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Zhao X, Yang L, Cao C, Song Z. The prognostic analysis of further axillary dissection in breast cancer with 1-2 positive sentinel lymph nodes undergoing mastectomy. Front Oncol 2024; 14:1406981. [PMID: 39161383 PMCID: PMC11330764 DOI: 10.3389/fonc.2024.1406981] [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: 03/25/2024] [Accepted: 07/22/2024] [Indexed: 08/21/2024] Open
Abstract
Background The ACOSOG Z0011 study has shown that axillary lymph node dissection (ALND) is an option to be considered in patients who had 1-2 metastatic sentinel lymph nodes (SLNs) who proceed with breast-conserving along with postoperative radiotherapy. However, there remains controversy regarding the applicability of this approach in patients who had a mastectomy. The aim of our study is to determine the prognostic differences and risk factors associated with the decision to opt for ALND in breast cancer patients who had 1-2 metastatic SLNs who receive a mastectomy. Methods The study conducted a retrospective analysis of patients diagnosed with cT1-2N0 breast cancer and treated at The Fourth Hospital of Hebei Medical University between January 2016 and December 2021, and patients were divided into two cohorts according to whether ALND was performed after sentinel lymph node biopsy (SLNB): SLNB cohort and SLNB + ALND cohort. Outcomes included the locoregional recurrence rate (LRR), disease-free survival (DFS), and overall survival (OS). Propensity score matching (PSM) was conducted to ensure the balance of variables between the two cohorts. Cox proportional hazard models were employed to ascertain the univariate and multivariate relative risks associated with survival. Results There were 812 cases enrolled. After the PSM, 234 receiving ALND and 234 not receiving ALND were matched. A median follow-up period of 56.72 ± 20.29 months was observed. During that time, no significant difference was identified in the DFS and OS in the SLNB + ALND cohort and the SLNB cohort (P = 0.208 and P = 0.102), except for those under 40 years old, SLNB + ALND group showed a reduction in LRR compared to SLNB group (11.1% vs. 2.12%, P = 0.044). Multivariate Cox analysis showed that younger (≤ 40 years), progesterone receptor (PR)-negative, and SLNB alone were independent risk factors for LRR; perineural invasion was a risk factor, while endocrinotherapy was a beneficial prognostic indicator for DFS and OS among patients with positive hormone receptor. Conclusion ALND does not impact DFS and OS in patients with 1-2 metastatic SLNs who have completed a mastectomy. Being younger (≤ 40 years), having a negative PR, and undergoing SLNB alone were independent risk factors for LRR. Given this finding, we recommend avoiding axillary treatment such as ALND or radiotherapy in patients without risk factors.
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Affiliation(s)
| | | | | | - Zhenchuan Song
- Department of Breast Center, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Yang L, Zhao X, Yang L, Chang Y, Cao C, Li X, Wang Q, Song Z. A new prediction nomogram of non-sentinel lymph node metastasis in cT1-2 breast cancer patients with positive sentinel lymph nodes. Sci Rep 2024; 14:9596. [PMID: 38671007 PMCID: PMC11053028 DOI: 10.1038/s41598-024-60198-0] [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: 01/14/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
We aimed to analyze the risk factors and construct a new nomogram to predict non-sentinel lymph node (NSLN) metastasis for cT1-2 breast cancer patients with positivity after sentinel lymph node biopsy (SLNB). A total of 830 breast cancer patients who underwent surgery between 2016 and 2021 at multi-center were included in the retrospective analysis. Patients were divided into training (n = 410), internal validation (n = 298), and external validation cohorts (n = 122) based on periods and centers. A nomogram-based prediction model for the risk of NSLN metastasis was constructed by incorporating independent predictors of NSLN metastasis identified through univariate and multivariate logistic regression analyses in the training cohort and then validated by validation cohorts. The multivariate logistic regression analysis revealed that the number of positive sentinel lymph nodes (SLNs) (P < 0.001), the proportion of positive SLNs (P = 0.029), lymph-vascular invasion (P = 0.029), perineural invasion (P = 0.023), and estrogen receptor (ER) status (P = 0.034) were independent risk factors for NSLN metastasis. The area under the receiver operating characteristics curve (AUC) value of this model was 0.730 (95% CI 0.676-0.785) for the training, 0.701 (95% CI 0.630-0.773) for internal validation, and 0.813 (95% CI 0.734-0.891) for external validation cohorts. Decision curve analysis also showed that the model could be effectively applied in clinical practice. The proposed nomogram estimated the likelihood of positive NSLNs and assisted the surgeon in deciding whether to perform further axillary lymph node dissection (ALND) and avoid non-essential ALND as well as postoperative complications.
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Affiliation(s)
- Liu Yang
- Department of Breast Center, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Xueyi Zhao
- Department of Breast Center, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Lixian Yang
- Department of Breast Surgery, Xingtai People's Hospital, Xingtai, 054000, China
| | - Yan Chang
- Department of Breast Surgery, Affiliated Hospital of Hebei Engineering University, Handan, 056000, China
| | - Congbo Cao
- Department of Breast Center, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Xiaolong Li
- Department of Breast Surgery, The Fourth Hospital of Shijiazhuang, Shijiazhuang, 050000, China
| | - Quanle Wang
- Department of Breast Surgery, The Fourth Hospital of Shijiazhuang, Shijiazhuang, 050000, China
| | - Zhenchuan Song
- Department of Breast Center, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050000, China.
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Alamoodi M, Patani N, Mokbel K, Wazir U, Mokbel K. Reevaluating Axillary Lymph Node Dissection in Total Mastectomy for Low Axillary Burden Breast Cancer: Insights from a Meta-Analysis including the SINODAR-ONE Trial. Cancers (Basel) 2024; 16:742. [PMID: 38398133 PMCID: PMC10886895 DOI: 10.3390/cancers16040742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Complete axillary lymph node dissection (cALND) was previously the standard of care for breast cancer (BC) patients with axillary node disease or macro-metastases found via sentinel lymph node biopsy (SLNB). However, due to significant morbidity, contemporary management now considers a more selective approach, influenced by studies like ACOSOG Z0011. This trial showed that cALND could be omitted without compromising local control or survival in patients with low axillary nodal disease burden undergoing breast-conserving therapy, radiotherapy, and systemic therapy. The relevance of this approach for women with low axillary nodal burden undergoing total mastectomy (TM) remained unclear. A PubMed search up to September 2023 identified 147 relevant studies, with 6 meeting the inclusion criteria, involving 4184 patients with BC and low-volume axillary disease (1-3 positive lymph nodes) undergoing TM. Postmastectomy radiotherapy receipt was similar in both groups. After a mean 7.2-year follow-up, both the pooled results and the meta-analysis revealed no significant differences in overall survival. The combined analysis of the published studies, including the subgroup analysis of the SINODAR-One trial, indicates no survival advantage for cALND over SLNB in T1-T2 breast cancer patients with 1-3 positive sentinel lymph nodes (pN1) undergoing mastectomy. This suggests that, following a multidisciplinary evaluation, cALND can be safely omitted. However, the impact of other patient, tumor, and treatment factors on survival requires consideration and therefore further prospective trials are needed for conclusive validation.
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Affiliation(s)
- Munaser Alamoodi
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
- Department of Surgery, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Neill Patani
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
- Institute for Women’s Health, University College London, London WC1N 1DZ, UK
| | - Kinan Mokbel
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
- Medical School, University of Exeter, Exeter EX1 2LU, UK
| | - Umar Wazir
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
| | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
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Li C, Zhang P, Lv J, Dong W, Hu B, Zhang J, Zhu H. Axillary management in patients with clinical node-negative early breast cancer and positive sentinel lymph node: a systematic review and meta-analysis. Front Oncol 2024; 13:1320867. [PMID: 38260843 PMCID: PMC10800700 DOI: 10.3389/fonc.2023.1320867] [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: 10/13/2023] [Accepted: 12/13/2023] [Indexed: 01/24/2024] Open
Abstract
Background The omission of axillary lymph node dissection (ALND) or axillary radiation (AxRT) remains controversial in patients with clinical node-negative early breast cancer and a positive sentinel lymph node. Methods We conducted a comprehensive review by searching PubMed, Embase, Web of Science, and Cochrane databases (up to November 2023). Our primary outcomes were overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and axillary recurrence (AR). Results We included 26 studies encompassing 145,548 women with clinical node-negative early breast cancer and positive sentinel lymph node. Pooled data revealed no significant differences between ALND and sentinel lymph node biopsy (SLNB) alone in terms of OS (hazard ratio [HR]0.99, 95% confidence interval [CI] 0.91-1.08, p=0.84), DFS (HR 1.04, 95% CI 0.90-1.19, p=0.61), LRR (HR 0.76, 95% CI 0.45-1.20, p=0.31), and AR (HR 1.01, 95% CI 0.99-1.03, p=0.35). Similarly, no significant differences were observed between AxRT and SLNB alone for OS (HR 0.57, 95% CI 0.32-1.02, p=0.06) and DFS (HR 0.52, 95% CI 0.26-1.05, p=0.07). When comparing AxRT and ALND, a trend towards higher OS was observed the AxRT group (HR 0.08, 95% CI 0.67-1.15), but the difference did not reach statistical significance (p=0.35, I2 = 0%). Additionally, no significant differences significance observed for DFS or AR (p=0.13 and p=0.73, respectively) between the AxRT and ALND groups. Conclusion Our findings suggest that survival and recurrence rates are not inferior in patients with clinical node-negative early breast cancer and a positive sentinel lymph node who receive SLNB alone compared to those undergoing ALND or AxRT.
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Affiliation(s)
- Changzai Li
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Pan Zhang
- College of Nursing and Rehabilitation, North China University of Science and Technology, Tangshan, Hebei, China
| | - Jie Lv
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Wei Dong
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Baoshan Hu
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Jinji Zhang
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Hongcheng Zhu
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
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Chen F, Li X, Lin X, Chen L, Lin Z, Wu H, Chen J. Can Axillary Lymph Node Dissection be Omitted in Breast Cancer Patients with Metastatic Sentinel Lymph Nodes Undergoing Mastectomy? A Systematic Review and Meta-Analysis of Real-World Evidence. World J Surg 2023; 47:2446-2456. [PMID: 37249632 DOI: 10.1007/s00268-023-07072-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND The omission of axillary lymph node dissection (ALND) in patients with breast cancer who have metastatic sentinel lymph nodes (SLNs) undergoing mastectomy remains controversial. This meta-analysis explored the clinicopathological factors affecting the selection of ALND and the influences of ALND on survival outcomes in patients receiving mastectomy with positive SLNs. METHODS Eligible studies published prior to 31 December 2022 were selected by searching the Embase, Web of Science and PubMed databases. Pooled analyses were performed using the number of events for clinicopathological parameters and HRs with 95% CIs for survival outcomes including disease-free survival (DFS), overall survival (OS), distant recurrence-free survival (DRFS) and locoregional recurrence-free survival (LRFS). RESULTS A total of 10 retrospective studies enrolling only breast cancer patients with limited SLN metastases (no more than 3 positive SLNs or micrometastatic SLNs) undergoing mastectomy were included. Performing ALND in mastectomy patients who had limited SLN metastases was significantly correlated with invasive ductal carcinomas, larger tumors, lymphovascular invasion, higher tumor grade, macrometastatic SLNs, more positive SLNs, extranodal extension, positive surgical margins, negative ER, administration of adjuvant chemotherapy and nonwhite race (P < 0.05). However, performing ALND did not result in significantly longer OS, DFS, LRFS or DRFS (P > 0.05) in these patients. CONCLUSION The present meta-analysis indicated that ALND may be safely avoided in patients with breast cancer who had limited SLN metastases undergoing mastectomy. Further well-designed randomized clinical trials are warranted to validate our results.
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Affiliation(s)
- Fulong Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Xiaowen Li
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Xianjun Lin
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Lijia Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Zhaoling Lin
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Hao Wu
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Jishang Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China.
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Tinterri C, Canavese G, Gatzemeier W, Barbieri E, Bottini A, Sagona A, Caraceni G, Testori A, Di Maria Grimaldi S, Dani C, Boni L, Bruzzi P, Fernandes B, Scorsetti M, Zambelli A, Gentile D. Sentinel lymph node biopsy versus axillary lymph node dissection in breast cancer patients undergoing mastectomy with one to two metastatic sentinel lymph nodes: sub-analysis of the SINODAR-ONE multicentre randomized clinical trial and reopening of enrolment. Br J Surg 2023; 110:1143-1152. [PMID: 37471574 PMCID: PMC10492188 DOI: 10.1093/bjs/znad215] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/15/2023] [Accepted: 06/13/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The initial results of the SINODAR-ONE randomized clinical trial reported that patients with T1-2 breast cancer and one to two macrometastatic sentinel lymph nodes treated with breast-conserving surgery, sentinel lymph node biopsy only, and adjuvant therapy did not present worse 3-year survival, regional recurrence, or distant recurrence rates compared with those treated with axillary lymph node dissection. To extend the recommendation of axillary lymph node dissection omission even in patients treated with mastectomy, a sub-analysis of the SINODAR-ONE trial is presented here. METHODS Patients with T1-2 breast cancer and no more than two metastatic sentinel lymph nodes undergoing mastectomy were analysed. After sentinel lymph node biopsy, patients were randomly assigned to receive either axillary lymph node dissection followed by adjuvant treatment (standard arm) or adjuvant treatment alone (experimental arm). The primary endpoint was overall survival. The secondary endpoint was recurrence-free survival. RESULTS A total of 218 patients were treated with mastectomy; 111 were randomly assigned to the axillary lymph node dissection group and 107 to the sentinel lymph node biopsy-only group. At a median follow-up of 33.0 months, there were three deaths (two deaths in the axillary lymph node dissection group and one death in the sentinel lymph node biopsy-only group). There were five recurrences in each treatment arm. No axillary lymph node recurrence was observed. The 5-year overall survival rates were 97.8 and 98.7 per cent in the axillary lymph node dissection treatment arm and the sentinel lymph node biopsy-only treatment arm, respectively (P = 0.597). The 5-year recurrence-free survival rates were 95.7 and 94.1 per cent in the axillary lymph node dissection treatment arm and the sentinel lymph node biopsy treatment arm, respectively (P = 0.821). CONCLUSION In patients with T1-2 breast cancer and one to two macrometastatic sentinel lymph nodes treated with mastectomy, the overall survival and recurrence-free survival rates of patients treated with sentinel lymph node biopsy only were not inferior to those treated with axillary lymph node dissection. To strengthen the conclusion of the trial, the enrolment of patients treated with mastectomy was reopened as a single-arm experimental study. REGISTRATION NUMBER NCT05160324 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | | | - Erika Barbieri
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alberto Bottini
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Sagona
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Giulia Caraceni
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alberto Testori
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Carla Dani
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Luca Boni
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Paolo Bruzzi
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Bethania Fernandes
- Department of Pathology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alberto Zambelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Medical Oncology and Haematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Damiano Gentile
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Elzayat I, Abdelaal M, Monib S. Safety and Efficacy of Mitoxantrone Hydrochloride Injection for Identification of Axillary Sentinel Lymph Nodes in Patients with Primary Breast Cancer. World J Surg 2023; 47:1956-1960. [PMID: 37085640 DOI: 10.1007/s00268-023-07011-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND The dual technique using blue dye in combination with a radioisotope is considered the gold standard for identifying sentinel lymph nodes (SLNs) in patients with breast cancer. Unfortunately, not all cancer centres have access to radioactive material, which jeopardizes the SLN identification rate and patient safety. AIM We aimed to assess the safety and efficacy of mitoxantrone hydrochloride injection (MHI) for identifying axillary SLNs in patients with primary breast cancer. PATIENTS AND METHODS We have conducted a prospective non-randomized analysis of patients diagnosed with invasive breast cancer who agreed to participate in the study between December 2019 and December 2022. We have used the patient's medical records to collect the data. We have used the SLN intraoperative identification rate as a marker for the efficacy of the technique and both the immediate and delayed complication rates and routine blood tests as markers for the safety of the technique. RESULTS Out of the 296 patients, 289 (97.6%) had their SLNs identified using MHI, while seven patients (2.3%) had four-node sampling carried out because the SLNs were not identified. Liver functions were not significantly affected by MHI, and there was no technique-related readmission or reported morbidity or mortality. CONCLUSION We have found that the MHI technique is still inferior to the combined radioactive directed technique and patent blue V dye in SLN identification. Yet, it may serve as a safe and reliable alternative in cases where the radioactive technique is unavailable.
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Affiliation(s)
- Ibrahim Elzayat
- General Surgery Department, Aswan University Hospital, Aswan, Egypt.
| | | | - Sherif Monib
- Breast Unit, West Hertfordshire Teaching Hospitals NHS Trust, Hertfordshire, UK
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Fan YJ, Li JC, Zhu DM, Zhu HL, Zhao Y, Zhu XB, Wu G, Bai TT. Efficacy and safety comparison between axillary lymph node dissection with no axillary surgery in patients with sentinel node-positive breast cancer: a systematic review and meta-analysis. BMC Surg 2023; 23:209. [PMID: 37495945 PMCID: PMC10369839 DOI: 10.1186/s12893-023-02101-8] [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: 12/12/2022] [Accepted: 07/07/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND This systematic review and meta-analysis aimed to study the evidence on the efficacy and safety of omitting axillary lymph node dissection (ALND) for patients with clinically node-negative but sentinel lymph node (SLN)-positive breast cancer using all the available evidence. METHODS The Embase, Medline, and Cochrane Library databases were searched through February 25, 2023. Original trials that compared only the sentinel lymph node biopsy (SLNB) with ALND as the control group for patients with clinically node-negative but SLN-positive breast cancer were included. The primary outcomes were axillary recurrence rate, total recurrence rate, disease-free survival (DFS), and overall survival (OS). Meta-analyses were performed to compare the odds ratio (OR) in rates and the hazard ratios (HR) in time-to-event outcomes between both interventions. Based on different study designs, tools in the revised Cochrane risk of bias tool were used for randomized trials and the risk of bias in nonrandomized studies of interventions to assess the risk of bias for each included article. Funnel plots and Egger's test were used for the publication's bias assessment. RESULTS In total, 30 reports from 26 studies were included in the systematic review (9 reports of RCTs, 21 reports of retrospective cohort studies). According to our analysis, omitting ALND in patients with clinically node-negative but SLN-positive breast cancer had a similar axillary recurrence rate (OR = 0.95, 95% confidence interval (CI): 0.76-1.20), DFS (HR = 1.02, 95% CI: 0.89-1.16), and OS (HR = 0.97, 95% CI: 0.92-1.03), but caused a significantly lower incidence of adverse events and benefited in locoregional recurrence rate (OR = 0.76, 95% CI: 0.59-0.97) compared with ALND. CONCLUSION For patients with clinically node-negative but SLN-positive breast cancer (no matter the number of the positive SLN), this review showed that SLNB alone had a similar axillary recurrence rate, DFS, and OS, but caused a significantly lower incidence of adverse events and showed a benefit for the locoregional recurrence compared with ALND. An OS benefit was found in the Macro subset that used SLNB alone versus complete ALND. Therefore, omitting ALND is feasible in this setting. TRIAL REGISTRATION CRD 42023397963.
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Affiliation(s)
- Yu-Jia Fan
- Thyroid & Breast Surgery Department,, Liaocheng People's Hospital, Liaocheng, 252000, Shandong Province, P. R. China
| | - Jin-Cheng Li
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China.
| | - De-Miao Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Hai-Long Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Yi Zhao
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Xin-Bing Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Gang Wu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Ting-Ting Bai
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
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Huang Z, Wu Z, Zou QQ, Xie YJ, Li LH, Huang YP, Wu FM, Huang D, Pan YH, Yang JR. Risk factors of non-sentinel lymph node metastasis in breast cancer with 1-2 sentinel lymph node macrometastases underwent total mastectomy: a case-control study. World J Surg Oncol 2023; 21:125. [PMID: 37024930 PMCID: PMC10077622 DOI: 10.1186/s12957-023-02888-z] [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: 09/22/2022] [Accepted: 01/09/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND The randomized trials which include ACOSOG Z0011 and IBCSG 23-01 had found that the survival rates were not different in patients with cT1/2N0 and 1-2 sentinel lymph node (SLN)-positive, macro/micrometastases who underwent breast-conserving therapy, and micrometastases who underwent total mastectomy (TM), when axillary lymph node dissection (ALND) was omitted. However, for patients with cT1/2N0 and 1-2 SLN macrometastases who underwent TM; there was still insufficient evidence from clinical studies to support whether ALND can be exempted. This study aimed to investigate the risk factors of non-sentinel lymph node (nSLN) metastasis in breast cancer patients with 1-2 SLN macrometastases undergoing TM. METHODS The clinicopathological data of 1491 breast cancer patients who underwent TM and SLNB from January 2017 to February 2022 were retrospectively analyzed. Univariate and multivariate analyses were performed to analyze the risk factors for nSLN metastasis. RESULTS A total of 273 patients with 1-2 SLN macrometastases who underwent TM were enrolled. Postoperative pathological data showed that 35.2% patients had nSLN metastasis. The results of multivariate analysis indicated that tumor size (TS) (P = 0.002; OR: 1.051; 95% CI: 1.019-1.084) and ratio of SLN macrometastases (P = 0.0001; OR: 12.597: 95% CI: 4.302-36.890) were the independent risk factors for nSLN metastasis in breast cancer patients with 1-2 SLN macrometastases that underwent TM. The ROC curve analysis suggested that when TS ≤22 mm and ratio of SLN macrometastases ≤0.33, the incidence of nSLN metastasis could be reduced to 17.1%. CONCLUSIONS The breast cancer patients with cT1/2N0 stage, undergoing TM and 1-2 SLN macrometastases, when the TS ≤22 mm and macrometastatic SLN does not exceed 1/3 of the total number of detected SLN, the incidence of nSLN metastasis is significantly reduced, but whether ALND can be exempted needs further exploration.
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Affiliation(s)
- Zhen Huang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Zhe Wu
- Department of Gynaecology, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, Nanning, China
| | - Quan-Qing Zou
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yu-Jie Xie
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Li-Hui Li
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yan-Ping Huang
- Department of Breast Surgery, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Feng-Ming Wu
- Department of Breast Surgery, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Dong Huang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yin-Hua Pan
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Jian-Rong Yang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China.
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Sousa N, Peleteiro B, Fougo JL. Total Tumor Load to assist in the decision for additional axillary surgery in the positive sentinel node breast cancer patients. Surg Oncol 2022; 45:101882. [PMID: 36395579 DOI: 10.1016/j.suronc.2022.101882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022]
Abstract
The Total Tumor Load (TTL) concept has been demonstrated to accurately predict the status of the non-sentinel lymph nodes (NSLN) in breast cancer patients. In 2019, our center implemented the TTL cut-off of 30,000 CK19 mRNA copies/μL as sole criterion for deciding on performing ALND. This retrospective, unicentric, study analyzed 87 cT1-3N0 breast cancer patients treated consecutively in a period of two years and aimed to evaluate the performance of this criterion. Secondary objectives included the comparison of the criterion versus our previous Clinical Decision Rule (CDR) versus ACOSOG Z0011 criteria for avoiding an ALND in proportion of patients spared an ALND and in proportion of patients left with a surgically untreated metastasized axilla. An interim analysis revealed new TTL cut-offs for deciding on performing an ALND. The 30,000 CK19 mRNA copies/μL criterion yielded an area under the ROC Curve (AUC) of 0.849, a false positive (FP) rate of 30.1% and a positive predictive value (PPV) of 38.9%. The 30,000 CK19 mRNA copies/μL criterion spared 58.6% of the patients an ALND versus 41.4% with CDR versus 73.6% with Z0011 and left 0.0% patients with a surgically untreated metastasized axilla versus 21.4% with CDR versus 42.9% with Z0011. The new TTL cut-off of 260,000 CK19 mRNA copies/μL for deciding on an ALND yielded an AUC of 0.753, a FP rate of 13.7% and a PPV of 47.4%. This new criterion spared 78.2% of the study sample an ALND and left 35.7% of metastasized axillae surgically untreated. This study emphasizes the need to find a new balance between locoregional control and the morbidity associated with Berg levels I + II axillary lymph node dissection.
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Affiliation(s)
- Nuno Sousa
- Faculty of Medicine, University of Porto, Portugal.
| | - Bárbara Peleteiro
- Faculty of Medicine, University of Porto, Portugal; Breast Center, Centro Hospitalar Universitário São João, Porto, Portugal; EPI Unit, Institute of Public Health, University of Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health, University of Porto, Portugal.
| | - José Luis Fougo
- Breast Center, Centro Hospitalar Universitário São João, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Portugal.
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Axilla lymph node dissection can be safely omitted in patients with 1-2 positive sentinel nodes receiving mastectomy: a large multi-institutional study and a systemic meta-analysis. Breast Cancer Res Treat 2022; 196:129-141. [PMID: 36076127 DOI: 10.1007/s10549-022-06727-9] [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: 04/13/2022] [Accepted: 08/26/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE This study aimed to evaluate whether axillary lymph node dissection (ALND) can be omitted in patients with 1-2 positive sentinel lymph nodes (SLNs) who received total mastectomy (TM). METHODS Consecutive breast cancer patients with 1-2 positive SLNs were retrospectively reviewed from a multi-institutional database. Patients were divided into sentinel lymph node biopsy (SLNB) group and ALND group. Administration of adjuvant chemotherapy and survival were compared between groups. To further verify the results, a meta-analysis was also conducted. RESULTS Among the 1161 enrolled patients, 893 (76.9%) received ALND and 268 (23.1%) underwent SLNB alone. Administration of chemotherapy was comparable between the two groups (91.1% vs. 90.6%, P = 0.798), which was consistent in TM (P = 0.638) and BCS cohort (P = 0.576). After a median follow-up of 36 months, no significant difference was observed between the two groups in recurrence-free survival (P = 0.583) regardless of surgery of breast. During further meta-analysis, 13 out of 4733 relative studies reported the association of axillary surgery and disease-free survival (DFS) or overall survival (OS) in 1-2 positive SLNs patients. Pooled analysis showed no difference in adjusted DFS (HR 0.84, 95% CI 0.70-1.02) or OS (HR 1.02, 95% CI 0.93-1.11) between SLNB and ALND groups. Survival benefit of ALND remained non-significant after restricting the analysis in four studies with patients only receiving BCS, or in three studies with patients only receiving TM. CONCLUSION Further ALND does not impact adjuvant chemotherapy administration or disease outcome in breast cancer patients with 1-2 positive SLNs treated with TM.
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Si J, Guo R, Pan H, Lu X, Guo Z, Han C, Xue L, Xing D, Wu W, Chen C. Axillary Lymph Node Dissection Can Be Omitted in Breast Cancer Patients With Mastectomy and False-Negative Frozen Section in Sentinel Lymph Node Biopsy. Front Oncol 2022; 12:869864. [PMID: 35494089 PMCID: PMC9046780 DOI: 10.3389/fonc.2022.869864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/14/2022] [Indexed: 11/15/2022] Open
Abstract
Background The IBCSG 23-01 and AMAROS trials both reported that axillary lymph node dissection (ALND) did not change survival rates in breast cancer patients with positive nodes detected by sentinel lymph node biopsy (SLNB). The aim of this study was to determine whether breast cancer patients with mastectomy and false-negative frozen section (FS) in SLNB could forgo ALND. Materials and Methods This was a retrospective study of cN0 patients diagnosed with primary invasive breast cancer treated by mastectomy and SLNB at our institute between January 2010 and December 2014. Patients with false-negative FS in SLNB were separated by the following management of axillary lymph node dissection in the non-ALND group (nonprocess or axillary radiation only) and ALND group (with or without radiation). Results A total of 212 patients were included, 86 and 126 patients in the non-ALND and ALND groups, respectively. The positive rate of non-sentinel lymph nodes (SLNs) was 15.87% (20/126) in the ALND group. In multivariate analysis, we found that patients with larger tumor size (>2 cm) (OR, 1.989; p = 0.030) and multifocal lesions (OR, 3.542; p = 0.029) tended to receive ALND. The positivity of non-SLNs in the ALND group was associated with SLN macrometastasis (OR, 3.551; p = 0.043) and lymphovascular invasion (OR, 6.158; p = 0.003). Also, removing more SLNs (≥3) was related to negativity in non-SLNs (OR, 0.255; p = 0.016). After a median follow-up of 59.43 months, RFS and OS of the two groups were similar (p = 0.994 and 0.441). In subgroup analysis, we found that 97 patients who met the inclusive criteria of the IBCSG 23-01 trial had similar RFS and OS between the non-ALND and ALND groups (p = 0.856 and 0.298). The positive rate of non-SLNs was 9.62% (5/52). Also, in 174 patients who met the criteria of the AMAROS trial, RFS and OS in the non-ALND and ALND groups were similar (p = 0.930 and 0.616). The positive rate of non-SLNs was 18.27% (19/104). Conclusion ALND can be carefully omitted in selected breast cancer patients with mastectomy and false-negative FS in SLNB. SLNB is relatively sufficient in the IBCSG 23-01-eligible patients, and axillary radiation was an effective option in the AMAROS-eligible patients.
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Affiliation(s)
- Jing Si
- Department of Breast Disease, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
- Cancer Research Center, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
- *Correspondence: Jing Si,
| | - Rong Guo
- Department of Breast Surgery, Breast Cancer Center of the Third Affiliated Hospital of Kunming Medical University, Cancer Hospital of Yunnan Province, Kunming, China
| | - Huan Pan
- Department of Central Laboratory, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Xiang Lu
- Department of Breast Disease, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Zhiqin Guo
- Department of Pathology, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Chao Han
- Department of Breast Disease, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Li Xue
- Department of Breast Disease, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Dan Xing
- Department of Breast Disease, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Wanxin Wu
- Department of Pathology, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Caiping Chen
- Department of Breast Disease, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
- Cancer Research Center, The First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
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