (66%) had a breast pathologic complete response. TAD patients were more likely to receive nodal radiation therapy (85% vs 78%; P = .01). The clipped node was successfully retrieved in 97% of TAD cases and 86% of SLNB cases (without localization). The mean (SD) number of sentinel lymph nodes retrieved was 3 (2) vs 4 (2) (P < .001), and the mean (SD) number of total lymph nodes removed was 3.95 (1.97) vs 4.44 (2.04) (P < .001) in the TAD and SLNB groups, respectively. The 5-year rates of any axillary, locoregional, and any invasive recurrence in the entire cohort were 1.0% (95% CI, 0.49%-2.0%), 2.7% (95% CI, 1.6%-4.1%), and 10% (95% CI, 8.3%-13%), respectively. The 3-year cumulative incidence of axillary recurrence did not differ between TAD and SLNB (0.5% vs 0.8%; P = .55). Conclusions and Relevance The results of this cohort study showed that axillary recurrence was rare in this setting and was not significantly lower after TAD vs SLNB. These results support omission of ALND in this population.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary M. Mrdutt
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Susie X. Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Callie Hlavin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Emilia J. Diego
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie M. Wong
- Department of Surgery, McGill University Medical School, Montreal, Quebec, Canada
- Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Andrea V. Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Neslihan Cabioglu
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - E. Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Abigail Ingham
- University of Glasgow and National Health Service Greater Glasgow and Clyde, Department of Academic Surgery, Glasgow, Scotland
| | | | | | - Christian Kurzeder
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Danilo Díaz Aybar
- Breast Service, Department of Surgery, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - Denise Vorburger
- Breast Cancer Unit, Comprehensive Cancer Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Dieter Michael Matlac
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Edvin Ostapenko
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Fabian Riedel
- Department of Gynecology and Obstetrics, Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Fitzal
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Francesco Meani
- Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Gruppo Ospedaliero Moncucco, Ticino, Switzerland
| | - Franziska Fick
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Jacqueline Sagasser
- Department of Obstetrics and Gynecology, University Hospital of Augsburg, Augsburg, Germany
| | - Jörg Heil
- Department of Gynecology and Obstetrics, Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Hasan Karanlık
- Division of Surgical Oncology, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | | | - Laszlo Romics
- University of Glasgow and National Health Service Greater Glasgow and Clyde, Department of Academic Surgery, Glasgow, Scotland
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Mahmut Muslumanoglu
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | | | - Marcelo Chávez Díaz
- Breast Service, Department of Surgery, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - Martin Heidinger
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Mattea Reinisch
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
- Charité–Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Mustafa Tukenmez
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | - Nadia Maggi
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Nicola Rocco
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital of Augsburg, Augsburg, Germany
| | | | | | - Sebastián Solé Zarhi
- Department of Radiation Oncology, IRAM–Universidad Diego Portales, Santiago, Chile
| | - Sherko Kuemmel
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
- Charité–Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Simona Bruzas
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
| | - Simona di Lascio
- Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Service of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Tanya L. Hoskin
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Uwe Güth
- Breast-Center Zurich AG, Zurich, Switzerland
| | - Valentina Ovalle
- Department of Radiation Oncology, IRAM–Universidad Diego Portales, Santiago, Chile
| | - Christoph Tausch
- Breast-Center Zurich AG, Zurich, Switzerland
- University of Basel, Basel, Switzerland
| | - Henry M. Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Abigail S. Caudle
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jean-Francois Boileau
- Department of Surgery, McGill University Medical School, Montreal, Quebec, Canada
- Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Judy C. Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Thorsten Kühn
- Department of Gynecology, Klinikum Esslingen, Esslingen, Germany
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Walter P. Weber
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Munck F, Jensen MB, Vejborg I, Gerlach MK, Maraldo MV, Kroman NT, Tvedskov THF. Residual Axillary Metastases in Node-Positive Breast Cancer Patients After Neoadjuvant Treatment: A Register-Based Study. Ann Surg Oncol 2024:10.1245/s10434-024-15354-1. [PMID: 38704502 DOI: 10.1245/s10434-024-15354-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/09/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Lymph node (LN) metastasis after neoadjuvant chemotherapy (NACT) generally warrants axillary lymph node dissection, which opposes guidelines of upfront surgery in many cases. We investigated the risk of having additional metastases in the axilla when the LNs removed by targeted axillary dissection (TAD) harbored metastases after NACT. We aimed to identify subgroups suitable for de-escalated axillary treatment. METHODS This register-based study used data from the Danish Breast Cancer Cooperative Group database. Data were analyzed with logistic regression models. The primary outcome was the metastatic burden in non-TAD LNs in patients with positive TAD LNs after NACT. RESULTS Among 383 patients, < 66.6% positive TAD LNs (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.17-0.62), only isolated tumor cells (ITCs) [OR 0.11, 95% CI < 0.01-0.82], and breast pathological complete response (pCR) [OR 0.07, 95% CI < 0.01-0.56] were associated with a low risk of having more than three positive non-TAD LNs. In 315 patients with fewer than three positive non-TAD LNs, the proportion of positive TAD LNs (OR 0.45, 95% CI 0.27-0.76 for 33.3-66.6% vs. > 66.6%), size of the TAD LN metastasis (OR 0.14, 95% CI 0.04-0.54 for ITC vs. macrometastasis), tumor size at diagnosis (OR 0.30, 95% CI 0.15-0.64 for 20-49 mm vs. ≥ 50 mm) and breast pCR (OR 0.38, 95% CI 0.15-0.96) were associated with residual LN metastases in the axilla. CONCLUSIONS Breast pCR or ITC only in TAD LNs can, with reasonable certainty, preclude more than three positive non-TAD LNs. Additionally, patients with only ITCs in the TAD LN had a low risk of having any non-TAD LN metastases after NACT. De-escalated axillary treatment may be considered in both subgroups.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark.
| | - Maj-Britt Jensen
- Danish Breast Cancer Group, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Maja V Maraldo
- Department of Clinical Oncology, Center of Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
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Heidinger M, Weber WP. Axillary Surgery for Breast Cancer in 2024. Cancers (Basel) 2024; 16:1623. [PMID: 38730576 PMCID: PMC11083357 DOI: 10.3390/cancers16091623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous 'one size fits all' radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.
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Affiliation(s)
- Martin Heidinger
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Walter P. Weber
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
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Connors C, Al-Hilli Z. De-escalation of Axillary Surgery After Neoadjuvant Therapy. Clin Breast Cancer 2024:S1526-8209(24)00108-3. [PMID: 38735808 DOI: 10.1016/j.clbc.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/25/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024]
Abstract
Surgical de-escalation of the axilla has evolved over the past 28 years since the emergence of sentinel lymph node surgery. Well-documented complications of the once standard of care axillary lymph node dissection (ALND), including lymphedema, led physician scientists towards a progressive push to study and incorporate less invasive techniques in the axilla. Many trials have justified oncologic safety of axillary de-escalation in patients who are spared neoadjuvant treatment. The applicability in the neoadjuvant setting, however, is less clear and axillary surgical approaches in this patient population have evolved at a slower pace. This review aims to analyze current data in axillary management for patients undergoing neoadjuvant treatment and to discuss current surgical approaches based on nodal pathologic response.
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Affiliation(s)
- Casey Connors
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Zahraa Al-Hilli
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH.
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Cavalcante FP, Zerwes FP, Souza ABA, Ziegelmann PK, Alcantara R, Cardoso A, Mattar A, Millen EC, Frasson AL. The use of blue dye alone for sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initially node-positive breast cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107967. [PMID: 38262300 DOI: 10.1016/j.ejso.2024.107967] [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: 09/18/2023] [Revised: 11/22/2023] [Accepted: 01/09/2024] [Indexed: 01/25/2024]
Abstract
INTRODUCTION False-negative sentinel lymph node biopsy (SLNB) rates following neoadjuvant chemotherapy (NACT) in initially node-positive (cN1/2) breast cancer patients are high, but decrease when lymph nodes are clipped, ≥3 sentinel lymph nodes (SLN) are removed or dual-tracer localization (radioisotope and blue dye) is used. Radiotracer, however, is often unavailable and outcomes with blue dye alone are unknown. MATERIALS AND METHODS Initially cT1-4, cN1/2 patients treated with NACT in 2013-2023 who underwent SLNB using blue dye alone were evaluated regarding SLN identification, axillary recurrence, disease-free and overall survival rates. RESULTS Of 119 patients included, 19 remained cN1/2 after NACT. SLNB was performed using blue dye alone in 100 ycN0 cases (84%), with an identification rate of 96%. The SLN was negative in 70/119 cases (i.e. 59% avoided axillary dissection). The number of SLN detected was ≥3 in 55/70 cases (78%) (median 3.1; 1-6). Median age was 49 years (25-84). Most were T2 (n = 40, 57.1%), N1 (n = 64, 91.4%). Predominant subtypes were ERBB2 (52.9%) and triple-negative (20%). No axillary recurrence occurred over a median 36-month period. Five-year disease-free and overall survival were, respectively, 85.9% (95%CI: 74-99.8) and 96.3% (95%CI: 89.4-100). The ERBB2 subtype (1.99, 95%CI: 1.02-3.85, p = 0.04) and N1 lymph node status (2.58, 95%CI: 1.54-9.10, p = 0.03) were associated with a greater likelihood of undergoing SLNB alone without axillary dissection. CONCLUSIONS SLNB with blue dye alone following NACT in initially cN1/2 patients avoided axillary dissection in almost 60% of cases, with no recurrences during the period evaluated. Longer follow-up studies are necessary.
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Affiliation(s)
| | - Felipe Pereira Zerwes
- Breast Surgery Department, Pontificia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil.
| | - Alessandra Borba Anton Souza
- Breast Surgery Department, Pontificia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil.
| | - Patrícia Klarmann Ziegelmann
- Department of Statistics and Postgraduate Program in Epidemiology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil.
| | - Ryane Alcantara
- Breast Surgery Department, Fortaleza General Hospital, Fortaleza, Ceará, Brazil.
| | - Amanda Cardoso
- Breast Surgery Department, Fortaleza General Hospital, Fortaleza, Ceará, Brazil.
| | - André Mattar
- Oncology Department, Women's Health Hospital, São Paulo, São Paulo, Brazil.
| | | | - Antonio Luiz Frasson
- Breast Surgery Department, Pontificia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil; Oncology Department, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil.
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Tauber N, Bjelic-Radisic V, Thill M, Banys-Paluchowski M. Controversies in axillary management of patients with breast cancer - updates for 2024. Curr Opin Obstet Gynecol 2024; 36:51-56. [PMID: 37678325 DOI: 10.1097/gco.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW For some time now, the question of de-escalation in axillary staging in breast cancer patients has been raised. The aim is to improve the patients' quality of life and reduce morbidity by optimizing surgical strategies with a high level of oncological safety. This review offers a current overview of published evidence and clinical practice, aiming to guide the surgical community as they reassess and reshape their practices. RECENT FINDINGS Years after introducing sentinel lymph node biopsy (SLNB) in clinically node negative breast cancer patients several guidelines suggest completely omitting SLNB in older patients with low-risk tumors. It is worth noting that for patients with a metastatic sentinel lymph node in the upfront surgery setting, a de-escalation of axillary surgery may in fact lead to an escalation of radiation therapy. Currently, there is limited evidence on the axillary surgical approach for patients with initially positive node status achieving complete axillary response (ycN0), resulting in heterogenous guideline recommendations. SUMMARY Innovative trials are contributing to a growing evidence on de-escalation of axillary surgery with the aim of reducing arm morbidity and improving long-term health-related quality of life.
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Affiliation(s)
- Nikolas Tauber
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck
| | | | - Marc Thill
- Department of Gynecology and Gynecological Oncology, Breast Center, AGAPLESION Markus Hospital, Frankfurt/M
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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9
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Loibl S, André F, Bachelot T, Barrios CH, Bergh J, Burstein HJ, Cardoso MJ, Carey LA, Dawood S, Del Mastro L, Denkert C, Fallenberg EM, Francis PA, Gamal-Eldin H, Gelmon K, Geyer CE, Gnant M, Guarneri V, Gupta S, Kim SB, Krug D, Martin M, Meattini I, Morrow M, Janni W, Paluch-Shimon S, Partridge A, Poortmans P, Pusztai L, Regan MM, Sparano J, Spanic T, Swain S, Tjulandin S, Toi M, Trapani D, Tutt A, Xu B, Curigliano G, Harbeck N. Early breast cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2024; 35:159-182. [PMID: 38101773 DOI: 10.1016/j.annonc.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Affiliation(s)
- S Loibl
- GBG Forschungs GmbH, Neu-Isenburg; Centre for Haematology and Oncology, Bethanien, Frankfurt, Germany
| | - F André
- Breast Cancer Unit, Medical Oncology Department, Gustave Roussy, Cancer Campus, Villejuif
| | - T Bachelot
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - C H Barrios
- Oncology Department, Latin American Cooperative Oncology Group and Oncoclínicas, Porto Alegre, Brazil
| | - J Bergh
- Department of Oncology-Pathology, Bioclinicum, Karolinska Institutet and Breast Cancer Centre, Karolinska Comprehensive Cancer Centre and University Hospital, Stockholm, Sweden
| | - H J Burstein
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - M J Cardoso
- Breast Unit, Champalimaud Foundation, Champalimaud Cancer Centre, Lisbon; Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - L A Carey
- Division of Medical Oncology, The University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, USA
| | - S Dawood
- Department of Oncology, Mediclinic City Hospital, Dubai, UAE
| | - L Del Mastro
- Medical Oncology Clinic, IRCCS Ospedale Policlinico San Martino, Genoa; Department of Internal Medicine and Medical Specialities, School of Medicine, University of Genoa, Genoa, Italy
| | - C Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Giessen and Marburg, Marburg
| | - E M Fallenberg
- Department of Diagnostic and Interventional Radiology, School of Medicine & Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - P A Francis
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - H Gamal-Eldin
- Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - K Gelmon
- Department of Medical Oncology, British Columbia Cancer, Vancouver, Canada
| | - C E Geyer
- Department of Internal Medicine, Hillman Cancer Center, University of Pittsburgh, Pittsburgh, USA
| | - M Gnant
- Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
| | - V Guarneri
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova; Oncology 2 Unit, Istituto Oncologico Veneto IOV IRCCS, Padova, Italy
| | - S Gupta
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - S B Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - M Martin
- Hospital General Universitario Gregorio Maranon, Universidad Complutense, GEICAM, Madrid, Spain
| | - I Meattini
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence; Department of Experimental and Clinical Biomedical Sciences 'M. Serio', University of Florence, Florence, Italy
| | - M Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - W Janni
- Department of Obstetrics and Gynaecology, University of Ulm, Ulm, Germany
| | - S Paluch-Shimon
- Sharett Institute of Oncology Department, Hadassah University Hospital & Faculty of Medicine Hebrew University, Jerusalem, Israel
| | - A Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - L Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven
| | - M M Regan
- Division of Biostatistics, Dana-Farber Cancer Institute, Harvard Medical School, Boston
| | - J Sparano
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - T Spanic
- Europa Donna Slovenia, Ljubljana, Slovenia
| | - S Swain
- Medicine Department, Georgetown University Medical Centre and MedStar Health, Washington, USA
| | - S Tjulandin
- N.N. Blokhin National Medical Research Centre of Oncology, Moscow, Russia
| | - M Toi
- Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, Bunkyo-ku, Japan
| | - D Trapani
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - A Tutt
- Breast Cancer Research Division, The Institute of Cancer Research, London; Comprehensive Cancer Centre, Division of Cancer Studies, Kings College London, London, UK
| | - B Xu
- Department of Medical Oncology, National Cancer Centre/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - G Curigliano
- Early Drug Development for Innovative Therapies Division, Istituto Europeo di Oncologia, IRCCS, Milan; Department of Oncology and Hemato-Oncology, University of Milano, Milan, Italy
| | - N Harbeck
- Breast Centre, Department of Obstetrics & Gynaecology and Comprehensive Cancer Centre Munich, LMU University Hospital, Munich, Germany
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10
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Zaborowski AM, Doogan K, Clifford S, Dowling G, Kazi F, Delaney K, Yadav H, Brady A, Geraghty J, Evoy D, Rothwell J, McCartan D, Heeney A, Barry M, Walsh SM, Stokes M, Kell MR, Allen M, Power C, Hill ADK, Connolly E, Alazawi D, Boyle T, Corrigan M, O’Leary P, Prichard RS. Nodal positivity in patients with clinically and radiologically node-negative breast cancer treated with neoadjuvant chemotherapy: multicentre collaborative study. Br J Surg 2024; 111:znad401. [PMID: 38055888 PMCID: PMC10763529 DOI: 10.1093/bjs/znad401] [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: 05/30/2023] [Revised: 10/06/2023] [Accepted: 11/05/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND The necessity of performing a sentinel lymph node biopsy in patients with clinically and radiologically node-negative breast cancer after neoadjuvant chemotherapy has been questioned. The aim of this study was to determine the rate of nodal positivity in these patients and to identify clinicopathological features associated with lymph node metastasis after neoadjuvant chemotherapy (ypN+). METHODS A retrospective multicentre study was performed. Patients with cT1-3 cN0 breast cancer who underwent sentinel lymph node biopsy after neoadjuvant chemotherapy between 2016 and 2021 were included. Negative nodal status was defined as the absence of palpable lymph nodes, and the absence of suspicious nodes on axillary ultrasonography, or the absence of tumour cells on axillary nodal fine needle aspiration or core biopsy. RESULTS A total of 371 patients were analysed. Overall, 47 patients (12.7%) had a positive sentinel lymph node biopsy. Nodal positivity was identified in 22 patients (29.0%) with hormone receptor+/human epidermal growth factor receptor 2- tumours, 12 patients (13.8%) with hormone receptor+/human epidermal growth factor receptor 2+ tumours, 3 patients (5.6%) with hormone receptor-/human epidermal growth factor receptor 2+ tumours, and 10 patients (6.5%) with triple-negative breast cancer. Multivariable logistic regression analysis showed that multicentric disease was associated with a higher likelihood of ypN+ (OR 2.66, 95% c.i. 1.18 to 6.01; P = 0.018), whilst a radiological complete response in the breast was associated with a reduced likelihood of ypN+ (OR 0.10, 95% c.i. 0.02 to 0.42; P = 0.002), regardless of molecular subtype. Only 3% of patients who had a radiological complete response in the breast were ypN+. The majority of patients (85%) with a positive sentinel node proceeded to axillary lymph node dissection and 93% had N1 disease. CONCLUSION The rate of sentinel lymph node positivity in patients who achieve a radiological complete response in the breast is exceptionally low for all molecular subtypes.
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Affiliation(s)
| | - Katie Doogan
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Siobhan Clifford
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gavin Dowling
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Farah Kazi
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Karina Delaney
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Himanshu Yadav
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Aaron Brady
- Department of Breast Surgery, Bon Secours Hospital Cork, Cork, Ireland
| | - James Geraghty
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Denis Evoy
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Jane Rothwell
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Damian McCartan
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Anna Heeney
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mitchel Barry
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Siun M Walsh
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Maurice Stokes
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Malcolm R Kell
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Allen
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Colm Power
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Arnold D K Hill
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Dhafir Alazawi
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Terence Boyle
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Mark Corrigan
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Peter O’Leary
- Department of Breast Surgery, Bon Secours Hospital Cork, Cork, Ireland
| | - Ruth S Prichard
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
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11
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Bozhok AA, Kashchenko VA, Ratnikov VA, Gornov SV, Suvorova YV, Manelov AE. [Fluorescence lymphography for sentinal lymph node biopsy in breast cancer]. Khirurgiia (Mosk) 2024:48-54. [PMID: 38380464 DOI: 10.17116/hirurgia202402248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
OBJECTIVE To study diagnostic value of fluorescence lymphography for sentinel lymph node biopsy in breast cancer. MATERIAL AND METHODS The study enrolled 25 patients with breast cancer T1-2N0-1M0 between March 2023 and July 2023. Eight ones underwent neoadjuvant chemotherapy. In 3 patients, morphologically verified metastases cN1 in axillary lymph nodes regressed after treatment. After sentinel lymph node biopsy, all patients underwent standard axillary lymphadenectomy. Subareolar injection of indocyanine green 1 ml (5 mg/ml) was performed immediately before surgery. Fluorescence imaging was performed using the MARS system. RESULTS Detection rate was 100%. Mean number of sentinel lymph nodes was 2. Metastatic lesions of sentinel lymph nodes were observed in 6 patients (24%) with micro-metastases in 2 cases. In 50% of cases, metastatic lesion did not extend beyond sentinel lymph nodes. False negative result was obtained in 1 (4%) patient. Mean number of metastases was 1.8 (max 3 in one patient). CONCLUSION Sentinel lymph node biopsy with fluorescence lymphography is a sensitive method. The advantages of this technique are visualization of subcutaneous lymphatic vessels and skin incision for access to sentinel lymph nodes, as well as visualization of sentinel lymph nodes after skin incision.
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Affiliation(s)
- A A Bozhok
- Saint Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - V A Kashchenko
- Sokolov North-Western Regional Scientific Clinical Center, St. Petersburg, Russia
| | - V A Ratnikov
- Sokolov North-Western Regional Scientific Clinical Center, St. Petersburg, Russia
| | - S V Gornov
- Russian Biotechnological University, Moscow, Russia
| | - Yu V Suvorova
- Sokolov North-Western Regional Scientific Clinical Center, St. Petersburg, Russia
| | - A E Manelov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
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12
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Tvedskov TF. Axillary surgery in oncologic breast surgery: a narrative review. Gland Surg 2023; 12:1774-1785. [PMID: 38229843 PMCID: PMC10788576 DOI: 10.21037/gs-23-362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/04/2023] [Indexed: 01/18/2024]
Abstract
Background and Objective With the improved survival for breast cancer there is now an increased focus on quality of life after treatment. Axillary surgery is known to be associated with significant risk of arm morbidity feared by the patients, and several studies have shown de-escalation is possible in different settings. In this review, an overview will be given on new techniques and procedures for de-escalation of axillary surgery in breast cancer patients and the subsequent implications for adjuvant systemic treatment. Methods This study is a narrative review. PubMed was searched for relevant publications in English published between January 2018-June 2023. Only publications with major impact on clinical practice have been included with main emphasis on meta-analysis. In addition, Clinicaltrial.gov has been searched for on-going studies. Key Content and Findings New tracer techniques are described as well as the on-going reduction in axillary lymph node dissection (ALND) at primary surgery even in node positive patients, and the axillary staging possibilities after down-staging of the axilla by neoadjuvant treatment. Finally axillary staging at local recurrence and in case of ductal carcinoma in situ is described. Conclusions ALND is no longer routinely recommended in many node positive patients and further de-escalation is investigated. The lack of knowledge on precise axillary status will require cooperating studies between oncologists and breast surgeons in order to avoid escalation of systemic treatment due to the lack of applicability of trial eligibility criteria. Furthermore, investigations on the use of axillary imaging for staging are needed.
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13
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Banys-Paluchowski M, Hartmann S, Ditsch N, Krawczyk N, Kühn T, de Boniface J, Banys-Kotomska J, Rody A, Krug D. Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy. Breast Care (Basel) 2023; 18:428-439. [PMID: 38130814 PMCID: PMC10731028 DOI: 10.1159/000533748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer. Summary Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement. Key Messages Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, Rostock, Germany
| | - Nina Ditsch
- Breast Cancer Center, Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Die Filderklinik, Filderstadt, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St. Göran’s Hospital, Stockholm, Sweden
| | - Joanna Banys-Kotomska
- I Department and Clinic of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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14
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer. Cancers (Basel) 2023; 15:5353. [PMID: 38001613 PMCID: PMC10670757 DOI: 10.3390/cancers15225353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
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15
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Siso C, Esgueva A, Rivero J, Morales C, Miranda I, Peg V, Gil-Moreno A, Espinosa-Bravo M, Rubio IT. Feasibility and safety of targeted axillary dissection guided by intraoperative ultrasound after neoadjuvant treatment. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106938. [PMID: 37244843 DOI: 10.1016/j.ejso.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/07/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Axillary management in cN + axillary nodes after neoadjuvant systemic therapy (NST) in breast cancer (BC) remains under research with the aim of de-escalation of axillary node dissection (ALND). Several axillary guided localization techniques have been reported. This study evaluates the safety of intraoperative ultrasound (IOUS) guided targeted axillary dissection (TAD) in a large sample after the results of ILINA trial. MATERIALS Prospective data have been collected from October 2015 to June 2022 in patients with cT0-T4 and positive axillary lymph nodes (cN1) treated with NST. Before NST, an ultrasound visible marker was placed into the positive node. After NST, IOUS guided TAD was performed including sentinel node biopsy (SLN). Until December 2019, all patients underwent an ALND after TAD procedure. From January 2020, ALND was spared in those patients with an axillary pathological complete response (pCR). RESULTS 235 patients were included. pCR (ypT0/is ypN0) was achieved in 29% patients. Identification rate (IR) of the clipped node by IOUS was 96% (95% IC, 92.5-98.1%) and IR of SLN was 95% (95% IC, 90.8-97.2%). False negative rate (FNR) for TAD procedure (SLN + clipped node) was 7.0% (95% IC, 2.3-15.7%), which decreased to 4.9% when a total of 3 or more nodes were removed. Axillary ultrasound before surgery assessed residual disease with an AUC of 0.5241. Residual axillary disease tend to be the most significant factor for axillary recurrences. CONCLUSIONS This study confirms the feasibility, safety and accuracy of IOUS guided surgery for axillary staging after NST in node positive BC patients.
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Affiliation(s)
- Christian Siso
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Antonio Esgueva
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Joaquin Rivero
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Clara Morales
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Ignacio Miranda
- Departament of Radiology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Vicente Peg
- Departament of Pathology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Antonio Gil-Moreno
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Martin Espinosa-Bravo
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Isabel T Rubio
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain.
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16
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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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17
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Untch M, Banys-Paluchowski M, Brucker SY, Budach W, Denkert C, Ditsch N, Fasching PA, Haidinger R, Heil J, Jackisch C, Janni W, Kolberg HC, Krug D, Loibl S, Lüftner D, van Mackelenbergh M, Radosa JC, Reimer T, Welslau M, Würstlein R, Harbeck N, Huober J. Treatment of Early Breast Cancer: The 18th St. Gallen International Breast Cancer Consensus Conference against the Background of Current German Treatment Recommendations. Geburtshilfe Frauenheilkd 2023; 83:1102-1116. [PMID: 37706057 PMCID: PMC10497346 DOI: 10.1055/a-2121-2495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/29/2023] [Indexed: 09/15/2023] Open
Abstract
This year's 18th St. Gallen (SG) consensus conference on the treatment of early breast cancer (SGBCC: St. Gallen International Breast Cancer Conference) focused on practice-oriented questions. The individual situation and risk-benefit assessment were discussed in great detail. As in previous years, a German working group of leading breast cancer experts presented the results of the international SGBCC 2023 against the background of German treatment recommendations - especially the updated treatment recommendations of the Arbeitsgemeinschaft Gynäkologische Onkologie e. V. (AGO) - for everyday clinical practice in Germany. The German treatment recommendations of AGO are based on the current evidence. The comparison with the clinical approach in Germany has proven useful, as the SGBCC panel consists of experts from different countries and disciplines. That is why country-specific characteristics can be incorporated into the SGBCC recommendations.
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Affiliation(s)
- Michael Untch
- Klinik für Gynäkologie und Geburtshilfe, interdisziplinäres Brustzentrum, HELIOS Klinikum Berlin Buch, Berlin, Germany
| | - Maggie Banys-Paluchowski
- Klinik für Frauenheilkunde und Geburtshilfe, Brustzentrum, Campus Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | | | - Wilfried Budach
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Carsten Denkert
- Institut für Pathologie, Philipps-Universität Marburg und Universitätsklinikum Marburg (UKGM), Marburg, Germany
| | - Nina Ditsch
- Klinik für Frauenheilkunde und Geburtshilfe, Brustzentrum, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Peter A. Fasching
- Frauenklinik des Universitätsklinikums Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Jörg Heil
- Brustzentrum Heidelberg, Klinik St. Elisabeth, Heidelberg, Germany
- Medizinische Fakultät Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
| | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana-Klinikum Offenbach GmbH, Offenbach, Germany
| | | | | | - David Krug
- Klinik für Strahlentherapie (Radioonkologie), Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Sibylle Loibl
- German Breast Group (GBG), Neu-Isenburg, Germany
- Centrum für Hämatologie und Onkologie Bethanien, Frankfurt am Main, Germany
| | - Diana Lüftner
- Immanuel Klinik Märkische Schweiz, Buckow, Germany
- Immanuel Klinik Rüdersdorf, Medizinische Hochschule Brandenburg, Rüdersdorf bei Berlin, Germany
| | - Marion van Mackelenbergh
- Gynäkologie und Geburtshilfe, Campus Kiel, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Julia C. Radosa
- Klinik für Gynäkologie, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Toralf Reimer
- Universitätsfrauenklinik und Poliklinik am Klinikum Südstadt Rostock, Rostock, Germany
| | - Manfred Welslau
- Onkologie Aschaffenburg, Hämato-Onkologische Schwerpunktpraxis am Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Rachel Würstlein
- Brustzentrum, Frauenklinik, LMU Klinikum München, München, Germany
| | - Nadia Harbeck
- Brustzentrum, Frauenklinik, LMU Klinikum München, München, Germany
| | - Jens Huober
- Brustzentrum Kantonsspital St. Gallen, St. Gallen, Switzerland
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Cebrecos I, Mension E, Alonso I, Castillo H, Sanfeliu E, Vidal-Sicart S, Ganau S, Vidal M, Schettini F. Nonsentinel Axillary Lymph Node Status in Clinically Node-Negative Early Breast Cancer After Primary Systemic Therapy and Positive Sentinel Lymph Node: A Predictive Model Proposal. Ann Surg Oncol 2023; 30:4657-4668. [PMID: 36809608 PMCID: PMC10319670 DOI: 10.1245/s10434-023-13231-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/24/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND In clinically node-negative (cN0) early stage breast cancer (EBC) undergoing primary systemic treatment (PST), post-treatment positive sentinel lymph node (SLN+) directs axillary lymph node dissection (ALND), with uncertain impacts on outcomes and increased morbidities. PATIENTS AND METHODS We conducted an observational study on imaging-confirmed cN0 EBC, who underwent PST and breast surgery that resulted in SLN+ and underwent ALND. The association among baseline/postsurgical clinic-pathological factors and positive nonsentinel additional axillary lymph nodes (non-SLN+) was analyzed with logistic regression. LASSO regression (LR) identified variables to include in a predictive score of non-SLN+ (ALND-predict). The accuracy and calibration were assessed, an optimal cut-point was then identified, and in silico validation with bootstrap was undertaken. RESULTS Non-SLN+ were detected in 22.2% cases after ALND. Only progesterone receptor (PR) levels and macrometastatic SLN+ were independently associated to non-SLN+. LR identified PR, Ki67, and type and number of SLN+ as the most efficient covariates. The ALND-predict score was built based on their LR coefficients, showing an area under the curve (AUC) of 0.83 and an optimal cut-off of 63, with a negative predictive value (NPV) of 0.925. Continuous and dichotomic scores had a good fit (p = 0.876 and p = 1.00, respectively) and were independently associated to non-SLN+ [adjusted odds ratio (aOR): 1.06, p = 0.002 and aOR: 23.77, p < 0.001, respectively]. After 5000 bootstrap-adjusted retesting, the estimated bias-corrected and accelerated 95%CI included the aOR. CONCLUSIONS In cN0 EBC with post-PST SLN+, non-SLN+ at ALND are infrequent (~22%) and independently associated to PR levels and macrometastatic SLN. ALND-predict multiparametric score accurately predicted absence of non-SLN involvement, identifying most patients who could be safely spared unnecessary ALND. Prospective validation is required.
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Affiliation(s)
- Isaac Cebrecos
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Eduard Mension
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Inmaculada Alonso
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Helena Castillo
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Esther Sanfeliu
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Department of Pathology, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Diagnosis Imaging Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergi Ganau
- Department of Radiology, Diagnosis Imaging Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Maria Vidal
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Medical Oncology Department, Hospital Clinic of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francesco Schettini
- Faculty of Medicine, University of Barcelona, Barcelona, Spain.
- Medical Oncology Department, Hospital Clinic of Barcelona, Barcelona, Spain.
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
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19
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Beck AC, Morrow M. Axillary lymph node dissection: Dead or still alive? Breast 2023; 69:469-475. [PMID: 36702672 PMCID: PMC10300611 DOI: 10.1016/j.breast.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 01/24/2023] Open
Abstract
Although sentinel lymph node biopsy is now the primary method of axillary staging and is therapeutic for patients with limited nodal disease, axillary lymph node dissection (ALND) is still necessary for staging in groups where sentinel lymph node biopsy has not been proven to be accurate and to maintain local control in those with a heavy axillary tumor burden. Additionally, newer approaches to systemic therapy tailored to risk level sometimes necessitate knowledge of the number of involved axillary nodes which can only be obtained with ALND. Ongoing trials will address whether there are additional circumstances where radiotherapy can replace ALND.
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Affiliation(s)
- Anna C Beck
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
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20
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Huerta-Rosario M, Mir M, Quispe-Vicuña C, Hwang H, Sarode V, Peng Y, Fang Y, Leitch M, Sahoo S. Intraoperative evaluation of sentinel lymph nodes in patients with breast cancer treated with systemic neoadjuvant therapy. J Clin Pathol 2023:jcp-2023-208862. [PMID: 37258252 DOI: 10.1136/jcp-2023-208862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/03/2023] [Indexed: 06/02/2023]
Abstract
AIMS Touch preparation (TP) and frozen section (FS) are the two methods routinely used in the intraoperative evaluation (IOE) of sentinel lymph nodes (SLNs) to detect metastases in patients with breast cancer. Both methods are extremely sensitive and specific in the primary surgery (non-neoadjuvant systemic therapy (non-NST)) setting. Since NST introduces unique challenges in the IOE of SLNs, the aim was to determine the accuracy of TP and FS in the IOE of SLNs in the NST setting and compare the results with the non-NST setting and to examine factors that contribute to any differences. METHODS We analysed 871 SLNs from 232 patients (615 SLNs from NST and 256 SLNs from non-NST settings) between 2016 through 2019. RESULTS In the NST group, TP alone (n=366) had a sensitivity of 45.7% and specificity of 99.7%; FS alone (n=90) had a sensitivity of 83.3% and specificity of 100%. When both TP and FS (n=135) were used, the sensitivity was 80.3% and the specificity was 98.6%.In the non-NST group, TP alone (n=193) had a sensitivity of 66.7% and specificity of 100%; FS alone (n=22) had a sensitivity and specificity of 100%; and combined TP and FS (n=34) had a sensitivity and specificity of 100% and 96%, respectively. CONCLUSIONS Evaluating SLNs intraoperatively in the NST setting can be challenging secondary to therapy-related changes. In the NST setting, FS has higher sensitivity and specificity compared with TP for the IOE of SLNs and should be the preferred method.
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Affiliation(s)
- Mariela Huerta-Rosario
- Facultad de Medicina, Universidad Señor de Sipán, Chiclayo, Peru
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | - Mariam Mir
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos Quispe-Vicuña
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Sociedad Científica de San Fernando, Lima, Peru
| | - Helena Hwang
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Venetia Sarode
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yan Peng
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yisheng Fang
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Marilyn Leitch
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sunati Sahoo
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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21
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Banys-Paluchowski M, Rubio IT, Ditsch N, Krug D, Gentilini OD, Kühn T. Real de-escalation or escalation in disguise? Breast 2023; 69:249-257. [PMID: 36898258 PMCID: PMC10017412 DOI: 10.1016/j.breast.2023.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
The past two decades have seen an unprecedented trend towards de-escalation of surgical therapy in the setting of early BC, the most prominent examples being the reduction of re-excision rates for close surgical margins after breast-conserving surgery and replacing axillary lymph node dissection by less radical procedures such as sentinel lymph node biopsy (SLNB). Numerous studies confirmed that reducing the extent of surgery in the upfront surgery setting does not impact locoregional recurrences and overall outcome. In the setting of primary systemic treatment, there is an increased use of less invasive staging strategies reaching from SLNB and targeted lymph node biopsy (TLNB) to targeted axillary dissection (TAD). Omission of any axillary surgery in the presence of pathological complete response in the breast is currently being investigated in clinical trials. On the other hand, concerns have been raised that surgical de-escalation might induce an escalation of other treatment modalities such as radiation therapy. Since most trials on surgical de-escalation did not include standardized protocols for adjuvant radiotherapy, it remains unclear, whether the effect of surgical de-escalation was valid in itself or if radiotherapy compensated for the decreased surgical extent. Uncertainties in scientific evidence may therefore lead to escalation of radiotherapy in some settings of surgical de-escalation. Further, the increasing rate of mastectomies including contralateral procedures in patients without genetic risk is alarming. Future studies of locoregional treatment strategies need to include an interdisciplinary approach to integrate de-escalation approaches combining surgery and radiotherapy in a way that promotes optimal quality of life and shared decision-making.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Isabel T Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital Augsburg, Augsburg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | | | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Interdisciplinary Breast Center, Die Filderklinik, Filderstadt, Germany.
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22
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Outcomes of Breast Cancer Patients with High Volume of Residual Disease Following Neoadjuvant Chemotherapy. Int J Radiat Oncol Biol Phys 2023; 115:622-628. [PMID: 36155213 DOI: 10.1016/j.ijrobp.2022.09.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE The use of neoadjuvant chemotherapy (NAC) in patients with operable breast cancer allows for assessment of treatment response and subsequent tailoring of adjuvant therapy. Data are limited with respect to outcomes among patients with a heavy residual tumor burden after NAC. We report outcomes in patients who had exceptionally poor responses to NAC: those with >9 involved nodes after NAC or with 5 cm or more of residual disease in the breast. METHODS AND MATERIALS Between June 2014 and April 2020, 1511 patients with breast cancer received NAC followed by surgery at our institution. Poor responders, defined as those with positive nodes or residual tumor in the breast, were identified for analysis. Patients were further classified into 3 groups for comparison purposes: (1) 1 to 3 positive nodes; (2) 4 to 9 positive nodes; or (3) >9 positive nodes and/or >5 cm of residual tumor, which was defined as high-volume residual (HVR). Recurrence and survival outcomes were compared based on residual disease burden after NAC. RESULTS Among 934 poor responders, 539 patients had 1 to 3 positive nodes (ypN1), 215 had 4 to 9 positive nodes (ypN2), and 180 had HVR disease. Specifically, 118 had >9 positive nodes (HVR), and 62 patients had >5 cm of residual tumor in the breast. With a median follow-up of 31 months (interquartile range, 18-46), the 5-year overall survival rate was 88% among ypN1, 76% among ypN2, and 72% among patients with HVR disease (P < .001). The 5-year distant recurrence-free survival and locoregional recurrence incidences were 82% and 7.6% among ypN1 versus 67% and 8.4% among ypN2 versus 53% and 12% among HVR, respectively. CONCLUSIONS Our work suggests that patients with HVR disease are at high risk for locoregional and distant recurrence as well as death, despite best available standard-of-care treatment. Intensification of locoregional therapies and/or alternative adjuvant systemic treatment may improve outcomes in these poor responders.
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23
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Ersoy E, Elsayad M, Pandiri M, Knee A, Cao QJ, Crisi GM. Intraoperative Lymph Node Assessment (Touch Preparation Only) for Metastatic Breast Carcinoma in Neoadjuvant and Non-neoadjuvant Settings. Arch Pathol Lab Med 2023; 147:149-158. [PMID: 35512225 DOI: 10.5858/arpa.2021-0520-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 02/05/2023]
Abstract
CONTEXT.— Touch preparation (TP) alone is discouraged for intraoperative lymph node (LN) assessment in the neoadjuvant setting (NAS) owing to overall low sensitivity in detecting metastatic breast cancer. OBJECTIVE.— To compare the sensitivity, specificity, and negative predictive value of intraoperative LN assessment via TP and examine potential causes of discrepancies along with the clinical, radiologic, and pathologic parameters in the NAS and non-neoadjuvant setting (NNAS). DESIGN.— A total of 99 LNs from 47 neoadjuvant patients and 108 LNs from 56 non-neoadjuvant patients were identified. Discordant cases were reviewed retrospectively to reveal the discrepancy reasons. Clinical, radiologic, and pathologic data were obtained from chart review and the pathology CoPath database. RESULTS.— The sensitivity, specificity, and negative predictive value of TP in NAS and NNAS were 34.2% versus 37.5%, 100% versus 100%, and 70.9% versus 90.2%, respectively. In NAS, discrepancy reasons were interpretation challenge due to lobular histotype, poor TP quality secondary to therapy-induced histomorphologic changes, and undersampling due to small tumor deposits (≤2 mm); the latter was the major reason in NNAS. More cases with macrometastasis were missed in NAS compared to NNAS (14 of 25 versus 1 of 10). The parameters associated with discrepancy were lobular histotype, histologic grade 2, estrogen receptor positivity, HER2 human epidermal growth factor receptor 2 negativity, multifocality, and pathologic tumor size greater than 10 mm in NAS; and lymphovascular space involvement and pathologic tumor size greater than 20 mm in NNAS. CONCLUSIONS.— In NAS, intraoperative TP alone should be used very cautiously owing to a high false-negative rate of macrometastasis, especially for patients with invasive lobular carcinoma and known axillary LN metastasis before neoadjuvant therapy.
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Affiliation(s)
- Esma Ersoy
- From the Department of Pathology (Ersoy, Elsayad, Pandiri, Cao, Crisi), University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield.,Ersoy is currently with the Department of Pathology of Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mahmoud Elsayad
- From the Department of Pathology (Ersoy, Elsayad, Pandiri, Cao, Crisi), University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield
| | - Madhavi Pandiri
- From the Department of Pathology (Ersoy, Elsayad, Pandiri, Cao, Crisi), University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield
| | - Alexander Knee
- From the Department of Medicine (Knee), University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield
| | - Q Jackie Cao
- From the Department of Pathology (Ersoy, Elsayad, Pandiri, Cao, Crisi), University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield
| | - Giovanna M Crisi
- From the Department of Pathology (Ersoy, Elsayad, Pandiri, Cao, Crisi), University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield.,Ersoy is currently with the Department of Pathology of Memorial Sloan Kettering Cancer Center, New York, New York
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24
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Vázquez JC, Piñero A, de Castro FJ, Lluch A, Martín M, Barnadas A, Alba E, Rodríguez-Lescure Á, Rojo F, Giménez J, Solá I, Quintana MJ, Bonfill X, Urrutia G, Sánchez-Rovira P. The value of sentinel lymph-node biopsy in women with node-positive breast cancer at diagnosis and node-negative tumour after neoadjuvant therapy: a systematic review. CLINICAL & TRANSLATIONAL ONCOLOGY : OFFICIAL PUBLICATION OF THE FEDERATION OF SPANISH ONCOLOGY SOCIETIES AND OF THE NATIONAL CANCER INSTITUTE OF MEXICO 2023; 25:417-428. [PMID: 36153763 DOI: 10.1007/s12094-022-02953-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE To conduct a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) in women with node-positive breast cancer at diagnosis and node-negative tumour after neoadjuvant therapy, compared to axillary lymph-node dissection. METHODS The more relevant databases were searched. Main outcomes were false-negative rate (FNR), sentinel lymph-node identification rate (SLNIR), negative predictive value (NPV), and accuracy. We conducted meta-analyses when appropriate. RESULTS Twenty studies were included. The pooled FNR was 0.14 (95% CI 0.11-0.17), the pooled SLNIR was 0.89 (95% CI 0.86-0.92), NPV was 0.83 (95% CI 0.79-0.87), and summary accuracy was 0.92 (95% CI 0.90-0.94). SLNB performed better when more than one node was removed and double mapping was used. CONCLUSIONS SLNB can be performed in women with a node-negative tumour after neoadjuvant therapy. It has a better performance when used with previous marking of the affected node and with double tracer.
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Affiliation(s)
- Juan C Vázquez
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Antonio Piñero
- GEICAM Spanish Breast Cancer Group, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Francisco J de Castro
- Complejo Asistencial de Salamanca, GEICAM Spanish Breast Cancer Group, Salamanca, Spain
| | - Ana Lluch
- Medical Oncology Unit, Centro de Investigación Biomédica en Red de Oncología, CIBERONC-ISCIII, GEICAM Spanish Breast Cancer Group, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | - Miguel Martín
- Instituto de Investigación Sanitaria Gregorio Marañón, Centro de Investigación Biomédica en Red de Oncología, CIBERONC-ISCIII, GEICAM Spanish Breast Cancer Group, Universidad Complutense de Madrid, Madrid, Spain
| | - Agustí Barnadas
- Medical Oncology Unit, Centro de Investigación Biomédica en Red de Oncología, CIBERONC-ISCIII, GEICAM Spanish Breast Cancer Group, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Emilio Alba
- Centro de Investigación Biomédica en Red de Oncología, GEICAM Spanish Breast Cancer Group, UGCI Oncología Médica, Hospitales Regional y Virgen de la Victoria, IBIMA, CIBERONC-ISCIII, Málaga, Spain
| | | | - Federico Rojo
- Centro de Investigación Biomédica en Red de Oncología, GEICAM Spanish Breast Cancer Group, Hospital Universitario Fundacion Jimenez Diaz, CIBERONC-ISCIII, Madrid, Spain
| | - Julia Giménez
- Instituto Valenciano de Oncologia-IVO-GEICAM Spanish Breast Cancer Group, Valencia, Spain
| | - Ivan Solá
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Maria J Quintana
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Bonfill
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gerard Urrutia
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pedro Sánchez-Rovira
- Medical Oncology Unit, GEICAM Spanish Breast Cancer Group, Complejo Hospitalario de Jaén, Jaén, Spain
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25
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Laws A, Kantor O, King TA. Surgical Management of the Axilla for Breast Cancer. Hematol Oncol Clin North Am 2023; 37:51-77. [PMID: 36435614 DOI: 10.1016/j.hoc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This review discusses the contemporary surgical management of the axilla in patients with breast cancer. Surgical paradigms are highlighted by clinical nodal status at presentation and treatment approach, including upfront surgery and neoadjuvant systemic therapy settings. This review focuses on the increasing opportunities for de-escalating the extent of axillary surgery in the era of sentinel lymph node biopsy, while also reviewing the remaining indications for axillary clearance with axillary lymph node dissection.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
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26
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Montagna G. Estimating the Benefit of Preoperative Systemic Therapy to Reduce the Extent of Breast Cancer Surgery: Current Standard and Future Directions. Cancer Treat Res 2023; 188:149-174. [PMID: 38175345 DOI: 10.1007/978-3-031-33602-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Once reserved for locally advanced tumors which were deemed inoperable at presentation, preoperative systemic therapy (PST) is nowadays increasingly used to treat early breast cancer. PST allows for in vivo assessment of tumor response, for tailoring of adjuvant systemic therapy and for de-escalation of breast and the axillary surgery. Increased rates of pathological complete response together with more accurate response assessment and surgical planning have led to a significant reduction in surgical morbidity. While surgical assessment remains the standard of care, ongoing studies are evaluating whether surgery can be omitted in patients who achieve a complete pathological response. In this chapter, I will review the impact of PST on surgical de-escalation and the data supporting the safety of this approach.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66Th Street, New York, NY, 10065, USA.
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27
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative axillary surgery is emerging in the surgical management of breast cancer. Breast Cancer 2023; 30:14-22. [PMID: 36342647 DOI: 10.1007/s12282-022-01409-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
Axillary lymph node dissection (ALND) has been the standard axillary treatment for breast cancer for a long time. However, ALND is associated with postoperative morbidities, including local sensory dysfunction, reduced shoulder mobility and most notably arm lymphedema. Recently, ALND can be avoided not only in clinically node-negative (cN0) patients with negative sentinel lymph nodes (SLNs), but also in patients with less than 3 positive SLNs receiving breast radiation, axillary radiation, or a combination of the two. Moreover, SLN biopsy has been adopted for use in clinically node-positive (cN +) patients presenting as cN0 after neoadjuvant chemotherapy (NAC); ALND may be avoided in cN + patients who convert to SLN-negative following NAC. Patients who undergo SLN biopsy alone have less postsurgical morbidities than those who undergo ALND. Nevertheless, ALND is still required in a select group of patients. A variety of conservative approaches to ALND have been developed to spare arm lymphatics to minimize arm lymphedema. These conservative procedures seem to decrease the incidence of lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, full conventional ALND removing all microscopic axillary disease may now be unnecessary in both cN0 patients and cN + patients. Regardless, emerging procedures for ALND should still be considered as investigational approaches, as further studies with longer follow-up are necessary to determine the safety of conservative ALND to spare arm lymphatics.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan. .,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.
| | - Masafumi Inokuchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Miki Yokoi-Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Emi Morioka
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Yusuke Haba
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
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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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Banys-Paluchowski M, Untch M, Krawczyk N, Thurmann M, Kühn T, Sehouli J, Gasparri ML, de Boniface J, Gentilini OD, Stickeler E, Ditsch N, Rody A, Paluchowski P, Blohmer JU. Current trends in diagnostic and therapeutic management of the axilla in breast cancer patients receiving neoadjuvant therapy: results of the German-wide NOGGO MONITOR 24 survey. Arch Gynecol Obstet 2022; 307:1547-1556. [PMID: 36214890 PMCID: PMC10110637 DOI: 10.1007/s00404-022-06804-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/21/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE In the last 2 decades, the optimal management of the axilla in breast cancer patients receiving neoadjuvant chemotherapy (NACT) has been one of the most frequently discussed topics. Little is known about the attitudes of surgeons/radiologists towards new developments such as targeted axillary dissection. Therefore, the NOGGO conducted a survey to evaluate the current approach to axillary management. METHODS A standardized digital questionnaire was sent out to > 200 departments in Germany between 7/2021 and 5/2022. The survey was supported by EUBREAST. RESULTS In total, 116 physicians completed the survey. In cN0 patients scheduled to receive NACT, 89% of respondents recommended sentinel lymph node biopsy (SLNB) after NACT. In case of ypN1mi(sn), 44% advised no further therapy, while 31% proposed ALND and 25% axillary irradiation. 64% of respondents recommended a minimally invasive axillary biopsy to cN + patients. TAD was used at the departments of 82% of respondents and was offered to all cN + patients converting to ycN0 by 57% and only to selected patients, usually based on the number of suspicious nodes at time of presentation, by 43%. The most common marking technique was a clip/coil. 67% estimated that the detection rate of their marker was very good or good. CONCLUSION This survey shows a heterogenous approach towards axillary management in the neoadjuvant setting in Germany. Most respondents follow current guidelines. Since only two-thirds of respondents experienced the detection rate of the marker used at their department as (very) good, future studies should focus on the comparative evaluation of different marking techniques.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Michael Untch
- Department of Gynecology and Obstetrics, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maria Thurmann
- Department of Gynecology and Obstetrics, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Jalid Sehouli
- Department of Gynecology With Center for Oncological Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Virchow Campus Clinic, Charité Medical University, Berlin, Germany.,Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Freie Universität Berlin, Berlin, Germany
| | - Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale Di Lugano, Lugano, Switzerland.,Faculty of Biomedicine, University of the Italian Switzerland (USI), Lugano, Switzerland
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
| | | | - Elmar Stickeler
- Department of Gynecology and Obstetrics, University Hospital Aachen, Aachen, Germany
| | - Nina Ditsch
- Department of Gynecology and Obstetrics, University of Augsburg, Augsburg, Germany
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics and Breast Cancer Center, Regio Klinikum Pinneberg, Pinneberg, Germany
| | - Jens-Uwe Blohmer
- Department of Gynecology and Breast Cancer Center, Charité Universitätsmedizin Berlin, Berlin, Germany
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Laury RJ, Gloyeske N, Mettman D, Wagner JL, Fan F. Intraoperative sentinel lymph node evaluation in patients with node-positive breast cancer status post neoadjuvant systemic therapy - An institutional experience. Ann Diagn Pathol 2022; 60:152012. [DOI: 10.1016/j.anndiagpath.2022.152012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 07/17/2022] [Indexed: 11/16/2022]
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Rates of pathologic nodal disease among cN0 and cN1 patients undergoing routine axillary ultrasound and neoadjuvant chemotherapy. Breast Cancer Res Treat 2022; 195:181-189. [PMID: 35900704 DOI: 10.1007/s10549-022-06677-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/04/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Routine axillary ultrasound (AxUS) in patients receiving neoadjuvant chemotherapy (NAC) remains controversial. Here, we report rates of AxUS-detected nodal disease among patients with normal clinical exams, and rates of pathologic nodal disease after NAC based on method of nodal disease detection. METHODS Clinicopathologic findings were prospectively collected for stage I-III breast cancer patients selected for NAC. All patients had pre-treatment AxUS, suspicious nodes were biopsied. The following four patient cohorts were examined: patients with suspicious exam or AxUS but negative biopsy (Suspicious cN0); those with normal exam and normal AxUS (Not Suspicious cN0); those with normal exam but suspicious AxUS and positive biopsy (AxUS-detected cN1); and those with abnormal exam and positive biopsy (exam-detected cN1). Sentinel (SLN) and non-sentinel lymph nodes (non-SLN) were evaluated by immunohistochemistry; nodal metastases of any size were considered positive. RESULTS 500 patients were included. Of 310 patients with normal axillary exams, 160 had suspicious AxUS, 65 were biopsy-negative (Suspicious cN0) and 95/310 (30.6%) were biopsy-positive (AxUS-detected cN1). Of 190 with abnormal axillary exams, 166 were biopsy-proven node-positive (exam-detected cN1) and 24 were AxUS or biopsy-negative (Suspicious cN0). Rates of pathologic nodal disease were 20/150 (13.3%) among Not Suspicious cN0 patients, 12/89 (13.5%) among Suspicious cN0 (p = 0.97). Rates of residual nodal disease were 55/95 (57.9%) among AxUS-detected cN1 patients, 102/166 (61.4%) among exam-detected cN1 (p = 0.57). CONCLUSION AxUS detected nodal disease in 30.6% of patients with normal clinical exams selected for NAC. Rates of pathologic nodal disease were similar among AxUS-detected and exam-detected cN1 patients.
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Sanders SB, Hoskin TL, Stafford AP, Boughey JC. Factors Influencing Non-sentinel Lymph Node Involvement in Patients with Positive Sentinel Lymph Node(s) After Neoadjuvant Chemotherapy for Breast Cancer. Ann Surg Oncol 2022; 29:7769-7778. [PMID: 35834142 DOI: 10.1245/s10434-022-12064-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND When a positive sentinel lymph node (SLN) is identified after neoadjuvant chemotherapy (NAC), completion axillary lymph node dissection (cALND) is generally recommended. We sought to evaluate the rate of non-SLN positivity and factors influencing this in patients with a positive SLN following NAC. METHODS We identified all patients at our hospital between 2006 and 2021 with a positive SLN (> 0.2 mm) following NAC who underwent cALND. Rates of positive non-SLN (NSLN) on cALND were compared by nodal status. Chi-square tests and multivariable logistic regression were used to assess factors predictive of positive NSLN and overall nodal burden. RESULTS Overall, 229 cases (177 cN+, 52 cN0 prior to NAC) with positive SLN(s) after NAC underwent cALND. Additional NSLN involvement was found in 129/229 (56.3%) patients, including 24/52 (46.2%) cN0 and 105/177 (59.3%) cN+ patients (p = 0.09). There was a trend for patients with SLN micrometastases to be less likely to have positive NSLN(s) than those with SLN macrometastases (38.5% vs. 58.6%; p = 0.05). Subgroup analyses showed no clinicopathologic factors significantly associated with additional axillary involvement for initially cN0 patients. Factors found to significantly influence NSLN positivity in the initially cN+ subgroup were HER2 status, multicentricity/multifocality, number of positive SLNs, and size of SLN metastasis. SLN metastasis size > 5 mm and three or more positive SLNs exerted the greatest influence on NSLN positivity. CONCLUSION Rates of nodal positivity on cALND in the setting of positive SLN after NAC are high, supporting the current standard of routine cALND. In cN+ disease, NSLN positivity varies by tumor biology, multicentricity/multifocality, number of positive SLNs, and SLN metastasis size.
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Affiliation(s)
- Stacy B Sanders
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Arielle P Stafford
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Singer L, Weiss A, Bellon JR, King TA. Regional Nodal Management After Preoperative Systemic Therapy. Semin Radiat Oncol 2022; 32:228-236. [DOI: 10.1016/j.semradonc.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nakhlis F, Portnow L, Gombos E, Daylan AEC, Leone JP, Kantor O, Richardson ET, Ho A, Dunn SA, Ohri N. Multidisciplinary Considerations in the Management of Breast Cancer Patients Receiving Neoadjuvant Chemotherapy. Curr Probl Surg 2022; 59:101191. [DOI: 10.1016/j.cpsurg.2022.101191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Harrison B. Update on sentinel node pathology in breast cancer. Semin Diagn Pathol 2022; 39:355-366. [PMID: 35803776 DOI: 10.1053/j.semdp.2022.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
Abstract
Pathologic examination of the sentinel lymph nodes (SLNs) in patients with breast cancer has been impacted by the publication of practicing changing trials over the last decade. With evidence from the ACOSOG Z0011 trial to suggest that there is no significant benefit to axillary lymph node dissection (ALND) in early-stage breast cancer patients with up to 2 positive SLNs, the rate of ALND, and in turn, intraoperative evaluation of SLNs has significantly decreased. It is of limited clinical significance to pursue multiple levels and cytokeratin immunohistochemistry to detect occult small metastases, such as isolated tumor cells and micrometastases, in this setting. Patients treated with neoadjuvant therapy, who represent a population with more extensive disease and aggressive tumor biology, were not included in Z0011 and similar trials, and thus, the evidence cannot be extrapolated to them. Recent trials have supported the safety and accuracy of sentinel lymph node biopsy (SLNB) in these patients when clinically node negative at the time of surgery. ALND remains the standard of care for any amount of residual disease in the SLNs and intraoperative evaluation of SLNs is still of value for real time surgical decision making. Given the potential prognostic significance of residual small metastases in treated lymph nodes, as well as the decreased false negative rate with the use of cytokeratin immunohistochemistry (IHC), it may be reasonable to maintain a low threshold for the use of cytokeratin IHC in post-neoadjuvant cases. Further recommendations for patients treated with neoadjuvant therapy await outcomes data from ongoing clinical trials. This review will provide an evidence-based discussion of best practices in SLN evaluation.
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Affiliation(s)
- Beth Harrison
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, United States.
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Gasparri ML, de Boniface J, Poortmans P, Gentilini OD, Kaidar-Person O, Banys-Paluchowski M, Di Micco R, Niinikoski L, Murawa D, Bonci EA, Pasca A, Rubio IT, Karadeniz Cakmak G, Kontos M, Kühn T. Axillary surgery after neoadjuvant therapy in initially node-positive breast cancer: international EUBREAST survey. Br J Surg 2022; 109:857-863. [PMID: 35766257 DOI: 10.1093/bjs/znac217] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/17/2022] [Accepted: 05/28/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND There is no consensus on axillary management after neoadjuvant therapy (NAT) in patients with clinically node-positive (cN+) breast cancer. To investigate current clinical practice, an international survey was conducted among breast surgeons and radiation oncologists. The aim of the first part of the survey was to provide a snapshot of international discrepancies regarding axillary surgery in this context. METHODS The European Breast Cancer Research Association of Surgical Trialists (EUBREAST) developed a web-based survey containing 39 questions describing clinical scenarios in the setting of axillary management in patients with cN1 disease converting to ycN0 after NAT. The survey was then distributed to breast surgeons and radiation oncologists via 14 breast cancer societies between April and October 2021. RESULTS Responses from 349 physicians in 45 countries were recorded. The most common post-NAT axillary surgery in patients with cN1 disease converting to ycN0 was targeted axillary dissection (54.2 per cent), followed by sentinel lymph node biopsy (SLNB) alone (20.9 per cent), level 1-2 axillary lymph node dissection (ALND) (18.4 per cent), level 1-3 ALND (4 per cent), and targeted lymph node biopsy (2.5 per cent). For SLNB alone, dual tracers were most commonly used (62.3 per cent). Management varied widely in patients with ambiguous axillary status before initiation of treatment or a residual metastatic burden in the axilla after NAT. In patients with ycN+ tumours, ALND was the preferred surgical approach for 66.8 per cent of respondents. CONCLUSION These results highlight the wide heterogeneity in surgical approaches to the axilla after NAT. To standardize the guidelines, further data from clinical research are urgently needed, which underlines the importance of the ongoing AXSANA (EUBREAST-3) study.
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Affiliation(s)
- Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, Lugano, CH.,Faculty of Biomedicine, University of the Italian Switzerland (USI), Lugano, Switzerland
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | | | - Orit Kaidar-Person
- Breast Radiation Unit, Oncology Institute, Sheba Hospital Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,GROW-School for Oncology and Developmental Biology or GROW (Maastro), Maastricht University, Maastricht, The Netherlands
| | - Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany.,Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Rosa Di Micco
- Breast Surgery Unit, San Raffaele University Hospital, Milan, Italy
| | - Laura Niinikoski
- Breast Surgery Unit, Comprehensive Cancer Center, Helsinki University Hospital, University of Helsinki, Finland
| | - David Murawa
- Department of General Surgery and Surgical Oncology, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland
| | - Eduard Alexandru Bonci
- Department of Surgical Oncology, "Prof. Dr. Ion Chiricuță" Institute of Oncology, Cluj-Napoca, Romania.,Department of Oncological Surgery and Gynecological Oncology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andrei Pasca
- Department of Surgical Oncology, "Prof. Dr. Ion Chiricuță" Institute of Oncology, Cluj-Napoca, Romania.,Department of Oncological Surgery and Gynecological Oncology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Isabel T Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain
| | - Guldeniz Karadeniz Cakmak
- Zonguldak BEUN The School of Medicine, General Surgery Department, Breast and Endocrine Unit, Kozlu/Zonguldak, Turkey
| | - Michalis Kontos
- 1st Department of Surgery, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Kühn
- Interdisciplinary Breast Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
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Management of the axilla in T1-2N1 breast cancer. NPJ Breast Cancer 2022; 8:69. [PMID: 35637226 PMCID: PMC9151923 DOI: 10.1038/s41523-022-00432-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/22/2022] [Indexed: 11/08/2022] Open
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Song YX, Xu Z, Liang MX, Liu Z, Hou JC, Chen X, Xu D, Fei YJ, Tang JH. Diagnostic accuracy of de-escalated surgical procedure in axilla for node-positive breast cancer patients treated with neoadjuvant systemic therapy: A systematic review and meta-analysis. Cancer Med 2022; 11:4085-4103. [PMID: 35502768 DOI: 10.1002/cam4.4769] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/19/2022] [Accepted: 04/10/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND More initial clinical node-positive breast cancer patients achieve axillary pathological complete response (ax-pCR) after neoadjuvant systemic therapy (NST). Restaging axillary status and performing de-escalated surgical procedures to replace routine axillary lymph nodes dissection (ALND) is urgently needed. Targeted axillary lymph node biopsy (TLNB) is a novel de-escalated surgical strategy marking metastatic axillary nodes before NST and targeted dissection and biopsy intraoperatively to tailor individual axillary management. METHODS This study provided a systematic review and meta-analysis to evaluate the feasibility and diagnosis accuracy of TLNB. Prospective and retrospective clinical trials on TLNB were searched from Pubmed, Embase, and Cochrane. Identification rate (IFR), false-negative rate (FNR), negative predictive value (NPV), and rate of ax-pCR were the outcomes of this meta-analysis. RESULTS One thousand nine hundred and twenty patients attempted TLNB, with an overall IFR of 93.5% (95% confidence interval [CI] 90.1%-96.2%). IFR of three nodal marking methods, namely iodine seeds, clips, and carbon dye, was 95.6% (95% CI 91.2%-98.7%), 91.7% (95% CI 87.3%-95.4%), and 97.1% (95% CI 89.1%-100.0%), respectively. Of them, 847 patients received ALND, with an overall FNR of 5.5% (95% CI 3.3%-8.0%), and NPV ranged from 90.1% to 96.1%. Regression analysis showed that the overlap of targeted and sentinel biopsied nodes might associate with IFRs and FNRs. CONCLUSION TLNB is a novel, less invasive surgical approach to distinguish initial node-positive breast cancer that achieves negative axillary conversion after NST. It yields an excellent IFR with a low FNR and a high NPV. A combination of preoperative imaging, intraoperative TLNB with SLNB, and postoperative nodal radiotherapy might affect the future treatment paradigm of primary breast cancer with nodal metastases.
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Affiliation(s)
- Yu-Xin Song
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Xu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming-Xing Liang
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Liu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun-Chen Hou
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiu Chen
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Di Xu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yin-Jiao Fei
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jin-Hai Tang
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Cavalcante FP, Abdala E, Weissmann L, Ferreira CEDS, Amorim G, de Oliveira VM, Guilgen G, Landeiro L, Pinho JRR, Pulchinelli Á, Ribeiro H, Souza R, Rosa DD. Impact of COVID-19 Disease in Early Breast Cancer Management: A Summary of the Current Evidence. JCO Glob Oncol 2022; 8:e2100357. [PMID: 35594492 PMCID: PMC9173577 DOI: 10.1200/go.21.00357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
An expert panel on breast cancer and COVID-19 disease was convened to address the impact of the COVID-19 pandemic for early breast cancer (eBC) management.
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Affiliation(s)
| | - Edson Abdala
- Department of Infectious and Parasitic Diseases, School of Medicine, University of São Paulo (USP), São Paulo, SP, Brazil
| | - Leonardo Weissmann
- Emílio Ribas Infectious Disease Institute, São Paulo, SP, Brazil
- Unaerp School of Medicine, Guarujá, SP, Brazil
- Brazilian Society of Infectology, São Paulo, SP, Brazil
| | | | - Gilberto Amorim
- Oncologia D'Or, Rio de Janeiro, RJ, Brazil
- Brazilian Breast Cancer Study Group (GBECAM), Porto Alegre, RS, Brazil
| | - Vilmar Marques de Oliveira
- Brazilian Society of Mastology, Rio de Janeiro, RJ, Brazil
- Santa Casa de São Paulo Hospital, São Paulo, SP, Brazil
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | - Gisah Guilgen
- Brazilian Breast Cancer Study Group (GBECAM), Porto Alegre, RS, Brazil
- Curitiba Cancer and Transplant Institute, Curitiba, PR, Brazil
- Nossa Senhora das Graças Hospital, Curitiba, PR, Brazil
| | - Luciana Landeiro
- Núcleo de Oncologia da Bahia (NOB)—Oncoclínicas Group, Salvador, BA, Brazil
| | - João Renato Rebello Pinho
- Albert Einstein Hospital, São Paulo, SP, Brazil
- Hospital das Clínicas, São Paulo, SP, Brazil
- School of Medicine, Medical Research Laboratories LIM 03/07, University of São Paulo, São Paulo, SP, Brazil
| | - Álvaro Pulchinelli
- Brazilian Society of Clinical Pathology/Laboratory Medicine, Rio de Janeiro, RJ, Brazil
- Fleury Group, São Paulo, SP, Brazil
- School of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Heber Ribeiro
- Brazilian Society of Oncology Surgery, Rio de Janeiro, RJ, Brazil
- AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Rafael Souza
- Cancer Treatment Institute (ITC), Campo Grande, MS, Brazil
| | - Daniela Dornelles Rosa
- Brazilian Breast Cancer Study Group (GBECAM), Porto Alegre, RS, Brazil
- Moinhos de Vento Hospital, Porto Alegre, RS, Brazil
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
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40
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Fusco N, Rizzo A, Costarelli L, Santinelli A, Cerbelli B, Scatena C, Macrì E, Pietribiasi F, d’Amati G, Sapino A, Castellano I. Pathological examination of breast cancer samples before and after neoadjuvant therapy: recommendations from the Italian Group for the Study of Breast Pathology - Italian Society of Pathology (GIPaM-SIAPeC). Pathologica 2022; 114:104-110. [PMID: 35414722 PMCID: PMC9248246 DOI: 10.32074/1591-951x-747] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/30/2022] Open
Abstract
Neoadjuvant therapy (NAT) in breast cancer is administered to downstage the tumor, de-escalate surgery, and provide prognostic information that can be used to tailor subsequent adjuvant therapy. In this respect, the pathological evaluation of both pre-NAT biopsies and post-NAT surgical specimens is crucial to precisely assess the treatment response. With the increasing possibilities of NAT protocols and the rising number of eligible patients, it has become extremely important to standardize the pathological response assessment. Here, we provide an update on the recommendations of the Italian Group for the Study of Breast Pathology - the Italian Society of Pathology (GIPaM-SIAPeC) for the analysis of breast cancer samples before and after NAT.
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41
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Piltin MA, Boughey JC. Axillary Management: How Has Neoadjuvant Chemotherapy Changed Our Surgical Approach? CURRENT BREAST CANCER REPORTS 2022. [DOI: 10.1007/s12609-022-00442-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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42
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Weiss A, King C, Grossmith S, Portnow L, Raza S, Nakhlis F, Dominici L, Barbie T, Minami C, Nimbkar S, Rhei E, Mittendorf EA, King TA. How Often Does Retrieval of a Clipped Lymph Node Change Adjuvant Therapy Recommendations? A Prospective, Consecutive, Patient Cohort Study. Ann Surg Oncol 2022; 29:3764-3771. [PMID: 35041097 DOI: 10.1245/s10434-022-11324-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/24/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prior studies examining sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) for cN1 patients have demonstrated that 20% of biopsied, clipped lymph nodes (cLNs) are nonsentinel lymph nodes (non-SLNs). Our goal was to determine how often the cLN was a non-SLN among both cN0 and cN1 patients and how often cLN pathology impacted management. METHODS Overall, 238 patients treated with NAC and surgery January 2019 to June 2020 were prospectively examined. Patients underwent routine axillary ultrasound, biopsy of suspicious nodes, and clip placement. Radioactive iodine-125 seed localization of the cLN was performed in cN1 patients only. Isolated tumor cells (ITCs) were considered node positive (ypN+) for both cN0 and cN1 cohorts. Chart review was performed to determine if cLNs were non-SLN and their ypN status. RESULTS Of 118 cN0 patients, 115 of 118 (97%) underwent successful SLNB, 33 of whom had a cLN present; 21 of 33 (64%) cLNs were non-SLNs. Overall, 9 of 118 (8%) were ypN+; no cLN was ypN+ without additional +SLNs. Of 120 cN1 patients, 104 of 120 (87%) converted to cN0, 98 of 104 (94%) of which had attempted SLNB, and 95 of 98 (97%) successfully mapped. The cLN was a non-SLN in 18 of 95 (19%). Overall, 58 of 104 (56%) cN1 patients were ypN+. One patient had a positive cLN in the absence of +SLNs. This patient underwent axillary lymph node dissection (ALND); adjuvant treatment recommendations were unchanged. CONCLUSIONS The cLN was a non-SLN in 19% of cN1 patients. cLN pathology did not impact adjuvant therapy recommendations, calling into question the utility of routinely clipping biopsied lymph nodes.
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Affiliation(s)
- Anna Weiss
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | - Claire King
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Samantha Grossmith
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Leah Portnow
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Sughra Raza
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Faina Nakhlis
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Laura Dominici
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Thanh Barbie
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Christina Minami
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Suniti Nimbkar
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Esther Rhei
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
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43
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Jang BS, Shin KH. Postmastectomy Radiation Therapy in Patients With Minimally Involved Lymph Nodes: A Review of the Current Data and Future Directions. J Breast Cancer 2022; 25:1-12. [PMID: 35199499 PMCID: PMC8876545 DOI: 10.4048/jbc.2022.25.e6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 11/30/2022] Open
Abstract
Radiation therapy for patients with pN1mi or pN1 disease breast cancer undergoing mastectomy has been debated for a long time. Even in low metastatic burden in sentinel node biopsy, occult non-sentinel axillary nodal involvement can exist. Radiotherapy can sterilize axillary metastatic burden and seems to contribute a very low local recurrence rate in mastectomy patients with minimally involved lymph nodes. However, it should be considered that systemic therapy is evolving and the local recurrence difference between radiotherapy and no radiotherapy is relatively small. Regarding postmastectomy radiotherapy in patients pN1mi or pN1 cancer, published prospective clinical trial results should be considered; however, there are no such relevant results of clinical trials yet. Consideration of postmastectomy radiation therapy in pN1mi or pN1 patients should be based on identifying the high-risk group in terms of recurrence, stage, or tumor biology. When radiotherapy is determined, radiation oncologists should attempt individualized treatment approaches, such as irradiation field, and consider specific settings, such as neoadjuvant therapy. In this review, the role of radiotherapy in mastectomy patients with minimally involved lymph nodes and the relevant considerations are discussed.
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Affiliation(s)
- Bum-Sup Jang
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
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44
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Guerini-Rocco E, Botti G, Foschini MP, Marchiò C, Mastropasqua MG, Perrone G, Roz E, Santinelli A, Sassi I, Galimberti V, Gianni L, Viale G. Role and evaluation of pathologic response in early breast cancer specimens after neoadjuvant therapy: consensus statement. TUMORI JOURNAL 2021; 108:196-203. [DOI: 10.1177/03008916211062642] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pathologic evaluation of early breast cancer after neoadjuvant therapy is essential to provide prognostic information based on tumor response to treatment (pathologic complete response [pCR] or non-pCR) and to inform therapy decisions after surgery. To harmonize the pathologist’s handling of surgical specimens after neoadjuvant therapy, a panel of experts in breast cancer convened to developed a consensus on six main topics: (1) definition of pCR, (2) required clinical information, (3) gross examination and sampling, (4) microscopic examination, (5) evaluation of lymph node status, and (6) staging of residual breast tumor. The resulting consensus statements reported in this document highlight the role of an accurate evaluation of tumor response and define the minimum requirements to standardize the assessment of breast cancer specimens after neoadjuvant therapy.
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Affiliation(s)
- Elena Guerini-Rocco
- Division of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Gerardo Botti
- Scientific Direction, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy
| | - Maria Pia Foschini
- Unit of Anatomic Pathology “M. Malpighi” at Bellaria Hospital, Department of Biomedical and Neuromotor Sciences, DIBINEM, University of Bologna, Bologna, Italy
| | - Caterina Marchiò
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Mauro Giuseppe Mastropasqua
- Department of Emergency and Organs Transplantation, Section of Anatomic Pathology, School of Medicine, University of Bari “Aldo Moro,” Bari, Italy
| | - Giuseppe Perrone
- Research Unit of Pathology, Campus Bio-Medico University, Rome, Italy
| | - Elena Roz
- Pathology Unit, La Maddalena Clinic for Cancer, Palermo, Italy
| | - Alfredo Santinelli
- Anatomic Pathology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Isabella Sassi
- Pathology Unit, San Raffaele University and Research Hospital, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Giuseppe Viale
- Division of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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45
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Al-Hilli Z, Weiss A, Armani A, Boughey JC, Blair SL. Breast cancer-The catalyst of contemporary trials design. J Surg Oncol 2021; 125:7-16. [PMID: 34897706 DOI: 10.1002/jso.26722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/07/2022]
Abstract
Surgical trials in breast cancer have catalyzed contemporary trial design for solid organ cancers and are a prime example of surgeons taking the lead in clinical trial design. Surgeons have lead trials that have improved patient outcomes and quality of life without sacrificing oncologic safety. We have evolved from radical mastectomy to breast conservation and sentinel node biopsy. Contemporary trial design in breast cancer now focus on personalizing care based on tumor genomics.
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Affiliation(s)
- Zahraa Al-Hilli
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anna Weiss
- Department of Surgery, Brigham and Women Hospital, Boston, Massachusetts, USA
| | - Ava Armani
- Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Judy C Boughey
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah L Blair
- Department of Surgery, University of California San Diego, San Diego, California, USA
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46
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Viale G, Fusco N. Pathology after neoadjuvant treatment - How to assess residual disease. Breast 2021; 62 Suppl 1:S25-S28. [PMID: 34810049 PMCID: PMC9097800 DOI: 10.1016/j.breast.2021.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/09/2021] [Indexed: 12/31/2022] Open
Abstract
While systemic therapy for non-metastatic, invasive breast cancer is provided to minimize the risk of recurrence, neoadjuvant therapy (NAT) is given prior to surgery to downstage the tumor and to evaluate treatment response. Downstaging the tumor may allow for less invasive surgery on the breast and axilla, thus avoiding the need for breast reconstruction, improving cosmetic outcomes, and reducing postoperative complications. With the rising number of NAT candidates, it is becoming increasingly important to standardize how tumor response is assessed after surgery. In the post-NAT setting, macroscopic assessment of surgical samples, extent of sampling for histology, and microscopic analysis require a different approach than in the primary surgery setting. In the neo-adjuvant setting, the close collaboration of pathologists, oncologists, surgeons, and radiologists within the multidisciplinary team is essential to ensure the best possible management of breast cancer patients. Here, we provide an update on the suggested procedures for an accurate assessment of tumor response to NAT, including the evaluation of all relevant parameters that correlate with long-term prognosis and inform the subsequent adjuvant interventions. Neoadjuvant therapy (NAT) is given to downstage the tumor and evaluate treatment response. It is extremely important to standardize how NAT tumor response is assessed after surgery. A tailored approach is required for gross examination and microscopic analysis of both tumor and lymph nodes (either sentinel and axillary). Changes of biomarkers status (i.e. ER, PgR, Ki67, and HER2) can occur after NAT and biomarkers should always be re-assessed. Collaboration of pathologists, oncologists, surgeons, and radiologists is necessary for the appropriate clinical management.
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Affiliation(s)
- Giuseppe Viale
- Department of Pathology, IEO, European Institute of Oncology IRCCS, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - Nicola Fusco
- Department of Pathology, IEO, European Institute of Oncology IRCCS, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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47
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Asirvatham JR, Jorns JM. How Do Pathologists in Academic Institutions Across the United States and Canada Evaluate Sentinel Lymph Nodes in Breast Cancer? A Practice Survey. Am J Clin Pathol 2021; 156:980-988. [PMID: 34164651 DOI: 10.1093/ajcp/aqab055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There are little data on how changes in the clinical management of axillary lymph nodes in breast cancer have influenced pathologist evaluation of sentinel lymph nodes. METHODS A 14-question survey was sent to Canadian and US breast pathologists at academic institutions (AIs). RESULTS Pathologists from 23 AIs responded. Intraoperative evaluation (IOE) is performed for selected cases in 9 AIs, for almost all in 10, and not performed in 4. Thirteen use frozen sections (FSs) alone. During IOE, perinodal fat is completely trimmed in 8, not trimmed in 9, and variable in 2. For FS, in 12 the entire node is submitted at 2-mm intervals. Preferred plane of sectioning is parallel to the long axis in 8 and perpendicular in 12. In 11, a single H&E slide is obtained, whereas 12 opt for multiple levels. In 11, cytokeratin is obtained if necessary, and immunostains are routine in 10. Thirteen consider tumor cells in pericapsular lymphatics as lymphovascular invasion (LVI), and 10 consider it isolated tumor cells (ITCs). CONCLUSIONS There is dichotomy in practice with near-equal support for routine vs case-by-case multilevel/immunostain evaluation, perpendicular vs parallel sectioning, complete vs incomplete fat removal, and tumor in pericapsular lymphatics as LVI vs ITCs.
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Affiliation(s)
- Jaya Ruth Asirvatham
- Department of Pathology, Baylor, Scott & White Health, Temple, TX, USA
- College of Medicine, Texas A&M University, College Station, TX, USA
| | - Julie M Jorns
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
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48
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Postmastectomy radiotherapy: a review. Curr Opin Oncol 2021; 33:547-552. [PMID: 34494609 DOI: 10.1097/cco.0000000000000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We review the role of postmastectomy radiotherapy (PMRT) in the management of patients with early breast cancer. RECENT FINDINGS PMRT in patients with 4 or more involved axillary lymph nodes is the current standard of care but the indications for PMRT in patients with 1-3 involved nodes remain controversial. The Early Breast Cancer Trialists' Collaborative Group meta-analysis of randomised trials of PMRT provides the most comprehensive level 1 evidence base. However, its applicability in contemporary practice in the context of recent multidisciplinary advances in surgery, radiation therapy and systemic therapy remains challenging. SUMMARY The lack of consensus on the indications for PMRT in patients with 1-3 positive nodes underpins the variations in the national and international guidelines on PMRT. We emphasise the need for contemporary randomised trial data, and the potential to refine patient selection for PMRT using novel biomarkers of recurrence and radiosensitivity.
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49
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Friedrich M, Kühn T, Janni W, Müller V, Banys-Pachulowski M, Kolberg-Liedtke C, Jackisch C, Krug D, Albert US, Bauerfeind I, Blohmer J, Budach W, Dall P, Fallenberg EM, Fasching PA, Fehm T, Gerber B, Gluz O, Hanf V, Harbeck N, Heil J, Huober J, Kreipe HH, Kümmel S, Loibl S, Lüftner D, Lux MP, Maass N, Möbus V, Mundhenke C, Nitz U, Park-Simon TW, Reimer T, Rhiem K, Rody A, Schmidt M, Schneeweiss A, Schütz F, Sinn HP, Solbach C, Solomayer EF, Stickeler E, Thomssen C, Untch M, Witzel I, Wöckel A, Thill M, Ditsch N. AGO Recommendations for the Surgical Therapy of the Axilla After Neoadjuvant Chemotherapy: 2021 Update. Geburtshilfe Frauenheilkd 2021; 81:1112-1120. [PMID: 34629490 PMCID: PMC8494519 DOI: 10.1055/a-1499-8431] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022] Open
Abstract
For many decades, the standard procedure to treat breast cancer included complete dissection of the axillary lymph nodes. The aim was to determine histological node status, which was then used as the basis for adjuvant therapy, and to ensure locoregional tumour control. In addition to the debate on how to optimise the therapeutic strategies of systemic treatment and radiotherapy, the current discussion focuses on improving surgical procedures to treat breast cancer. As neoadjuvant chemotherapy is becoming increasingly important, the surgical procedures used to treat breast cancer, whether they are breast surgery or axillary dissection, are changing. Based on the currently available data, carrying out SLNE prior to neoadjuvant chemotherapy is not recommended. In contrast, surgical axillary management after neoadjuvant chemotherapy is considered the procedure of choice for axillary staging and can range from SLNE to TAD and ALND. To reduce the rate of false negatives
during surgical staging of the axilla in pN+
CNB
stage before NACT and ycN0 after NACT, targeted axillary dissection (TAD), the removal of > 2 SLNs (SLNE, no untargeted axillary sampling), immunohistochemistry to detect isolated tumour cells and micro-metastases, and marking positive lymph nodes before NACT should be the standard approach. This most recent update on surgical axillary management describes the significance of isolated tumour cells and micro-metastasis after neoadjuvant chemotherapy and the clinical consequences of low volume residual disease diagnosed using SLNE and TAD and provides an overview of this yearʼs AGO recommendations for surgical management of the axilla during primary surgery and in relation to neoadjuvant chemotherapy.
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Affiliation(s)
- Michael Friedrich
- Klinik für Frauenheilkunde und Geburtshilfe, HELIOS Klinikum Krefeld, Krefeld, Germany
| | | | - Wolfgang Janni
- Frauenklinik, Klinikum der Universität Ulm, Ulm, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Maggie Banys-Pachulowski
- Klinik für Frauenheilkunde und Geburtshilfe, UK-SH, Lübeck, Germany.,Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach, Offenbach, Germany
| | - David Krug
- Universitätsklinikum Schleswig-Holstein, Klinik für Strahlentherapie, Campus Kiel, Kiel, Germany
| | - Ute-Susann Albert
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Ingo Bauerfeind
- Frauenklinik, Klinikum Landshut gemeinnützige GmbH, Landshut, Germany
| | - Jens Blohmer
- Klinik für Gynäkologie mit Brustzentrum des Universitätsklinikums der Charité, Berlin, Germany
| | - Wilfried Budach
- Strahlentherapie, Radiologie Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Peter Dall
- Frauenklinik, Städtisches Klinikum Lüneburg, Lüneburg, Germany
| | - Eva M Fallenberg
- Klinikum der Universität München, Campus Großhadern, Institut für Klinische Radiologie, München, Germany
| | | | - Tanja Fehm
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt, Klinikum Südstadt Rostock, Rostock, Germany
| | - Oleg Gluz
- Evangelisches Krankenhaus Bethesda, Brustzentrum, Mönchengladbach, Germany
| | - Volker Hanf
- Frauenklinik, Nathanstift Klinikum Fürth, Fürth, Germany
| | - Nadia Harbeck
- Brustzentrum, Klinik für Gynäkologie und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, München, Germany
| | - Jörg Heil
- Universitäts-Klinikum Heidelberg, Brustzentrum, Heidelberg, Germany
| | - Jens Huober
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Germany
| | | | | | - Sibylle Loibl
- German Breast Group Forschungs GmbH, Neu-Isenburg, Germany
| | - Diana Lüftner
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité, Berlin, Germany
| | - Michael Patrick Lux
- Kooperatives Brustzentrum Paderborn, Klinik für Gynäkologie und Geburtshilfe, Frauenklinik, St. Louise, Paderborn, St. Josefs-Krankenhaus, Salzkotten, St. Vincenz Krankenhaus GmbH, Germany
| | - Nicolai Maass
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Volker Möbus
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Frankfurt Höchst GmbH, Frankfurt am Main, Germany
| | - Christoph Mundhenke
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ulrike Nitz
- Evangelisches Krankenhaus Bethesda, Brustzentrum, Mönchengladbach, Germany
| | - Tjoung-Won Park-Simon
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Hannover, Hannover, Germany
| | - Toralf Reimer
- Universitätsfrauenklinik am Klinikum Südstadt, Klinikum Südstadt Rostock, Rostock, Germany
| | - Kerstin Rhiem
- Zentrum Familiärer Brust- und Eierstockkrebs, Universitätsklinikum Köln, Köln, Germany
| | - Achim Rody
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marcus Schmidt
- Klinik und Poliklinik für Geburtshilfe und Frauengesundheit der Johannes-Gutenberg-Universität Mainz, Mainz, Germany
| | | | - Florian Schütz
- Klinik für Gynäkologie und Geburtshilfe, Diakonissen Krankenhaus Speyer, Speyer, Germany
| | - Hans-Peter Sinn
- Sektion Gynäkopathologie, Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Christine Solbach
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Erich-Franz Solomayer
- Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Universitätsklinikum Aachen, Aachen, Germany
| | - Christoph Thomssen
- Universitätsfrauenklinik, Martin-Luther-Universität Halle-Wittenberg, Halle-Wittenberg, Germany
| | - Michael Untch
- Klinik für Gynäkologie und Geburtshilfe, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Isabell Witzel
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Achim Wöckel
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marc Thill
- Klinik für Gynäkologie und Gynäkologische Onkologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Nina Ditsch
- Frauenklinik, Universitätsklinikum Augsburg, Augsburg, Germany
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50
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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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