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Zhang M, Sun Y, Wu H, Xiao J, Chen W, Wang H, Yang B, Luo H. Prognostic analysis of cT1-3N1M0 breast cancer patients who have responded to neoadjuvant therapy undergoing various axillary surgery and breast surgery based on propensity score matching and competitive risk model. Front Oncol 2024; 14:1319981. [PMID: 38327751 PMCID: PMC10847357 DOI: 10.3389/fonc.2024.1319981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Background Sentinel lymph node biopsy (SLNB) in breast cancer patients with positive clinical axillary lymph nodes (cN1+) remains a topic of controversy. The aim of this study is to assess the influence of various axillary and breast surgery approaches on the survival of cN1+ breast cancer patients who have responded positively to neoadjuvant therapy (NAT). Methods Patients diagnosed with pathologically confirmed invasive ductal carcinoma of breast between 2010 and 2020 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. To mitigate confounding bias, propensity score matching (PSM) analysis was employed. Prognostic factors for both overall survival (OS) and breast cancer-specific survival (BCSS) were evaluated through COX regression risk analysis. Survival curves were generated using the Kaplan-Meier method. Furthermore, cumulative incidence and independent prognostic factors were assessed using a competing risk model. Results The PSM analysis matched 4,890 patients. Overall survival (OS) and BCSS were slightly worse in the axillary lymph node dissection (ALND) group (HR = 1.10, 95% CI 0.91-1.31, p = 0.322 vs. HR = 1.06, 95% CI 0.87-1.29, p = 0.545). The mastectomy (MAST) group exhibited significantly worse OS and BCSS outcomes (HR = 1.25, 95% CI 1.04-1.50, p = 0.018 vs. HR = 1.37, 95% CI 1.12-1.68, p = 0.002). The combination of different axillary and breast surgery did not significantly affect OS (p = 0.083) but did have a significant impact on BCSS (p = 0.019). Competing risk model analysis revealed no significant difference in the cumulative incidence of breast cancer-specific death (BCSD) in the axillary surgery group (Grey's test, p = 0.232), but it showed a higher cumulative incidence of BCSD in the MAST group (Grey's test, p = 0.001). Multivariate analysis demonstrated that age ≥ 70 years, black race, T3 stage, ER-negative expression, HER2-negative expression, and MAST were independent prognostic risk factors for both OS and BCSS (all p < 0.05). Conclusion For cN1+ breast cancer patients who respond positive to NAT, the optimal surgical approach is combining breast-conserving surgery (BCS) with SLNB. This procedure improves quality of life and long-term survival outcomes.
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Affiliation(s)
- Maoquan Zhang
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Yingming Sun
- Department of Medical and Radiation Oncology, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Huasheng Wu
- Department of Hepatobiliary Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Jian Xiao
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Wenxin Chen
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Hebin Wang
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Binglin Yang
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Huatian Luo
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
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Boersma LJ, Mjaaland I, van Duijnhoven F. Regional radiotherapy after primary systemic treatment for cN+ breast cancer patients. Breast 2023; 68:181-188. [PMID: 36805769 PMCID: PMC9975253 DOI: 10.1016/j.breast.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/02/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
Pathologic complete response (pCR) after Primary Systemic Treatment (PST) for breast cancer is associated with excellent long-term outcomes. With increasing use of PST, the indication for regional nodal irradiation (RNI) has been challenged. The aim of this paper is to review the literature on de-escalation of RNI in patients treated with PST. We found no level 1 evidence on de-escalation of RNI after PST, but several randomized trials are ongoing. Consequently, current de-escalation strategies are based on cohort studies. These studies showed that in patients with low nodal tumour burden (LNTB) (≤3 suspicious nodes at imaging) prior to PST, and ypN0 based on Axillary Lymph Node Dissection (ALND), omission of RNI resulted in very low regional recurrences (RR) without compromising survival. In patients with LNTB and ypN0 based on Sentinel Lymph Node Biopsy (SLNB), omission of axillary treatment also resulted in low RR; the majority of these patients received local radiotherapy. Similarly, in patients with ypN1 (ALND) disease, omission of RNI resulted in low 5-year RR rates. Low RR-rates were also found in the few studies replacing ALND by RNI, in patients with ypN1 (SLNB) disease. In patients with high nodal tumour burden prior to PST and ypN0 (SLNB), replacing ALND by RNI also resulted in low RR. Due to the limited number of patients, these data should be interpreted with caution. We conclude that although level 1 evidence is lacking, de-escalation of RNI after PST can be considered in selected cases.
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Affiliation(s)
- Liesbeth J Boersma
- Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Ingvil Mjaaland
- Division of Medicine, Stavanger University Hospital, Stavanger, Norway.
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3
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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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4
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Abstract
There is growing interest in neoadjuvant endocrine therapy (NET) for the treatment of hormone receptor-positive, human epidermal growth factor receptor 2 -negative (HR + HER2-) breast cancer. Expanding the use of genomic assays demonstrates that many patients with HR + HER2-breast cancer do not benefit from chemotherapy, leading to growing interest in NET as a less toxic alternative. Although NET's ability to downsize breast tumors and achieve breast conservation is well-known, axillary surgery algorithms are not well-defined. Here we review primary endocrine therapy, the landmark NET clinical trials, and management of residual nodal disease following NET.
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Affiliation(s)
- Anna Weiss
- Division of Breast Surgery, Brigham and Women's Hospital, Dana-Farber/Brigham Cancer Center, Harvard Medical School, 450 Brookline Avenue, YC 1220, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Brigham and Women's Hospital, Dana-Farber/Brigham Cancer Center, Harvard Medical School, 450 Brookline Avenue, YC 1220, Boston, MA, USA.
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5
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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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6
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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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7
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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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8
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Kumar D, Chintamani, Naghma S, Gupta S. The Dual Method (Dye and Ultrasound) for Axillary Mapping in Patients Receiving Neoadjuvant Chemotherapy for Locally Advanced Breast Cancer. JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/jmedsci.jmedsci_416_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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9
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Barrio AV, Montagna G, Mamtani A, Sevilimedu V, Edelweiss M, Capko D, Cody HS, El-Tamer M, Gemignani ML, Heerdt A, Kirstein L, Moo TA, Pilewskie M, Plitas G, Sacchini V, Sclafani L, Tadros A, Van Zee KJ, Morrow M. Nodal Recurrence in Patients With Node-Positive Breast Cancer Treated With Sentinel Node Biopsy Alone After Neoadjuvant Chemotherapy-A Rare Event. JAMA Oncol 2021; 7:1851-1855. [PMID: 34617979 DOI: 10.1001/jamaoncol.2021.4394] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Prospective trials have demonstrated sentinel lymph node (SLN) false-negative rates of less than 10% when 3 or more SLNs are retrieved in patients with clinically node-positive breast cancer rendered clinically node-negative with neoadjuvant chemotherapy (NAC). However, rates of nodal recurrence in such patients treated with SLN biopsy (SLNB) alone are unknown because axillary lymph node dissection (ALND) was performed in all patients, limiting adoption of this approach. Objective To evaluate nodal recurrence rates in a consecutive cohort of patients with clinically node-positive (cN1) breast cancer receiving NAC, followed by a negative SLNB using a standardized technique, and no further axillary surgery. Design, Setting, and Participants From November 2013 to February 2019, a cohort of consecutively identified patients with cT1 to cT3 biopsy-proven N1 breast cancer rendered cN0 by NAC underwent SLNB with dual tracer mapping and omission of ALND if 3 or more SLNs were identified and all were pathologically negative. Metastatic nodes were not routinely clipped, and localization of clipped nodes was not performed. The study was performed in a single tertiary cancer center. Intervention Omission of ALND in patients with cN1 breast cancer after NAC if 3 or more SLNs were pathologically negative. Main Outcome and Measures The primary outcome was the rate of nodal recurrence among patients with cN1 breast cancer treated with SLNB alone after NAC. Results Of 610 patients with cN1 breast cancer treated with NAC (median [IQR] age, 49 [40-58] years), 555 (91%) converted to cN0 and underwent SLNB; 234 (42%) had 3 or more negative SLNs and had SLNB alone. Median age was 49 years. Median tumor size was 3 cm; 144 (62%) were ERBB2 (formerly HER2)-positive, and 43 (18%) were triple negative. Most (212 [91%]) received doxorubicin-based NAC, 205 (88%) received adjuvant radiotherapy (RT), and 164 (70%) also received nodal RT. At a median follow-up of 40 months, there was 1 axillary nodal recurrence synchronous with local recurrence in a patient who refused RT. Among patients who received RT (n = 205), there were no nodal recurrences. Conclusions and Relevance This cohort study found that in patients with cN1 disease rendered cN0 with NAC, with 3 or more negative SLNs with SLNB alone, nodal recurrence rates were low, without routine nodal clipping. These findings potentially support omitting ALND in such patients.
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Affiliation(s)
- Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Varadan Sevilimedu
- Biostatistical Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcia Edelweiss
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Deborah Capko
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laurie Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa Sclafani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Audree Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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10
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Weber WP, Matrai Z, Hayoz S, Tausch C, Henke G, Zwahlen DR, Gruber G, Zimmermann F, Seiler S, Maddox C, Ruhstaller T, Muenst S, Ackerknecht M, Kuemmel S, Bjelic-Radisic V, Kurzeder C, Újhelyi M, Vrieling C, Satler R, Meyer I, Becciolini C, Bucher S, Simonson C, Fehr PM, Gabriel N, Maráz R, Sarlos D, Dedes KJ, Leo C, Berclaz G, Dubsky P, Exner R, Fansa H, Hager C, Reisenberger K, Singer CF, Reitsamer R, Reinisch M, Winkler J, Lam GT, Fehr MK, Naydina T, Kohlik M, Clerc K, Ostapenko V, Fitzal F, Nussbaumer R, Maggi N, Schulz A, Markellou P, Lelièvre L, Egle D, Heil J, Knauer M. Tailored axillary surgery in patients with clinically node-positive breast cancer: Pre-planned feasibility substudy of TAXIS (OPBC-03, SAKK 23/16, IBCSG 57-18, ABCSG-53, GBG 101). Breast 2021; 60:98-110. [PMID: 34555676 PMCID: PMC8463904 DOI: 10.1016/j.breast.2021.09.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 11/24/2022] Open
Abstract
Aim We developed tailored axillary surgery (TAS) to reduce the axillary tumor volume in patients with clinically node-positive breast cancer to the point where radiotherapy can control it. The aim of this study was to quantify the extent of tumor load reduction achieved by TAS. Methods International multicenter prospective study embedded in a randomized trial. TAS is a novel pragmatic concept for axillary surgery de-escalation that combines palpation-guided removal of suspicious nodes with the sentinel procedure and, optionally, imaging-guided localization. Pre-specified study endpoints quantified surgical extent and reduction of tumor load. Results A total of 296 patients were included at 28 sites in four European countries, 125 (42.2%) of whom underwent neoadjuvant chemotherapy (NACT) and 71 (24.0%) achieved nodal pathologic complete response. Axillary metastases were detectable only by imaging in 145 (49.0%) patients. They were palpable in 151 (51.0%) patients, of whom 63 underwent NACT and 21 had residual palpable disease after NACT. TAS removed the biopsied and clipped node in 279 (94.3%) patients. In 225 patients with nodal disease at the time of surgery, TAS removed a median of five (IQR 3–7) nodes, two (IQR 1–4) of which were positive. Of these 225 patients, 100 underwent ALND after TAS, which removed a median of 14 (IQR 10–17) additional nodes and revealed additional positive nodes in 70/100 (70%) of patients. False-negative rate of TAS in patients who underwent subsequent ALND was 2.6%. Conclusions TAS selectively reduced the tumor load in the axilla and remained much less radical than ALND. Tailored axillary surgery is a novel concept for clinically node-positive breast cancer Tailored axillary surgery selectively removes positive lymph nodes Tailored axillary surgery is much less radical than axillary dissection Tailored axillary surgery removes the clipped node in the vast majority of patients
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Affiliation(s)
- Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Zoltan Matrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary; University of Szeged, H-6725 Szeged, Hungary
| | | | | | - Guido Henke
- Department of Radiation Oncology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland; Breast Center, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | - Daniel R Zwahlen
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Günther Gruber
- Institute of Radiotherapy, Klinik Hirslanden, Zurich, Switzerland
| | - Frank Zimmermann
- University of Basel, Basel, Switzerland; Department of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | | | | | | | - Simone Muenst
- University of Basel, Basel, Switzerland; Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Markus Ackerknecht
- University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | | | | | - Christian Kurzeder
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Mihály Újhelyi
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Conny Vrieling
- Department of Radiation Oncology, Hirslanden Clinique des Grangettes, Geneva, Switzerland
| | - Rok Satler
- Breast Center, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Inna Meyer
- Breast Center, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Charles Becciolini
- Breast Center, Réseau Hospitalier Neuchâtelois, La Chaux-de-Fonds, Switzerland
| | - Susanne Bucher
- Breast Center, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Colin Simonson
- Department of Gynecology, Centre Hospitalier du Haut-Valais (SZO), Sion, Switzerland
| | - Peter M Fehr
- Breast Center Graubünden, Cantonal Hospital Graubünden, Chur, Switzerland
| | | | - Robert Maráz
- Department of Oncology, Bacs-Kiskun Country Hospital, Kecskemet, Hungary
| | - Dimitri Sarlos
- Breast Center, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Konstantin J Dedes
- Breast Cancer Center, University Hospital of Zurich, Zurich, Switzerland
| | - Cornelia Leo
- Breast Center, Cantonal Hospital Baden, Baden, Switzerland
| | | | - Peter Dubsky
- Breast Center, Hirslanden Klinik St. Anna, Lucerne, Switzerland; Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Ruth Exner
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Hisham Fansa
- Breast Center Zürich, Bethanien & Spital Zollikerberg, Zurich, Switzerland
| | - Christopher Hager
- Department of Gynecology and Obstetrics, City Hospital, Dornbirn, Austria
| | - Klaus Reisenberger
- Department of Gynecology and Obstetrics, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Christian F Singer
- Department of Gynecology and Obstetrics and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Roland Reitsamer
- Breast Center, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | - Jelena Winkler
- Breast Center, Basel Bethesda Hospital, Basel, Switzerland
| | - Giang Thanh Lam
- Breast Center, University Hospital of Geneva, Geneva, Switzerland
| | | | | | | | - Karine Clerc
- Brustzentrum Freiburg, Centre du sein Fribourg, Fribourg, Switzerland
| | | | - Florian Fitzal
- Department of Surgery and Breast Health Center, Medical University of Vienna, Vienna, Austria
| | - Rahel Nussbaumer
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Alexandra Schulz
- University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Pagona Markellou
- Breast Center, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | | | - Daniel Egle
- Breast Cancer Center Tirol, Department of Gynecology, Medical University Innsbruck, Innsbruck, Austria
| | - Jörg Heil
- Breast Center Heidelberg, Heidelberg, Germany
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
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11
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The Present and Future of Neoadjuvant Endocrine Therapy for Breast Cancer Treatment. Cancers (Basel) 2021; 13:cancers13112538. [PMID: 34064183 PMCID: PMC8196711 DOI: 10.3390/cancers13112538] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary The treatment of breast cancer has evolved considerably over the last two decades, leading toward individualized disease management. Hormone-sensitive breast cancers constitute the vast majority of cases and endocrine therapy is the mainstay of their treatment. On the other hand, neoadjuvant or pre-surgical treatments provide a number of advantages for tumor management. In this review we will discuss the existing evidence on neoadjuvant endocrine therapy, as well as its possible future indications. Abstract Endocrine therapy (ET) has established itself as an efficacious treatment for estrogen receptor-positive (ER+) breast cancers, with a reduction in recurrence rates and increased survival rates. The pre-surgical approach with chemotherapy (NCT) has become a common form of management for large, locally advanced, or high-risk tumors. However, a good response to NCT is not usually expected in ER+ tumors. Good results with primary ET, mainly in elderly women, have encouraged studies in other stages of life, and nowadays neoadjuvant endocrine treatment (NET) has become a useful approach to many ER+ breast cancers. The aim of this review is to provide an update on the current state of art regarding the present and the future role of NET.
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Montagna G, Corso G, Di Micco R, Van Den Rul N, Rocco N. Axillary management after neoadjuvant treatment. MINERVA CHIR 2020; 75:400-407. [PMID: 33345526 DOI: 10.23736/s0026-4733.20.08600-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since its introduction nearly 30 years ago, sentinel lymph node biopsy (SLNB) has become the standard technique to stage the axilla for the great majority of patients with early breast cancer. While the accuracy of SLNB in clinically node-negative patients who undergo neoadjuvant chemotherapy (NAC) is similar to the upfront surgery setting, modifications of the technique to improve the false negative rate are necessary in node-positive patients at presentation. Currently, patients who present with matted nodes, cN1 patients who fail to downstage to cN0 with NAC and those with pathological residual disease have an indication to undergo axillary lymph node dissection. Ongoing trials will confirm if extensive nodal irradiation can replace surgery in patients with residual nodal disease after NAC and if nodal radiotherapy can be omitted in patients who achieve nodal pathological complete response. The aim of this review was to focus on the open questions on the management of the axilla after NAC.
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Affiliation(s)
- Giacomo Montagna
- Breast Unit, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA - .,Breast Center, University Hospital of Basel, Basel, Switzerland -
| | - Giovanni Corso
- Division of Breast Surgery, IRCCS European Institute of Oncology, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Rosa Di Micco
- Breast Surgery Unit, IRCCS San Raffaele Hospital, Milan, Italy.,Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | | | - Nicola Rocco
- Group for Reconstructive and Therapeutic Advancements (GRETA) Milan-Naples-Catania, Milan, Italy
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Montagna G, Sevilimedu V, Fornier M, Jhaveri K, Morrow M, Pilewskie ML. How Effective is Neoadjuvant Endocrine Therapy (NET) in Downstaging the Axilla and Achieving Breast-Conserving Surgery? Ann Surg Oncol 2020; 27:4702-4710. [PMID: 32839900 PMCID: PMC7554166 DOI: 10.1245/s10434-020-08888-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/30/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Neoadjuvant endocrine therapy (NET) is effective in downstaging large hormone receptor-positive (HR+) breast cancers and increasing rates of breast-conserving surgery (BCS), but data regarding nodal pathologic complete response (pCR) are sparse. We reported nodal and breast downstaging rates with NET, and compared axillary response rates following NET and neoadjuvant chemotherapy (NAC). METHODS Consecutive stage I-III breast cancer patients treated with NET and surgery from January 2009 to December 2019 were identified from a prospectively maintained database. Nodal pCR rates were compared between biopsy-proven node-positive patients treated with NET, and HR+/HER2- patients treated with NAC from November 2013 to July 2019. RESULTS 127 cancers treated with NET and 338 with NAC were included. NET recipients were older, more likely to have lobular and lower-grade tumors, and higher HR expression. With NET, the nodal pCR rate was 11% (4/38) of biopsy-proven cases, and the breast pCR rate was 1.6% (2/126). Nodal-dowstaging rates with NET and NAC were not significantly different (11% vs 18%; P = 0.37). Patients achieving nodal pCR with NET versus NAC were older (median age 70 vs 50, P = 0.004) and had greater progesterone receptor (PR) expression (85% vs 13%, P = 0.031), respectively. Of patients not candidates for BCS due to a large tumor relative to breast size, 36/47 (77%) became BCS-eligible with NET (median PR expression 55% vs 5% in those remaining ineligible, P < 0.05). CONCLUSION Although nodal pCR is more frequent than breast pCR, NET is more likely to de-escalate breast surgery than axillary surgery. However, with a nodal pCR rate of 11%, NET remains an option for downstaging node-positive patients without clear indications for NAC.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Fornier
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Komal Jhaveri
- Breast Medicine Service, Department of Medicine, 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
| | - Melissa L Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Laws A, Specht MC. Leveraging Neoadjuvant Chemotherapy to Minimize the Burden of Axillary Surgery: a Review of Current Strategies and Surgical Techniques. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00388-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Laws A, Dillon K, Kelly BN, Kantor O, Hughes KS, Gadd MA, Smith BL, Lamb LR, Specht M. Node-Positive Patients Treated with Neoadjuvant Chemotherapy Can Be Spared Axillary Lymph Node Dissection with Wireless Non-Radioactive Localizers. Ann Surg Oncol 2020; 27:4819-4827. [PMID: 32740737 DOI: 10.1245/s10434-020-08902-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/30/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Targeted axillary dissection (TAD) involves sentinel lymph node biopsy (SLNB) and excision of a biopsy-proven node marked by a clip. This study evaluates the feasibility of non-radioactive wireless localizers for targeted excision of clipped axillary lymph nodes. METHODS We identified biopsy-proven, node-positive breast cancer patients treated with neoadjuvant therapy (NAT) and TAD from 2016 to 2020, and included those with a clipped node localized using SAVI SCOUT, Magseed, or RFID Tag. Primary outcome measures were (1) successful localization (ultrasound or mammographic-guided placement < 10 mm from target), and (2) retrieval of the clipped node during TAD, documented by specimen radiography or gross visualization. Secondary outcomes included rates of completion axillary lymph node dissection (cALND) and complications. RESULTS Overall, 57 patients were included; 1 (1.8%) patient had no clip visible at the time of localization, and no radiographic confirmation of clip placement at the time of biopsy, and was therefore excluded. In the remaining 56 patients, localization was successful in 53 (94.6%) patients and the clipped node was retrieved during TAD in 51 (91.1%) patients. Twenty-three of 27 (85.2%) ypN0 patients were spared cALND; 3 (11.1%) patients had cALND for failed clipped node retrieval during TAD, and 1 (3.7%) for false-positive frozen section. In patients with TAD alone, the rates of axillary seroma and infection were 20.0% and 8.6%, respectively. CONCLUSIONS Wireless non-radioactive localizers are feasible for axillary localization after NAT, with high success rates of retrieving clipped nodes. The lack of signal decay is an advantage of these devices, allowing flexibility in timing of placement.
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Affiliation(s)
- Alison Laws
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Kayla Dillon
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Bridget N Kelly
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Olga Kantor
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Kevin S Hughes
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Michele A Gadd
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Barbara L Smith
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Leslie R Lamb
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle Specht
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
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Montagna G, Mamtani A, Knezevic A, Brogi E, Barrio AV, Morrow M. Selecting Node-Positive Patients for Axillary Downstaging with Neoadjuvant Chemotherapy. Ann Surg Oncol 2020; 27:4515-4522. [PMID: 32488513 DOI: 10.1245/s10434-020-08650-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Axillary lymph node dissection (ALND) can be avoided in node-positive patients who receive neoadjuvant chemotherapy (NAC) if three or more negative sentinel lymph nodes (SLNs) are retrieved. We evaluate how often node-positive patients avoid ALND with NAC, and identify predictors of identification of three or more SLNs and of nodal pathological complete response (pCR). METHODS From November 2013 to July 2019, all patients with cT1-3, biopsy-proven N1 tumors who converted to cN0 after NAC received SLN biopsy (SLNB) with dual mapping and were identified from a prospectively maintained database. RESULTS 630 consecutive N1 patients were eligible for axillary downstaging with NAC; 573 (91%) converted to cN0 and had SLNB, and 531 patients (93%) had three or more SLNs identified. Lymphovascular invasion (LVI; odds ratio [OR] 0.46, 95% confidence interval [CI] 0.24-0.87; p = 0.02) and increasing body mass index (BMI; OR 0.77, 95% CI 0.62-0.96 per 5-unit increase; p = 0.02) were significantly associated with failure to identify three or more SLNs. 255/573 (46%) patients achieved nodal pCR; 237 (41%) had adequate mapping. Factors associated with ALND avoidance included high grade (OR 2.51, 95% CI 1.6-3.94, p = 0.001) and receptor status (HR+/HER2- [referent]: OR 1.99, 95% CI 1.15-3.46 [p = 0.01] for HR-/HER2-, OR 3.93, 95% CI 2.40-6.44 [p < 0.001] for HR+/HER2+, and OR 8.24, 95% CI 4.16-16.3 [p < 0.001] for HR-/HER2+). LVI was associated with a lower likelihood of avoiding ALND (OR 0.28, 95% CI 0.18-0.43; p < 0.001). CONCLUSIONS ALND was avoided in 41% of cN1 patients after NAC. Increased BMI and LVI were associated with lower retrieval rates of three or more SLNs. ALND avoidance rates varied with receptor status, grade, and LVI. These factors help select patients most likely to avoid ALND.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea Knezevic
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Boughey JC. Identifying Residual Nodal Disease in Sentinel Lymph Node Surgery After Neoadjuvant Chemotherapy for Breast Cancer. Ann Surg Oncol 2019; 26:3794-3797. [PMID: 31429022 DOI: 10.1245/s10434-019-07733-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Indexed: 11/18/2022]
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