Axillary nodal disease burden is not associated with an elevated 21-gene recurrence score in post-menopausal women presenting with a clinically negative axilla

BACKGROUND

The predictive and prognostic value of the recurrence score (RS) has emphasized the importance of tumor biology and has reduced the prognostic implications of limited nodal burden in post-menopausal women with HR+/HER2-invasive breast cancer (IBC). It is unclear whether routine axillary staging has a continued role in the management of small, clinically node negative (cN0) HR+/HER2- IBC. We sought to estimate the association of RS with pN stage.

METHODS

Patients >50yo diagnosed with cN0, HR+/HER2- IBC (2015-2019) with an available RS were identified from the National Cancer Database. The clinicopathologic characteristics and rates of pN-stage (pN0, pN1, pN2/3) were compared for RS of ≤25 vs. >25.

RESULTS

The median patient age was 64.1 (IQR 58-69) and the majority (75%) of tumors displayed ductal histology. Most (81.6%) were cT1 on presentation and pT1 (74.7%) on final pathology. There were 130,568 (86.2%) with a RS ​≤ ​25 and 20,879 (13.8%) with a RS ​> ​25. On final pathology, 128,995 (85.2%) were pN0 and 21,991 (14.5%) pN1. Of the pN1, 2699 (12.3%) yielded a RS ​> ​25. There were 461 (0.3%) patients with pN2-pN3 disease. Of those, 57 (12.4%) had RS ​> ​25.

CONCLUSION

In our analysis, pN0 and pN1 tumors are biologically similar by gene expression assay in postmenopausal patients with similar proportions of high RS. These data support the notion that tumor biology examined via RS may have more prognostic and predictive value than metastatic dissemination to limited lymph nodes. These findings support the ongoing evaluation of routine axillary staging in postmenopausal patients with HR+/HER2- IBC.

Optimising of axillary therapy in breast cancer: lessons from the past to plan for a better future

In this narrative review, we aim to explore the ability of radiation therapy to eradicate breast cancer regional node metastasis. It is a journey through data of older trials without systemic therapy showing the magnitude of axillary therapy (surgery versus radiation) on cancer control. Considering that both systemic and loco-regional therapies were shown to reduce any recurrence with a complex interaction, our review includes surgical, radiation, and radiobiology consideration for breast cancer, and provide our view of future practise. The aim is to provide information optimise radiation therapy in the era of primary systemic therapy.

Impact of Imaging-Guided Localization on Performance of Tailored Axillary Surgery in Patients with Clinically Node-Positive Breast Cancer: Prospective Cohort Study Within TAXIS (OPBC-03, SAKK 23/16, IBCSG 57-18, ABCSG-53, GBG 101)

BACKGROUND

Tailored axillary surgery (TAS) is a novel surgical concept for clinical node-positive breast cancer. It consists of the removal of the sentinel lymph nodes (LNs), as well as palpably suspicious nodes. The TAS technique can be utilized in both the upfront and neoadjuvant chemotherapy (NACT) setting. This study assessed whether/how imaging-guided localization (IGL) influenced TAS.

PATIENTS AND METHODS

This was a prospective observational cohort study preplanned in the randomized phase-III OPBC-03/TAXIS trial. IGL was performed at the surgeon's discretion for targeted removal of LNs during TAS. Immediate back-up axillary lymph node dissection (ALND) followed TAS according to TAXIS randomization.

RESULTS

Five-hundred patients were included from 44 breast centers in six countries, 151 (30.2%) of whom underwent NACT. IGL was performed in 84.4% of all patients, with significant variation by country (77.6-100%, p < 0.001). No difference in the median number of removed (5 vs. 4, p = 0.3) and positive (2 vs. 2, p = 0.6) LNs by use of IGL was noted. The number of LNs removed during TAS with IGL remained stable over time (p = 0.8), but decreased significantly without IGL, from six (IQR 4-6) in 2019 to four (IQR 3-4) in 2022 (p = 0.015). An ALND was performed in 249 patients, removing another 12 (IQR 9-17) LNs, in which a median number of 1 (IQR 0-4) was positive. There was no significant difference in residual nodal disease after TAS with or without IGL (68.0% vs. 57.6%, p = 0.2).

CONCLUSIONS

IGL did not significantly change either the performance of TAS or the volume of residual nodal tumor burden.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03513614.

Impact of axillary surgery on outcome of clinically node positive breast cancer treated with neoadjuvant chemotherapy

PURPOSE

Axillary Lymph Node Dissection (ALND) is recommended for breast cancer patients who present with clinically node positive disease (cN1) especially if they have residual nodal disease (ypN+) following neoadjuvant therapy (NAT). It is unknown whether axillary dissection improves outcome for these patients.

METHODS

A prospectively maintained database was used to identify all patients who were diagnosed with cTis-T4N1M0 breast cancer treated with NAT.

RESULTS

In our study, of 292 cN1 breast cancer patients who received NAT, we compared ALND with targeted axillary surgery (TAS) in ypN+ patients. ALND was performed in 75% of the ypN+ subgroup, while 25% underwent TAS. Axillary recurrence occurred in four ALND patients, but no recurrence was observed in the TAS group (p = 0.21). Five-year axillary recurrence-free survival was 100% for TAS and 90% for ALND (p = 0.21). Overall survival at five years was 97% for TAS and 85% for ALND (p = 0.39). Disease-free survival rates at five years were 51% for TAS and 61% for ALND (p = 0.9). Clinicopathological variables were similar between the groups, although some differences were noted. ALND patients had smaller clinical tumor size, larger pathological tumor size, more lymph nodes retrieved, larger tumor deposits, higher rates of extranodal extension, and greater prevalence of macrometastatic nodal disease. Tumor subtype and size of lymph node tumor deposit independently predicted survival.

CONCLUSION

Axillary recurrence is infrequent in cN1 patients treated with NAT. Our study found that ALND did not reduce the occurrence of axillary recurrence or enhance overall survival. It is currently uncertain which patients benefit from axillary dissection.

Does body mass index influence surgical options and overall survival in breast cancer patients?

Obesity is a relevant risk factor in breast cancer (BC), but little is known about the effects of overweight and obesity in surgical outcomes of BC patients. The aim of this study is to analyse surgical options and associated overall survival (OS) in overweight and obese women with BC. In this study, 2143 women diagnosed between 2012 and 2016 at the Portuguese Oncology Institute of Porto (IPO-Porto) were included, and the clinicopathological information was retrieved from the institutional database. Patients were stratified by body mass index (BMI). Statistical analysis included Pearson's chi-squared test with statistical significance set at p < 0.05. Multinomial, binary logistic regression and cox proportional-hazards model were also performed to calculate odd ratios and hazard ratios with 95% confidence intervals for adjusted and non-adjusted models. The results revealed no statistical difference in histological type, topographic localization, tumour stage and receptor status and in the number of surgical interventions. Overweight women have increased probability to be subjected to sentinel node biopsy. Obese and overweight women are more likely to be submitted to conservative surgery and contrariwise, less likely to undergo total mastectomy. Patients submitted to conservative surgery and not submitted to total mastectomy had a favourable OS although without statistical significance. No significant differences were observed in OS when stratified by BMI. Our results revealed significant variations regarding the surgical options in overweight and obese patients, but these were not translated in OS difference. More research is recommended to better address treatment options in overweight and obese BC patients.

Changes in Surgical Management of the Axilla Over 11 Years - Report on More Than 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial

BACKGROUND

Axillary surgery after neoadjuvant chemotherapy (NAC) is becoming less extensive. We evaluated the evolution of axillary surgery after NAC on the multi-institutional I-SPY2 prospective trial.

METHODS

We examined annual rates of sentinel lymph node (SLN) surgery with resection of clipped node, if present), axillary lymph node dissection (ALND), and SLN and ALND in patients enrolled in I-SPY2 from January 1, 2011 to December 31, 2021 by clinical N status at diagnosis and pathologic N status at surgery. Cochran-Armitage trend tests were calculated to evaluate patterns over time.

RESULTS

Of 1578 patients, 973 patients (61.7%) had SLN-only, 136 (8.6%) had SLN and ALND, and 469 (29.7%) had ALND-only. In the cN0 group, ALND-only decreased from 20% in 2011 to 6.25% in 2021 (p = 0.0078) and SLN-only increased from 70.0% to 87.5% (p = 0.0020). This was even more striking in patients with clinically node-positive (cN+) disease at diagnosis, where ALND-only decreased from 70.7% to 29.4% (p < 0.0001) and SLN-only significantly increased from 14.6% to 56.5% (p < 0.0001). This change was significant across subtypes (HR-/HER2-, HR+/HER2-, and HER2+). Among pathologically node-positive (pN+) patients after NAC (n = 525) ALND-only decreased from 69.0% to 39.2% (p < 0.0001) and SLN-only increased from 6.9% to 39.2% (p < 0.0001).

CONCLUSIONS

Use of ALND after NAC has significantly decreased over the past decade. This is most pronounced in cN+ disease at diagnosis with an increase in the use of SLN surgery after NAC. Additionally, in pN+ disease after NAC, there has been a decrease in use of completion ALND, a practice pattern change that precedes results from clinical trials.

Langer's arch in axillary dissections from patients with breast cancer: a retrospective study

PURPOSE

The study aimed to assess the frequency of Langer's arch in patients undergoing axillary dissection for breast cancer.

METHODS

From January-2015 to March-2020, in a general hospital in México City, female patients undergoing axillary dissection for breast cancer were studied. The analysis involved: demographic and anthropometric data, type of surgical treatment, histopathologic diagnosis, number of lymph nodes harvested, and frequency of Langer's arch finding.

RESULTS

The sample studied was 123 axillary dissections. The mean age of the patients was 59 ± 10.5-years. Modified radical mastectomy was done in 117 cases (95.1%). Ductal carcinoma occurred in 96 cases (78%). The mean number of lymph nodes harvested was 24 ± 6.5. Langer's arch finding occurred in 33 cases (26.8%).

CONCLUSION

Langer's arch is frequent in our patients undergoing axillary dissection for breast cancer.

Sentinel Node Biopsy in Patients With Breast Carcinoma Without Axillary Involvement at Diagnosis Receiving Primary Systemic Therapy

BACKGROUND

Primary systemic therapy (PST) has acquired great importance in breast cancer (BC) in the last few years. In this scenario, even if it is accepted to perform SLNB before PST, most of the guidelines remark the advantages of this practice after it, such as avoiding another surgery to the patient, a rapid start of the treatment and no need of axillary dissection in cases of pathologic complete response (pCR). Nevertheless, the lack of knowledge of the initial axillary state and the need to practice axillary dissection with any axillary disease are claimed to be some other disadvantages. There are no randomized studies yet that can conclude the optimal timing of SLNB in PST, so for the moment we may settle for our common practice.

PATIENTS AND METHODS

We studied all the cases attended in the Breast Unit that joined the inclusion criteria between 2011 and 2019 in our hospital and we compared the group with SLNB before PST with the group with SLNB after PST in terms of unnecessary axillary dissection and description features.

RESULTS

We included 223 female patients diagnosed with BC and without clinical nor radiological axillary disease (cN0), who had received NAC and SLNB performed before or after it. We observed a higher proportion of high-grade histological tumors (G3), tumors with aggressive phenotypes (Basal like and Her 2 enriched), and younger women in the group of SLNB before NAC compared with the SLNB after NAC group (P < .01). Despite this, we did not find any difference in the number of positive SLNBs or in the number of ALND performed between the 2 groups. We found a higher proportion of ALND with all the lymph node (LN) negatives in the SLNB before NAC group.

CONCLUSION

Taking into account that in the observation period we did not use ACOSOG Z0011 criteria with all the SLNBs, we figure out what would have been the real results nowadays following these criteria. In this scenario we conclude that patients with luminal phenotype seemed to benefit from practicing SLNB before NAC in terms of avoiding axillary dissections. We could not make any conclusion in the rest of the phenotypes. However, prospective studies are needed to confirm if this affirmation could be proved.

Uncertainties and controversies in axillary management of patients with breast cancer

The aims of this Oncoplastic Breast Consortium and European Breast Cancer Research Association of Surgical Trialists initiative were to identify uncertainties and controversies in axillary management of early breast cancer and to recommend appropriate strategies to address them. By use of Delphi methods, 15 questions were prioritized by more than 250 breast surgeons, patient advocates and radiation oncologists from 60 countries. Subsequently, a global virtual consensus panel considered available data, ongoing studies and resource utilization. It agreed that research should no longer be prioritized for standardization of axillary imaging, de-escalation of axillary surgery in node-positive cancer and risk evaluation of modern surgery and radiotherapy. Instead, expert consensus recommendations for clinical practice should be based on current evidence and updated once results from ongoing studies become available. Research on de-escalation of radiotherapy and identification of the most relevant endpoints in axillary management should encompass a meta-analysis to identify knowledge gaps, followed by a Delphi process to prioritize and a consensus conference to refine recommendations for specific trial designs. Finally, treatment of residual nodal disease after surgery was recommended to be assessed in a prospective register.

Role of methylprednisolone in the prevention of seroma formation after mastectomy: A randomized controlled trial

Background

Seroma formation after mastectomy with axillary dissection is a major source of morbidity and results in a significant delay in starting the adjuvant treatment. Many different strategies, including the usage of steroids, have been tried to reduce the incidence of seroma with varying outcomes. This study aimed to assess the effect of a single dose of intracavitary methylprednisolone (MP) on seroma formation in patients undergoing total mastectomy with axillary lymph node dissection (ALND).

Methods

A randomized controlled trial was conducted at our institute, from January 2018 till June 2019. In the intervention group of 36 patients, 80 mg of MP solution was injected into the wound on post operative day 1. The drain was clamped for 8 hours and then released. In the control group of 36 patients, saline was administered and the drain output was compared between the groups.

Results

The mean drain volume in the intervention group was 409.08 mL and in the control group it was 566.97 mL (P < 0.005). The mean drain removal time was 7.86 days and 10.33 days in the intervention and control group, respectively (P < 0.0004).

Conclusion

A single dose of intracavitary MP significantly reduced seroma formation and facilitated early removal of drain in patients undergoing total mastectomy with ALND.

Axillary Reverse Mapping in the Prevention of Lymphoedema: A Systematic Review and Pooled Analysis

BACKGROUND

This is a systematic review of randomized controlled trials (RCT) comparing the use of axillary reverse mapping (ARM) with conventional technique for axillary dissection (AD) in breast cancer surgery.

METHODS

This review was written in line with the PRISMA protocol. Articles were retrieved from PubMed, EMBASE, CINAHL and Cochrane databases, using keywords ..úaxillary reverse mapping..Ñ and "axillary lymph node dissection". Non-RCT were excluded. Abstracts were screened independently by 2 reviewers. Data from eligible studies were retrieved for qualitative synthesis and pooled analysis. 73 publications were identified for initial screening.

RESULTS

68 articles were excluded from analysis according to the pre-defined systematic review protocol. 5 RCTS with 1696 subjects were included for analysis. 802 patients received ARM, 894 patients received AD. Pooled ARM node detection rate was 84.9% (Range 79.2 - 94.9%). There was a lower rate of post-operative lymphedema in ARM group patients across all 5 RCTs. The pooled lymphedema incidence in the ARM group was 4.8% (37/766) when compared to 18.8% (164/873) in the AD group (P < .0001). Axillary recurrence rate with median followof 37 months was 1.03% (8/778) in the ARM group, which was identical to 1.03% (9/870) in the AD group (P = 1).

CONCLUSION

ARM resulted in decreased incidence of lymphedema. There was no significant increase in axillary recurrence at 37 months post-operation.

Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer: A multicentre study on 1,950 patients

BACKGROUND

Type of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized.

PATIENTS AND METHODS

1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR).

RESULTS

Independent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75-0.80). After external validation the accuracy of the nomogram was confirmed.

CONCLUSION

The accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients.

The involvement of axillary reverse mapping nodes in patients with clinically node-negative breast cancer

BACKGROUND

Axillary reverse mapping (ARM) was developed to preserve the lymphatic drainage from the upper arm during sentinel lymph-node (SLN) biopsy or axillary lymph-node dissection (ALND). However, the oncological safety of ARM has been controversial because of not infrequent involvement of ARM nodes.

METHODS

Patients with clinically negative nodes (cN0) underwent SLN biopsy and ARM. SLNs were identified using blue dye and radioisotope, and ARM nodes were traced using the fluorescent method. Patients with positive SLN underwent the standard ALND. After surgery, they were followed up for more than 3 years.

RESULTS

A total of 507 patients with cN0 breast cancer were enrolled between May 2009 and November 2017. SLNs were identified in 499 (98%) of 507 patients, and ARM nodes were identified in 159 (31%) patients in the SLN field. The crossover rate of SLN-ARM nodes was 28%. Among 95 patients with positive SLNs, 70 patients underwent conventional ALND. ARM nodes were identified in 65 (93%) of those patients in the ALND field. The mean number of removed ARM nodes was 7.2 (range 0-25) in patients who underwent the standard ALND. Although ARM nodes were involved in 18 of 65 patients, the involved ARM nodes were the same SLNs identified in 14 (78%) patients. Since SLN-ARM nodes should be removed, ARM nodes were involved only in 4 (5.7%) patients after SLN biopsy.

CONCLUSIONS

Except for positive SLN-ARM nodes, the involvement of ARM nodes is infrequent in patients with positive SLN.

Tailored axillary surgery in patients with clinically node-positive breast cancer: Pre-planned feasibility substudy of TAXIS (OPBC-03, SAKK 23/16, IBCSG 57-18, ABCSG-53, GBG 101)

Aim

We developed tailored axillary surgery (TAS) to reduce the axillary tumor volume in patients with clinically node-positive breast cancer to the point where radiotherapy can control it. The aim of this study was to quantify the extent of tumor load reduction achieved by TAS.

Methods

International multicenter prospective study embedded in a randomized trial. TAS is a novel pragmatic concept for axillary surgery de-escalation that combines palpation-guided removal of suspicious nodes with the sentinel procedure and, optionally, imaging-guided localization. Pre-specified study endpoints quantified surgical extent and reduction of tumor load.

Results

A total of 296 patients were included at 28 sites in four European countries, 125 (42.2%) of whom underwent neoadjuvant chemotherapy (NACT) and 71 (24.0%) achieved nodal pathologic complete response. Axillary metastases were detectable only by imaging in 145 (49.0%) patients. They were palpable in 151 (51.0%) patients, of whom 63 underwent NACT and 21 had residual palpable disease after NACT. TAS removed the biopsied and clipped node in 279 (94.3%) patients. In 225 patients with nodal disease at the time of surgery, TAS removed a median of five (IQR 3–7) nodes, two (IQR 1–4) of which were positive. Of these 225 patients, 100 underwent ALND after TAS, which removed a median of 14 (IQR 10–17) additional nodes and revealed additional positive nodes in 70/100 (70%) of patients. False-negative rate of TAS in patients who underwent subsequent ALND was 2.6%.

Conclusions

TAS selectively reduced the tumor load in the axilla and remained much less radical than ALND.

•

Tailored axillary surgery is a novel concept for clinically node-positive breast cancer

•

Tailored axillary surgery selectively removes positive lymph nodes

•

Tailored axillary surgery is much less radical than axillary dissection

•

Tailored axillary surgery removes the clipped node in the vast majority of patients

Axillary surgery in node-positive breast cancer

Long-term follow-up data from multicenter phase III non-inferiority trials confirmed the safety of omission of axillary dissection in selected patients with clinically node-negative, sentinel node-positive breast cancer. Several ongoing trials investigate extended eligibility of the Z0011 protocol in the adjuvant setting. De-escalation of axillary surgery in patients with clinically node-positive breast cancer is currently limited to the neoadjuvant setting, where the sentinel procedure is used to determine nodal pathological complete response. Targeted axillary dissection lowers the false-negative rate of the sentinel procedure, which, however, is consistently associated with a very low risk of axillary recurrence in several recent single-center series. Axillary dissection remains standard care in patients with residual disease after neoadjuvant chemotherapy while the results of Alliance A011202 are pending. The TAXIS trial investigates the role of tailored axillary surgery in patients with clinically node-positive breast cancer, a novel concept designed to selectively remove positive nodes in the adjuvant and neoadjuvant setting.

Axillary dissection versus axillary observation for low risk, clinically node-negative invasive breast cancer: a systematic review and meta-analysis

Purpose

1. To systematically analyse studies comparing survival outcomes between axillary lymph-node dissection (ALND) and axilla observation (Obs), in women with low-risk, clinically node-negative breast cancer. 2. To consider results in the context of current axillary surgery de-escalation trials and studies.

Methods

9 eligible studies were identified, 6 RCTs and 3 non-randomized studies (4236 women in total). Outcomes assessed: overall survival (OS) and disease-free survival (DFS). The logged (ln) hazard ratio (HR) was calculated and used as the statistic of interest. Data was grouped by follow-up.

Results

Meta-analyses found no significant difference in OS at 5, 10 and 25-years follow-up (5-year ln HR = 0.08, 95% CI − 0.09, 0.25, 10-year ln HR =  0.33, 95% CI − 0.07, 0.72, 25-year ln HR = 0.00, 95% CI − 0.18, 0.19). ALND caused improvement in DFS at 5-years follow-up (ln HR = 0.16, 95% CI 0.03, 0.29), this was not demonstrated at 10 and 25-years follow-up (10-year ln HR = 0.07, 95% CI − 0.09, 0.23, 25-year ln HR = − 0.03, 95% CI − 0.21, 0.16). Studies supporting ALND for DFS at 5-years follow-up had greater relative chemotherapy use in the ALND cohort.

Conclusion

ALND does not cause a significant improvement in OS in women with clinically node-negative breast cancer. ALND may improve DFS in the short term by tailoring a proportion of patients towards chemotherapy. Our evidence suggests that when the administration of systemic therapy is balanced between the two arms, axillary de-escalation studies will likely find no difference in OS or DFS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12282-021-01273-6.

Management of the Axilla and the Breast After Neoadjuvant Chemotherapy in Patients with Breast Cancer: A Systematic Review

Breast cancer is the most common cancer in women worldwide. Breast cancer is traditionally treated with surgery, plus adjuvant systemic therapy and radiotherapy as required. Neoadjuvant chemotherapy (NACT) for the treatment of breast cancer is used for locally advanced operable breast cancer to reduce the tumor size, to perform breast conserving surgery, and to perform a limited axillary approach. Adjuvant chemotherapy for the treatment of inflammatory breast cancer and even in inoperable breast cancer is used to increase overall survival time and to delay disease progression while relieving symptoms. NACT for breast cancer is a new strategy that was introduced toward the end of the 20^th century and is increasingly used in the treatment of breast cancer. At present, NACT is increasingly being used to reduce the need for axillary dissection and to convert patients with large tumors to candidates for breast conservation therapy in both locally advanced and operable breast cancers. Breast conserving procedures are currently more preferred by surgeons and axillary dissection is being replaced by sentinel lymph node biopsy after chemotherapy. One of the targets of neoadjuvant systemic therapy is to try to perform a less aggressive surgery by breast conservation, mainly for cosmetic reasons and avoiding axillary dissection mainly for arm mobility, pain, and lymphedema risk. The other target of neoadjuvant systemic therapy is to see the response of the tumor to chemotherapy and determine the treatment accordingly. Neoadjuvant systemic therapy increases the rate of complete pathological response by clearing the breast and axilla from tumor cells before surgery. In this review, we examine the key points of using the NACT in breast cancer, considering radiological imaging methods, surgical management, and reconstruction after NACT.

Effect of sentinel lymph node biopsy on upper limb function in women with early breast cancer: A systematic review of clinical trials

PURPOSE

Axillary surgery is still essential in the management of early breast cancer. Conservative procedures like sentinel lymph node biopsy (SLNB) are less invasive than the traditional axillary node dissection (ALND). However, some extent of ipsilateral upper limb dysfunction might still occur. This systematic review aimed to describe the incidence of lymphedema, pain, sensory, and motor disorders after SLNB in women with early breast cancer.

METHODS

We conducted a systematic review of randomized controlled trials. The search was performed on Pubmed, EMBASE, CINAHAL, and Web of Science. The search was based on the following concepts: breast cancer, sentinel lymph node biopsy, axillary dissection, upper limb complications. The risk of bias was evaluated using the Cochrane Rob 2.0 toll.

RESULTS

We obtained 979 unique registries from the primary search and 381 additional records from the included articles' reference lists. Fifty-one articles were assessed as full text. Nine studies were included in the review. A total of 5161 patients undergone SLNB, and 4110 patients were assessed for ipsilateral arm complications. Six months after the surgery, 0-11% of patients presented lymphedema, 11-16% pain, 2-22% sensory disorders, and 0-9% motor disorders.

CONCLUSIONS

SLNB was associated with persistent postoperative complications. The burden of complications, although lower when compared to ALND, should not be ignored.

PROTOCOL REGISTRATION

PROSPERO registration number CRD42018090540, registered July 09, 2018.

What we learned in axillary management of breast cancer patients at the American society of clinical oncology (ASCO) 2020 virtual meeting? The EUBREAST point of view

In 2020, the American Society of Clinical Oncology (ASCO) annual meeting was held as a virtual conference. Overall, 461 abstracts focused on breast cancer management. As European Breast Cancer Association of Surgical Trialists (EUBREAST) we summarize and comment the results of these abstracts dealing with axillary management in breast cancer patients and offer an interpretation on how these findings may be incorporated into clinical practice and further research.

The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements

BACKGROUND

Chronic breast cancer-related lymphedema (BCRL) is a potentially serious complication following treatment. Monitoring for progression to BCRL may allow for earlier detection and intervention, reducing the rate of progression to chronic BCRL. Therefore, the purpose of this meta-analysis is to evaluate the impact of monitoring techniques on the incidence of chronic BCRL among patients monitored by bioimpedance spectroscopy (BIS) and circumference as compared to background rates.

METHODS

Eligible peer-reviewed studies from PubMed, CINHAL, or Google Scholar that were published in English from 2013 onward and conducted in North America, Europe, or Oceania. Incidence rates abstracted from studies were classified by BCRL monitoring method: background (no standardized BIS or circumference assessments), BIS or circumference. A random-effects model was used to calculate a pooled annualized estimate of BCRL incidence while accounting for clinical and methodological heterogeneity. Subgroup analyses examined differences in duration of follow-up as well as breast and axillary surgery.

RESULTS

50 studies were included, representing over 67,000 women. The annualized incidence of BCRL was 4.9% (95% CI: 4.3-5.5) for background studies (n = 35), 1.5% (95% CI: 0.6-2.4) for BIS-monitored studies (n = 7), and 7.7% (95% CI: 5.6-9.8) for circumference-monitored studies (n = 11). The cumulative BCRL incidence rate in BIS-monitored patients was 3.1% as compared to 12.9% with background monitoring (69% reduction) and 17.0% with circumference-monitored patients (81% reduction).

CONCLUSIONS

Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic BCRL with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.

Oncological safety of selective axillary dissection after axillary reverse mapping in node-positive breast cancer

INTRODUCTION

Although the need for axillary lymph node dissection (AD) is decreasing in breast cancer patients, it remains necessary in some cases. Axillary reverse mapping (ARM) enables the detection of upper extremity lymphatic drainage that may be spared during selective axillary dissection (SAD) so as to reduce the risk of lymphedema. The ability of the ARM-SAD procedure to reduce the incidence of lymphedema is being tested in an ongoing randomized trial. Crossover between arm drainage and breast drainage is well documented in the axilla, however, and whether the procedure is oncologically safe remains controversial. We aim to assess the axillary failure rate when a few nodes draining the upper arm are being spared by the ARM-SAD.

METHODS

We report oncological outcomes, and axillary failure in particular, in the first 100 consecutive axillary node-positive patients treated with ARM-SAD as part of a pilot study and a randomized trial.

RESULTS

A median of 18 (IQR 14-22) axillary nodes were excised per patient. During the follow-up (median 51 months, IQR 34-91), 11 patients experienced a treatment failure, but only one - treated with neoadjuvant chemotherapy - developed overt axillary disease as a first (and isolated) event. The crude rate of axillary failure was 1.36% (95% CI: 0.19-9.63) with an estimated 5-year crude cumulative incidence of 1.85% (95% CI: 0-5.47%).

CONCLUSIONS

The axillary failure rate was low in our patients and did not exceed rates reported in the literature after standard AD, thus indicating that the ARM-SAD procedure is oncologically safe.

Axillary surgery in breast cancer: An updated historical perspective

This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing efforts of researchers toward new challenges, as documented by extensive studies and trials. Axillary surgery has evolved, aiming to offer the best oncologic treatment and improve the quality of life of women. Axillary lymph-node dissection (ALND) has been replaced by sentinel lymph-node biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with minimal morbidity, and becoming the standard of care in the management of breast cancer. However, this is only the beginning. Strategies in defining systemic and radiotherapeutic treatments have gradually been optimized, offering increasingly refined and targeted breast cancer treatment tools. In recent years, the paradigm of completion ALND after a positive SLNB has been questioned, and several studies have led to revolutionary changes in clinical practice. Moreover, the increasingly pivotal role played by neoadjuvant chemotherapy (NAC) has had a profound effect on the extent of axillary surgery, paving the way to a more finite "targeted" procedure in women with node-positive breast cancer who convert to negative nodes clinically after NAC. The utility of SLNB itself and its subsequent omission in women with negative nodes clinically and breast conservative surgery is also under scientific evaluation. The changes over time in the surgical approach to breast cancer have been numerous and significant. The novel emerging perspective characterized by recent advances in biology and genetics, in dedicated axillary ultrasound imaging and chemotherapy regimens, is the present reality that points to the future of axillary node treatment in breast cancer.

Predictive value of tumor-infiltrating lymphocytes for pathological response to neoadjuvant chemotherapy in breast cancer patients with axillary lymph node metastasis

PURPOSE

We investigated the role of tumor-infiltrating lymphocytes (TILs) in pretreatment primary breast cancer to predict pathological response to neoadjuvant chemotherapy (NAC) in patients with clinical node-positive disease (cN +).

METHODS

The subjects of this study were 60 patients with cN + , who received NAC followed by breast surgery with axillary lymph node dissection (ALND). We conducted a semi-quantitative assessment of TILs in pretreatment primary tumors and their association with clinicopathological factors and axillary lymph node metastasis.

RESULTS

We observed a higher number of TILs in tumors with negative hormone receptors, positive human epidermal growth factor receptor 2, or high Ki67. TILs were associated with a favorable response to NAC in primary tumors. The rate of axillary pathologic complete response (Ax-pCR) was significantly higher in patients with a high number of TILs than in patients with a low number of TILs (72.0% versus 17.1%, p < 0.001). In multivariable analysis, a high number of TILs was a significant predictor of Ax-pCR as well as of pCR of the primary tumor after NAC. Importantly, all patients with HER2-positive tumors in the high TILs group showed Ax-pCR on ALND.

CONCLUSION

TILs in pretreatment primary breast cancer had the potential to predict therapeutic efficacy of NAC in patients with clinical node-positive disease.

The Effects of Platelet-Rich Plasma to Decrease the Risk of Seroma Formation After Mastectomy and Axillary Dissection

BACKGROUND

Seroma, which is the most common complication after mastectomy and axillary dissection, is the leakage of the lymphovascular fluid into the dead space. It can cause local complications varying from delayed wound healing to infection and skin flap necrosis. The aim of this study was to evaluate whether platelet-rich plasma (PRP) reduces the risk of seroma formation.

MATERIALS AND METHODS

A total of 24 Wistar albino rats were randomly divided into three groups of eight rats in each. For the rats in group 1, no additional procedures were carried out. The rats in groups 2 and 3 were applied with 0.25 and 0.5 mL/cm² PRP, respectively, to the operation site. The groups were compared in respect of adhesion scores, histopathologic examination, and tissue seroma volume.

RESULTS

The mean seroma volume was 2.19 ± 0.78 mL in group 1, 1.43 ± 0.35 mL in group 2, and 0.96 ± 0.24 mL in group 3. The seroma volumes of groups 3 and 2 were significantly lower than those in group 1. In the macroscopic assessment the mean general adhesion score was 6 ± 0.75 in group 3. The other general adhesion scores were 5.25 ± 0.70 and 2.12 ± 0.64 in groups 2 and 1, respectively. The adhesion scores of groups 3 and 2 were significantly higher than those of group 1. The mean inflammatory cell score was 0.87 ± 0.83 in group 3, 2.0 ± 0.92 in group 2, and 3.0 ± 0.53 in group 1. There were significantly lower levels of inflammatory cells in group 3 than in the other groups and the group 2 inflammatory cell count was lower than that of group 1. Fibroblast density score was significantly higher in group 3 (2.50 ± 1.06) compared with the other groups. Neovascularization was significantly higher in groups 3 and 2 compared with group 1. The mean neovascularization score was 2.25 ± 1.16 and 2.12 ± 1.12 in groups 2 and 3, respectively. There were no statistically significant differences between the groups in respect of collagen levels.

CONCLUSIONS

Local application of PRP in rats after experimental mastectomy and axillary dissection was observed to decrease seroma formation and to increase neovascularization and fibroblast density.

Evaluating the impact of axillary dissection on recurrence-free survival by extent of nodal disease in invasive lobular carcinoma of the breast

PURPOSE

Clinical trials have shown that axillary lymph node dissection (ALND) can be avoided for many breast cancer patients with limited nodal involvement. However, whether its omission is safe for those with invasive lobular carcinoma (ILC) is still questioned. We sought to evaluate the impact of ALND on recurrence-free survival (RFS) by extent of nodal disease in patients with ILC.

METHODS

We performed a retrospective, cross-sectional analysis of ILC patients treated between 1990 and 2019 at our institution. Patients underwent either breast conservation surgery (BCS) or mastectomy. We used univariate and multivariate statistics in Stata 14.2 to evaluate associations between extent of axillary surgery and time to recurrence stratified by nodal burden.

RESULTS

Of 520 cases, 387 (78.4%) were node negative, 74 (14.9%) had 1-2 positive nodes, and 59 (11.4%) had three or more positive nodes. Most patients (93.3%) had hormone receptor-positive disease, and 94.8% had low or intermediate-grade tumors. The rate of ALND significantly decreased over time (p < 0.002). Using a multivariate model, there was no significant difference in RFS estimates based on receipt of ALND (HR = 0.53, 95% CI 0.17-1.64, p = 0.27), which also held true for patients with 1-2 positive nodes using a test of interaction (HR = 0.91, 95% CI 0.12-6.76, p = 0.92).

CONCLUSIONS

These findings support the safety of omitting ALND in selected patients with ILC. Further studies of axillary management in ILC and imaging tools to predict nodal involvement and therapeutic response are warranted.

Patterns of Failure in Women Who Have Residual Nodal Disease After Neoadjuvant Chemotherapy for Breast Cancer According to Extent of Lymph Node Surgery

BACKGROUND

Optimal surgical management of limited axillary nodal disease following neoadjuvant chemotherapy (NAC) for breast cancer is evolving. Concerns exist with respect to leaving residual disease in the axilla when omitting axillary lymph node dissection (ALND) in this setting. We sought to determine whether extent of nodal surgery altered patterns of failure and patient outcomes.

PATIENTS AND METHODS

We identified 70 patients with breast cancer who were confirmed cN0 after NAC yet had residual nodal disease (ypN1) on sentinel lymph node biopsy (SLNB). Twenty-eight patients underwent SLNB alone and 42 underwent SLNB+completion (c)ALND in a non-randomized fashion. Most (n = 65) patients underwent adjuvant regional nodal irradiation (RNI). Detailed patterns of failure data were obtained for each patient.

RESULTS

The median follow-up was 43.5 months. There were 30 (43%) recurrences. Of these, 5 were isolated locoregional failures, and 24 were distant failures. There were no significant differences in local (P = .13), regional (P = .62), or distant (P = .47) failure between patients who underwent SLNB alone versus SLNB+cALND. Seventeen (24%) patients died. Overall survival was similar in both groups with median overall survival not reached for those who underwent SLNB and 109 months for those who underwent SLNB+cALND (P = .45).

CONCLUSIONS

There were no differences in patterns of recurrence among patients with 1 to 3 involved lymph nodes after NAC who underwent SLNB alone versus SLNB+cALND in the setting of RNI. We await the results of ongoing, prospective clinical trials to confirm the relative merits of RNI in lieu of cALND in these patients.

Standard and controversies in sentinel node in breast cancer patients

Axillary management in breast cancer is still controversial. Recent clinical trials have clearly demonstrated that in breast-conserving surgery, axillary dissection could be an overtreatment when metastases are present in only 1-2 sentinel lymph nodes. Nonetheless, axillary dissection remains the principal treatment in patients undergoing mastectomy with at least one metastatic sentinel lymph node and in patients eligible for breast conserving surgery with three or more positive sentinel lymph nodes. In this analytical review, we discuss the clinical evidence, taking into account recent guidelines, for axillary management.

Inflammatory Breast Cancer in Pregnancy and Lactation

Inflammatory breast cancer (IBC) represents only 1% to 5% of all breast malignancies and is an extremely aggressive subtype. At time of diagnosis, up to 85% of patients will present with regional nodal metastases and up to 30 % will have metastasis to distant organs. There is limited medical literature describing treatment guidelines for IBC during gestation. The best diagnostic tools are core needle and full-thickness skin punch biopsies to assess presence of dermal lymphatic invasion. Breast Ultrasound is preferred to mammogram, but mammography could still be done with proper fetal shielding. Ultrasound and Magnetic resonance imaging are used for staging. Pregnant patients should be managed with special attention to the health of the fetus by a multidisciplinary team. Treatment based on current guidelines consist of a sequence of systemic chemotherapy followed by mastectomy with axillary dissection (modified radical mastectomy), and even if good clinical nodal response to neoadjuvant therapy is obtained, sentinel node biopsy is not recommended. Radiation therapy is to be given once the baby has been delivered. Chemotherapy is not recommended in the first trimester, and anti-estrogen hormonal therapy, as well as targeted Her2-neu therapies are contraindicated during the length of the pregnancy. There is no evidence that early termination improves the outcome. However, given the poor prognosis of IBC, patients should be fully counseled on the risks and benefits of continuing or terminating an early pregnancy.

Surgery for Pregnancy-Associated Breast Cancer

Surgery in the form of both mastectomy and breast conservation is the main step in the treatment of breast cancer. Numerous studies have shown an equivalent long-term survival for breast conserving surgery (BCS) and mastectomy . Patients desire and tumor characteristics, especially size and multicentricity, are the key factors that affect the decision between these two types of surgery . Patients with any contraindication for radiotherapy or previous history of radiation to the breast field are not suitable for BCS . There are few absolute contraindications for BCS , and early pregnancy is listed among them; mastectomy is preferred in the first trimester of pregnancy to avoid the impact of delaying radiation therapy on outcome of the cancer.

Management of the axilla in patients with breast cancer and positive sentinel lymph node biopsy: An evidence-based update in a European breast center

The surgical approach to the axilla in breast cancer has been a controversial issue for more than three decades. Data from recently published trials have provided practice-changing recommendations in this scenario. However, further controversies have been triggered in the surgical community, resulting in heterogeneous diffusion of these recommendations. The development of clinical guidelines for the management of the axilla in patients with breast cancer is a work in progress. A multidisciplinary team discussion was held at the research hospital Policlinico San Matteo from the Università degli Studi di Pavia with the aim to update recommendations for the management of the axilla in patients with breast cancer. An evidence-based approach is presented. Our multidisciplinary panel determined that axillary dissection after a positive sentinel lymph node biopsy may be avoided in cN0 patients with micro/macrometastasis to ≤2 sentinel nodes, with age ≥40y, lesions ≤3 cm, who have not received neoadjuvant chemotherapy and have planned breast conservation (BCS) with whole breast radiotherapy (WBRT). Cases with gross (>2 mm) ECE in SLNs are evaluated on individual basis for completion ALND, axillary radiotherapy or omission of both. Patients fulfilling the criteria listed above who undergo mastectomy, may also avoid axillary dissection after multidisciplinary discussion of individual cases for consideration of axillary irradiation. Women 70 years or older with hormone receptors positive invasive lesions ≤3 cm, clinically negative nodes, and serious or multiple comorbidities who undergo BCS with WBRT, may forgo axillary staging/surgery (if mastectomy or larger tumor, comorbidities and life expectancy are taken into account).

Mastectomy is no longer an indication for postoperative opioid prescription at discharge

BACKGROUND

A 10-step protocol employing multimodal analgesia was implemented in patients undergoing mastectomy to decrease the quantity of opioids prescribed at discharge.

METHODS

Patients who received the Enhanced Recovery After Surgery (ERAS) protocol were compared to a control group. Inpatient and discharge prescription of opioids were compared using oral morphine equivalents (OMEs), along with postoperative pain scores.

RESULTS

Between 2017 and 2018, fifty-seven patients were eligible for inclusion: 20 patients received ERAS and 37 received usual care (UC). The ERAS group received a mean of 2.4 (0-13) inpatient OMEs and the UC group received 13.7 (0-80) (p = 0.002). The ERAS group received 2.0 (0-40) OMEs at discharge and the UC group received 59.8 (0-120) (p < 0.001). Postoperative pain scores were significantly lower in the patients who received the ERAS protocol.

CONCLUSIONS

Patients who received the ERAS protocol required less postoperative opioids and reported lower pain scores when compared to a control group.

[Sentinel node and breast cancer: A state-of-the-art in 2019]

Since 1994 and Giuliano's description of sentinel lymph node technique, this procedure has considerably improved and is nowadays, one of the essential pillars in the management of breast cancer. Neoadjuvant chemotherapy (NAC) is effective on regional control, especially on axillary lymph node. Various learned societies recommend that the initial proved GS can be realized before (CNGOF 2010, Saint-Paul de Vence 2013, ESMO 2015, St-Gallen 2015, NCCN 2016) or after (ASCO 2014, ESMO 2015, Saint-Gallen 2015) CNA when the patient is considered like N0. In patients with initial lymph node involvement, GS searching it is not yet recommended. SLN detection before NAC remains an important prognostic factor especially in N+ patients before surgery. The purpose of this article was a reviewing of medical literature regarding possible indications for SLN detection and axillary dissection in patients with NAC according to sentinel lymph node status. The secondary objective was to put forward different perspectives and studies dealing with this subject. The complete pathological response appears to be an important selection criterion for proposing SLN to these patients and avoiding a "useless" AD. It is important to include patients in the trials to make recommendations progress on SLN after NAC and avoid a rate of uninjured AD.

St. Gallen/Vienna 2019: A Brief Summary of the Consensus Discussion on the Optimal Primary Breast Cancer Treatment

This year, the St. Gallen Consensus Conference on early breast cancer treatment standards took place for the third time in Vienna, Austria, which is where the next conference will also take place (next date: March 17-20, 2021!). Once again, more than 3,000 participants from over 100 countries came together, and, overall, the 2019 St. Gallen/Vienna conference was a great success. After 3 days of reviews conducted by a global faculty concerning the most important evidence published in the last 2 years, the Consensus votes' challenge was to define the impact on routine everyday practice. This year, the conference's main theme was the optimization of early breast cancer therapies by assessment of the magnitude of benefit, aiming at further refinement when compared to de-escalation and escalation, which were mainly the topic of the 2017 conference. Patient empowerment and the importance of shared decision-making were particularly emphasized. The traditional panel votes were moderated by Eric Winer from Harvard, and for the most part, they managed to clarify most of the critical questions. This brief report by Editors of Breast Care summarizes the results of the 2019 international panel votes with respect to locoregional and systemic treatment as a quick news update for our readers, but it expressly does not intend to replace the official St. Gallen Consensus publication that will follow shortly in Annals of Oncology.

Trends in axillary lymph node dissection for early-stage breast cancer in Europe: Impact of evidence on practice

BACKGROUND

Data from recently published trials have provided practice-changing recommendations for the surgical approach to the axilla in breast cancer. Patients with T1-2 lesions, treated with breast conservation, who have not received neoadjuvant chemotherapy and have 1-2 positive sentinel nodes (Z0011-criteria) may avoid axillary lymph node dissection (ALND). We aim to describe the dissemination of this practice in Europe over an extended period of time.

METHODS

Our source of data was the eusomaDB, a central data warehouse of prospectively collected information of the European Society of Breast Cancer Specialists (EUSOMA). We identified cases fulfilling Z0011-criteria from 2005 to 2016 from 34 European breast centers and report trends in ALND. Data derived from Germany, Italy, Belgium, Switzerland, Austria, and Netherlands.

RESULTS

6671 patients fulfilled Z0011-criteria. Rates of ALND showed a statistically significant decrease from 2010 (89%) to 2011 (73%), reaching 46% in 2016 (p < 0.001). After multivariable analysis, factors associated with higher probability of ALND were earlier year of surgery, younger age, increasing tumor size and grade, and being operated in Italy (p < 0.001). The minimum and maximal rates of ALND in the most recent two-year period (2015-2016) were 0% and 83% in two centers located in different countries (p < 0.001).

CONCLUSION

Our study demonstrates, a decrease in rates of ALND that started after year 2010 through the end of the study period. Wide differences were observed among centers and countries indicating the need to spread unified clinical guidelines in Europe to allow for homogeneous evidence-based practice patterns.

Does the number of removed axillary lymphnodes in high risk breast cancer patients influence the survival?

Background

The decision making process for axillary dissection has changed in recent years for patients with early breast cancer and positive sentinel lymph nodes (LN). The question now arises, what is the optimal surgical treatment for patients with positive axillary LN (pN+). This article tries to answer the following questions:

Is there a survival benefit for breast cancer patients with 3 or more positive LN (pN3+) and with more than 10 removed LN?

Is there a survival benefit for high risk breast cancer patients (triple negative or Her2 + breast cancer) and with 3 or more positive LN (pN3+) with more than 10 removed LN?

In pN + patients is the prognostic value of the lymph node ratio (LNR) of pN+/pN removed impaired if 10 or less LN are removed?

Methods

A retrospective database analysis of the multi center cohort database BRENDA (breast cancer under evidence based guidelines) with data from 9625 patients from 17 breast centers was carried out. Guideline adherence was defined by the 2008 German National consensus guidelines.

Results

2992 out of 9625 patients had histological confirmed positive lymph nodes. The most important factors for survival were intrinsic sub types, tumor size and guideline adherent chemo- and hormonal treatment (and age at diagnosis for overall survival (OAS)). Uni-and multivariable analyses for recurrence free survival (RFS) and OAS showed no significant survival benefit when removing more than 10 lymph nodes even for high-risk patients. The mean and median of LNR were significantly higher in the pN+ patients with ≤10 excised LN compared to patients with > 10 excised LN. LNR was in both, uni-and multivariable, analysis a highly significant prognostic factor for RFS and OAS in both subgroups of pN + patients with less respective more than 10 excised LN. Multivariable COX regression analysis was adjusted by age, tumor size, intrinsic sub types and guideline adherent adjuvant systemic therapy.

Conclusion

The removal of more than 10 LN did not result in a significant survival benefit even in high risk pN + breast cancer patients.

Validation of a Nomogram Predicting Non-Sentinel Lymph Node Metastases among Patients with Breast Cancer after Primary Systemic Therapy - a transSENTINA Substudy

Background

Prediction of non-sentinel lymph node (SLN) status after primary systemic therapy (PST) may allow tailored axillary staging. The aim of this analysis was to compare established nomograms from i) the primary operative (n = 6) and ii) the neoadjuvant (n = 1) setting with an optimized nomogram to predict non-SLN status in patients after PST.

Methods

181 patients converting from cN1 prior to PST to ycN0 but found to have a histologically positive SLN in the SENTINA trial were analyzed. Established models were applied. An optimized model was compiled using univariate and subsequent multivariable logistic regression (backward selection, likelihood ratio test).

Results

Area-under-the-curve (AUC) values from the primary operative models showed sufficient performance (0.82-0.71). For the neoadjuvant model, the AUC was found to be inferior to prior analyses (0.66) but within published confidence intervals. The SENTINA nomogram comprised the diameter of the largest lymph node (p = 0.006, odds ratio (OR) = 1.19), tumor size prior to PST (p = 0.085, OR = 1.31), and number of all positive SLN (p = 0.083, OR = 2.04). This model was validated using a separate cohort of arm C (n = 168, AUC 0.79, 95% confidence interval 0.74-0.85).

Conclusion

We validated 7 models of prediction of non-SLN among patients showing axillary conversion through PST. Our own 'SENTINA nomogram' yielded AUC values comparable to previous nomograms.

Prognostic Importance of Tumor Deposits in the Ipsilateral Axillary Region of Breast Cancer Patients

Tumor deposits (TD) are irregular discrete tumor masses in adipose tissue, discontinuous from the primary tumor, that are described in various cancers. The incidence and/or prognostic value of TD in breast carcinomas have not been studied so far. We reevaluated 145 breast cancer patients, diagnosed and treated between 2001 and 2006 at our institution for the presence and incidence of TD. Histologic type, grade, size of the primary tumor, estrogen receptor, progesterone receptor, human epidermal growth factor receptor-2 status of the tumor, and presence of peritumoral lymphovascular invasion were included in the data. TD were detected in 42 cases (29.0%). The mean age of the patients was 52.2 years (27-82). Most patients (79.3%) had either invasive carcinoma of no special type (NST) or invasive lobular carcinoma, and most tumors (86.9%) were either grade 2 or 3. After excluding TD from the number of metastatic lymph nodes, the pN status of 9 patients changed. Univariate analysis of 110 patients with follow-up information revealed that the new pN status (p = 0.036), presence of local recurrence (p = 0.016) and TD (p = 0.003) were significantly correlated with distant metastases. The median follow-up of the patients was 84 months (5-161), 10-year disease-free survival and overall survival were 67.2% and 73.7%, respectively. In multivariate analysis, presence of TD remained independently associated with distant metastasis (p = 0.002). The probability of distant metastasis was 3.3 times higher in patients with TD. These results emphasize that TD are present in breast cancer patients, and that their presence should warn the clinician in terms of possible distant metastasis. Therefore, presence of TD, the evaluation of which is neither time consuming nor require sophisticated methods, should be included in pathology reports.

Axillary dissection for breast cancer using electrocautery versus ultrasonic dissectors: A prospective randomized study

BACKGROUND

The major morbidities of modified radical mastectomy both short- and long-term are sequelae of axillary dissection. Flap complications, prolonged seroma, need for axillary drainage, wound infection, lymphedema, shoulder stiffness, and paresthesia are major causes for morbidity after axillary dissection. Different techniques have been implemented to tackle these problems. Few of these include reducing the axillary dead space, using various forms of energy devices.

AIMS

We have prospectively compared two energy sources, namely, ultrasonic dissector (UD) against the electrocautery dissection in axillary dissection for breast cancer with respect to outcomes.

MATERIALS AND METHODS

One hundred female patients with breast cancer undergoing modified radical mastectomy were randomized to either of the two arms - axillary dissection using UD and axillary dissection using electrocautery. The parameters taken into consideration were operating time, operative blood loss, amount and duration of axillary drainage, flap complications, nodal yield, and postoperative pain scoring.

RESULTS

There were no significant differences overall between the two groups with respect to oncological safety and functional outcomes.

The sentinel lymph node of breast cancer and the radiation oncologist

If the indications of sentinel lymph node biopsy and axillary lymph node dissection have been the subject of many trials, the indications of radiotherapy, in the absence of axillary lymph node dissection are a matter of debate. We reviewed the available literature on this topic and tried to draw some practical applications. In case of negative result of a sentinel lymph node biopsy, patients could be viewed as having pN0 disease and indications of adjuvant radiotherapy based on this paradigm. However, when the result of a sentinel lymph node biopsy was positive and no axillary lymph node dissection performed, indications of adjuvant radiotherapy are not so clear. For example, micrometastases could indicate a nodal irradiation as in the AMAROS trial, or not as in the IBCSG trial. Indications of postmastectomy radiotherapy are also not clearly defined in this setting. In the end, a clinical proposal was designed, emphasizing the unanswered questions.

Late Shoulder-Arm Morbidity Using Ultrasound Scalpel in Axillary Dissection for Breast Cancer: A Retrospective Analysis

BACKGROUND

We aimed to assess whether the use of the harmonic scalpel (HS) in axillary dissection would reduce long-term shoulder-arm morbidity compared to traditional instruments (TIs).

MATERIALS AND METHODS

A retrospective analysis on 180 patients who underwent standard axillary dissection for breast cancer between 2007 and 2015 was carried out. All patients were evaluated for postoperative pain, impairment of shoulder-arm mobility, seroma formation in axilla, frozen shoulder, and lymphedema.

RESULTS

HS procedure on average was 50% shorter compared to the TI technique. HS reduced by 4.5 times the risk of axillary seroma. TIs were associated with 4 times higher risk of developing a painful frozen shoulder.

CONCLUSIONS

Use of the HS was associated with reduced costs and a positive long-term effect on shoulder-arm morbidity. Axillary seromas are not the only reason of later postoperative shoulder-arm morbidity: other mechanisms are hypothesized in the onset of this very disabling disorder.

Critical review of axillary recurrence in early breast cancer

Around 2% of early breast cancer cases treated with axillary lymph node dissection (ALND) underwent axillary recurrence (AR) and it has a deleterious effect in prognosis. Different scenarios have incorporated Sentinel Lymph Node (SLN) Biopsy (SLNB) instead of ALND as part of the standard treatment and more effective systemic treatment has also been incorporated in routine management after first curative surgery and after regional recurrence. However, there is concern about the effect of SLNB alone over AR risk and how to predict and treat AR. SLN biopsy (SLNB) has been largely accepted as a valid option for SLN-negative cases, and recent prospective studies have demonstrated that it is also safe for some SLN-positive cases and both scenarios carry low AR rates. Different studies have identified clinicopathological factors related to aggressiveness as well as high-risk molecular signatures can predict the development of locoregional recurrence. Other publications have evaluated factors affecting prognosis after AR and find that time between initial treatment and AR as well as tumor aggressive behavior influence patient survival. Retrospective and prospective studies indicate that treatment of AR should include local and systemic treatment for a limited time.

Enhanced Axillary Evaluation Using Reflector-Guided Sentinel Lymph Node Biopsy: A Prospective Feasibility Study and Comparison With Conventional Lymphatic Mapping Techniques

BACKGROUND

Recently there are efforts to use sentinel lymph node biopsy (SLNB) techniques after neoadjuvant chemotherapy (NAC) to minimize axillary surgery. However, studies have shown higher false negative rates in this scenario, which might result in inaccurate assessment of treatment response and patient prognosis as well as leaving residual disease behind. In this study, we describe the use of reflector-guided excision of the percutaneously biopsied node (PBN) as an aid to conventional SLNB and its predictor of the axillary status after NAC.

PATIENTS AND METHODS

This was a single-institution analysis of patients who underwent axillary fiducial-reflector placement and subsequent SLNB compared with conventional SLNB.

RESULTS

Nineteen patients in the reflector group were matched with 19 patients who underwent conventional SLNB (conventional group). The PBN was identified in the SLNB in 19 patients (100%) in the reflector group and in 9 patients (47.3%) in the conventional group (P = .002). In the remaining 10 patients in the conventional group, the PBN was identified in the axillary lymph node dissection specimen in 4 patients (21%) and not identified in 6 patients (31.7%). Among the 38 patients, traditional mapping failed to identify the PBN in 13 patients (34.2%). The PBN was negative in 10 patients (36%) and positive in 18 patients (64%); no additional positive nodes were identified among patients with a negative PBN, correctly reflecting the status of the axilla in 100% of cases.

CONCLUSION

Mapping failure after NAC might compromise SLNB. Reflector-guided excision of the PBN is not only facile and feasible, but more accurately reflects the status of the axilla after NAC.

[Impact of the preservation of the branches of intercostobrachial nerve on the quality of life of patients operated for a breast cancer]

AIM

The aim of this study was to assess the impact of the preservation of the intercostobrachial nerve on the quality of life of patients operated for breast cancer.

METHODS

This study was ancillary to cost comparison study of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. It was a prospective multicenter, observational, non-randomized study. The quality of life was assessed using two questionnaires: QLQ-C30 and specific module QLQ-BR23 Surveys have been performed before initiation of surgery, one week, and 1 month, 8 months and 12 months after discharge from hospitalization for the first surgical procedure.

RESULTS

Five hundred and seventy-eight patients with preservation of intercostobrachial nerve without axillary lymph node dissection (C- P+), 85 without preservation of nerve and axillary lymph node dissection (C+P-) and 57 with preservation of nerve and axillary lymph node dissection (C+P+) have been included in the study. The changing arm symptoms score was significantly different during follow-up between the three groups (P<0.001). This difference between the two groups C- P+ and C+P+ was significant clinically at one week [16.9, IC95%: 11.9 to 22 (P<0.01)], and persisted for up to 12 months [9.9, IC95%: 3.2 à16.6 (P=0.022)]. There was no difference between the group C+P- and C+P+. Results for physical functioning score were similar.

CONCLUSION

Preservation of the intercostobral nerve is not associated with better quality of life. Only axillary lymph node dissection has an impact on quality of life.

Non-visualized sentinel nodes in breast cancer patients; prevalence, risk factors, and prognosis

BACKGROUND

Evidence and consensus is lacking in international guidelines regarding axillary treatment recommendations for patients in whom a sentinel lymph node (SLN) cannot be visualized (non-vSLN) during the sentinel node procedure. In this study we aimed to determine the prevalence of non-vSLNs in a Dutch population of breast cancer patients and to examine predictors and survival rate for non-vSLN.

METHODS

A nationwide, retrospective, population-based study was performed including 116,920 patients with invasive breast cancer who underwent a SLN procedure in the Netherlands between January 2005 and December 2013.

RESULTS

Of the 76,472 clinically negative patients who underwent a SLN procedure, 1924 patients (2.5%) had a non-vSLN, of whom 1552 (80.7%) underwent an ALND. Multivariate analysis showed predictive factors for non-vSLN: older age (p < 0.001), diagnosis in the period 2005-2009 (p < 0.001), larger tumor size (p = 0.003), and extensive nodal involvement (p < 0.001). Multivariate survival analysis showed a significantly worse survival (HR 1.18, 95% CI 1.03-1.34, p = 0.015) for non-vSLNs patients. However, in the non-vSLN group, an ALND was not statistically significantly associated with a better survival (HR 0.96, 95% CI 0.53-1.75, p = 0.891).

CONCLUSION

Patients with non-vSLNs had less favorable disease characteristics and a worse survival compared to patients with a visualized SLN. Performing an ALND was not associated with a significantly better survival in patients with non-vSLNs. However, further research on the necessity of axillary treatment in this specific patient group is required.

Prognostic impact of macrometastasis linear size in sentinel node biopsy for breast carcinoma

AIM

The aim of the present study was to evaluate the risk of axillary non-sentinel lymph-node metastases (ALN) in breast cancer patients presenting macrometastasis (Mac-m) in the sentinel lymph node (SN).

MATERIALS AND METHODS

A retrospective series of 1464 breast cancers from patients who underwent ALN dissection following the diagnosis of Mac-m in the sentinel node (SN) was studied. In all the cases the MAC-m linear size was evaluated and correlated with presence or absence of non-SN ALN metastases.

RESULTS

Non-SN metastases were detected in 644∖1464 cases (43.98%). The risk of further axillary metastases ranged from 20.2% (37/183) in cases with Mac-m between 2 and 2.9 mm, to 65.3% (262/401) in cases with Mac-m measuring > 10 mm. The risk of non-SN ALN metastases showed a 3% increase, parallel to each mm increment in SN metastasis size. The data evaluated with the receiver operating characteristic (ROC) curve showed that the Mac-m could be subdivided according to a new cut-off of 7 mm. pT1 tumours, with Mac-m < 7 mm had a risk of non-SN ALN metastases of <30%. Furthermore 109/127 of these (85.8%) had 3 or less non-SN ALN -metastases.

CONCLUSIONS

The present data give a detailed description on the risk of non-SN ALN involvement, that may be useful in the evaluation of breast cancer patients. It is suggested that a Mac-m size of <7 mm is related to a low residual axillary disease burden in breast cancer patients with small (pT1) tumours.

St. Gallen/Vienna 2017: A Brief Summary of the Consensus Discussion about Escalation and De-Escalation of Primary Breast Cancer Treatment

For the second time, the St. Gallen Consensus Conference on early breast cancer treatment standards took place in Vienna, Austria, where it will remain for the foreseeable future (next date: March 20-23, 2019). With the probably most prominent line-up of global breast cancer experts and more than 3,000 participants from over 100 countries, the 2017 St. Gallen/Vienna conference again was a huge success. A generation change took place with respect to the Conference Co-Chairpersons. Traditionally, the experts from all continents reviewed publications from the past 2 years, and discussed whether new diagnostic or therapeutic means were ready for routine everyday practice. This year, the conference's main theme was 'Escalating and Deescalating Treatment', and the traditional panel votings clarified a number of issues in this respect. Several subjects of all breast cancer modalities were further de-escalated (surgery: 'no ink on tumor' clearly confirmed as standard; resection within new limits after neoadjuvant systemic therapy; axillary dissection may also be avoided after mastectomy under certain circumstances; radiotherapy: hypofractionation is standard of care in breast conserving therapy; chemotherapy: can be avoided in low-risk patients). However, others were escalated: surgery: after neoadjuvant treatment and after mastectomy a positive sentinel node leads to axillary dissection; radiotherapy: regional nodes have to be irradiated in 4+ nodes situations; adjuvant therapy: bisphosphonates as standard for postmenopausal women. There was no clear panel opinion on the optimal use of multigenomic assays. As always, the panel recommendations are strictly opinion-based, and try to depict the 'usual' treatment for the 'average' patients. This rapid report by the editors-in-chief of Breast Care summarizes the results of the 2017 international panel votings with respect to loco-regional systemic treatment, and does not intend to replace the official St. Gallen Consensus publication.

Venous anomalies of the axilla: a single-institution experience

AIM

Surgical treatment is still the cornerstone in the treatment of breast cancer, a very common neoplasia, particularly affecting the female elderly population. Axillary dissection is crucial in the treatment of some tumours, but variations in axillary vessels anatomy are poorly described in standard anatomy and surgical textbook. We aimed to describe anatomical variations in axillary vessels found in our institutional experience.

PATIENTS AND METHODS

A prospective 3-year study was conducted in our institution from January 2012 to December 2014. Sixty-one consecutive axillary lymph node dissections (ALNDs) were performed in 61 patients who underwent surgery for stage II and III invasive breast cancer. Anatomical details of axillary vascular anatomy and its variations have been evaluated, described and stored in a prospective database.

RESULTS

Sixty-one ALNDs have been performed in the study period. The anatomy of lateral thoracic vein, angular vein and axillary vein was studied and compared with standard anatomical description. Eighteen percentage of venous variations were found out of the 61 dissection performed.

CONCLUSIONS

Vascular anatomy of axilla is complex and variable. A better knowledge of all possible variations might be helpful in preventing injuries during ALND.

Use of Low-Thrombin Fibrin Sealant Glue After Axillary Lymphadenectomy for Breast Cancer to Reduce Hospital Length and Seroma

BACKGROUND

Axillary lymphadenectomy for primary breast cancer produces a non-negligible rate of postoperative lymphorrhea, prolonged hospital stays, and multiple seroma punctures. We evaluated the impact of low-thrombin fibrin sealant glue on surgical wounds in patients undergoing axillary lymph node dissection for breast cancer.

METHODS

We conducted an observational study of 149 patients who underwent axillary lymphadenectomy for primary breast cancer between January 2014 and December 2015. Data were obtained from 2 successive prospective studies. The hospital stay length and morbidity (seromas, punctures) were compared between 2 groups: patients who had padding sutures and low-thrombin fibrin sealant glue without drainage (n = 49) and patients with drainage alone (n = 100). Hospital costs were assessed from the hospital perspective.

RESULTS

The mean hospital stay length was shorter in the fibrin sealant group (2.6 vs. 4.7 days; P < .001). Seroma magnitude and punctures were similar in patients treated with fibrin sealant compared with patients with drainage alone. The rate of needle aspiration for seroma was similar irrespective of whether or not a drain or fibrin sealant was used (30.6% vs. 33.0%, P = .77).

CONCLUSION

Low-thrombin fibrin sealant glue does not significantly reduce the amount of fluid produced in the axilla after breast surgery; however, its systematic use may help reduce hospital stays and costs.

[Feasibility and accuracy of day surgery: Review of 396 operated breast cancer patients]

INTRODUCTION

Breast cancer surgery is suitable for outpatient practice. Indeed, this is a planned surgery with short operative time. Objective was to evaluate the recognized success indicators in day surgery: rate of conversion into conventional hospitalization, rate of complications and re-hospitalizations the month following surgery.

METHODS

Consecutive cases of breast cancer patients operated in day surgery were prospectively entered into the Day Surgery database between 25 November 2012 and 31 December 2013. Patient characteristics and tumor pathology, preoperative procedures and type of surgery were collected. Statistical analysis was performed.

RESULTS

Three hundred and ninety-six consecutive patients were included. The mean age was 54 years [25-84], we performed 382 conservative breast surgery (98.2%), 238 sentinel node (60.1%) and 40 axillary lymphadenectomy (10.1%). Thirty-nine scheduled for outpatient surgery were hospitalized in conventional surgery being a conversion rate of 9.8%, 95% CI [6.9-12.7] with 24 patients because of a drainage (61.5%). We have observed 15 complications in the month after the surgery (3.7%, 95% CI [1.8-5.6]), and 5 rehospitalization in the month following surgery (1.2%, IC 95% [0.1-2.3]).

CONCLUSION

Postoperative complication and readmissions are very low (<5%) after breast ambulatory surgery. This confirms its feasibility and safety in a breast cancer center. Adaptating anaesthetic methods to ambulatory care and preparing patient going home with an axillary drain are necessary to reduce rate of conversion to hospitalisation.