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Schiavone A, Ventimiglia F, Zarba Meli E, Taffurelli M, Caruso F, Gentilini OD, Del Mastro L, Livi L, Castellano I, Bernardi D, Minelli M, Fortunato L. Third national surgical consensus conference of the Italian Association of Breast Surgeons (ANISC) on management after neoadjuvant chemotherapy: The difficulty in reaching a consensus. Eur J Surg Oncol 2024; 50:108351. [PMID: 38701582 DOI: 10.1016/j.ejso.2024.108351] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/15/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION Neoadjuvant chemotherapy (NAC) has a profound impact on surgical management of breast cancer. For this reason, the Italian Association of Breast Surgeons (ANISC) promoted the third national Consensus Conference on this subject, open to multidisciplinary specialists. MATERIALS AND METHODS The Consensus Conference was held on-line in November 2022, and after an introductory session with five core-team experts, participants were asked to vote on eleven controversial issues, while results were collected in real-time with a polling system. RESULTS A total of 164 dedicated specialists from 74 Breast Centers participated. Consensus was reached for only three of the eleven issues, including: 1) the indication to assess the response with Magnetic Resonance Imaging (79 %); 2) the need to re-assess the biological factors of the residual tumor if present (96 %); 3) the possibility of omitting a formal axillary node dissection for cN1 patients if a pathologic Complete Response (pCR) was confirmed with analysis of one or more sentinel lymph nodes (82 %). The majority voted in favor of mapping both the breast and nodal lesions pre-NAC (59 %), and against the omission of sentinel lymph node biopsy in cN0 patients in the case of pathologic or clinical Complete Response (69 %). In cases of cT3/cN1+ tumors with pCR, only 8 % of participants considered appropriate the omission of Post-Mastectomy Radiation Therapy. CONCLUSION There is still a wide variability in surgical approaches after NAC in the "real world". As NAC is increasingly used, multidisciplinary teams should be attuned to conforming their procedures to the rapid advances in this field.
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Affiliation(s)
- Alfonso Schiavone
- Breast Center, San Giovanni-Addolorata Hospital, Via Dell'Amba Aradam 8, 00184, Rome, Italy; Department of Surgical Science, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy.
| | - Fabrizio Ventimiglia
- Breast Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Emanuele Zarba Meli
- Breast Center, San Giovanni-Addolorata Hospital, Via Dell'Amba Aradam 8, 00184, Rome, Italy
| | - Mario Taffurelli
- Breast Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Francesco Caruso
- Breast Unit, Humanitas Istituto Clinico Catanese, Contrada Cubba 11, SP54, 95045, Misterbianco, CT, Italy
| | | | - Lucia Del Mastro
- Breast Unit, IRCCS Ospedale Policlinico San Martino, Department of Internal Medicine and Medical Specialties (DIMI), Largo Rosanna Benzi 10, 16132, Genova, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, P.zza San Marco 4, 50121, Florence, Italy
| | - Isabella Castellano
- Pathology Unit, Department of Medical Sciences, University of Turin, Via Giuseppe Verdi 8, 10124, Turin, Italy
| | - Daniela Bernardi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Mauro Minelli
- Breast Center, San Giovanni-Addolorata Hospital, Via Dell'Amba Aradam 8, 00184, Rome, Italy
| | - Lucio Fortunato
- Breast Center, San Giovanni-Addolorata Hospital, Via Dell'Amba Aradam 8, 00184, Rome, Italy
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Fairhurst K, Roberts K, Fairbrother P, Potter S. Current use of drains and management of seroma following mastectomy and axillary surgery: results of a United Kingdom national practice survey. Breast Cancer Res Treat 2024; 203:187-196. [PMID: 37878150 PMCID: PMC10787912 DOI: 10.1007/s10549-023-07042-7] [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: 03/29/2023] [Accepted: 07/06/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE Up to 40% of the 56,000 women diagnosed with breast cancer each year in the UK undergo mastectomy. Seroma formation following surgery is common, may delay wound healing, and be uncomfortable or delay the start of adjuvant treatment. Multiple strategies to reduce seroma formation include surgical drains, flap fixation and external compression exist but evidence to support best practice is lacking. We aimed to survey UK breast surgeons to determine current practice to inform the feasibility of undertaking a future trial. METHODS An online survey was developed and circulated to UK breast surgeons via professional and trainee associations and social media to explore current attitudes to drain use and management of post-operative seroma. Simple descriptive statistics were used to summarise the results. RESULTS The majority of surgeons (82/97, 85%) reported using drains either routinely (38, 39%) or in certain circumstances (44, 45%). Other methods for reducing seroma such as flap fixation were less commonly used. Wide variation was reported in the assessment and management of post-operative seromas. Over half (47/91, 52%) of respondents felt there was some uncertainty about drain use after mastectomy and axillary surgery and two-thirds (59/91, 65%) felt that a trial evaluating the use of drains vs no drains after simple breast cancer surgery was needed. CONCLUSIONS There is a need for a large-scale UK-based RCT to determine if, when and in whom drains are necessary following mastectomy and axillary surgery. This work will inform the design and conduct of a future trial.
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Affiliation(s)
- K Fairhurst
- Centre for Surgical Research, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England.
| | - K Roberts
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - P Fairbrother
- Independent Cancer Patient Voice (ICPV), London, England
| | - S Potter
- Centre for Surgical Research, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
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Ibrahim M, Habashy H, Monib S. Iatrogenic Breast Lymphoedema: Incidence, Diagnosis, and Associated Risk Factors. Indian J Surg Oncol 2023; 14:637-643. [PMID: 37900657 PMCID: PMC10611671 DOI: 10.1007/s13193-023-01725-9] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/25/2023] [Indexed: 03/09/2023] Open
Abstract
While upper limb lymphoedema following breast and axillary surgery is well established in the literature, breast lymphoedema is rarely documented. Our primary objective was to identify risk factors of breast lymphoedema, and our secondary aim was to assess the possibility of using a breast ultrasound scan to assess breast lymphoedema. This study was a case series analysis, including patients who had wide local excision for primary breast cancer treatment between January 2013 and January 2018. Patients' demographics, including age, weight, body mass index (BMI), breast volume, tumour characteristics, and histological findings, were noted. All patients had a clinical assessment and ultrasound scan 6 months and 12 months after surgery, comparing ipsilateral to the contralateral breast skin, subcutaneous thickness, as well as parenchymal changes. We have included two hundred eighty-six breast cancer; the mean age was 54.7 years SD 17.3, the mean weight was 76.5 kg SD 12.6, the mean BMI was 31.5 SD 5.2, and the mean breast volume was 1223 ml SD 179. This study identified breast lymphoedema in patients with clinically detected skin oedema in the absence of radiotherapy skin changes; skin and subcutaneous 5 mm added thickness more than the contralateral side, and based on that, 22 patients (7.7%) were found to have breast lymphoedema. We have also found that patients with high BMI, larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance had an increased incidence of breast lymphoedema. The incidence of breast lymphoedema in this cohort was 7.7%. We suggest that breast lymphoedema should be considered if skin and subcutaneous thickness are 5 mm more than the contralateral side in the absence of severe radiotherapy skin changes. Also, we have found that high body mass index (BMI), larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance are associated with an increased incidence of breast lymphoedema.
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Affiliation(s)
- Mohamed Ibrahim
- General Surgery Department, Fayoum University Hospital, Faiyum, Egypt
| | - Hany Habashy
- General Surgery Department, Fayoum University Hospital, Faiyum, Egypt
| | - Sherif Monib
- St Albans Hospital Breast Unit, West Hertfordshire Hospitals NHS Trust, Waverley Rd, St Albans, AL3 5PN UK
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Heidinger M, Maggi N, Dutilh G, Mueller M, Eller RS, Loesch JM, Schwab FD, Kurzeder C, Weber WP. Use of sentinel lymph node biopsy in elderly patients with breast cancer - 10-year experience from a Swiss university hospital. World J Surg Oncol 2023; 21:176. [PMID: 37287038 DOI: 10.1186/s12957-023-03062-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/04/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The Choosing Wisely initiative recommended the omission of routine sentinel lymph node biopsy (SLNB) in patients ≥ 70 years of age, with clinically node-negative, early stage, hormone receptor (HR) positive and human epidermal growth factor receptor 2 (Her2) negative breast cancer in August 2016. Here, we assess the adherence to this recommendation in a Swiss university hospital. METHODS We conducted a retrospective single center cohort study from a prospectively maintained database. Patients ≥ 18 years of age with node-negative breast cancer were treated between 05/2011 and 03/2022. The primary outcome was the percentage of patients in the Choosing Wisely target group who underwent SLNB before and after the initiative went live. Statistical significance was tested using chi-squared test for categorical and Wilcoxon rank-sum tests for continuous variables. RESULTS In total, 586 patients met the inclusion criteria with a median follow-up of 2.7 years. Of these, 163 were ≥ 70 years of age and 79 were eligible for treatment according to the Choosing Wisely recommendations. There was a trend toward a higher rate of SLNB (92.7% vs. 75.0%, p = 0.07) after the Choosing Wisely recommendations were published. In patients ≥ 70 years with invasive disease, fewer received adjuvant radiotherapy after omission of SLNB (6.2% vs. 64.0%, p < 0.001), without differences concerning adjuvant systemic therapy. Both short-term and long-term complication rates after SLNB were low, without differences between elderly patients and those < 70 years. CONCLUSIONS Choosing Wisely recommendations did not result in a decreased use of SLNB in the elderly at a Swiss university hospital.
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Affiliation(s)
- Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
- Universitätsspital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Gilles Dutilh
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | - Ruth S Eller
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Julie M Loesch
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Fabienne D Schwab
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Christian Kurzeder
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Chen JH, Canner JK, Myers K, Camp M. Concomitant Use of Biopsy Clips and Wire Localization in Invasive Breast Cancer is Associated With Successful Clip Retrieval. Clin Breast Cancer 2023; 23:e163-e172. [PMID: 36646538 DOI: 10.1016/j.clbc.2022.12.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/11/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Surgical management of the axilla in patients with clinically node-positive breast cancer has shifted to less invasive surgical approaches, such as sentinel lymph node dissection (SLND) and targeted axillary dissection (TAD). Successful retrieval of the biopsy clip marking the lymph node of interest is crucial for assessment of pathologic response and locoregional disease control. METHODS We performed a retrospective review of patients ≥18 years old with invasive breast cancer and biopsy-proven axillary LN involvement, who underwent LN clip placement from January 2012 to July 2017 at Johns Hopkins Hospital. RESULTS Of the 128 eligible patients, the median age at diagnosis was 51.5 years (range, 23-92 years) with predominately stage T2-3 disease (54.7% T2, 42.2% T3), of ductal histology (76.6%), and located in the upper outer quadrant (42.2%). Among the 63.3% (81) of patients who received neoadjuvant systemic therapy, 43.2% (35) had a partial response and 30.9% (25) had a complete response. Axillary procedures performed consisted of 36.7% (47) SLND/TAD, 53.9% (69) ALND, and 9.4% (12) SLND/TAD with conversion to ALND. The clipped LN was successfully retrieved in 63.8% (30) of SLND/TADs, 39.1% (27) of ALNDs, and 58.3% (7) of SLND/TADs followed by ALND. Pre-operative node localization by wire and/or skin markings was performed for 16.4% (21) of patients. Among these, 90.5% (19) of clipped LNs were successfully retrieved, compared to 42.1% (45) retrieved in axillary procedures without preoperative node localization. CONCLUSION Use of preoperative targeted node localization improved rate of clipped LN retrieval across all three types of axillary procedures.
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Affiliation(s)
- Jennifer H Chen
- School of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Joe K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Kelly Myers
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Melissa Camp
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD.
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Laws A, Kantor O, King TA. Surgical Management of the Axilla for Breast Cancer. Hematol Oncol Clin North Am 2023; 37:51-77. [PMID: 36435614 DOI: 10.1016/j.hoc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This review discusses the contemporary surgical management of the axilla in patients with breast cancer. Surgical paradigms are highlighted by clinical nodal status at presentation and treatment approach, including upfront surgery and neoadjuvant systemic therapy settings. This review focuses on the increasing opportunities for de-escalating the extent of axillary surgery in the era of sentinel lymph node biopsy, while also reviewing the remaining indications for axillary clearance with axillary lymph node dissection.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
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Abstract
Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated after publication of ACOSOG Z0011 data in 2010. Currently, prospective randomized surgical trials investigating the omission of SLNB in upfront breast-conserving surgery (BCS) and in the neoadjuvant setting, respectively. Several prospective randomized trials (SOUND, INSEMA, BOOG 2013-08, and NAUTILUS) with axillary observation alone versus SLNB in cN0 patients and primary BCS have primary objectives to evaluate oncologic safety when omitting SLNB. The Italian SOUND trial was the earliest to open in 2012 and has completed accrual in 2017. First oncologic outcome data are expected soon for SOUND and at the end of 2024 for INSEMA. Improvements in systemic treatments for breast cancer have increased the rates of pathologic complete response (pCR) in patients receiving neoadjuvant systemic therapy (NAST), offering the opportunity to de-escalate surgery in patients who have a pCR. Two prospective single-arm trials (EUBREAST-01, ASICS) include only patients with the highest likelihood of having a pCR after NAST (triple-negative or HER2-positive breast cancer) and type of surgery will be defined according to the response to NAST rather than on the classical T and N status. The ongoing trials will hopefully help us to understand whether we might take the best therapeutic decisions without the pathologic evaluation of nodal status.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059, Rostock, Germany.
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Montagna G. Estimating the Benefit of Preoperative Systemic Therapy to Reduce the Extent of Breast Cancer Surgery: Current Standard and Future Directions. Cancer Treat Res 2023; 188:149-174. [PMID: 38175345 DOI: 10.1007/978-3-031-33602-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Once reserved for locally advanced tumors which were deemed inoperable at presentation, preoperative systemic therapy (PST) is nowadays increasingly used to treat early breast cancer. PST allows for in vivo assessment of tumor response, for tailoring of adjuvant systemic therapy and for de-escalation of breast and the axillary surgery. Increased rates of pathological complete response together with more accurate response assessment and surgical planning have led to a significant reduction in surgical morbidity. While surgical assessment remains the standard of care, ongoing studies are evaluating whether surgery can be omitted in patients who achieve a complete pathological response. In this chapter, I will review the impact of PST on surgical de-escalation and the data supporting the safety of this approach.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66Th Street, New York, NY, 10065, USA.
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Reimer T, Stachs A, Veselinovic K, Polata S, Müller T, Kühn T, Heil J, Ataseven B, Reitsamer R, Hildebrandt G, Knauer M, Golatta M, Stefek A, Zahm DM, Thill M, Nekljudova V, Krug D, Loibl S, Gerber B. Patient-reported outcomes for the Intergroup Sentinel Mamma study (INSEMA): A randomised trial with persistent impact of axillary surgery on arm and breast symptoms in patients with early breast cancer. EClinicalMedicine 2023; 55:101756. [PMID: 36457648 PMCID: PMC9706517 DOI: 10.1016/j.eclinm.2022.101756] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/03/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In clinically node-negative breast cancer patients, the INSEMA trial (NCT02466737) assessed the non-inferiority of avoiding sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). Here we present patient-reported outcomes (PROs) as a secondary endpoint. METHODS PROs were assessed for patients with no axillary surgery, SLNB alone, and ALND. Quality of life (QoL) questionnaire EORTC QLQ-C30 and its breast cancer module (BR23) were used at baseline (pre-surgery) and 1, 3, 6, 12, and 18 months after surgery. The QoL scores were compared using repeated measures mixed models based on the safety set. FINDINGS Between 2015 and 2019, 5502 patients were recruited for the first randomization, and 5154 were included in the intent-to-treat set (4124 SLNB versus 1030 no SLNB). In the case of one to three macrometastases after SLNB, 485 patients underwent second randomization (242 SLNB alone versus 243 ALND). Questionnaire completion response remained high throughout the trial: over 70% at all time points for the first randomization. There were significant differences for the BRBS (breast symptoms) and BRAS (arm symptoms) scores favoring the no SLNB group in all post-baseline assessments. Patients in the SLNB group showed significantly and clinically relevant higher scores for BRAS (differences in mean values ≥5.0 points at all times), including pain, arm swelling, and impaired mobility in all postoperative visits, with the highest difference at one month after surgery. Scoring of the QLQ-C30 questionnaire revealed no relevant differences between the treatment groups, although some comparisons were statistically significant. INTERPRETATION This is one of the first randomized trials investigating the omission of SLNB in clinically node-negative patients and the first to report comprehensive QoL data. Patients with no SLNB benefitted regarding arm symptoms/functioning, while no relevant differences in other scales were seen. FUNDING Supported by German Cancer Aid (Deutsche Krebshilfe, Bonn, Germany), Grant No. 110580 and Grant No. 70110580 to University Medicine Rostock.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059 Rostock, Germany
- Corresponding author. Department of Obstetrics and Gynecology, The University of Rostock, Suedring 81, 18059 Rostock, Germany.
| | - Angrit Stachs
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059 Rostock, Germany
| | - Kristina Veselinovic
- Department of Obstetrics and Gynecology, University of Ulm, Prittwitzstr. 43, 89075 Ulm, Germany
| | - Silke Polata
- Breast Center, Evangelisches Waldkrankenhaus Spandau, Stadtrandstr. 555, 13589 Berlin, Germany
| | - Thomas Müller
- Women's Hospital, Klinikum Hanau GmbH, Leimenstr. 20, 63450 Hanau, Germany
| | - Thorsten Kühn
- Women's Hospital, Klinikum Esslingen, Hirschlandstr. 97, 73730 Esslingen, Germany
| | - Jörg Heil
- Breast Unit, University Hospital, University of Heidelberg, Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Beyhan Ataseven
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte, Henricistr. 92, 45136 Essen, Germany
- Department of Obstetrics and Gynecology, LMU University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Roland Reitsamer
- Breast Center, LKH Salzburg, Paracelsus Medical University Clinics, Müllner Hauptstr. 48, A-5020 Salzburg, Austria
| | - Guido Hildebrandt
- Department of Radiotherapy, University of Rostock, Südring 75, 18059 Rostock, Germany
| | - Michael Knauer
- Brustzentrum Ost, Rohrschacher Str. 286, CH-9016 St. Gallen, Switzerland
| | - Michael Golatta
- Breast Unit, Sankt Elisabeth Hospital, Max-Reger-Str. 5-7, 69121 Heidelberg, Germany
| | - Andrea Stefek
- Women's Hospital, Johanniter-Hospital Stendal, Wendstr. 31, 39576 Stendal, Germany
| | - Dirk-Michael Zahm
- Breast Center, SRH Waldklinikum Gera, Str. des Friedens 122, 07548 Gera, Germany
| | - Marc Thill
- Department of Gynecology and Gynecological Oncology, Agaplesion Markus Hospital, W.-Epstein-Str. 4, 60431 Frankfurt/Main, Germany
| | | | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Str., 24105 Kiel, Germany
| | - Sibylle Loibl
- German Breast Group, Dornhofstr. 10, 63263 Neu-Isenburg, Germany
| | - Bernd Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059 Rostock, Germany
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Singh R, Cao L, Sarode AL, Kharouta M, Shenk R, Miller ME. Trends in surgery and survival for T1-T2 male breast cancer: A study from the National Cancer Database. Am J Surg 2023; 225:75-83. [PMID: 36208958 DOI: 10.1016/j.amjsurg.2022.09.043] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 08/14/2022] [Accepted: 09/20/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Despite evidence that early-stage male breast cancer (MBC) can be treated the same as in females, we hypothesized that men undergo more extensive surgery. METHODS Patients with clinical T1-2 breast cancer were identified in the National Cancer Database 2004-2016. Trends in surgery type and overall survival were compared between sexes. RESULTS Of 9,782 males and 1,078,105 females, most were cN0 with AJCC stage I/II disease. Unilateral mastectomy was most common in men (67.1% vs. 24.1%, p < 0.001) and partial mastectomy in women (64.7% vs. 26.4%, p < 0.001), with no significant change over time. Over 1/3 of men received ALND in 2016. While overall survival was superior in females (HR 0.83, 95% CI 0.73-0.94, p = 0.003), partial mastectomy was associated with a 42% reduction in mortality risk for males (HR 0.58, 95% CI 0.4-0.8, p = 0.003). CONCLUSIONS De-escalation of surgery could be considered for MBC to improve survival and align with current standards of care.
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Affiliation(s)
- Rashi Singh
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA; University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), USA
| | - Lifen Cao
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA; University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), USA
| | - Anuja L Sarode
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA; University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), USA
| | - Michael Kharouta
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert Shenk
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA; University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), USA
| | - Megan E Miller
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA; University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), USA.
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Cha C, Jeong J, Kim HK, Nam SJ, Seong MK, Woo J, Park WC, Ryu S, Chung MS. Survival benefit from axillary surgery in patients aged 70 years or older with clinically node-negative breast cancer: A population-based propensity-score matched analysis. Eur J Surg Oncol 2022; 48:2385-2392. [PMID: 35922281 DOI: 10.1016/j.ejso.2022.07.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Older patients with breast cancer have good prognosis and most die from diseases other than breast cancer. Previous studies suggested that the surgical extent in older patients could be reduced. We aimed to compare survival outcomes in patients aged ≥70 years with clinically node-negative breast cancer, based on whether axillary surgery was performed. METHODS A total of 2,995 patients with breast cancer aged ≥70 years who underwent breast surgery were included in the Korean Breast Cancer Registry. Patients were classified into two groups according to the performance of axillary surgery. We used propensity score matching for demographic and treatment factors to minimize selection bias. We compared the 5-year overall survival (OS) and breast cancer-specific survival (BCSS). RESULTS Among 708 patients after 3:1 propensity score matching, 531 underwent breast surgery with axillary surgery and 177 underwent breast surgery alone. Of all patients, 51.7% had T1 stage, and 73.2% underwent mastectomy. Approximately 31.2% of patients received chemotherapy. Among patients who did not undergo axillary surgery, the 5-year OS and BCSS rates were 85.2% and 96.7%, respectively. The hazard ratio of axillary surgery for OS was 0.943 (95% confidence interval 0.652-1.365, p = 0.757), indicating no significant difference between two groups. CONCLUSIONS Our study demonstrates that axillary surgery in a matched cohort of older patients with breast cancer and clinically negative nodes does not provide a survival benefit compared to patients undergoing breast surgery alone. These findings suggest that axillary surgery may be safely omitted in a select group of patients aged ≥70 years with clinically node-negative cancer. Further studies are needed to identify potential candidates for omitting axillary surgery.
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Affiliation(s)
- Chihwan Cha
- Department of Surgery, Hanyang University College of Medicine, Seoul, South Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei Univeristy College of Medicine, Seoul, South Korea
| | - Hong-Kyu Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Min-Ki Seong
- Department of Surgery, Korea Cancer Centre Hospital, Korea Institutes of Radiological and Medical Sciences, Seoul, South Korea
| | - Joohyun Woo
- Department of Surgery, Ewha Womans University Medical Center, Seoul, South Korea
| | - Woo-Chan Park
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Soorack Ryu
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, South Korea
| | - Min Sung Chung
- Department of Surgery, Hanyang University College of Medicine, Seoul, South Korea.
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12
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de Wild SR, Simons JM, Vrancken Peeters MJTFD, Smidt ML, Koppert LB. De-Escalating Axillary Surgery in Node-Positive Breast Cancer Treated with Neoadjuvant Systemic Therapy. Breast Care (Basel) 2022; 16:584-589. [PMID: 35087361 DOI: 10.1159/000518376] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/03/2021] [Indexed: 11/19/2022] Open
Abstract
Background There is a trend towards de-escalating axillary staging and treatment in breast cancer patients. On account of neoadjuvant systemic therapy, node-positive breast cancer patients can achieve a pathological complete response of the axilla. It is hypothesized that these patients do not benefit from an axillary lymph node dissection (ALND), and thus may be spared the risk of severe post-surgical morbidity. In an effort to omit standard ALND, less invasive axillary staging procedures are being implemented to establish response-guided treatment. However, it is unclear which less invasive staging procedure is most accurate, and long-term data are missing with regard to their oncologic safety. Summary This article provides an overview of the literature on currently used less invasive axillary staging procedures, the accuracy and feasibility of these procedures in clinical practice, important issues concerning axillary treatment, and issues to be addressed in ongoing or future studies. Key messages More evidence is needed regarding the safety of replacing standard ALND by less invasive axillary staging procedures in terms of long-term prognosis. These less invasive staging procedures not only serve to select patients who may benefit from treatment de-escalation, but also to select patients who may benefit from treatment escalation.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Janine M Simons
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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13
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Abstract
The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013-08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.
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Affiliation(s)
- Eliza H Hersh
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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14
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Corsi F, Albasini S, Sorrentino L, Armatura G, Carolla C, Chiappa C, Combi F, Curcio A, Della Valle A, Ferrari G, Gasparri ML, Gentilini O, Ghilli M, Listorti C, Mancini S, Marinello P, Meani F, Mele S, Pertusati A, Roncella M, Rovera F, Sgarella A, Tazzioli G, Tognali D, Folli S. 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. Breast 2021; 60:131-137. [PMID: 34624755 PMCID: PMC8503563 DOI: 10.1016/j.breast.2021.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/30/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Fabio Corsi
- Breast Unit, Department of Surgery, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", Università di Milano, Milan, Italy.
| | - Sara Albasini
- Breast Unit, Department of Surgery, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Luca Sorrentino
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università di Milano, Milan, Italy
| | - Giulia Armatura
- Chirurgia Generale, Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige, Italy
| | - Claudia Carolla
- Breast Unit, Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Francesca Combi
- Breast Unit Azienda Ospedaliero-Universitaria Policlinico Modena, Italy
| | - Annalisa Curcio
- Chirurgia Senologica, Ospedale Morgagni Pierantoni, Ausl Romagna, Forlì, Italy
| | - Angelica Della Valle
- Breast Surgery, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Guglielmo Ferrari
- Breast Surgery Unit, AUSL-IRCCS Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Maria Luisa Gasparri
- Service of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Oreste Gentilini
- Breast Surgery, San Raffaele University and Research Hospital, Milano, Italy
| | - Matteo Ghilli
- Breast Cancer Centre, University Hospital of Pisa, Italy
| | - Chiara Listorti
- Breast Unit, Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Mancini
- Breast Surgery, Department of Surgery, ASST Fatebenefratelli Sacco, Milano, Italy
| | - Peter Marinello
- Chirurgia Generale, Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige, Italy
| | - Francesco Meani
- Service of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, Lugano, Switzerland
| | - Simone Mele
- Breast Surgery Unit, AUSL-IRCCS Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Anna Pertusati
- General Surgery I, Department of Surgery, ASST Fatebenefratelli Sacco, Milano, Italy
| | | | | | - Adele Sgarella
- Breast Surgery, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Università degli Studi di Pavia, Pavia, Italy
| | - Giovanni Tazzioli
- Breast Unit Azienda Ospedaliero-Universitaria Policlinico Modena, Italy
| | - Daniela Tognali
- Chirurgia Senologica, Ospedale Morgagni Pierantoni, Ausl Romagna, Forlì, Italy
| | - Secondo Folli
- Breast Unit, Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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15
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Bodet ML, Roosen A, Hequet D, Rouzier R. [Therapeutic de-escalation in breast cancer surgery]. Bull Cancer 2021:S0007-4551(21)00363-5. [PMID: 34656300 DOI: 10.1016/j.bulcan.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 11/20/2022]
Abstract
The surgical management of breast cancer has been marked by a therapeutic de-escalation from radical surgery to breast conservation and from axillary curage to sentinel lymph node sampling. With regard to breast surgery, the de-escalation of treatment has been largely due to organized screening, which has made it possible to diagnose tumors of smaller volume or at an earlier stage. The indications for conservative surgery have been broadened by the addition of radiotherapy on one hand, and the introduction of adjuvant and neo-adjuvant treatments on the other hand. In an effort to de-escalate surgery, totally non-invasive techniques such as radiofrequency, HIFU (High Intensity Focused Ultrasound) or cryotherapy have been tested. Currently, three trials are underway to evaluate active surveillance, without surgery, in the management of certain low-risk ductal carcinomas in situ (DCIS). Regarding axillary procedures, the sentinel node technique has allowed axillary staging in patients with early breast cancer without clinical or radiological lymph node involvement. Currently, international recommendations (ASCO, NCCN) and the consensus of experts in St Gallen do not recommend additional curage in cases of macro or micrometastatic invasion of the sentinel lymph nodes if the criteria of ACOSOG Z0011 are met. The question now arises as to the relevance of a biopsy of suspected axillary nodes during the initial workup and the usefulness of the sentinel node technique in the case of a negative initial workup.
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16
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Abstract
Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.
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Affiliation(s)
- Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA.
| | - Avia Wilkerson
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA
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17
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Chen R, Li S, Li Y, Zhu Q, Shi X, Xu L, Xu Y, Zhang W, Huang X, Wang J, Zha X. Can axillary surgery be omitted in patients with breast pathologic complete response after neoadjuvant systemic therapy for breast cancer? A real-world retrospective study in China. J Cancer Res Clin Oncol 2021. [PMID: 34398298 DOI: 10.1007/s00432-021-03763-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Studies show that axillary surgery can be potentially omitted in certain breast cancer patients who achieve breast pathologic complete response (pCR) after neoadjuvant systemic therapy (NST). However, potential differences between the ypT0 and ypTis subgroups remain to be explored. Furthermore, whether axillary surgery can be omitted in patients with clinically assessed positive axillary lymph nodes (cN+) remains unknown. This study was to evaluate the status of axillary lymph nodes for patients who achieved breast pCR after NST in the real-world study. METHODS This retrospective cohort study included 258 patients with early or locally advanced breast cancer who underwent breast and axillary surgery after NST. Clinical and pathologic data were compared between patients with breast pCR (ypT0/is) and those without breast pCR. RESULTS The rate of breast pCR after NST was 27.1% (70/258). Among the patients with initial cN0, the rate of axillary pCR was similar between the breast pCR and breast non-pCR groups (100% vs. 85.7%, P = 0.1543). Among those with breast pCR, the rate of axillary pCR was 100% in both the ypT0 and ypTis subgroups. Furthermore, among those with initial cN+, the rate of axillary pCR was higher in the breast pCR group than in the breast non-pCR group (82.7% vs. 22.9%, P < 0.0001). Among the patients with breast pCR, the rate of axillary pCR was higher in the ypT0 subgroup than in the ypTis subgroup (94.3% vs. 58.8%, P = 0.0034). CONCLUSION Axillary surgery may potentially be omitted in patients with initial cN0 who achieve breast pCR (ypT0/is), and may also be considered for omission in patients with initial cN+ who achieve ypT0 (not ypTis).
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18
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de Wild SR, Simons JM, Vrancken Peeters MJTFD, Smidt ML, Koppert LB. MINImal vs. MAXimal Invasive Axillary Staging and Treatment After Neoadjuvant Systemic Therapy in Node Positive Breast Cancer: Protocol of a Dutch Multicenter Registry Study (MINIMAX). Clin Breast Cancer 2021; 22:e59-e64. [PMID: 34446364 DOI: 10.1016/j.clbc.2021.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Node positive breast cancer (cN+) patients with an axillary pathologic complete response after neoadjuvant systemic therapy (NST) are not expected to benefit from axillary lymph node dissection (ALND). Therefore, less invasive axillary staging procedures have been introduced to establish response-guided treatment. However, evidence is lacking with regard to their oncologic safety and impact on quality of life (QoL). We hypothesize that if response-guided treatment is given, less invasive staging procedures are non-inferior to standard ALND in terms of oncologic safety, and superior to standard ALND in terms of QoL. PATIENTS AND METHODS MINIMAX is a Dutch multicenter registry study that includes patients with cN1-3M0 unilateral invasive breast cancer, who receive NST, followed by axillary staging and treatment according to local protocols. In a retrospective registry of ±4000 patients, the primary endpoint is oncologic safety at 5 and 10 years (disease-free, breast-cancer-specific and overall survival, and axillary recurrence rate). In a prospective multicenter registry, the primary endpoints are QoL at 1 and 5 years, and we aim to verify the 5-year oncologic safety. With an estimated 5-year disease-free survival of 72.5% and anticipated loss to follow-up of 10%, a sample size of 549 is needed to have 80% power to detect non-inferiority (with a 10% margin) of less invasive staging procedures. CONCLUSION In cN+ patients treated with NST, less invasive axillary staging procedures are already implemented globally. Evidence is needed to support the assumed oncologic safety and superior QoL of such procedures. This study will contribute to evidence-based guidelines.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgical Oncology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - Janine M Simons
- Department of Surgical Oncology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | - Marjolein L Smidt
- Department of Surgical Oncology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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19
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De Luca A, Frusone F, Buzzacchino F, Amabile MI, Taffurelli M, Del Mastro L, Rutgers EJT, Sacchini V, Caruso F, Minelli M, Fortunato L. First Surgical National Consensus Conference of the Italian Breast Surgeons association (ANISC) on breast cancer management in neoadjuvant setting: Results and summary. Eur J Surg Oncol 2021; 47:1913-1919. [PMID: 33972142 DOI: 10.1016/j.ejso.2021.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/31/2022] Open
Abstract
RATIONALE On October 15th, 2020, the first Surgical National Consensus Conference on neoadjuvant chemotherapy (NACT) was promoted by the Italian Association of Breast Surgeons (ANISC). METHOD The Consensus Conference was entirely held online due to anti-Covid-19 restrictions and after an introductory four lectures held by national and international experts in the field, a total of nine questions were presented and a digital "real-time" voting system was obtained. A consensus was reached if 75% or more of all panelists agreed on a given question. RESULTS A total of 202 physicians, from 76 different Italian Breast Centers homogeneously distributed throughout the Italian country, participated to the Conference. Most participants were surgeons (75%). Consensus was reached for seven out of the nine considered topics, including management of margins and lymph nodes at surgery, and there was good correspondence between the 32 "Expert Panelists" and the "Participants" to the Conference. Consensus was not achieved regarding the indications to NACT for high-grade luminal-like breast tumors, and the need to perform an axillary lymph node dissection in case of micrometastases in the sentinel lymph node after NACT. CONCLUSIONS NACT is a topic of major interest among surgeons, and there is need to develop shared guidelines. While a Consensus was obtained for most issues presented at this Conference, controversies still exist regarding indications to NACT in luminal B-like tumors and management of lymph node micrometastases. There is need for clinical studies and analysis of large databases to improve our knowledge on this subject.
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Affiliation(s)
- Alessandro De Luca
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Federico Frusone
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Maria Ida Amabile
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy.
| | - Mario Taffurelli
- IRCCS Policlinico di Sant'Orsola, University of Bologna, Bologna, Italy
| | - Lucia Del Mastro
- IRCCS Ospedale Policlinico San Martino, Breast Unit, and Department of Internal Medicine and Medical Specialties (DIMI), Genova, Italy
| | - Emiel J T Rutgers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, 10065, USA
| | - Francesco Caruso
- Department of Oncological Surgery, Humanitas Catanese Center of Oncology, Catania, Italy
| | - Mauro Minelli
- Division of Medical Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Lucio Fortunato
- Breast Centre, San Giovanni-Addolorata Hospital, Rome, Italy.
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20
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Thomssen C, Balic M, Harbeck N, Gnant M. St. Gallen/Vienna 2021: A Brief Summary of the Consensus Discussion on Customizing Therapies for Women with Early Breast Cancer. Breast Care (Basel) 2021; 16:135-143. [PMID: 34002112 PMCID: PMC8089428 DOI: 10.1159/000516114] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 12/19/2022] Open
Abstract
Because of the COVID-19 pandemic, the 2021 St. Gallen/Vienna Consensus Conference on Early Breast Cancer Treatment Standards had to be held virtually. Despite the challenge of convening global contributors to both the conference itself as well as the important Consensus Panel, the scientific committee and the organizers managed to organize a well-received scientific conference, and also the panel discussion was well received in the worldwide scientific community, as indicated by numerous positive feedbacks already within the first 24 h. The virtual format was unusual, but opened the door for new elements such as Consensus questions proposed from the audience, but also live audience interaction on both days − the Consensus was split into 2 parts in order to accommodate as many time zones globally as possible, leading to almost a doubling of discussion time compared to previous meetings. Also, about 3,400 participants from over 100 countries and all continents came together, including many colleagues who could attend for the first time from world regions with restrictions that so far did not allow the travel to Vienna. Traditionally, the Panel votings and discussions were preceded by 3 days of high-level live-discussions about the lectures that were available on demand already a week before. Also, all the lectures and live discussions in mini-panels are made available online for at least 6 months (https://www.oncoconferences.ch/events/bcc-2021/). The traditional panel votings were once more moderated by Eric Winer from Harvard and included interactive elements such as audience votings and audience questions, presented by Michael Gnant. This rapid report by the editors-in-chief of Breast Care summarizes the results of the 2021 international panel votings with respect to locoregional and systemic treatment as a quick news update for our readers and clearly does not intend to replace the official St. Gallen Consensus publication that will follow shortly in Annals of Oncology.
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Affiliation(s)
- Christoph Thomssen
- Department of Gynaecology, Martin-Luther-University, Halle an der Saale, Germany
| | - Marija Balic
- Department of Internal Medicine, Division of Oncology, Medical University Graz, Graz, Austria
| | - Nadia Harbeck
- Breast Center, Department of Obstetrics and Gynecology, University of Munich (LMU), Munich, Germany
| | - Michael Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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21
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Villa G, Mandarano R, Scirè-Calabrisotto C, Rizzelli V, Del Duca M, Montin DP, Paparella L, De Gaudio AR, Romagnoli S. Chronic pain after breast surgery: incidence, associated factors, and impact on quality of life, an observational prospective study. Perioper Med (Lond) 2021; 10:6. [PMID: 33622393 PMCID: PMC7903732 DOI: 10.1186/s13741-021-00176-6] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain after breast surgery (CPBS) has a disabling impact on postoperative health status. Mainly because of the lack of a clear definition, inconsistency does exist in the literature concerning both the actual incidence and the risk factors associated to CPBS. The aim of this prospective, observational study is to describe the incidence of and risk factors for CPBS, according to the definition provided by the IASP taskforce. The impact of CPBS on patients' function and quality of life is also described. METHODS Women aged 18+ undergoing oncological or reconstructive breast surgery from Jan until Apr 2018 at the Breast Unit of Careggi Hospital (Florence, Italy) were prospectively observed. Postoperative pain was measured at 0 h, 3 h, 6 h, 12 h, 24 h, 48 h, and 3 months (CPBS) after surgery. Preoperative, intraoperative, and postoperative factors were compared in CPBS and No-CPBS groups through multivariate logistic regression analysis. RESULTS Among the 307 patients considered in this study, the incidence of CPBS was 28% [95% CI 23.1-33.4%]. Results from the logistic regression analysis suggest that axillary surgery (OR [95% CI], 2.99 [1.13-7.87], p = 0.03), preoperative use of pain medications (OR [95% CI], 2.04 [1.20-3.46], p = 0.01), and higher dynamic NRS values at 6 h postoperatively (OR [95% CI], 1.28 [1.05-1.55], p = 0.01) were all independent predictors for CPBS. CONCLUSIONS Chronic pain after breast surgery is a frequent complication. In our cohort, long-term use of analgesics for pre-existing chronic pain, axillary surgery, and higher dynamic NRS values at 6 h postoperatively were all factors associated with increased risk of developing CPBS. The possibility to early detect persistent pain, particularly in those patients at high risk for CPBS, might help physicians to more effectively prevent pain chronicisation. TRIAL REGISTRATION ClinicalTrials.gov registration NCT04309929 .
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Affiliation(s)
- Gianluca Villa
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy.
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla,3, Florence, 50100, Italy.
| | - Raffaele Mandarano
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Caterina Scirè-Calabrisotto
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Valeria Rizzelli
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Martina Del Duca
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Diego Pomarè Montin
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Laura Paparella
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla,3, Florence, 50100, Italy
| | - A Raffaele De Gaudio
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla,3, Florence, 50100, Italy
| | - Stefano Romagnoli
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla,3, Florence, 50100, Italy
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Sharma RD, Sharmin A, Sinha A, Solomon A, Huynh I, Alani A, Nagarajakumar A, Kasem A, Doddi S. Is it Possible to Predict Non Sentinel Node Positivity on the Basis of mRNA Copy Numbers of CK19 Receptor in Breast Cancer? Clin Breast Cancer 2021; 21:e561-e564. [PMID: 33712365 DOI: 10.1016/j.clbc.2021.01.012] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/25/2020] [Accepted: 01/18/2021] [Indexed: 11/18/2022]
Abstract
AIMS To determine if there is any correlation between the number of positive non-sentinel lymph nodes (NSLN) and the mRNA copy numbers of cytokeratin 19 receptor on one step nucleic acid amplification (OSNA) in the sentinel lymph node (SLN). METHODS An 8-year retrospective study of consecutive patients who had primary surgery and sentinel node biopsy for breast cancer from January 2011 to December 2018 was carried out. All these patients had intra-operative analysis of sentinel lymph nodes by OSNA. Patients who had neoadjuvant chemotherapy or neoadjuvant endocrine therapy were excluded. RESULTS There were 1159 patients with an age range of 24 to 90 years and a mean age of 63 years in this study. A total of 1324 SLNs were analyzed by OSNA. Macrometastasis was found in 120 patients and they underwent axillary lymph node dissection (ALND). A total of 2405 NSLNs were analyzed. Of the patients who had ALND, 51 (43%) patients had negative NSLNs and 69 (57%) had positive NSLNs. The mean mRNA copy numbers respectively for the 2 groups were 853,665 and 609,855. The difference between the means is not statistically significant (P = 0.82). Also the Receiver Operating Characteristic (ROC) Curve of the total CK-19 mRNA copy number for both groups-negative and positive NSLN were almost identical (Figure 3) indicating mRNA copy numbers cannot be used to discriminate between positive and negative non-sentinel lymph nodes. CONCLUSION It is clear from our study that in patients who have ALND due to macromets on OSNA, there is no correlation between the total tumor load as represented by mRNA copy numbers and the likelihood of positive non-sentinel lymph nodes. We therefore cannot rely solely on the mRNA copy numbers to decide on ALND.
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Affiliation(s)
- Rishabha Deva Sharma
- Department of General and Breast Surgery, Royal United Hospitals Bath NHS, Foundation Trust, Bath, UK
| | - Afroza Sharmin
- Department of Breast Surgery, Kings College NHS Foundation Trust, Princess Royal, University Hospital, Orpington, BR6 8ND, UK
| | - Aaditya Sinha
- Department of General Surgery, Worcester Royal Hospital, Worcester, UK
| | - Ashley Solomon
- Department of Breast Surgery, Kings College NHS Foundation Trust, Princess Royal, University Hospital, Orpington, BR6 8ND, UK
| | - Isabelle Huynh
- Department of Breast Surgery, Kings College NHS Foundation Trust, Princess Royal, University Hospital, Orpington, BR6 8ND, UK.
| | - Azhar Alani
- Department of Breast Surgery, Kings College NHS Foundation Trust, Princess Royal, University Hospital, Orpington, BR6 8ND, UK
| | - Anupama Nagarajakumar
- Department of Breast Surgery, Kings College NHS Foundation Trust, Princess Royal, University Hospital, Orpington, BR6 8ND, UK
| | - Abdul Kasem
- Department of Breast Surgery, Kings College NHS Foundation Trust, Princess Royal, University Hospital, Orpington, BR6 8ND, UK
| | - Sudeendra Doddi
- Department of Breast Surgery, Kings College NHS Foundation Trust, Princess Royal, University Hospital, Orpington, BR6 8ND, UK.
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Farkas N, Wong J, Monib S, Thomson S. Reply to: Chylous leak after axillary clearance in a patient with duplicity of the axillary vein. Eur J Surg Oncol 2020; 46:1772-1773. [PMID: 32665135 DOI: 10.1016/j.ejso.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Nicholas Farkas
- Breast Unit, West Hertfordshire Hospitals NHS Trust, United Kingdom.
| | - Joshua Wong
- Breast Unit, West Hertfordshire Hospitals NHS Trust, United Kingdom
| | - Sherif Monib
- Breast Unit, West Hertfordshire Hospitals NHS Trust, United Kingdom
| | - Simon Thomson
- Breast Unit, West Hertfordshire Hospitals NHS Trust, United Kingdom
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24
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Nayyar A, Strassle PD, Schlottmann F, Jadi J, Moses CG, Black JA, Gallagher KK, McGuire KP. Disparities in the Use of Sentinel Lymph Node Dissection for Early Stage Breast Cancer. J Surg Res 2020; 254:31-40. [PMID: 32408028 DOI: 10.1016/j.jss.2020.03.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/11/2020] [Accepted: 03/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical trials have long established the long-term safety of omitting axillary lymph node dissection (ALND) after sentinel lymph node dissection (SLND) in patients with clinically node-negative early stage breast cancer. The variations in utilization of SLND and ALND in this patient population, however, are currently unknown. METHODS Adult female patients (40 years and older) within the National Cancer Database diagnosed with breast cancer between January 2013 and December 2015, who had clinical T1-T2 and N0 disease, and who underwent either SLND (with or without subsequent ALND) or ALND were included. Differences in utilization across race, ethnicity, insurance type, facility, and residential characteristics were assessed using multivariable logistic regression. RESULTS Overall, 271,689 patients were included, of which 26,527 (10%) received ALND and 245,162 (90%) underwent SLND. After adjusting for demographics and cancer characteristics, black (odds ratio [OR], 1.11; 95% confidence interval [95% CI], 1.06-1.17) and Hispanic women (OR, 1.16; 95% CI, 1.10-1.24) were more likely to receive ALND. Patients without health insurance (OR, 1.33; 95% CI, 1.19-1.47), compared with private health insurance, and those receiving treatment at community cancer centers (OR, 1.60; 95% CI, 1.53-1.67), compared with academic/research centers, were also more likely to receive ALND. CONCLUSIONS Although the vast majority of women undergo SLND, significant disparities exist in its utilization for early stage breast cancer, with traditionally underserved patients receiving unwarranted extensive axillary surgery. Increased patient and surgeon education is needed to decrease variations in care that can affect patient's quality of life.
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25
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Arisio R, Borella F, Porpiglia M, Durando A, Bellino R, Bau MG, DE Sanctis C, Danese S, Benedetto C, Katsaros D. Axillary Dissection vs. no Axillary Dissection in Breast Cancer Patients With Positive Sentinel Lymph Node: A Single Institution Experience. In Vivo 2020; 33:1941-1947. [PMID: 31662523 DOI: 10.21873/invivo.11689] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 07/28/2019] [Accepted: 08/01/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Axillary surgery of breast cancer patients is undergoing a paradigm shift, as axillary lymph node dissection's (ALND) usefulness is being questioned in the treatment of patients with tumor-positive sentinel lymph node biopsy (SLNB). The aim of this study was to investigate the overall survival (OS) and relapse-free survival (RFS) of patients with positive SLNB treated with ALND or not. PATIENTS AND METHODS We investigated 617 consecutive patients with cN0 operable breast cancer with positive SLNB undergoing mastectomy or conservative surgery. A total of 406 patients underwent ALND and 211 were managed expectantly. RESULTS No significant difference in OS and RFS was found between the two groups. The incidence of loco-regional recurrence in the SLNB-only group and the ALND group was low and not significant. CONCLUSION The type of breast cancer surgery and the omission of ALND does not improve OS or RSF rate in cases with metastatic SLN.
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Affiliation(s)
- Riccardo Arisio
- Department of Surgical Sciences, Sant'Anna Hospital, Turin, Italy
| | - Fulvio Borella
- Gynecology and Obstetrics 1, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Mauro Porpiglia
- Gynecology and Obstetrics 1, Department of Surgical Sciences, University of Turin, Turin, Italy.,Breast Unit, Sant'Anna Hospital, Turin, Italy
| | - Antonio Durando
- Breast Unit, Sant'Anna Hospital, Turin, Italy.,Gynecology and Obstetrics 2, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Roberto Bellino
- Breast Unit, Sant'Anna Hospital, Turin, Italy.,Gynecology and Obstetrics 2, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Maria Grazia Bau
- Breast Unit, Sant'Anna Hospital, Turin, Italy.,Gynecology and Obstetrics 3, Sant'Anna Hospital, Turin, Italy
| | - Corrado DE Sanctis
- Breast Unit, Sant'Anna Hospital, Turin, Italy.,Gynecology and Obstetrics 3, Sant'Anna Hospital, Turin, Italy
| | - Saverio Danese
- Breast Unit, Sant'Anna Hospital, Turin, Italy.,Gynecology and Obstetrics 4, Sant'Anna Hospital, Turin, Italy
| | - Chiara Benedetto
- Gynecology and Obstetrics 1, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Dionyssios Katsaros
- Gynecology and Obstetrics 1, Department of Surgical Sciences, University of Turin, Turin, Italy .,Breast Unit, Sant'Anna Hospital, Turin, Italy
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Farkas N, Wong J, Monib S, Thomson S. A systematic review of chyle leaks and their management following axillary surgery. Eur J Surg Oncol 2020; 46:931-42. [PMID: 32033823 DOI: 10.1016/j.ejso.2020.01.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/08/2020] [Accepted: 01/24/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Chyle leaks following surgery to the axilla are seldom encountered with an incidence <0.7%. Management varies with no consensus in the literature. Injury to branching tributaries of the thoracic duct may require lengthy management at significant cost to patient and clinical team. This paper aims to provide an up-to-date review to support clinical management. METHODS The term 'chyle' was combined with 'breast' or 'axilla.' EMBASE, Medline and PubMed database searches were conducted. All papers published in English were included with no exclusion date limits. RESULTS 51 cases from 31 papers. All were female (mean age = 53.3yrs). 47/51 leaks were left-sided. 5/51 underwent sentinel node biopsy, 19/51 level II axillary node clearance (ANC), 23/51 level III ANC, 5/51 not specified. 59% (30/51) of leaks were identified within 2 postoperative days (mean = 3.3days). 96% initially managed conservatively: Drain = 38/51; low-fat diet = 34/51; compression bandaging = 20/51; Aspiration = 6/51. 40/51 (78%) were successfully managed conservatively, 11 patients returned to theater for secondary management. 7/11 recorded volumes >500mls/24 hrs before secondary surgery. Mean resolution time from initial surgery was 17.3days (range = 4-64days). No statistically significant difference (p = 0.72) in time to resolution between conservatively and surgically managed patients. CONCLUSIONS Chyle leaks are rarely seen following axillary surgery. Aberrant thoracic duct anatomy represents the likeliest aetiology. We advocate early recognition and tailored individual management. Conservative management with non-suction drainage, low-fat diet and axillary compression bandaging appear effective where output <500ml/24 hrs. Secondary surgical management should be considered in high chylous output (<500mls/24 hrs) patients unresponsive to conservative measures. We propose a management algorithm to aide clinicians.
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27
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Wu S, Wang Y, Li J, Zhang N, Mo M, Klimberg S, Kaklamani V, Cochet A, Shao Z, Cheng J, Liu G. Subtype-Guided 18 F-FDG PET/CT in Tailoring Axillary Surgery Among Patients with Node-Positive Breast Cancer Treated with Neoadjuvant Chemotherapy: A Feasibility Study. Oncologist 2019; 25:e626-e633. [PMID: 32297448 DOI: 10.1634/theoncologist.2019-0583] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/25/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the value of 18 [F]-fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) in tailoring axillary surgery by predicting nodal response among patients with node-positive breast cancer after neoadjuvant chemotherapy (NAC). METHODS One hundred thirty-three patients with breast cancer with biopsy-confirmed nodal metastasis were prospectively enrolled. 18 F-FDG PET/CT scan was performed before NAC (a second one after two cycles with baseline maximum standardized uptake value [SUVmax ] ≥2.5), and a subset of patients underwent targeted axillary dissection (TAD). All the patients underwent axillary lymph node dissection (ALND). The accuracy was calculated by a comparison with the final pathologic results. RESULTS With the cutoff value of 2.5 for baseline SUVmax and 78.4% for change in SUVmax , sequential 18 F-FDG PET/CT scans demonstrated a sensitivity of 79.0% and specificity of 71.4% in predicting axillary pathologic complete response with an area under curve (AUC) of 0.75 (95% confidence interval, 0.65-0.84). Explorative subgroup analyses indicated little value for estrogen receptor (ER)-negative, human epidermal growth factor receptor 2 (HER2)-positive patients (AUC, 0.55; sensitivity, 56.5%; specificity, 50.0%). Application of 18 F-FDG PET/CT could spare 19 patients from supplementary ALNDs and reduce one of three false-negative cases in TAD among the remaining patients without ER-negative/HER2-positive subtype. CONCLUSION Application of the subtype-guided 18 F-FDG PET/CT could accurately predict nodal response and aid in tailoring axillary surgery among patients with node-positive breast cancer after NAC, which includes identifying candidates appropriate for TAD or directly proceeding to ALND. This approach might help to avoid false-negative events in TAD. IMPLICATIONS FOR PRACTICE This feasibility study showed that 18 [F]-fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) could accurately predict nodal response after neoadjuvant chemotherapy (NAC) among patients with breast cancer with initial nodal metastasis except in estrogen receptor-negative, human epidermal growth factor receptor 2-positive subtype. Furthermore, the incorporation of 18 F-FDG PET/CT can tailor subsequent axillary surgery by identifying patients with residual nodal disease, thus sparing those patients supplementary axillary lymph node dissection. Finally, we have proposed a possibly feasible flowchart involving 18 F-FDG PET/CT that might be applied in post-NAC axillary evaluation.
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Affiliation(s)
- Siyu Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Yujie Wang
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jianwei Li
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Na Zhang
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Miao Mo
- Clinical Statistics Center, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Suzanne Klimberg
- Division of Breast Surgical Oncology, Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Virginia Kaklamani
- Division of Hematology and Oncology, Northwestern University, Chicago, Illinois, USA
| | - Alexandre Cochet
- Department of Nuclear Medicine, Centre Georges-François Leclerc, University Hospital of Dijon, Dijon, France
| | - Zhiming Shao
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Jingyi Cheng
- Department of Nuclear Medicine, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Guangyu Liu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
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Garcia-Etienne CA, Mansel RE, Tomatis M, Heil J, Biganzoli L, Ferrari A, Marotti L, Sgarella A, Ponti A. Trends in axillary lymph node dissection for early-stage breast cancer in Europe: Impact of evidence on practice. Breast 2019; 45:89-96. [PMID: 30925382 DOI: 10.1016/j.breast.2019.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 03/07/2019] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Carlos A Garcia-Etienne
- Breast Surgery, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Italy.
| | | | - Mariano Tomatis
- AOU Città della Salute e della Scienza, CPO Piemonte and EUSOMA Data Centre, Turin, Italy
| | | | | | - Alberta Ferrari
- Breast Surgery, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Italy
| | | | - Adele Sgarella
- Breast Surgery, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Italy
| | - Antonio Ponti
- AOU Città della Salute e della Scienza, CPO Piemonte and EUSOMA Data Centre, Turin, Italy
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Rupp J, Hadamitzky C, Henkenberens C, Christiansen H, Steinmann D, Bruns F. Frequency and risk factors for arm lymphedema after multimodal breast-conserving treatment of nodal positive breast Cancer - a long-term observation. Radiat Oncol 2019; 14:39. [PMID: 30845971 PMCID: PMC6407279 DOI: 10.1186/s13014-019-1243-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/25/2019] [Indexed: 01/11/2023] Open
Abstract
Background Arm-lymphedema is a major complication after breast cancer. Recent studies demonstrate the validity of predicting Breast Cancer Related Lymphedema (BCRL) by self-reports. We aimed to investigate the rate of BCRL and its risk factors in the long-term using self-reported symptoms. Methods Data was collected from 385 patients who underwent multimodal therapy for nodal positive breast cancer, including breast conserving surgery, axillary dissection, and local or locoregional radiotherapy. Two validated questionnaires were used for the survey of BCRL (i.e. LBCQ-D and SDBC-D). These were analysed collectively with retrospective data of our medical records. Results 23.5% (n = 43) suffered a permanent BCRL (stage II-III) after a median follow-up time of 10.1 years (4.9–15.9 years); further 11.5% (n = 23) reported at least one episode of reversible BCRL (Stage 0-I) during the follow-up time. 87.1% of the patients with lymphedema developed this condition in the first two years. Adjuvant chemotherapy was a significant risk factor for the appearance of BCRL (p = 0.001; 95%-CI 7.7–10.2). Conclusions Breast cancer survivors face a high risk of BCRL, particularly if axillary dissection was carried out. Almost 90% of BCRL occurred during the first two years after radiotherapy. Self-report of symptoms seems to be a suitable instrument of early detection of BCRL.
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Affiliation(s)
- Julia Rupp
- Department of Radiation Oncology, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Germany.,Department of Gynecology and Obstetrics, DIAKOVERE Hospital Henriettenstift, Hannover, Germany
| | - Catarina Hadamitzky
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany.,Practice for Lympho-Vascular Diseases, Bahnhofstraße 12, Hannover, Germany
| | - Christoph Henkenberens
- Department of Radiation Oncology, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Hans Christiansen
- Department of Radiation Oncology, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Diana Steinmann
- Department of Radiation Oncology, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Frank Bruns
- Department of Radiation Oncology, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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Kühn T, Classe JM, Gentilini OD, Tinterri C, Peintinger F, de Boniface J. Current Status and Future Perspectives of Axillary Management in the Neoadjuvant Setting. Breast Care (Basel) 2018; 13:337-341. [PMID: 30498418 DOI: 10.1159/000492437] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 01/18/2023] Open
Abstract
Axillary surgery has undergone considerable changes in recent years, especially in relation to patients who undergo neoadjuvant chemotherapy (NACT). Due to constantly decreasing rates of recurrence and death from breast cancer, modern surgical strategies aim at de-escalating the extent of local treatment and avoiding unnecessary procedures. This relates especially to lymph node surgery which is associated with considerable morbidity. In patients who initially present with clinically node-negative disease, sentinel lymph node biopsy (SLNB) is increasingly performed after NACT. The determination of the post-NACT nodal status does not only spare patients from additional surgery but also allows the assessment of pathologic complete response which is increasingly becoming an important tool for treatment planning. Since more than 70% of these patients have a ypN0 status after NACT, future trials will aim to identify patients who might be spared any axillary surgery after NACT. In patients who initially present with positive lymph nodes, the success rates of SLNB in terms of detection and accuracy are less favorable compared to those in patients who undergo primary surgery. The clinical significance of this is unclear. To reduce unnecessary axillary dissection in patients with cN1ycN0 status, prospective outcome data after SLNB without further lymph node removal are urgently needed. Improvements in surgical technique by localizing positive nodes at the time of diagnosis and removing them in a targeted surgical procedure (targeted axillary dissection) are under evaluation. Risk assessment and patient selection (including gene expression profiles) might be other ways of safely omitting axillary dissection.
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Affiliation(s)
- Thorsten Kühn
- Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Jean-Marc Classe
- Institut de Cancerologie de l'Ouest, Centre Gauducheau, Nantes, France
| | | | | | - Florentia Peintinger
- Department of Gynecology and Obstetrics, General Hospital Leoben, Leoben, Austria.,Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Jana de Boniface
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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de Boniface J, Schmidt M, Engel J, Smidt ML, Offersen BV, Reimer T. What Is the Best Management of cN0pN1(sn) Breast Cancer Patients? Breast Care (Basel) 2018; 13:331-336. [PMID: 30498417 DOI: 10.1159/000491704] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 11/19/2022] Open
Abstract
Although the majority of breast cancer patients are clinically node-negative (cN0) at diagnosis, 15-20% will have a metastatic sentinel lymph node (SLN, pN1(sn)). While a less radical approach regarding axillary surgery in cN0 patients with a positive SLN biopsy is advocated, the limitations of 5 published trials on axillary management in pN1(sn) are discussed intensely in the literature and support the performance of ongoing validation and extension trials, especially considering the lack of data in the setting of mastectomy. As locoregional radiotherapy has a significant effect on both recurrence and survival, a standardization of locoregional radiotherapy in the situation of SLN biopsy alone in pN1(sn) patients has to be defined in the future, and de-escalation trials should embrace a truly multidisciplinary approach. This is also of utmost importance considering the fact that high-volume nodal disease requires an intensified adjuvant chemotherapy strategy to which patients omitting axillary dissection cannot be stratified. Finally, there is mounting evidence that the therapeutic role of extensive axillary surgery in low-volume nodal disease is negligible, and multidisciplinary and translational efforts must be undertaken to individualize treatment in order to gain a reasonable balance between necessary staging information and unnecessary treatment-related morbidity.
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Affiliation(s)
- Jana de Boniface
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Marcus Schmidt
- Division of Molecular Medicine, Department of Obstetrics and Gynecology, Comprehensive Cancer Center, University Medical Center Mainz, Mainz, Germany
| | - Jutta Engel
- Munich Cancer Registry (MCR), Institute for Medical Information Processing, Biometry and Epidemiology (IBE) at the University Hospital of Munich, Ludwig Maximilians-University (LMU), Munich, Germany
| | - Marjolein L Smidt
- Division of Surgical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
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Del Riego J, Diaz-Ruiz MJ, Teixidó M, Ribé J, Vilagran M, Canales L, Sentís M. The impact of axillary ultrasound with biopsy in overtreatment of early breast cancer. Eur J Radiol 2017; 98:158-164. [PMID: 29279156 DOI: 10.1016/j.ejrad.2017.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 10/03/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE (a) To compare the axillary tumor burden detected by fine-needle aspiration cytology (FNAC) versus sentinel lymph node biopsy (SLNB). (b) To evaluate the relationship between axillary tumor burden and the number of suspicious lymph nodes detected by axillary ultrasonography (US). (c) To calculate the false-positive and false-negative rates for FNAC in patients fulfilling ACOSOG Z0011 criteria. METHODS Retrospective multicenter cross-sectional study of 355 pT1 breast cancers. SLNB and axillary lymph node dissection (ALND) were gold standards. Low axillary burden (≤2 positive lymph nodes); high burden (>2 positive lymph nodes). Patients ACOSOG Z0011: false-positive (positive FNAC+low burden), false-negative (negative FNAC+high burden). RESULTS High axillary burden: in entire series 38.5% FNAC+ vs. 5.7% SLNB+ (p<0.0001). In subgroup fulfilling ACOSOG Z0011 criteria: 45.5% vs 6.7%, respectively (p<0.001). 61 positive axillary US. With 1 suspicious node on axillary US: 95.6% had ≤2 involved nodes (including pN0); with 2 suspicious nodes: 60% had >2 involved nodes. In ACOSOG Z0011 patients, with 1 suspicious node, 93.7% had ≤2 involved nodes. Of the 37 FNAC in ACOSOG Z0011patients: 54.5% false-positives for high burden; 3.8% false-negatives. CONCLUSIONS FNAC-positive tumors have greater axillary burden, even in patients fulfilling ACOSOG Z0011 criteria. Using axillary US/FNAC to triage patients meeting Z0011 criteria may result in axillary overtreatment. The number of suspicious nodes seen in axillary US is related with the final axillary burden and should be taken into account when deciding to do FNAC in patients fulfilling ACOSOG Z0011 criteria.
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Affiliation(s)
- Javier Del Riego
- Women's Imaging, Department of Radiology, UDIAT Centre Diagnòstic, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Univertitat Autònoma de Barcelona, 1 Parc Tauli, Sabadell, Barcelona, Spain.
| | - María Jesús Diaz-Ruiz
- Breast Imaging, Department of Radiology, Althaia Xarxa Assistencial Universitària de Manresa, 1-3 Dr. Joan Soler St., Manresa, Barcelona, Spain
| | - Milagros Teixidó
- Breast Imaging, Department of Radiology, Consorci Sanitari de Terrassa, s/n Torrebonica Av., Terrassa, Barcelona, Spain
| | - Judit Ribé
- Breast Imaging, Department of Radiology, Consorci Hospitalari de Vic, Hospital General de Vic, 1 Francesc Pla "el vigata" St., Vic, Barcelona, Spain
| | - Mariona Vilagran
- Women's Imaging, Department of Radiology, UDIAT Centre Diagnòstic, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Univertitat Autònoma de Barcelona, Sabadell, Spain
| | - Lydia Canales
- Breast Imaging, Department of Radiology, Hospital General de Granollers, Hospital Universitari, Fundació Privada Hospital Asil de Granollers, s/n Francesc Ribas Av., Gronollers, Barcelona, Spain
| | - Melcior Sentís
- Breast Imaging, Department of Radiology, Hospital Universitari Mútua Terrassa, 5, Doctor Robert Pl., Terrassa, Barcelona, Spain
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Fleming CA, McCarthy K, Ryan C, McCarthy A, O'Reilly S, O'Mahony D, Browne TJ, Redmond P, Corrigan MA. Evaluation of Discordance in Primary Tumor and Lymph Node Response After Neoadjuvant Therapy in Breast Cancer. Clin Breast Cancer 2017; 18:e255-e261. [PMID: 29246703 DOI: 10.1016/j.clbc.2017.11.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) offers a unique opportunity to assess tumor response to systemic agents. However, a discrepancy may exist between the response of the primary tumor and involved nodes. We report on the frequency of response discordance after NAT in breast cancer. PATIENTS AND METHODS All consecutive node-positive patients receiving NAT in our department from 2009 to 2014 were identified. Patient demographics, and radiologic and pathologic features were tabulated. Tumor response was estimated by magnetic resonance imaging of the breast. Lymph node (LN) response was estimated from pathologic treatment response measurements. Statistical analysis was performed. RESULTS A total of 108 node-positive patients treated with NAT were eligible for inclusion. Median age was 51.73 years (range, 20-87 years). All patients underwent axillary clearance, and 62% underwent mastectomy. A 40% mean reduction in tumor size was observed. Statistically, a positive correlation between tumor and LN response after NAT was observed (Spearman correlation coefficient, r = 0.46, P < .001). Complete pathologic response was observed in 17 patients (15.7%). However, 21 patients experienced complete LN response, with only 81% of these patients (n = 17) experiencing a complete response in tumor also. A complete response was observed in tumor in 20 patients, and this predicted complete nodal response in 85% of cases (n = 17). Fifteen percent of primary tumors with complete pathologic response had persistently positive LNs. CONCLUSION A significant discordance exists between the primary tumor and LN response, representing a concern for the lack of response of occult regional or systemic metastases due to potential biologic heterogeneity.
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Affiliation(s)
| | - Karen McCarthy
- Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Ciara Ryan
- Department of Histopathology, Cork University Hospital, Cork, Ireland
| | - Aoife McCarthy
- Department of Histopathology, Cork University Hospital, Cork, Ireland
| | - Seamus O'Reilly
- Breast Research Centre, Cork University Hospital, Cork, Ireland
| | | | - Tara Jane Browne
- Department of Histopathology, Cork University Hospital, Cork, Ireland
| | - Paul Redmond
- Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Mark A Corrigan
- Breast Research Centre, Cork University Hospital, Cork, Ireland
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Co M, Ng J, Kwong A. Air Travel and Postoperative Lymphedema-A Systematic Review. Clin Breast Cancer 2017; 18:e151-e155. [PMID: 29157874 DOI: 10.1016/j.clbc.2017.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/08/2017] [Accepted: 10/11/2017] [Indexed: 11/15/2022]
Abstract
Lymphedema is not uncommon after axillary dissection for breast cancer. Improved survival of patients with breast cancer from advances in adjuvant therapy has resulted in increased awareness of the quality of life for long-term survivors. Air travel has been postulated as 1 of the risk factors of lymphedema exacerbation. In the present systematic review, we sought to critically evaluate the current data on this topic. The present study was registered in the Research Registry. A systematic review of lymphedema and air travel was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. The Medline, EMBASE, CINAHL, and Cochrane databases were searched for English-language studies up to June 2017 with a predefined strategy. The retrieved studies were independently screened and rated for relevance. Data were extracted by 2 of us. A total of 55 studies were identified using predefined keywords; 12 studies were included using the criteria stated in the study protocol. A pooled analysis of 2051 patients with a history of air travel revealed that ≤ 14.5% developed lymphedema after air flight. However, a subsequent analysis of 4 studies with a control arm showed that 107 of 1189 patients (9%) with a documented history of air travel developed lymphedema compared with 204 of 2356 patients (8.7%) who had not flown (χ2 test; P = .80). Two studies (1030 patients) evaluated the effect of lymphedema on patients' air travel patterns. Of the 1030 patients, 141 (13.7%) had totally avoided air travel after the development of lymphedema. However, air travel was not adversely associated with the development of lymphedema.
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Affiliation(s)
- Michael Co
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong Special Administrative Region
| | - Judy Ng
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong Special Administrative Region
| | - Ava Kwong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong Special Administrative Region.
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Abstract
Purpose of Review Axillary staging in the context of breast cancer is a contentious topic due to the varied practices across UK, Europe, and America. The ACOSOG Z0011 trial has questioned the role of axillary ultrasound in women with breast cancer. Published data has shown that women with ultrasound-positive lymph nodes have a worse prognosis than those with ultrasound-negative lymph nodes. Axillary ultrasound is limited as the sentinel lymph node (SLN) cannot be identified using B-mode ultrasound; however, with the advent of contrast-enhanced ultrasound (CEUS), this has now changed. Recent Findings The published literature has shown that the sentinel lymph node can be identified using CEUS. The rates are equivalent to blue dye alone but currently inferior to the dual technique of sentinel lymph node biopsy. There are several different contrast agents that can be used and the agents that remain in the sentinel lymph node for longer can identify areas of poor enhancement, allowing for targeted biopsy. Summary CEUS has the potential to revolutionize the way we manage the axilla in the future and may even replace surgical staging.
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Affiliation(s)
- Nisha Sharma
- Breast Unit, Level 1 Chancellor Wing, St James Hospital, Beckett Street, Leeds, LS9 7TF UK.,University of Leeds, Leeds, LS2 9JT UK
| | - Karina Cox
- Department of Breast Surgery, Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ UK
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Weiss A, Mittendorf EA, DeSnyder SM, Hwang RF, Bea V, Bedrosian I, Hoffman K, Adrade B, Sahin AA, Kuerer HM, Hunt KK, Caudle AS. Expanding Implementation of ACOSOG Z0011 in Surgeon Practice. Clin Breast Cancer 2017; 18:276-281. [PMID: 29100726 DOI: 10.1016/j.clbc.2017.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/11/2017] [Accepted: 10/06/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND After publication of American College of Surgeons Oncology Group (ACOSOG) Z0011, surgeons at our institution limited axillary surgery to sentinel lymph node dissection (SLND) in 76% of patients meeting trial eligibility criteria. Our study objective was to assess incorporation of the trial data into practice 5 years later. PATIENTS AND METHODS Patients with clinical T1-2, N0 invasive breast cancer undergoing breast conserving surgery were included. Comparisons were made between patients who underwent axillary lymph node dissection (ALND) and those that had no further surgery. RESULTS A total of 396 patients were included. Twelve percent (48/396) had positive SLNs; ALND was performed in 8% (4/48). Patients who underwent ALND were more likely to have 2 positive SLNs (50%, 2/4 vs. 2%, 1/44; P = .02) and microscopic extranodal extension (75%, 3/4 vs. 18%, 8/44; P = .03) than those that did not undergo ALND. Patients who underwent ALND also had a higher nomogram-predicted probability of having additional positive non-SLNs (53%) than those who had SLND alone (22%) (P = .0002). No patients had intraoperative assessment of SLNs performed. CONCLUSIONS The practice of omitting ALND in ACOSOG Z0011-eligible patients has expanded over 5 years. Clinicopathologic features continue to impact this decision. Intraoperative SLN assessment is no longer performed.
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Affiliation(s)
- Anna Weiss
- Department of Surgical Oncology, Brigham and Women's Hospital, Boston, MA
| | - Elizabeth A Mittendorf
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sarah M DeSnyder
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rosa F Hwang
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vivian Bea
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen Hoffman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Beatriz Adrade
- Department of Breast Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aysegul A Sahin
- Department of Pathology Administration, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Abigail S Caudle
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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Dominici LS, Sineshaw HM, Jemal A, Lin CC, King TA, Freedman RA. Patterns of axillary evaluation in older patients with breast cancer and associations with adjuvant therapy receipt. Breast Cancer Res Treat 2018; 167:555-66. [PMID: 28990127 DOI: 10.1007/s10549-017-4528-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Although axillary lymph node status has traditionally been a key factor in informing adjuvant breast cancer therapy recommendations, this information may be less relevant as our focus shifts more towards tumor biology, particularly in older patients where comorbidity influences treatment decisions and nodal staging and/or surgery may not improve outcomes. We examined patterns of axillary surgery and associations between axillary surgery and receipt of adjuvant treatment in older breast cancer patients. METHODS Women aged ≥ 65 years with clinically node-negative, stage I-II breast cancer treated between 2012 and 2013 were identified using the National Cancer Data Base. Using multivariable logistic regression, we examined associations between axillary surgery and age, adjusting for patient, clinical, and facility factors. We also examined receipt of adjuvant treatment by nodal surgery. RESULTS Among 68,205 women, 40.1% were aged 65-70, 24.5% were 71-75, 17.4% were 76-80, and 18.0% were > 80. Overall, 91.2% had axillary surgery (67.8% sentinel lymph node biopsy, 11.7% axillary lymph node dissection, 11.7% unspecified/unknown axillary surgery); 88.0% of those aged ≥ 70 with lower risk, hormone receptor-positive tumors underwent axillary surgery. In adjusted analyses, compared to patients aged 65-70, increasing age was associated with lower odds of any axillary surgery (ages 71-75: OR 0.64, 95% CI 0.57-0.71; ages 76-80: OR 0.33, 95% CI 0.30-0.37; age > 80: OR 0.08, 95% CI 0.07-0.08). Axillary surgery was associated with higher odds of receipt of radiation after breast conservation and receipt of chemotherapy in human epidermal growth factor 2-positive disease. CONCLUSIONS In a large nationwide dataset, the vast majority of older women with clinically node-negative breast cancer underwent axillary staging despite uncertainty about its impact on survival, particularly for those with lower-risk disease. Further study on how to tailor node assessment in older patients is warranted.
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Schmidt-Hansen M, Bromham N, Hasler E, Reed MW. Axillary surgery in women with sentinel node-positive operable breast cancer: a systematic review with meta-analyses. Springerplus 2016; 5:85. [PMID: 26848425 PMCID: PMC4729721 DOI: 10.1186/s40064-016-1712-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/12/2016] [Indexed: 11/10/2022]
Abstract
Traditionally, women with node-positive operable breast cancer have received complete axillary lymph node dissection (ALND), which is associated with significant morbidity, but recently less invasive alternatives have been explored. We conducted a systematic review of randomised controlled trials assessing alternative approaches to axillary surgery in patients with pathologically-confirmed sentinel node-positive operable breast cancer. We searched on 16/3/15 the Specialized Register of the Cochrane Breast Cancer group; CENTRAL; MEDLINE; PreMEDLINE; EMBASE; WHO International Clinical Trials Registry Portal; ClinicalTrials.gov; conference proceedings from ASCO and the San Antonio Breast Cancer meetings; checked reference lists and contacted authors to identify relevant studies. Double, independent study sifting, extraction, appraisal and summarising were undertaken using standard Cochrane Collaboration methodology. We included three studies (2020 patients) comparing ALND with sentinel lymph node dissection (SLND) to SLND alone, and two studies (1899 patients) comparing ALND to axillary radiotherapy (aRT). No differences in survival or recurrence were observed between ALND and SLND or aRT, but morbidity may have been increased in ALND, and all the results were subject to different biases, such as recruitment bias, performance bias, and outcome-reporting bias. Whilst it is encouraging that there appears to be no adverse effect on recurrence or survival, it will be appropriate to confirm these findings and provide additional data confirming quality of life effects and long term outcomes.
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Affiliation(s)
- Mia Schmidt-Hansen
- />National Collaborating Centre for Cancer, Park House, Greyfriars Road, Cardiff, CF10 3AF Wales, UK
| | - Nathan Bromham
- />National Collaborating Centre for Cancer, Park House, Greyfriars Road, Cardiff, CF10 3AF Wales, UK
| | - Elise Hasler
- />National Collaborating Centre for Cancer, Park House, Greyfriars Road, Cardiff, CF10 3AF Wales, UK
| | - Malcolm W. Reed
- />Brighton and Sussex Medical School, University of Sussex, Brighton, BN1 9PX UK
- />Brighton and Sussex University Teaching Hospitals Trust, Brighton, UK
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Marrazzo A, Boscaino G, Marrazzo E, Taormina P, Toesca A. Breast cancer subtypes can be determinant in the decision making process to avoid surgical axillary staging: A retrospective cohort study. Int J Surg 2015; 21:156-61. [PMID: 26253849 DOI: 10.1016/j.ijsu.2015.07.702] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 07/18/2015] [Accepted: 07/27/2015] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The need for performing axillary lymph-node dissection in early breast cancer when the sentinel lymph node (SLN) is positive has been questioned in recent years. The purpose of this study was to identify a low-risk subgroup of early breast cancer patients in whom surgical axillary staging could be avoided, and to assess the probability of having a positive lymph-node (LN). METHODS We evaluated the cohort of 612 consecutive women affected by early breast cancer. We considered age, tumor size, histological grade, vascular invasion, lymphatic invasion and cancer subtype (Luminal A, Luminal B HER-2+, Luminal B HER-2-, HER-2+, and Triple Negative) as variables for univariate and multivariate analyses to assess probability of there being a positive SLN o nonsentinel lymph node (NSLN). Chi-square, Fisher's Exact test and Student's t tests were used to investigate the relationship between variables; whereas logit models were used to estimate and quantify the strength of the relationship among some covariates and SLN or the number of metastases. RESULTS A significant positive effect of vascular invasion and lymphatic invasion (odds ratios are 4 and 6), and a negative effect of TN (odds ratios is 10) were noted. With respect to positive NSLN, size alone has a significant (positive) effect on tumor presence, but focusing on the number of metastases, also age has a (negative) significant effect. CONCLUSION This work shows correlation between subtypes and the probability of having positive SLN. Patients not expressing vascular invasion, lymphatic invasion and, moreover, a triple-negative tumor subtype may be good candidates for breast conservative surgery without axillary surgical staging.
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Affiliation(s)
- Antonio Marrazzo
- Department of Surgical, Oncological and Stomatological Sciences, Policlinico Hospital "Paolo Giaccone", University of Palermo, Via del Vespro, 129, 90127 Palermo, Italy.
| | - Giovanni Boscaino
- Department of Economics, Business and Statistics Sciences, University of Palermo, Viale delle Scienze, 90128 Palermo, Italy
| | - Emilia Marrazzo
- Department of Surgical, Oncological and Stomatological Sciences, Policlinico Hospital "Paolo Giaccone", University of Palermo, Via del Vespro, 129, 90127 Palermo, Italy.
| | - Pietra Taormina
- Breast Unit, Clinic "Macchiarella", Viale Regina Margherita, 25, 90138 Palermo, Italy
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology, Via Giuseppe Ripamonti, 435, 20141 Milan, Italy.
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del Riego J, Diaz-Ruiz MJ, Teixidó M, Ribé J, Vilagran M, Canales L, Sentís M; Grup de Mama Vallès-Osona-Bages (GMVOB; Cooperative Breast Workgroup Vallés-Osona-Bagés). The impact of preoperative axillary ultrasonography in T1 breast tumours. Eur Radiol 2016; 26:1073-81. [PMID: 26162580 DOI: 10.1007/s00330-015-3901-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/08/2015] [Accepted: 06/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To (a) determine the diagnostic validity of axillary ultrasound (AUS) in pT1 tumours and whether fine-needle aspiration (FNA) improves its diagnostic performance, and (b) determine the negative predictive value (NPV) of AUS in a simulation environment (cutoff: two lymph nodes with macrometastases) in patients fulfilling American College of Surgeons Oncology Group (ACOSOG) Z0011 criteria. MATERIALS AND METHODS This retrospective multicentre cross-sectional study analysed diagnostic accuracy in 355 pT1 breast cancers. All patients underwent AUS; visible nodes underwent FNA regardless of their AUS appearance. Sentinel node biopsy and axillary lymph node dissection (ALND) were gold standards. Data were analysed considering micrometastases 'positive' and considering micrometastases 'N negative'. The simulation environment included all patients fulfilling ACOSOG Z0011 criteria. RESULTS Axillary involvement: 22.8 %; AUS sensitivity: 46.9 % (Nmic positive)/66.7 % (Nmic negative); AUS+FNA sensitivity: 52.6 % (pNmic positive)/72.0 % (pNmic negative). In the simulation environment, AUS had 75.0 % sensitivity, 88.9 % specificity and 99.2 % NPV. CONCLUSION AUS has moderate sensitivity in T1 tumours. As ALND is unnecessary in micrometastases, considering micrometastases 'N negative' increases the practical impact of AUS. In patients fulfilling ACOSOG Z0011 criteria, AUS alone can predict cases unlikely to benefit from ALND. KEY POINTS • AUS+FNA can predict axillary involvement, thus avoiding SNB. • Not all patients with axillary involvement need ALND. • Axillary tumour load determines axillary management. • AUS could classify patients according to axillary load.
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Martelli G, Boracchi P, Orenti A, Lozza L, Maugeri I, Vetrella G, Agresti R. Axillary dissection versus no axillary dissection in older T1N0 breast cancer patients: 15-year results of trial and out-trial patients. Eur J Surg Oncol 2014; 40:805-12. [PMID: 24768443 DOI: 10.1016/j.ejso.2014.03.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/29/2014] [Accepted: 03/31/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Our randomized trial found no survival advantage for axillary dissection (AD) compared observation only (no AD) in older patients with early breast cancer and a clinically negative axilla, indicating that AD is unnecessary. We compared characteristics and outcomes in out-trial patients with those in trial patients to provide indications as to whether AD can be safely omitted outside the trial setting. METHODS The trial started in 1996, recruiting 238 patients age 65-80 years with cT1cN0 breast cancer, randomized to conservative surgery with or without AD. Over the recruitment period, 109 eligible patients who refused to participate in the trial, also received conservative breast surgery with or without AD depending on patient preference/surgeon opinion. Trial and out-trial patients received conventionally-fractioned whole breast radiation and tamoxifen for five years. Endpoints were breast cancer mortality, overall survival, and cumulative incidence of axillary disease in patients not receiving AD. RESULTS After 15 years of follow-up, breast cancer mortality and overall survival did not differ between the AD and no AD arms, in either the trial or out-trial cohorts. The 15-year cumulative incidence of axillary relapse was 6% in the no AD arm of the trial group, and zero in the no AD arm of the out-trial group. CONCLUSIONS Outside the trial setting, older patients with T1N0 breast cancer can be safely treated by conservative surgery, postoperative radiotherapy and tamoxifen for five years (if ER-positive). Axillary surgery is appropriate only for the small proportion of patients who develop overt axillary disease during follow-up.
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Affiliation(s)
- G Martelli
- Breast Unit, National Cancer Institute of Milan, Milan, Italy.
| | - P Boracchi
- Department of Clinical Science and Community Health, University of Milan, Italy
| | - A Orenti
- Department of Clinical Science and Community Health, University of Milan, Italy
| | - L Lozza
- Radiotherapy Unit, National Cancer Institute of Milan, Milan, Italy
| | - I Maugeri
- Breast Unit, National Cancer Institute of Milan, Milan, Italy
| | - G Vetrella
- Unit of Preventive Gynecology, Melegnano Hospital, Melegnano, Italy
| | - R Agresti
- Breast Unit, National Cancer Institute of Milan, Milan, Italy
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