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Blumencranz P, Habibi M, Shivers S, Acs G, Blumencranz LE, Yoder EB, van der Baan B, Menicucci AR, Dauer P, Audeh W, Cox CE. ASO Visual Abstract: The Predictive Utility of MammaPrint and BluePrint in Identifying Patients with Locally Advanced Breast Cancer Who are Most Likely to have Nodal Downstaging and a Pathologic Complete Response After Neoadjuvant Chemotherapy. Ann Surg Oncol 2024; 31:393-394. [PMID: 37787953 DOI: 10.1245/s10434-023-14317-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Affiliation(s)
| | | | - Steve Shivers
- Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Geza Acs
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | | | | | | | | | | | - Charles E Cox
- Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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Blumencranz P, Habibi M, Shivers S, Acs G, Blumencranz LE, Yoder EB, van der Baan B, Menicucci AR, Dauer P, Audeh W, Cox CE. The Predictive Utility of MammaPrint and BluePrint in Identifying Patients with Locally Advanced Breast Cancer Who are Most Likely to Have Nodal Downstaging and a Pathologic Complete Response After Neoadjuvant Chemotherapy. Ann Surg Oncol 2023; 30:8353-8361. [PMID: 37658272 PMCID: PMC10625953 DOI: 10.1245/s10434-023-14027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 07/10/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NCT) increases the feasibility of surgical resection by downstaging large primary breast tumors and nodal involvement, which may result in surgical de-escalation and improved outcomes. This subanalysis from the Multi-Institutional Neo-adjuvant Therapy MammaPrint Project I (MINT) trial evaluated the association between MammaPrint and BluePrint with nodal downstaging. PATIENTS AND METHODS The prospective MINT trial (NCT01501487) enrolled 387 patients between 2011 and 2016 aged ≥ 18 years with invasive breast cancer (T2-T4). This subanalysis includes 146 patients with stage II-III, lymph node positive, who received NCT. MammaPrint stratifies tumors as having a Low Risk or High Risk of distant metastasis. Together with MammaPrint, BluePrint genomically (g) categorizes tumors as gLuminal A, gLuminal B, gHER2, or gBasal. RESULTS Overall, 45.2% (n = 66/146) of patients had complete nodal downstaging, of whom 60.6% (n = 40/66) achieved a pathologic complete response. MammaPrint and combined MammaPrint and BluePrint were significantly associated with nodal downstaging (p = 0.007 and p < 0.001, respectively). A greater proportion of patients with MammaPrint High Risk tumors had nodal downstaging compared with Low Risk (p = 0.007). When classified with MammaPrint and BluePrint, more patients with gLuminal B, gHER2, and gBasal tumors had nodal downstaging compared with HR+HER2-, gLuminal A tumors (p = 0.538, p < 0.001, and p = 0.013, respectively). CONCLUSIONS Patients with genomically High Risk tumors, defined by MammaPrint with or without BluePrint, respond better to NCT and have a higher likelihood of nodal downstaging compared with patients with gLuminal A tumors. These genomic signatures can be used to select node-positive patients who are more likely to have nodal downstaging and avoid invasive surgical procedures.
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Affiliation(s)
| | | | - Steve Shivers
- Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Geza Acs
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | | | | | | | | | | | - Charles E Cox
- Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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Shah CS, Whitworth PW, Shivers S, Mittal K, Bremer T, Cox CE. Impact on Radiation Therapy Recommendation and Treatment Modality for Patients with Ductal Carcinoma In Situ Using the 7Gene Biosignature: Analysis of the PREDICT Study. Int J Radiat Oncol Biol Phys 2023; 117:e206. [PMID: 37784864 DOI: 10.1016/j.ijrobp.2023.06.1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Breast conserving surgery (BCS) followed by adjuvant radiotherapy (RT) has been a mainstay in the treatment of DCIS based on multiple randomized trials demonstrating a local recurrence benefit with RT. However, these studies have failed to identify subsets of patients who did or did not benefit from adjuvant RT after BCS, raising concerns regarding both over and undertreatment. Thus, better prognostic and predictive tools are needed to appropriately risk stratify patients and understand their benefit of RT. The 7-gene predictive DCIS biosignature provides a validated score (DS) for women undergoing BCS that assesses their 10-year risk of in-breast and invasive recurrence with and without adjuvant RT. This trail was designed to evaluate the decision impact of the 7-gene predictive biosignature score on DCIS treatment recommendations. MATERIALS/METHODS The PREDICT study is a prospective, multi-institutional trial for patients who received DCISionRT testing as part of their routine care. The registry includes females 26 and older who are diagnosed with DCIS, are candidates for BCS, and eligible for RT. Treating physicians completed treatment recommendation forms before and after receiving test reports to capture surgical, radiation and hormonal treatment (HT) recommendations and patient preferences. Analysis was performed in 2,012 patients treated at 63 clinical sites. RESULTS Median age was 62 years old with 32% grade 3 and 10% size 2.5 cm or greater. Post-test, RT recommendation changed for 38% of patients (p<0.001), with a net reduction of 20% in patients recommended to receive RT(p<0.001). The DCISionRT test results had the greatest impact (OR 26.2, 95% CI 19.1-36.4, when analyzed categorically using DS>3 cut-off; 2.3 per DS, 95% CI 2.1-2.6, when evaluated continuously) on post-test RT recommendation in multivariable analysis when compared to all other factors including patient preference, patient clinical and tumor pathological factors, patient race/ethnicity, treatment facility, physician specialty. The post-test RT recommendation rate increased with increasing DS (0-2, 2-4, 4-10) on a categorical basis, with odds ratios of 6.8 DS (2-4 vs 0-2), and 35.0 for DS (4-10 vs 0-2). After DCISionRT test result, patient preference was the second most important factor in post-testing RT recommendation. There was also a significant change in the modality of RT recommended to 34% of those patients recommended RT pre-test and post-test by radiation oncologists (n = 937), with intensified RT modality for higher DS (p<0.001) and de-escalation for lower DS (p<0.001). CONCLUSION This analysis of over 2,000 patients demonstrates significant changes in recommendations to add or omit RT based on the 7-gene predictive. The integration of DCISionRT into clinical decision processes has substantial impact on recommendations aimed at optimal management to prevent over- or under-treatment.
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Affiliation(s)
- C S Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | | | | | | | - C E Cox
- University of South Florida Morsani College of Medicine, Tampa, FL
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Vicini FA, Shah CS, Margenthaler J, Dabbs D, Wärnberg F, Weinmann S, Whitworth PW, Czerniecki B, Mann GB, Shivers S, Mittal K, Bremer T. Limitations in the Application of Clinicopathologic Factors Alone in Predicting Radiation Benefit for Women with Low-Risk DCIS after Breast Conserving Surgery: The Impact of a 7-Gene Biosignature Based on 10-Year Ipsilateral Breast Recurrence (IBR) Rates. Int J Radiat Oncol Biol Phys 2023; 117:S5. [PMID: 37784513 DOI: 10.1016/j.ijrobp.2023.06.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Most women diagnosed with ductal carcinoma in situ (DCIS) receive radiotherapy (RT) after breast conserving surgery (BCS); however, clinical trials show that over 70% of women with BCS alone will not have a recurrence and therefore not benefit from RT. Traditionally, clinicopathologic (CP) factors have been used to select for whom to de-escalate treatment, but prospective trials have failed to identify a low risk CP group that did not benefit from RT with respect to local control. This study assessed the re-classification of patients with low-risk CP into Risk groups defined by the 7-gene biosignature and compared to 10-yr IBR rates. MATERIALS/METHODS Women (n = 926) from four international DCIS cohorts treated with BCS had formalin-fixed paraffin embedded tissue samples analyzed at a CLIA lab (Laguna Hills, CA). CP low-risk patients were identified using a) RTOG-9804-like criteria [Nuclear Grade 1 or 2 & Size ≤2.5 cm & non-Palpable & Screen Detected & margin negative (no-ink on tumor)] and b) MSKCC-like criteria [low-risk score<220, determined using nomogram weighted factors (excluding: number of re-excisions and RT treatment), and using no-ink-on-tumor instead of close margin]. The 7-gene DCIS biosignature combined biomarkers with CP factors (age, size, palpability, and margin status) using an algorithm reporting a Decision Score (DS) and Residual Risk subtype (RRt). Women with low-risk CP were classified into biosignature Low Risk (DS≤2.8, no RRt) or High Risk (DS>2.8 +/- RRt) groups. 10yr in-breast event (IBR) rates with and without RT were assessed by Kaplan-Meier rates and Cox proportional hazard analyses. RESULTS Overall, 37% of all women were classified into the biosignature Low Risk group, while 51% and 34% were classified into CP low-risk groups (RTOG-9804-like, MSKCC-like, respectively). The biosignature Low Risk group (n = 338) had a 10-yr IBR risk of 5.6% after BCS and no significant RT benefit (absolute RT benefit = 0.8%, p = 0.70), 99% negative predictive value (NPV) for RT benefit. CP low-risk groups had 10-yr IBR rates of 12% and 8% after BCS without RT with absolute 6% (p = 0.04) and 4% (p = 0.1) IBR rate reductions with RT. The biosignature reclassified 51% and 63% of CP low-risk patients into the biosignature High Risk group. Importantly, these patients had higher IBR rates without RT (20% and 12%) and significant 13% (p = 0.005) and 8% (p = 0.01) absolute IBR rate reductions from RT. CP low-risk patients with concordant biosignature Low Risk demonstrated no significant RT benefit. CONCLUSION The 7-gene predictive biosignature more reliably identified patients with low 10-yr IBR rates and no significant RT benefit than the traditional CP low-risk criteria (RTOG-9804-like, MSKCC-like). Importantly, those CP low-risk patients who were re-classified as biosignature High Risk had increased 10-year IBR rates and significant RT benefit.
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Affiliation(s)
- F A Vicini
- Department of Radiation Oncology, GenesisCare, Farmington Hills, MI
| | - C S Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - J Margenthaler
- Siteman Cancer Center, Washington University St. Louis, St Louis, MO
| | | | - F Wärnberg
- University of Gothenburg, Gothenburg, Sweden
| | - S Weinmann
- Kaiser Permanente Center for Health Research, Portland, OR
| | | | - B Czerniecki
- H. Lee Moffitt Cancer Center and Research Institute, Department of Breast Oncology, Tampa, FL
| | - G B Mann
- The University of Melbourne, Melbourne, Australia
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Bremer T, Mittal K, Wärnberg F, Dabbs D, Shivers S, Wadsten C. A Biosignature Integrating Immune and Metabolic Signaling Axes to Assess Limited Radiation Therapy Response in Early-Stage Breast Cancer from a Low-Risk Cohort. Int J Radiat Oncol Biol Phys 2023; 117:e165-e166. [PMID: 37784766 DOI: 10.1016/j.ijrobp.2023.06.1001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Radiation therapy (RT) post breast conserving surgery (BCS) reduces in-breast recurrence (IBR) rate in early-stage invasive breast cancer (BC) patients. The RT treatment recommendation is often driven by clinicopathological (CP) factors; however, CP factors alone have limited ability to identify which women significantly benefit from RT, or those with higher IBR risk after BCS plus RT. Biologic factors driving unique phenotypes, in addition to CP, may improve prediction of RT response. In this study we evaluated the role of immune and metabolic signaling axes in predicting RT response in hormone receptor positive, HER2 negative, early-stage BC patients. MATERIALS/METHODS Biomarkers from immune and metabolic signaling axes were studied in a cohort of 939 women from Sweden, at a CLIA certified lab (Laguna Hills, CA). Formalin fixed paraffin embedded tissues were assayed for protein expression using multiplex immunofluorescence and multi-spectral imaging. Immune and metabolic axes were assessed using biomarkers combined with a non-linear model, adjusting for patient age. RT prediction by the model was assessed, along and adjusted for CP factors and also among patients over 50-yrs. The model defined patient risk groups that were analyzed for IBR rate using Kaplan Meier analyses and Cox proportional hazards to test for RT-risk group interaction. RESULTS Within the cohort, 440 patients had hormone receptor positive, HER2 negative BC treated with BCS (negative margins) and +/- RT without chemotherapy, where 296 patients had complete biomarker data. CP factors individually were not predictive for RT benefit, but grade was prognostic for IBR rate (p = 0.02) after BCS without RT. In multivariable analysis, adjusting for CP factors (grade, palpability, continuous size and age), the model was predictive for RT benefit (p-interaction = 0.046), identifying patients (n = 129) with worse RT benefit (HR = 7.8) compared to baseline RT benefit. The model was not prognostic for IBR rate in patients treated with BCS without RT (16% 10-yr IBR rate) but identified patients with increased IBR rates after BCS plus RT (HR = 3.9, p<0.001), where corresponding 10-yr IBR rates increased from 3% to 15%. The model was also predictive for RT benefit in women over 50-yrs (p-interaction = 0.05). The model identified 28% of women over 50-yrs who had increased IBR rates after BCS plus RT (HR = 4.0, p = 0.004), where corresponding 10-yr IBR rates increased from 3% to 12%. CONCLUSION The model incorporating metabolic and immune signaling axes assessed in the study was predictive for RT benefit among women with early-stage hormone receptor positive, HER2 negative BC. While CP factors were not predictive of RT benefit, the inclusion of metabolic and immune signaling axes improved identification of patients with high residual risk after BCS plus RT and can potentially aid in personalized treatment of early-stage breast cancer based on individualized risk.
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Affiliation(s)
| | | | - F Wärnberg
- University of Gothenburg, Gothenburg, Sweden
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Shah C, Vicini F, Wärnberg F, Weinmann S, Mann G, Rabinovitch R, Whitworth P, Margenthaler J, Leo M, Dabbs D, Mittal K, Shivers S, Bremer T. Re-Thinking Clinicopathologic Risk Assessment in DCIS: Pooled Data from Validation Studies Comparing a 7-gene DCIS Assay to Clinicopathologic Features Alone. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Wärrnberg F, Wadsten C, Karakatsanis A, Bagge RO, Holmberg E, Karlsson P, Lindman H, Whitworth PW, Sawyer E, Shah C, Shivers S, Vicini F, Mann BG, Bremer T. Abstract P3-18-01: Assessmentof DCISionRT for guiding radiotherapy of DCIS in Sweden. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p3-18-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Radiotherapy (RT) after breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS) reduces the relative ipsilateral breast event (IBE) risk by 50%. The DCISionRT® test estimates IBE risk in DCIS women treated with BCS, and RT benefit. The test has been validated in five cohorts, including the SweDCIS randomized trial. Swedish national guidelines define low-risk DCIS using clinicopathology criteria. Methods: We determined the number of women irradiated per IBE prevented and treatment-costs based on 10-year outcomes from the SweDCIS trial. Four strategies were compared: no RT (Strategy 1); RT for all (Strategy 2), RT for DCISionRT Elevated Risk only (Strategy 3); Swedish DCIS Guidelines, omit RT for low-risk (Strategy 4). In SweDCIS, women were randomised to RT or not after BCS, 1988-2000 (n=1046). Data for DCISionRT biomarkers (PR, HER2, Ki67, FOXA1, p16/INK4A, SIAH2, COX2) and clinical factors (age, tumor size, margin, palpability) were available for 504 women with negative margins. A decision score (DS, 0-10) was reported. The associations between Low (DS≤3) and Elevated Risk (DS>3) groups, and 10-year recurrences, and RT effect were assessed. Algorithms for mean treatment costs depending on adjuvant RT and type of recurrence, including secondary surgery, reconstruction, RT, and chemotherapy were based on data from 74 women with recurrence (41 invasive/33 in situ). Costs were based on diagnostic related grouping (DRG) in Sweden, 2020 and transformed to US dollar($). Results: In the SweDCIS validation of DCISionRT, the test divided women into Elevated (52%) and Low Risk (48%) groups. In the Elevated Risk group, RT decreased 10-year relative total and invasive recurrence rates, HR 0.32 (95%CI 0.17-0.58) and 0.24 (0.08-0.74), respectively with absolute decrease of 15.5% (5.9-25.0%) and 9.3% (2.0-16.5%). In the Low Risk group, the relative RT benefit was lower, HR 0.53 (0.28-1.02) and 0.84 (0.30-2.31), with decrease of 5.7% (-0.8-12.2%) and 1.2% (-5.7-8.2%). Invasive and in situ recurrences had an average treatment cost of $21,228 and $19,777, respectively. Treatment of recurrences after initial RT was $983 less expensive. RT-cost was $4,899. Strategy 1: For every 1000 women, 186 develop an IBE within 10-years after BCS without RT, with a treatment-cost in Sweden of $3,752,099. Strategy 2: Treating all women with RT prevents 108 IBE with treatment-costs of $6,467,113. Strategy 3: Treating women at DS Elevated Risk with RT prevents 81 IBE and 480 women are spared RT, with treatment-costs of $4,681,394. The cost of the test is not included. Strategy 4: Using Swedish Guidelines, prevents 100 recurrences and 870 receives RT with treatment-costs of $5,998,002. Compared to Strategy 1, Strategies 2, 3 and 4 decrease IBEs with increased treatment-costs. Treatment-costs increased $25,139/IBE prevented by Strategy 2, $11,473/IBE prevented by Strategy 3, and $26,115/IBE prevented by Strategy 4. The number of women irradiated per IBE prevented were 9.3, 6.4, and 10.1 for strategies 2, 3 and 4, respectively, relative to Strategy 1. Conclusion Strategy 1 (to omit RT) had the lowest treatment-costs and the highest number of recurrences. Strategy 3, using DCISionRT had the lowest number irradiated per IBE prevented at the lowest treatment-cost per IBE prevented.
Table 1.DCIS BCS +/-RTRT%Recurrences per 1000 womenCost including RT and treatment of recurrence per 1000BCS RT(-)0%186$3,752,099BCS RT(+)100%78$6,467,113DCISionRT52%105$4,681,394Swedish Guidelines*87%86$5,998,002*Low-risk criteria from modified Swedish national guidelines NG 1–2, <1.5 cm, negative margin, and <52 years (mean age for menopause)
Citation Format: Fredrik Wärrnberg, Charlotta Wadsten, Andrea Karakatsanis, Roger Olofsson Bagge, Erik Holmberg, Per Karlsson, Henrik Lindman, Pat W Whitworth, Elinor Sawyer, Chirag Shah, Steve Shivers, Frank Vicini, Bruce G Mann, Troy Bremer. Assessmentof DCISionRT for guiding radiotherapy of DCIS in Sweden [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-18-01.
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Affiliation(s)
- Fredrik Wärrnberg
- Dept. of Surgery, Sahlgrenska Academy at Gothenburg Univeristy, Gothenburg, Sweden
| | - Charlotta Wadsten
- Deparment of Surgery, Sumdsvall Hospital, Umeå University, Umeå, Sweden
| | | | - Roger Olofsson Bagge
- Dept of Surgery, Sahlgrenska Academy at Gothenburg Univeristy, Gothenburg, Sweden
| | - Erik Holmberg
- Dept. of Oncology, Sahlgrenska Academy at Gothenburg Univeristy, Gothenburg, Sweden
| | - Per Karlsson
- Dept. of Oncologu, Sahlgrenska Academy at Gothenburg Univeristy, Gothenburg, Sweden
| | - Henrik Lindman
- Dept. of Oncology, Uppsala University, Gothenburg, Sweden
| | | | - Elinor Sawyer
- Guys Cancer Centre, Kings College, London, United Kingdom
| | - Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | | | | | - Bruce G Mann
- Department of Surgery, University of Melbourne, Melbourne, Australia
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Shah C, Bremer T, Cox C, Whitworth P, Patel R, Patel A, Brown E, Gold L, Rock D, Riley L, Kesslering C, Brown S, Gabordi R, Pellicane J, Rabinovich R, Khan S, Templeton S, Majithia L, Willey SC, Wärnberg F, Gerber NK, Shivers S, Vicini FA. The Clinical Utility of DCISionRT ® on Radiation Therapy Decision Making in Patients with Ductal Carcinoma In Situ Following Breast-Conserving Surgery. Ann Surg Oncol 2021; 28:5974-5984. [PMID: 33821346 PMCID: PMC8526470 DOI: 10.1245/s10434-021-09903-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of radiation therapy (RT) following breast-conserving surgery (BCS) in ductal carcinoma in situ (DCIS) remains controversial. Trials have not identified a low-risk cohort, based on clinicopathologic features, who do not benefit from RT. A biosignature (DCISionRT®) that evaluates recurrence risk has been developed and validated. We evaluated the impact of DCISionRT on clinicians' recommendations for adjuvant RT. METHODS The PREDICT study is a prospective, multi-institutional, observational registry in which patients underwent DCISionRT testing. The primary endpoint was to identify the percentage of patients where testing led to a change in RT recommendations. RESULTS Overall, 539 women were included in this study. Pre DCISionRT testing, RT was recommended to 69% of patients; however, post-testing, a change in the RT recommendation was made for 42% of patients compared with the pre-testing recommendation; the percentage of women who were recommended RT decreased by 20%. For women initially recommended not to receive an RT pre-test, 35% had their recommendation changed to add RT following testing, while post-test, 46% of patients had their recommendation changed to omit RT after an initial recommendation for RT. When considered in conjunction with other clinicopathologic factors, the elevated DCISionRT score risk group (DS > 3) had the strongest association with an RT recommendation (odds ratio 43.4) compared with age, grade, size, margin status, and other factors. CONCLUSIONS DCISionRT provided information that significantly changed the recommendations to add or omit RT. Compared with traditional clinicopathologic features used to determine recommendations for or against RT, the factor most strongly associated with RT recommendations was the DCISionRT result, with other factors of importance being patient preference, tumor size, and grade.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | | | - Eric Brown
- Comprehensive Breast Care, Michigan Healthcare Professionals, Troy, MI, USA
| | - Linsey Gold
- Comprehensive Breast Care, Michigan Healthcare Professionals, Troy, MI, USA
| | | | - Lee Riley
- St. Luke's Hospital, Allentown, PA, USA
| | - Christy Kesslering
- Radiation Oncology Department, Northwestern Medicine, Warrenville, IL, USA
| | | | | | | | - Rachel Rabinovich
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | | | - Fredrik Wärnberg
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Naamit K Gerber
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, New York, NY, USA
| | | | - Frank A Vicini
- GenesisCare, Michigan Healthcare Professionals, Farmington Hills, MI, USA.
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Shah C, Bremer T, Cox C, Whitworth P, Patel R, Patel A, Brown E, Gold L, Rock D, Riley L, Kesslering C, Brown S, Gabordi R, Pellicane J, Rabinovich R, Khan S, Templeton S, Majithia L, Willey SC, Wärnberg F, Gerber NK, Shivers S, Vicini FA. Correction to: The Clinical Utility of DCISionRT ® on Radiation Therapy Decision Making in Patients with Ductal Carcinoma In Situ Following Breast-Conserving Surgery. Ann Surg Oncol 2021; 28:878. [PMID: 33997922 DOI: 10.1245/s10434-021-10138-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | | | - Eric Brown
- Comprehensive Breast Care, Michigan Healthcare Professionals, Troy, MI, USA
| | - Linsey Gold
- Comprehensive Breast Care, Michigan Healthcare Professionals, Troy, MI, USA
| | | | - Lee Riley
- St. Luke's Hospital, Allentown, PA, USA
| | - Christy Kesslering
- Radiation Oncology Department, Northwestern Medicine, Warrenville, IL, USA
| | | | | | | | - Rachel Rabinovich
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | | | - Fredrik Wärnberg
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Naamit K Gerber
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, New York, NY, USA
| | | | - Frank A Vicini
- GenesisCare, Michigan Healthcare Professionals, Farmington Hills, MI, USA.
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Bremer T, Shivers S, Kesslering C, Vicini F. Age and Grade as a Function of Decision Score in Women Diagnosed with DCIS. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Bremer T, Kesslering C, Patel R, Shivers S, Whitworth P, Vicini F. A Novel Biosignature to Assess Residual Risk in Early Stage Invasive Breast Cancer after Standard Breast Conserving Surgery. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Husain K, Zhang A, Shivers S, Davis-Yadley A, Coppola D, Yang CS, Malafa MP. Chemoprevention of Azoxymethane-induced Colon Carcinogenesis by Delta-Tocotrienol. Cancer Prev Res (Phila) 2019; 12:357-366. [DOI: 10.1158/1940-6207.capr-18-0290] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/17/2018] [Accepted: 03/29/2019] [Indexed: 11/16/2022]
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Blumencranz P, Habibi M, Treece T, Blumencranz L, Yoder E, Audeh W, Carter E, McNaughton L, Roussos J, Shivers S, Acs G, Cox C, MINT Investigators G. Abstract PD8-04: Neoadjuvant chemotherapy for breast cancer: Nodal downstaging is highly correlated with pathological complete response. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-pd8-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Neoadjuvant chemotherapy (NAC) is employed in patients with larger tumors to attempt to downstage locally advanced cancers to allow breast conservation and to assess in vivo tumor response. The Multi-Institutional Neoadjuvant Therapy MammaPrint Project I (MINT) study asked a secondary question of whether complete nodal downstaging could also be achieved with NAC.
Methods: This analysis included 147 eligible invasive breast cancer patients with high tumor burdens, classified as cT2-4N0-3M0 (T2 greater than 3.5cm if N0). Patients who had a positive core biopsy and/or fine needle aspiration (FNA) on an axillary node prior to starting NAC were included in this analysis. Those who had a surgical sentinel lymph node biopsy were not included. Nodal involvement was established following neoadjuvant treatment by axillary lymph node dissection (ALND).
Results: This population was 54% postmenopausal, average age 53 yrs (range 25 to 80 yrs). Tumor characteristics were 91% invasive ductal carcinoma; 65% T2, 29% T3, 6% T4; 87% LN1, 13% LN2-3; 3% low grade, 38% intermediate grade, 59% high grade; 65% ER-positive, 49% PR-positive, and 28% HER2-positive by immunohistochemistry; 84% High Risk (HR) and 16% Low Risk (LR) by MammaPrint (MP). After NAC, 45% (66/147) of these LN-positive patients were down-staged to ypN0 and also achieved a complete pathological response in the primary tumor. The potential for down-staging was inversely-related to tumor burden, where 47% (60/128) of N1, 35% (6/17) of N2, and 0% (0/2) of N3 patients were down-staged to ypN0. There were 3 patients who were down-staged (2 N2 to N1, and 1 N3 to N2), but not to ypN0. At surgery, 34% (44/128) of patients had no change, and 19% (24/129) progressed in LN staging.
Pre vs Post NAC Nodal StagePre NAC Nodal StageypN0ypN1ypN2ypN3TotalcN16044222128cN2626317cN3 112Total6646296147
Conclusions: We confirmed that upon achieving a complete response of the primary tumor that there was also a pathologic complete response in the LN. About 53% of patients had no change or progression of LN involvement following NAC.
Citation Format: Blumencranz P, Habibi M, Treece T, Blumencranz L, Yoder E, Audeh W, Carter E, McNaughton L, Roussos J, Shivers S, Acs G, Cox C, MINT Investigators Group. Neoadjuvant chemotherapy for breast cancer: Nodal downstaging is highly correlated with pathological complete response [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-04.
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Affiliation(s)
- P Blumencranz
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - M Habibi
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - T Treece
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - L Blumencranz
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - E Yoder
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - W Audeh
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - E Carter
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - L McNaughton
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - J Roussos
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - S Shivers
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - G Acs
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - C Cox
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
| | - Group MINT Investigators
- Morton Plant Hospital, Clearwater, FL; Johns Hopkins Breast Center at Bayview, Baltimore, MD; Agendia, Inc, Irvine, CA; University of South Florida, Tampa, FL; Florida Hospital Tampa, Tampa, FL
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Lengacher CA, Reich RR, Paterson CL, Shelton M, Shivers S, Ramesar S, Pleasant ML, Budhrani-Shani P, Groer M, Post-White J, Johnson-Mallard V, Kane B, Cousin L, Moscoso MS, Romershausen TA, Park JY. A Large Randomized Trial: Effects of Mindfulness-Based Stress Reduction (MBSR) for Breast Cancer (BC) Survivors on Salivary Cortisol and IL-6. Biol Res Nurs 2018; 21:39-49. [PMID: 30079756 DOI: 10.1177/1099800418789777] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Breast cancer survivors (BCS) often experience psychological and physiological symptoms after cancer treatment. Mindfulness-based stress reduction (MBSR), a complementary and alternative therapy, has reduced subjective measures of stress, anxiety, and fatigue among BCS. Little is known, however, about how MBSR affects objective markers of stress, specifically the stress hormone cortisol and the pro-inflammatory cytokine interleukin-6 (IL-6). In the present study, BCS ( N = 322) were randomly assigned to a 6-week MBSR program for BC or usual-care control. Measurements of cortisol, IL-6, symptoms, and quality of life were obtained at orientation and 6 weeks. Cortisol and IL-6 were also measured prior to and after the MBSR(BC) class Weeks 1 and 6. The mean age of participants was 56.6 years and 69.4% were White non-Hispanic. Most had Stage I (33.8%) or II (35.7%) BC, and 35.7% had received chemotherapy and radiation. Cortisol levels were reduced immediately following MBSR(BC) class compared to before the class Weeks 1 and 6 (Wilcoxon-signed rank test; p < .01, d = .52-.56). IL-6 was significantly reduced from pre- to postclass at Week 6 (Wilcoxon-signed rank test; p < .01, d = .21). No differences were observed between the MBSR(BC) and control groups from baseline to Week 6 using linear mixed models. Significant relationships with small effect sizes were observed between IL-6 and both symptoms and quality of life in both groups. Results support the use of MBSR(BC) to reduce salivary cortisol and IL-6 levels in the short term in BCS.
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Affiliation(s)
| | - Richard R Reich
- 2 H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Carly L Paterson
- 3 Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | - Melissa Shelton
- 1 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Steve Shivers
- 4 Department of Surgery, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Sophia Ramesar
- 1 College of Nursing, University of South Florida, Tampa, FL, USA
| | | | | | - Maureen Groer
- 1 College of Nursing, University of South Florida, Tampa, FL, USA
| | | | | | - Bradley Kane
- 1 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Lakeshia Cousin
- 1 College of Nursing, University of South Florida, Tampa, FL, USA
| | | | | | - Jong Y Park
- 2 H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Reich RR, Lengacher CA, Klein TW, Newton C, Shivers S, Ramesar S, Alinat CB, Paterson C, Le A, Park JY, Johnson-Mallard V, Elias M, Moscoso M, Goodman M, Kip KE. A Randomized Controlled Trial of the Effects of Mindfulness-Based Stress Reduction (MBSR[BC]) on Levels of Inflammatory Biomarkers Among Recovering Breast Cancer Survivors. Biol Res Nurs 2017; 19:456-464. [PMID: 28460534 DOI: 10.1177/1099800417707268] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE The purpose of this substudy of a large randomized controlled trial was to evaluate the efficacy of the Mindfulness-Based Stress Reduction (Breast Cancer) (MBSR[BC]) program compared to usual care (UC) in normalizing blood levels of pro-inflammatory cytokines among breast cancer survivors (BCS). METHOD A total of 322 BCS were randomized to either a 6-week MBSR(BC) program or a UC. At baseline and 6 and 12 weeks, 10 ml of venous blood and demographic and clinical data were collected and/or updated. Plasma cytokines (interleukin [IL]-1β, IL-6, IL-10, tumor necrosis factor [TNF] α, transforming growth factor [TGF] β1, soluble tumor necrosis factor receptor [sTNFR] 1) were assayed. Linear mixed models were used to assess cytokine levels across three time points (baseline and 6 and 12 weeks) by group (MBSR[BC] vs. UC). RESULTS Of the six measured cytokines, three were nondetectable at rates greater than 50% (IL-10, IL-1β, TGF-β1) and, because of overall low prevalence, were not analyzed further. For the remaining cytokines (TNFα, IL-6, sTNFR1), results showed that TNFα and IL-6 increased during the follow-up period (between 6 and 12 weeks) rather than during the MBSR(BC) training period (between baseline and 6 weeks), while sTNFR1 levels did not change significantly across the 12-week period. CONCLUSIONS Study results suggest that MBSR(BC) affects cytokine levels in BCS, mainly with increases in TNFα and IL-6. The data further suggest that B-cell modulation may be a part of immune recovery during breast cancer management and that increases in TNFα and IL-6 may be markers for MBSR(BC)-related recovery.
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Affiliation(s)
- Richard R Reich
- 1 Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Thomas W Klein
- 3 Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Cathy Newton
- 3 Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Steve Shivers
- 4 Breast Health Clinical and Research Integrated Strategic Program, University of South Florida, Tampa, FL, USA
| | - Sophia Ramesar
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Carissa B Alinat
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | | | - Alice Le
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Jong Y Park
- 1 Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Maya Elias
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Manolete Moscoso
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Matthew Goodman
- 7 Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Kevin E Kip
- 8 Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL, USA
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Reich RR, Lengacher CA, Alinat CB, Kip KE, Paterson C, Ramesar S, Han HS, Ismail-Khan R, Johnson-Mallard V, Moscoso M, Budhrani-Shani P, Shivers S, Cox CE, Goodman M, Park J. Mindfulness-Based Stress Reduction in Post-treatment Breast Cancer Patients: Immediate and Sustained Effects Across Multiple Symptom Clusters. J Pain Symptom Manage 2017; 53:85-95. [PMID: 27720794 PMCID: PMC7771358 DOI: 10.1016/j.jpainsymman.2016.08.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/05/2016] [Accepted: 08/03/2016] [Indexed: 01/04/2023]
Abstract
CONTEXT Breast cancer survivors (BCS) face adverse physical and psychological symptoms, often co-occurring. Biologic and psychological factors may link symptoms within clusters, distinguishable by prevalence and/or severity. Few studies have examined the effects of behavioral interventions or treatment of symptom clusters. OBJECTIVES The aim of this study was to identify symptom clusters among post-treatment BCS and determine symptom cluster improvement following the Mindfulness-Based Stress Reduction for Breast Cancer (MBSR(BC)) program. METHODS Three hundred twenty-two Stage 0-III post-treatment BCS were randomly assigned to either a six-week MBSR(BC) program or usual care. Psychological (depression, anxiety, stress, and fear of recurrence), physical (fatigue, pain, sleep, and drowsiness), and cognitive symptoms and quality of life were assessed at baseline, six, and 12 weeks, along with demographic and clinical history data at baseline. A three-step analytic process included the error-accounting models of factor analysis and structural equation modeling. RESULTS Four symptom clusters emerged at baseline: pain, psychological, fatigue, and cognitive. From baseline to six weeks, the model demonstrated evidence of MBSR(BC) effectiveness in both the psychological (anxiety, depression, perceived stress and QOL, emotional well-being) (P = 0.007) and fatigue (fatigue, sleep, and drowsiness) (P < 0.001) clusters. Results between six and 12 weeks showed sustained effects, but further improvement was not observed. CONCLUSION Our results provide clinical effectiveness evidence that MBSR(BC) works to improve symptom clusters, particularly for psychological and fatigue symptom clusters, with the greatest improvement occurring during the six-week program with sustained effects for several weeks after MBSR(BC) training. TRIAL REGISTRATION Name and URL of Registry: ClinicalTrials.gov. Registration number: NCT01177124.
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Affiliation(s)
- Richard R Reich
- Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.
| | | | - Carissa B Alinat
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Kevin E Kip
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Carly Paterson
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Sophia Ramesar
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Heather S Han
- Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | | | | | - Manolete Moscoso
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Pinky Budhrani-Shani
- Nelda C. Stark College of Nursing, Texas Woman's University, Houston, Texas, USA
| | - Steve Shivers
- University of South Florida Breast Health Clinical and Research Integrated Strategic Program, Tampa, Florida, USA
| | - Charles E Cox
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Matthew Goodman
- Department of Internal Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jong Park
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida, USA
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Reintgen M, Murray L, Akman K, Giuliano R, Lozicki A, Shivers S, Reintgen D. Evidence for a better nodal staging system for melanoma: the clinical relevance of metastatic disease confined to the sentinel lymph nodes. Ann Surg Oncol 2012; 20:668-74. [PMID: 23054112 DOI: 10.1245/s10434-012-2652-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Indexed: 01/30/2023]
Abstract
BACKGROUND The hypothesis tested in this study was whether patients with stage III metastatic melanoma confined to their sentinel lymph nodes (SLNs) had a more favorable prognosis than patients who had SLN and non-SLN (NSLN) metastases. METHODS Patients were identified who were clinically negative in their regional basins but with lymphatic mapping were found to have positive SLNs (331 patients). All patients subsequently underwent a complete lymph node dissection of the lymphatic basin involved, and the total number of metastatic SLNs and NSLNs were documented. RESULTS As the regional metastatic disease involves NSLNs, disease-free survival (DFS) and overall survival (OS) decreases. For patients with a total of 2 nodes positive, those with disease confined to the SLNs had a significant better prognosis (DFS and OS: P < .00001) than those in whom 1 SLN and 1 non-SLN was involved. This difference was apparent for those patients with N2 and N3 disease (2 or more nodes positive in their regional basin). A multivariate regression analysis that included Breslow thickness, ulceration, number of positive nodes, and NSLN positivity showed that NSLN positivity (P = .0019) was the most powerful predictor of DFS and OS. CONCLUSIONS When metastatic melanoma overwhelms the SLN and involves NSLNs, the biologic behavior changes to portend a worse survival, regardless of the total node count positive. These data make the argument that the current N staging system should be changed to incorporate SLN vs NSLN involvement.
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Affiliation(s)
- Michael Reintgen
- Department of Surgery, University of South Florida, Tampa, Florida, USA
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18
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Jakub JW, Huebner M, Shivers S, Nobo C, Puleo C, Harmsen WS, Reintgen DS. The Number of Lymph Nodes Involved with Metastatic Disease Does Not Affect Outcome in Melanoma Patients as Long as All Disease Is Confined to the Sentinel Lymph Node. Ann Surg Oncol 2009; 16:2245-51. [DOI: 10.1245/s10434-009-0530-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 04/14/2009] [Accepted: 05/02/2009] [Indexed: 01/18/2023]
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Abstract
Molecular staging of cancers hold the promise of being more accurate compared with routine histology, particularly with regard to determining regional-nodal status. With newer reverse transcriptase-PCR (RT-PCR)-based assays, sensitivities reported are as high as identifying one cancer cell in a background of a million normal cells. Although this sensitivity is 100-times what the human eye can differentiate under the microscope, the new challenge becomes determining the relevance of this low-volume disease in the regional basin, in particular, the sentinel lymph node (SLN). Patients with melanomas greater than 0.75 mm in tumor thickness participated in a research study that examined their SLNs with routine histology, immunhistochemical staining and a RT-PCR assay based on the tyrosinase probe. A total of 311 patients were involved in the study and patients whose SLN were negative from all three assays for metastatic disease had a good survival, with a 92% disease-free survival (DFS) and a 97% overall survival (OS) regardless of the tumor thickness or the ulceration status of the primary melanoma. Patients upstaged with the RT-PCR assay had a significantly decreased DFS and OS compared with patients who were SLN negative. Patients who had enough tumor burden in the SLN that allowed their metastatic disease to be identified with routine histology had a 48% recurrence rate at 5 years. A recently published meta-analysis confirmed that molecular staging of the SLN in melanoma contains important prognostic information. Micrometastatic disease missed by routine histology in the SLN in melanoma patients is clinically relevant disease. Molecular staging has the potential of providing a more accurate staging in the SLN, for prognostication and directing adjuvant therapies.
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Affiliation(s)
- Steve Shivers
- Lakeland Regional Cancer Center, Cutaneous Oncology Program, Lakeland, FL, USA, Lakeland Regional Cancer Center, Cutaneous Oncology Program, Lakeland, FL, USA
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20
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Leong SPL, Cady B, Jablons DM, Garcia-Aguilar J, Reintgen D, Jakub J, Pendas S, Duhaime L, Cassell R, Gardner M, Giuliano R, Archie V, Calvin D, Mensha L, Shivers S, Cox C, Werner JA, Kitagawa Y, Kitajima M. Clinical patterns of metastasis. Cancer Metastasis Rev 2006; 25:221-32. [PMID: 16770534 DOI: 10.1007/s10555-006-8502-8] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In human solid cancer, lymph node status is the most important indicator for clinical outcome. Recent developments in the sentinel lymph node concept and technology have resulted in a more precise way of examining micrometastasis in the sentinel lymph node and the role of lymphovascular system in the facilitation of cancer metastasis. Different patterns of metastasis are described with respect to different types of solid cancer. Expect perhaps for papillary carcinoma and sarcoma, the overwhelming evidence is that solid cancer progresses in an orderly progression from the primary site to the regional lymph node or the sentinel lymph node in the majority of cases with subsequent dissemination to the systemic sites. The basic mechanisms of cancer metastasis through the lymphovascular system form the basis of rational therapy against cancer. Beyond the clinical patterns of metastasis, it is imperative to understand the biology of metastasis and to characterize patterns of metastasis perhaps due to heterogeneous clones based on their molecular signatures.
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Affiliation(s)
- Stanley P L Leong
- Department of Surgery, University of California, and UCSF Comprehensive Cancer Center, San Francisco, CA, USA.
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22
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Abstract
Lymphatic mapping and sentinel lymph node (SLN) biopsy have changed the standard of care for patients with malignant melanoma, by providing a less morbid procedure to obtain the nodal staging information that is critical for therapeutic decisions. Detailed examination of the SLN identifies patients who have an increased risk for recurrence and death. Patients whose melanoma is upstaged with very sensitive assays based on reverse transcriptase polymerase chain reaction technology are better targeted for clinical trials or surgical or adjuvant therapies. In the future, melanoma may be "ultrastaged" by examining the SLNs, peripheral blood, and bone marrow. This may improve identification of patients who are surgically cured of their disease and therefore can be spared the side effects of more radical surgery or the toxicities of adjuvant therapy. The lymphatic mapping procedure is the most accurate way to determine the tumor status of the regional lymph nodes.
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Affiliation(s)
- Douglas S Reintgen
- Cutaneous Oncology Program, Lakeland Regional Cancer Center, Lakeland, Florida, USA.
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23
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Reintgen D, Pendas S, Jakub J, Swor G, Giuliano R, Bauer J, Cassall R, Duhaime L, Alsarrai M, Shivers S. National trials involving lymphatic mapping for melanoma: the multicenter selective lymphadenectomy trial, the sunbelt melanoma trial, and the florida melanoma trial. Semin Oncol 2004; 31:363-73. [PMID: 15190494 DOI: 10.1053/j.seminoncol.2004.03.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Radioguided surgery and lymphatic mapping provide more accurate staging and a less morbid operation for the patient with malignant melanoma. It has rapidly become the standard of care for the nodal staging of this disease. Regional and national trials have been designed to address various questions that concern the application of this technique. The Multicenter Selective Lymphadenectomy Trial (MSLT), being performed by Donald Morton at the John Wayne Cancer Institute, is a national trial that will address whether this surgical strategy provides a survival benefit for patients. The national, industry-sponsored SunBelt Melanoma Trial (SBMT), with Kelly McMasters from the University of Louiville as the principle investigator, will determine the role of molecular staging in patients who undergo sentinel lymph node (SLN) harvest. In another arm of the study, the role of adjuvant interferon alfa (IFN) will be examined in patients with minimal disease in the regional basin, those patients with just one microscopically positive SLN. Finally, the Florida Melanoma Trial (FMT), with the central office and laboratory located at the Lakeland Regional Cancer Center, is a regional, industry-sponsored trial that will determine whether all patients with a positive SLN need to undergo a complete lymph node dissection (CLND) of the affected basin. Clinicians await the results of these three trials to help to determine the final role of radioguided surgery in patients with malignant melanoma.
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Affiliation(s)
- Douglas Reintgen
- Cutaneous Oncology Clinic, Lakeland Regional Cancer Center, FL 33804-1057, USA
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24
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Niu G, Bowman T, Huang M, Shivers S, Reintgen D, Daud A, Chang A, Kraker A, Jove R, Yu H. Roles of activated Src and Stat3 signaling in melanoma tumor cell growth. Oncogene 2002; 21:7001-10. [PMID: 12370822 DOI: 10.1038/sj.onc.1205859] [Citation(s) in RCA: 330] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2002] [Revised: 07/03/2002] [Accepted: 07/09/2002] [Indexed: 12/13/2022]
Abstract
Activation of protein tyrosine kinases is prevalent in human cancers and previous studies have demonstrated that Stat3 signaling is a point of convergence for many of these tyrosine kinases. Moreover, a critical role for constitutive activation of Stat3 in tumor cell proliferation and survival has been established in diverse cancers. However, the oncogenic signaling pathways in melanoma cells remain to be fully defined. In this study, we demonstrate that Stat3 is constitutively activated in a majority of human melanoma cell lines and tumor specimens examined. Blocking Src tyrosine kinase activity, but not EGF receptor or JAK family kinases, leads to inhibition of Stat3 signaling in melanoma cell lines. Consistent with a role of Src in the pathogenesis of melanoma, we show that c-Src tyrosine kinase is activated in melanoma cell lines. Significantly, melanoma cells undergo apoptosis when either Src kinase activity or Stat3 signaling is inhibited. Blockade of Src or Stat3 is also accompanied by down-regulation of expression of the anti-apoptotic genes, Bcl-x(L) and Mcl-1. These findings demonstrate that Src-activated Stat3 signaling is important for the growth and survival of melanoma tumor cells.
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Affiliation(s)
- Guilian Niu
- Immunology Program, H Lee Moffitt Cancer Center and Research Institute, Department of Oncology, University of South Florida College of Medicine, Tampa, Florida, FL 33612, USA
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Shivers S, Cox C, Leight G, Beauchamp D, Blumencranz P, Ross M, Reintgen D. Final results of the Department of Defense multicenter breast lymphatic mapping trial. Ann Surg Oncol 2002; 9:248-55. [PMID: 11923131 DOI: 10.1007/bf02573062] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lymphatic mapping and sentinel lymph node (SLN) biopsy have the potential to become the standard of care for nodal staging in breast cancer patients, but their widespread utility outside of university-based centers has not been determined. This study describes the final results from a national multi-institutional trial designed to determine the role of preoperative lymphoscintigraphy in breast lymphatic mapping, the rate of success for finding an SLN, and the rate of skip metastasis for patients with invasive breast cancer across all practice scenarios. METHODS Lymphatic mapping techniques involving the combined use of blue dye and radiocolloid were taught to participating surgeons through a formal 2-day training course at the Moffitt Cancer Center. In protocol 1, surgeons performed their first 20 to 25 cases of breast mapping with SLN biopsy followed by complete axillary lymph node dissection. In protocol 2, after the learning phase, surgeons did not perform axillary lymph node dissection unless a SLN was positive for metastatic disease. RESULTS Forty-two institutions, including 12 university-based research centers, participated in the trial. From July 1, 1997, through January 31, 1999, a total of 965 patients were accrued. Lymphoscintigraphy identified drainage to an axillary SLN 64% of the time, but by using sensitive handheld gamma probes at the time of the operation, an axillary SLN could be identified 86% of the time. The rate of success for finding an axillary SLN was 92.8% for cases performed at the Moffitt Cancer Center. For other university centers, the rate of success of identifying an axillary SLN was 91.4%, and for other community/regional hospitals in the study, it was 85.2%. For cases in which protocol 1 was followed, the rate of false-negative SLN biopsy was 4%. There was no axillary nodal recurrence after a negative SLN in protocol 2 when a negative SLN biopsy was followed by observation. The median follow-up for the patients on protocol 2 was 16 months. CONCLUSIONS These data show a high rate of success for finding an axillary SLN and a low rate of skip metastasis in a national multicenter study of lymphatic mapping for breast cancer. This study suggests that SLN biopsy for breast cancer can be performed successfully in community/regional hospitals, as well as in major university-based centers.
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Affiliation(s)
- Steve Shivers
- Department of Surgery, Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, Florida, USA
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Sung J, Li W, Shivers S, Reintgen D. Molecular analysis in evaluating the sentinel node in malignant melanoma. Ann Surg Oncol 2001; 8:29S-30S. [PMID: 11599893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The most powerful predictor of cancer mortality in solid tumors is the status of regional lymph nodes. If the presence or absence of regional nodal metastases will determine which patient receives formal dissection or which patient enters adjuvant therapy, then a technique is needed to accurately screen lymph node samples for occult disease. Routine histopathologic examination commonly underestimates the number of patient with metastases. The use of reverse transcription-polymerase chain reaction (RT-PCR) method increased the detection of nodal metastases exponentially. Studies have shown that RT-PCR is a sensitive, reproducible, and efficient technique with prognostic significance. If identification of micrometastases through RT-PCR can lead to improved clinical outcome, then this more accurate method of staging would become the new standard in cancer care.
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Affiliation(s)
- J Sung
- Cutaneous Oncology Program, Moffitt Cancer Center, University of South Florida, Tampa 33612, USA
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Abstract
INTRODUCTION To date, studies of breast cancer lymphatic mapping (LM) have analyzed success with respect to individual surgeons. However, LM and sentinel lymph node biopsy (SLNBx) are procedures that require institutional multidisciplinary cooperation between the departments of radiology, pathology, and surgery. Thus, it is important to evaluate these procedures with respect to the institution. This study examines 30 institutions to clarify the value of the institutional volume index (IVI) (cases/month) to the outcome of LM and SLNBx in breast cancer. METHODS From July 1997 to July 1999, 30 institutions participated in the Department of Defense national breast LM trial. All participants underwent a 2-day training course for surgeons, nuclear medicine physicians, and pathologists. The records for each institution were prospectively accrued and submitted to a database. The false negatives, failure rates, and IVI were calculated for each institution. A logistic regression model plots the relationship between IVI and institutional failure rate. Using a multivariate analysis, mapping failure was analyzed as a function of case number with respect to the individual surgeon and the institution as a whole. RESULTS False negative results were demonstrated in only 5 (4%) cases among all institutions and were excluded from further analysis due to small numbers. Mapping failures were found in all but 7 of the 30 institutions whose data were complete. There were 71 mapping failures among 74 surgeons over 555 cases, which yielded an overall failure rate of 12.79% (71 555). The logistic regression model revealed an inverse relationship between IVI and institutional failure rate. However, the multivariate analysis revealed that the individual surgeon performance was the most significant factor in determining institutional mapping success. CONCLUSION Failure to map can be a function of multiple factors including surgical skill, surgical volume index, and injection method of the SLN patient, all under the quality control of an institution. The surgical failure rate on the other hand is a function of surgical skill, surgical volume, and injection methods. While differences in mapping success exist across institutions, this disparity is not due to factors associated with the institution as a whole, but lie with the individual surgeon.
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Affiliation(s)
- E Dupont
- Department of Surgery, at the University of South Florida, Tampa, Florida 33612, USA.
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Reintgen D, Li W, Stall A, Linn J, Shivers S. Metastatic melanoma to regional lymph nodes. In Vivo 2000; 14:213-20. [PMID: 10757080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
There is an epidemic of melanoma in the United States and throughout most parts of the word. Recent advancements in the management of this disease has provided the patient with more options. The emerging technology of lymphatic mapping and sentinel node biopsy results in a more conservative, less morbid procedure to obtain nodal staging information. At the same time, providing the pathologist the 1-2 nodes from the basin most likely to contain metastatic disease, allows for a more detailed examination of the sentinel lymph node. This more detailed examination may include serial sectioning, immunohistochemical staining or even molecular biology techniques based on RT-PCR to provide more accurate staging. National trials are ongoing to examine the clinical relevance of the disease that is detected and the 'upstaging' that occurs with more sensitive assays for occult metastases.
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Affiliation(s)
- D Reintgen
- Cutaneous Oncology Program, Moffitt Cancer Center, University of South Florida, Tampa, USA.
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Reintgen D, Shivers S. Sentinel lymph node micrometastasis from melanoma. Proven methodology and evolving significance. Cancer 1999; 86:551-2. [PMID: 10440680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Reintgen D, Stall A, Shivers S, Li W, Agarwala SS, Legha SS. Malignant Melanoma: Staging and Treatment of Localized and Advanced Disease. Cancer Control 1999; 6:398-404. [PMID: 10758573 DOI: 10.1177/107327489900600417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- D Reintgen
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, 33612, USA
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Reintgen D, Joseph E, Lyman GH, Yeatman T, Balducci L, Ku NN, Berman C, Shons A, Wells K, Horton J, Greenberg H, Nicosia S, Clark R, Shivers S, Li W, Wang X, Cantor A, Cox C. The Role of Selective Lymphadenectomy in Breast Cancer. Cancer Control 1997; 4:211-219. [PMID: 10763020 DOI: 10.1177/107327489700400302] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND: Axillary node dissection is considered a standard staging procedure in patients with breast cancer. The procedure is associated with significant morbidity and provides pathologists with many lymph nodes to evaluate. METHODS: A total of 174 women participated in a trial that included preoperative lymphoscintigraphy and intraoperative lymphatic mapping using a combination of a vital blue dye and radiocolloid mapping. RESULTS: The intraoperative lymphatic mapping correctly identified a sentinel lymph node (SLN) in 160 (92%) of 174 patients. One skip metastasis (0.7%) occurred in 136 women who had a subsequent complete node dissection. CONCLUSIONS: Lymphatic mapping and SLN biopsy using a combination of mapping techniques provide accurate nodal staging for women with breast cancer. With this technique, approximately 70% to 80% of women with no axillary metastases could be spared the morbidity of a complete node dissection.
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Affiliation(s)
- D Reintgen
- Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612, USA
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Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N, Shivers S, Berman C, Wells K, Rapaport D, Shons A, Horton J, Greenberg H, Nicosia S, Clark R, Cantor A, Reintgen DS. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA 1996. [PMID: 8946902 DOI: 10.1001/jama.276.22.1818] [Citation(s) in RCA: 224] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- J J Albertini
- Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa 33612-9497, USA
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