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Krug D, Vladimirova V, Untch M, Kühn T, Schneeweiss A, Denkert C, Ataseven B, Solbach C, Gerber B, Tesch H, Golatta M, Seiler S, Heil J, Nekljudova V, Holtschmidt J, Loibl S. Breast-conserving surgery is not associated with increased local recurrence in patients with early-stage node-negative triple-negative breast cancer treated with neoadjuvant chemotherapy. Breast 2024; 74:103701. [PMID: 38422624 PMCID: PMC10910157 DOI: 10.1016/j.breast.2024.103701] [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: 01/03/2024] [Revised: 02/10/2024] [Accepted: 02/23/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy (NACT) is routinely used for patients with triple-negative breast cancer (TNBC). Upfront breast-conserving therapy (BCT) consisting of breast-conserving surgery (BCS) and adjuvant radiotherapy (RT) has been shown to be associated with improved outcome in patients with early TNBC as compared to mastectomy. METHODS We identified 2632 patients with early TNBC from the German Breast Group meta-database. Patients with cT1-2 cN0 and ypN0, available surgery and follow-up data were enrolled. Data of 1074 patients from 8 prospective NACT trials were available. Endpoints of interest were locoregional recurrence as first site of relapse (LRR), disease-free survival (DFS) and overall survival (OS). We performed univariate and multivariate Fine-Gray analysis and Cox regression models. RESULTS After a median follow-up of 64 months, there were 94 (8.8%) locoregional events as first site of relapse. Absence of pathologic complete response (pCR) was associated with increased LRR upon uni- and multivariate analysis (hazard ratio [HR] = 2.28; p < 0.001 and HR = 2.22; p = 0.001). Type of surgery was not associated with LRR. Patients in the BCS-group had better DFS and OS (DFS: HR = 0.47; p < 0.001 and OS: HR = 0.40; p < 0.001). BCS was associated with improved DFS and OS upon multivariate analysis (DFS: HR = 0.51; p < 0.001; and OS HR = 0.43; p < 0.001), whereas absence of pCR was associated with worse DFS and OS (DFS: HR = 2.43; p < 0.001; and OS: HR = 3.15; p < 0.001). CONCLUSIONS In this retrospective analysis of patients with early stage node-negative TNBC treated with NACT, BCS was not associated with an increased risk of LRR but with superior DFS and OS.
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Affiliation(s)
- David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany.
| | | | | | - Thorsten Kühn
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany; Department of Gynecology and Obstectrics, Die Filderklinik, Filderstadt, Germany
| | - Andreas Schneeweiss
- National Center for Tumor Diseases, University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Carsten Denkert
- Institut für Pathologie, Philipps-Universität Marburg und Universitätsklinikum Marburg (UKGM), Marburg, Germany
| | - Beyhan Ataseven
- Department of Gynecology, Gynecologic Oncology and Obstetrics, Bielefeld University, Medical School and University Medical Center OWL, Klinikum Lippe, Detmold, Germany
| | - Christine Solbach
- Goethe University Frankfurt, Department of Gynecology and Obstetrics, University Hospital, Germany
| | - Bernd Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Hans Tesch
- Center for Hematology and Oncology Bethanien, Frankfurt, Germany
| | - Michael Golatta
- Department of Gynecology and Obstetrics, University of Heidelberg, Heidelberg, Germany; Brustzentrum Heidelberg Klinik St. Elisabeth, Max-Reger-Straße 5-7, 69121 Heidelberg, Germany
| | | | - Jörg Heil
- Department of Gynecology and Obstetrics, University of Heidelberg, Heidelberg, Germany; Brustzentrum Heidelberg Klinik St. Elisabeth, Max-Reger-Straße 5-7, 69121 Heidelberg, Germany
| | | | | | - Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Center for Hematology and Oncology Bethanien, Frankfurt, Germany
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Sunen I, Isabel Garcia Barrado A, Cruz Ciria S, Garcia Maroto J, Gros Bañeres B, Garcia Mur C. Is contrast-enhanced mammography (CEM) an alternative to MRI in assessing the response to primary systemic therapy of breast cancer? Eur J Radiol 2024; 170:111270. [PMID: 38141263 DOI: 10.1016/j.ejrad.2023.111270] [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: 07/09/2023] [Revised: 12/03/2023] [Accepted: 12/14/2023] [Indexed: 12/25/2023]
Abstract
PURPOSE To evaluate the accuracy of contrast-enhanced mammography (CEM) and magnetic resonance imaging (MRI) in the assessing radiological response to primary systemic therapy (PST). METHOD Prospective study between February 2021 and October 2022. Women with breast cancer and indication of PST were enrolled. CEM and MRI were performed before and after PST, and the findings, including size and radiological response pattern, were compared with the size of the residual lesion measured in surgical specimens and its Miller-Payne classification (considered the gold standard). Two of four independent radiologists, with 2 years of CEM experience and 10 years of MRI experience, reviewed the images while being blinded to the results of the other technique. The agreement between measurements was evaluated using the Pearson correlation coefficient (r) and Lin's coefficient. RESULTS Forty-eight women with breast cancer who required PST were enrolled in the study, with a mean age of 57.21 ± 10.14 years. A total of thirty-three participants (68.75 %) completed the study. The correlation between CEM and MRI measurements was high before PST (r: 0.97), and local staging was identical for 45 out of 48 patients. MRI demonstrated better accuracy in predicting residual tumor size than CEM, with Lin's coefficient 0.91 and 0.73, respectively. However, no significant differences were observed in predicting response to therapy. Both methods tended to overestimate the size and degree of response in our study, with mean overestimations of 2.87 mm in CEM and 0.51 mm in MRI. CONCLUSION CEM was found to be as accurate as MRI in predicting response to PST, indicating its potential as an alternative imaging technique, but further research is necessary.
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Affiliation(s)
- Ines Sunen
- Department of Radiology, Nuestra Señora de Gracia Hospital, Zaragoza, Spain.
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Kim N, Kim JY, Park W, Cho WK, Kim TG, Im YH, Ahn JS, Lee JE, Nam SJ, Kim SW, Yu J, Chae BJ, Lee SK, Ryu JM, Park YH, Kim H. Benefit of postoperative regional nodal irradiation in patients receiving preoperative systemic therapy with docetaxel/carboplatin/trastuzumab/pertuzumab for HER2-positive breast cancer. Breast 2023; 72:103594. [PMID: 37924622 PMCID: PMC10654605 DOI: 10.1016/j.breast.2023.103594] [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: 08/07/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 11/06/2023] Open
Abstract
AIM The role of regional nodal irradiation (RNI) after preoperative systemic treatment (PST) with targeted therapy for HER2-positive breast cancer remains uncertain. This study aimed to investigate the impact of RNI on locoregional recurrence (LRR) and disease-free survival (DFS) outcomes after docetaxel/carboplatin/trastuzumab/pertuzumab (TCHP) for PST. METHODS We retrospectively analyzed 255 patients who were treated with six cycles of TCHP between 2016 and 2019. The patients were divided into four groups based on clinical nodal involvement: group A, with no nodal disease; group B, with axillary lymph node (AXL) level I; group C, with AXL level I with II/III; and group D, with supraclavicular or internal mammary nodes. RESULTS The RNI group had more advanced nodal disease (C/D) than the no RNI group (56.9 % vs. 6.8 %). With a median follow-up of 51.3 months, there were two (0.8 %), three (1.2 %), and 15 (5.9 %) local, regional, and distant metastases, respectively. LRR did not differ significantly according to the RNI (2.6 % vs. 1.0 %, p = 0.651). Group D had the most frequent distant metastases (17.5 %; p = 0.005). The 4-year DFS rate was 92.7 %, and DFS did not improve significantly after RNI (p = 0.074). When stratified by clinical nodal groups and pathological axillary response, RNI had no effect on LRR/DFS outcomes. CONCLUSION With a rare incidence of LRR, RNI did not significantly affect LRR or DFS in patients with HER2-positive breast cancer after with PST-TCHP. However, intensive systemic treatment is required for advanced diseases (C/D). Selective de-intensified RNI and intensified systemic treatment should be investigated in future studies.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji-Yeon Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Gyu Kim
- Department of Radiation Oncology, Samsung Changwon Hospital, Changwon, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Young-Hyuck Im
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Seok Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Eon Lee
- Department of Radiation Oncology, Samsung Changwon Hospital, Changwon, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Seok Jin Nam
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seok Won Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jonghan Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung Joo Chae
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sei Kyung Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jai-Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yeon Hee Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Li S, Qi W, Cao L, Xu C, Cai R, Chen J, Cai G. Nodal response to primary systemic therapy predicts prognosis of cN3c breast cancer patients receiving multimodality therapy. Breast 2023; 70:92-99. [PMID: 37423063 DOI: 10.1016/j.breast.2023.06.008] [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: 04/05/2023] [Revised: 05/22/2023] [Accepted: 06/18/2023] [Indexed: 07/11/2023] Open
Abstract
AIM To investigate the survival outcomes, patterns and risks of recurrence in cN3c breast cancer patients after multimodality therapy, as well as the predictors of candidates for ipsilateral supraclavicular (SCV) area boosting. METHOD Consecutive cN3c breast cancer patients from January 2009 to December 2020 were retrospectively reviewed. Based on nodal response to primary systemic therapy (PST), patients were categorized into three groups: clinical complete response (cCR) not achieved in SCV lymph nodal (SCLN, Group A), SCLN cCR but axillary node (ALN) did not achieve pathological complete response (pCR, Group B), cCR in SCLN and pCR in ALN (Group C). RESULTS The median follow-up time was 32.7 months. The 5-year overall survival (OS) and recurrence-free survival (RFS) were 64.6% and 43.7% respectively. Multivariate analysis showed cumulative SCV dose and ypT stage, ALN response and SCV response to PST were significantly associated with OS and RFS respectively. Compared with Group A or B, Group C showed significantly improved 3 y-RFS (53.8% vs 73.6% vs 100%, p = 0.003), and the lowest rate of DM as first failure (37.9% vs 23.5% vs 0%, p = 0.010). In Group A, the 3 y-OS for patients receiving the cumulative SCV dose of ≥60 Gy versus <60 Gy was 78.0% versus 57.3% (p = 0.029). CONCLUSION Nodal response to PST is an independent prognostic factor for survival and pattern of failure. A cumulative SCV dose of ≥60 Gy is positively associated with improved OS, especially in Group A. Our data supports the perspective of optimizing radiotherapeutic strategy based on nodal response.
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Affiliation(s)
- Shuyan Li
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weixiang Qi
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Cheng Xu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rong Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiayi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Gang Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Senkus E, Cardoso MJ, Kaidar-Person O, Łacko A, Meattini I, Poortmans P. De-escalation of axillary irradiation for early breast cancer - Has the time come? Cancer Treat Rev 2021; 101:102297. [PMID: 34656018 DOI: 10.1016/j.ctrv.2021.102297] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 08/08/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 01/18/2023]
Abstract
Introduction of sentinel lymph node biopsy, initially in clinically node-negative and subsequently in patients presenting with involved axilla and downstaged by primary systemic therapy, allowed for significant decrease in morbidity compared to axillary lymph node dissection. Concurrently, regional nodal irradiation was demonstrated to improve outcomes in most node-positive patients. Additionally, over the last decades, introduction of more effective systemic therapies has resulted in improvements not only at distant sites, but also in locoregional control, creating space for de-escalation of locoregional treatments. We discuss the data on de-escalation in axillary surgery and irradiation, both in patients undergoing upfront surgery and primary systemic therapy, with special emphasis on the feasibility of omission of nodal irradiation in patients undergoing primary systemic therapy. In view of the accumulating evidence, omission of axillary irradiation may be considered in clinically node-positive patients converting after primary systemic therapy to pathologically negative nodes on sentinel lymph node biopsy (preferably also with in-breast pCR), presenting with lower initial nodal stage, older age and were treated with breast-conserving surgery followed by whole breast irradiation. Omission of regional nodal irradiation in patients with aggressive tumor phenotypes achieving a pCR is under investigation. In patients undergoing preoperative endocrine therapy the adoption of axillary management strategies utilized in case of upfront surgery seems more suitable than those used in post chemotherapy-based primary systemic therapy setting.
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Affiliation(s)
- Elżbieta Senkus
- Department of Oncology & Radiotherapy, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland.
| | - Maria Joao Cardoso
- Breast Unit, Champalimaud Foundation, Av Brasilia, 1400-038 Lisbon, Portugal; Nova Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisbon, Portugal.
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, at Sheba Medical Center, Derech Sheba 2, Ramat Gan 52662, Israel; GROW-School for Oncology and Developmental Biology (Maastro), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands; The Sackler School of Medicine, Tel-Aviv University, Ramat Aviv 6997801, Tel-Aviv, Israel.
| | - Aleksandra Łacko
- Department of Oncology, Wroclaw Medical University, plac Hirszfelda 12, 53-413 Wrocław, Poland; Department of Clinical Oncology, Breast Unit, Lower Silesian Oncology Centre, plac Hirszfelda 12, 53-413 Wroclaw, Poland.
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Viale Morgagni 50, 50134 Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Philip Poortmans
- Iridium Netwerk, Oosterveldlaan 24, 2610 Wilrijk-Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Campus Drie Eiken, Building S. Universiteitsplein 1, 2610 Wilrijk-Antwerp, Belgium.
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Tőkés T, Tőkés AM, Szentmártoni G, Kiszner G, Mühl D, Molnár BÁ, Kulka J, Krenács T, Dank M. Prognostic and Clinicopathological Correlations of Cell Cycle Marker Expressions before and after the Primary Systemic Therapy of Breast Cancer. Pathol Oncol Res 2020; 26:1499-1510. [PMID: 31446607 PMCID: PMC7297700 DOI: 10.1007/s12253-019-00726-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/14/2019] [Indexed: 12/14/2022]
Abstract
We aimed to analyze the expression of cell-cycle regulation markers - minichromosome maintenance protein 2 (MCM2), Ki-67, Cyclin-A and phosphohistone-H3 (PHH3) - in pre-treatment core-biopsy samples of breast carcinomas in correlation with known predictive and prognostic factors. Totally 52 core biopsy samples obtained prior to neoadjuvant therapy were analyzed. Immunohistochemistry was performed to analyze the expression of MCM2, Ki-67, Cyclin A and PHH3, which were correlated with the following clinicopathological parameters: clinical TNM, tumor grade, biological subtype, the presence of tumor infiltrating lymphocytes (TIL), pathological tumor response rate to the neoadjuvant therapy and patient survival. All investigated markers showed higher expression in high grade and in triple negative tumors (p < 0.01 and p < 0.05, respectively). Hormone receptor negative tumors showed significantly higher expression of Ki-67 (p < 0.01), MCM2 (p < 0.01) and Cyclin A (p < 0.01) than hormone receptor positive ones. Tumors with increased TIL showed significantly higher Ki-67 expression (p = 0.04). Pattern analysis suggested that novel cell-cycle marker-based subgrouping reveals predictive and prognostic potential. Tumors with high MCM2, Cyclin A or PHH3 expression showed significantly higher rate of pathological complete remission. Tumors with early relapse (progression-free survival ≤2 years) and shortened overall survival also show a higher rate of proliferation. Our cell cycle marker (Ki-67, MCM2, Cyclin A, PHH3) based testing could identify tumors with worse prognosis, but with a favorable response to primary systemic therapy. The pattern of cell-cycle activity could also be useful for predicting early relapse, but our findings need to be further substantiated in larger patient cohorts.
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Affiliation(s)
- Tímea Tőkés
- Oncology Center, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, H-1083, Hungary.
| | - Anna-Mária Tőkés
- 2nd Department of Pathology, Semmelweis University, Üllői út 93, Budapest, H-1091, Hungary
| | - Gyöngyvér Szentmártoni
- Oncology Center, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, H-1083, Hungary
| | - Gergő Kiszner
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, Budapest, H-1085, Hungary
| | - Dorottya Mühl
- Oncology Center, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, H-1083, Hungary
| | - Béla Ákos Molnár
- 1st Department of Surgery, Semmelweis University, Üllői út 78/A, Budapest, H-1083, Hungary
| | - Janina Kulka
- 2nd Department of Pathology, Semmelweis University, Üllői út 93, Budapest, H-1091, Hungary
| | - Tibor Krenács
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, Budapest, H-1085, Hungary
| | - Magdolna Dank
- Oncology Center, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, H-1083, Hungary
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Di Micco R, Zuber V, Fiacco E, Carriero F, Gattuso MI, Nazzaro L, Panizza P, Gianolli L, Canevari C, Di Muzio N, Pasetti M, Sassi I, Zambetti M, Gentilini OD. Sentinel node biopsy after primary systemic therapy in node positive breast cancer patients: Time trend, imaging staging power and nodal downstaging according to molecular subtype. Eur J Surg Oncol 2019; 45:969-975. [PMID: 30744944 DOI: 10.1016/j.ejso.2019.01.219] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/20/2019] [Accepted: 01/29/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The management of axilla after Primary Systemic Therapy (PST) for breast cancer is a highly debated field. Despite the proven axillary downstaging occurring after PST, there is still some degree of reluctance in applying sentinel node biopsy (SNB) in the neoadjuvant setting. PATIENTS AND METHODS We performed a retrospective analysis on 181 PST patients with axillary positive nodes at presentation treated between 2005 and 2017 at San Raffaele Hospital in Milan. The aim was to observe the application time trend of SNB, to determine the imaging staging power and the axillary downstaging according to molecular subtypes. RESULTS Median follow-up after surgery was 32.5(IQR: 12-59) months. After PST, 119 (65.7%) patients had no clinically palpable nodes, 72 (39.7%) converted to N0 on final imaging and 34 (18.8%) underwent SNB with an increasing application trend. Axillary-US showed the highest accuracy (69.3%) in re-staging axilla after PST. Staging power of preoperative testing varied with tumour biology: Positive Predictive Value was higher in Luminal A (80% for clinical examination and 100% for axillary-US) and Luminal B (72% and 70.5%) tumours, whilst Negative Predictive Value was higher in HER2 positive (100% and 93.3%), and triple negative (71.4% and 93.3%) tumours. Ninety five (52.5%) patients experienced axillary downstaging after PST, by molecular subtype 15% (3/20) in Luminal A, 46.4% (45/97) in Luminal B, 90.9% (20/22) in HER2+ and 70.3% (26/37) in triple negative breast tumours. CONCLUSION SNB application after PST for breast cancer in node positive patients at presentation is increasing. Pre-operative axillary imaging and tumour biology help identify patients who might be candidates for SNB as a single staging procedure.
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Affiliation(s)
- Rosa Di Micco
- Breast Surgery Unit, San Raffaele Hospital, Milan, Italy; Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Veronica Zuber
- Breast Surgery Unit, San Raffaele Hospital, Milan, Italy
| | - Enrico Fiacco
- Breast Surgery Unit, San Raffaele Hospital, Milan, Italy
| | | | | | | | - Pietro Panizza
- Breast Radiology Unit, San Raffaele Hospital, Milan, Italy
| | - Luigi Gianolli
- Nuclear Medicine Unit, San Raffaele Hospital, Milan, Italy
| | - Carla Canevari
- Nuclear Medicine Unit, San Raffaele Hospital, Milan, Italy
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Liedtke C, Kolberg HC, Kerschke L, Görlich D, Bauerfeind I, Fehm T, Fleige B, Helms G, Lebeau A, Stäbler A, Schmatloch S, Hausschild M, Schwentner L, von Minckwitz G, Loibl S, Untch M, Kühn T. Systematic analysis of parameters predicting pathological axillary status (ypN0 vs. ypN+) in patients with breast cancer converting from cN+ to ycN0 through primary systemic therapy (PST). Clin Exp Metastasis 2018; 35:777-783. [PMID: 30324492 DOI: 10.1007/s10585-018-9938-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 06/20/2018] [Accepted: 09/20/2018] [Indexed: 12/14/2022]
Abstract
Optimization of axillary staging among patients converting from clinically node-positive disease to clinically node-negative disease through primary systemic therapy is needed. We aimed at developing a nomogram predicting the probability of positive axillary status after chemotherapy based on clinical/pathological parameters. Patients from study arm C of the SENTINA trial were included. Univariable/multivariable analyses were performed for 13 clinical/pathological parameters to predict a positive pathological axillary status after chemotherapy using logistic regression models. Odds ratios and 95%-confidence-intervals were reported. Model performance was assessed by leave-one-out cross-validation. Calculations were performed using the SAS Software (Version 9.4, SAS Institute Inc., Cary, NC, USA). 369 of 553 patients in Arm C were included in multivariable analysis. Stepwise backward variable selection based on a multivariable analysis resulted in a model including estrogen receptor (ER) status (odds ratio (OR) 3.916, 95% confidence interval (CI) 2.318-6.615, p < 0.001), multifocality (OR 2.106, 95% CI 1.203-3.689, p = 0.0092), lymphovascular invasion (OR 9.196, 95% CI 4.734-17.864, p < 0.001), and sonographic tumor diameter after PST (OR 1.034, 95% CI 1.010-1.059, p = 0.0051). When validated, our model demonstrated an accuracy of 70.2% using 0.5 as cut-point. An area under the curve of 0.81 was calculated. The use of individual parameters as predictors of lymph node status after chemotherapy resulted in an inferior accuracy. Our model was able to predict the probability of a positive axillary nodal status with a high accuracy. The use of individual parameters showed reduced predictive performance. Overall, tumor biology was the strongest parameter in our models.
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Affiliation(s)
- C Liedtke
- Department of Gynecology, Charité University Hospital Berlin, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany.
| | | | - L Kerschke
- Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität, Münster, Germany
| | - D Görlich
- Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität, Münster, Germany
| | - I Bauerfeind
- Department of Gynecology and Obstetrics, Klinikum Landshut, Landshut, Germany
| | - T Fehm
- Department of Gynecology and Obstetrics, University Hospital Düsseldorf, Dusseldorf, Germany
| | - B Fleige
- Department of Pathology, Multidisciplinary Breast Centre, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - G Helms
- Department of Gynecology and Obstetrics, University Medical Centre Tübingen, Tübingen, Germany
| | - A Lebeau
- Department of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Stäbler
- Department of Pathology, University of Tübingen, Tübingen, Germany
| | | | - M Hausschild
- Klinikum Rheinfelden, Schweiz, Rheinfelden, Switzerland
| | - L Schwentner
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | | | - S Loibl
- German Breast Group, Neu Isenburg, Germany
| | - M Untch
- Department of Gynecology and Obstetrics, Multidisciplinary Breast Centre, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - T Kühn
- Department of Gynecology and Obstetrics, Interdisciplinary Breast Centre, Klinikum Esslingen, Esslingen, Germany
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9
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Andreis D, Bonardi S, Allevi G, Aguggini S, Gussago F, Milani M, Strina C, Spada D, Ferrero G, Ungari M, Rocca A, Nanni O, Roviello G, Berruti A, Harris AL, Fox SB, Roviello F, Polom K, Bottini A, Generali D. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with T2 to T4, N0 and N1 breast cancer. Breast 2016; 29:55-61. [PMID: 27428471 DOI: 10.1016/j.breast.2016.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 05/25/2016] [Revised: 06/30/2016] [Accepted: 07/02/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Histological status of axillary lymph nodes is an important prognostic factor in patients receiving surgery for breast cancer (BC). Sentinel lymph node (SLN) biopsy (B) has rapidly replaced axillary lymph node dissection (ALND), and is now the standard of care for axillary staging in patients with clinically node-negative (N0) operable BC. The aim of this study is to compare pretreatment lymphoscintigraphy with a post primary systemic treatment (PST) scan in order to reduce the false-negative rates for SLNB. METHODS In this single-institution study we considered 170 consecutive T2-4 N0-1 M0 BC patients treated with anthracycline-based PST. At the time of incisional biopsy, we performed sentinel lymphatic mapping. After PST, all patients repeated lymphoscintigraphy with the same methodology. During definitive surgery we performed further sentinel lymphatic mapping, SLNB and ALND. RESULTS The SLN was removed in 158/170 patients giving an identification rate of 92.9% (95% confidence interval (CI) = 88.0-96.3%) and a false-negative rate of 14.0% (95% CI = 6.3-25.8%). SLNB revealed a sensitivity of 86.0% (95% CI = 74.2-93.7%), an accuracy of 94.9% (95% CI = 90.3-97.8%) and a negative predictive value of 92.7% (95% CI = 86.1-96.8%). CONCLUSION Identification rate, sensitivity and accuracy are in accordance with other studies on SLNB after PST, even after clinically negative node conversion following PST. This study confirms that diagnostic biopsy and neoadjuvant chemotherapy maintain breast lymphatic drainage unaltered.
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Affiliation(s)
- D Andreis
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy
| | - S Bonardi
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy
| | - G Allevi
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy
| | - S Aguggini
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy
| | - F Gussago
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy
| | - M Milani
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy
| | - C Strina
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy
| | - D Spada
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy
| | - G Ferrero
- U.O. di Anatomia Patologica, Azienda Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100 Cremona, Italy
| | - M Ungari
- U.O. di Anatomia Patologica, Azienda Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100 Cremona, Italy
| | - A Rocca
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy
| | - O Nanni
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy
| | - G Roviello
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy; Section of Pharmacology and University Center DIFF - Drug Innovation Forward Future, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25124 Brescia, Italy
| | - A Berruti
- Oncologia Medica, Spedali Civili di Brescia, Università di Brescia, Italy
| | - A L Harris
- Weatherall Molecular Oncology Laboratories, Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, OX3 9DS Oxford, UK
| | - S B Fox
- Peter MacCallum Cancer Centre, St Andrews Place, East Melbourne, Victoria 3002, Australia
| | - F Roviello
- Department of Medical, Surgical and Neuroscience, Unit of General and Minimally Invasive Surgery, University of Siena, Viale Bracci 11, 53100 Siena, Italy
| | - K Polom
- Department of Medical, Surgical and Neuroscience, Unit of General and Minimally Invasive Surgery, University of Siena, Viale Bracci 11, 53100 Siena, Italy
| | - A Bottini
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy
| | - D Generali
- U.O. Chirurgia Generale ad Indirizzo Senologico, S.S. Terapia Molecolare e Farmacogenomica - Dipartimento di Chirurgia, Azienda Ospedaliera Istituti Ospitalieri, 26100 Cremona, Italy; Department of Medical, Surgery and Health Sciences, University of Trieste, Piazza Ospitale 1, 34129 Trieste, Italy.
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10
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Tőkés T, Tőkés AM, Szentmártoni G, Kiszner G, Madaras L, Kulka J, Krenács T, Dank M. Expression of cell cycle markers is predictive of the response to primary systemic therapy of locally advanced breast cancer. Virchows Arch 2016; 468:675-86. [PMID: 27026269 DOI: 10.1007/s00428-016-1925-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 06/04/2015] [Revised: 11/16/2015] [Accepted: 03/07/2016] [Indexed: 12/18/2022]
Abstract
We aimed to analyze to what extent expression of four cell cycle regulation markers-minichromosome maintenance protein (MCM2), Ki-67, cyclin A, and phosphohistone-H3 (PHH3)-predict response to primary systemic therapy in terms of pathological complete remission (pCR). In search of an accurate and reproducible scoring method, we compared computer-assisted (CA) and routine visual assessment (VA) of immunoreactivity. We included 57 patients with breast cancer in the study. The cell cycle markers were detected using immunohistochemistry on pre-therapy core biopsy samples. Parallel CA (validated by manual labeling) and standard VA were performed and compared for diagnostic agreement and predictive value for pCR. CA and VA results were dichotomized based on receiver operating characteristic analysis defined optimal cut-off values. "High" was defined by staining scores above the optimal cut-off, while "low" had staining scores below the optimal cut-off. The CA method resulted in significantly lower values for Ki-67 and MCM2 compared to VA (mean difference, -3.939 and -4.323). Diagnostic agreement was highest for cyclin A and PHH3 (-0.586 and -0.666, respectively). Regardless of the method (CA/VA) used, all tested markers were predictive of pCR. Optimal cut-off-based dichotomization improved diagnostic agreement between the CA and VA methods for every marker, in particular for MCM2 (κ = 1, p < 0.000). Cyclin A displayed excellent agreement (κ = 0.925; p < 0.000), while Ki-67 and PHH3 showed good agreement (κ = 0.789, p < 0.000 and κ = 0.794, p < 0.000, respectively). We found all cell cycle markers (Ki-67, MCM2, cyclin A, and PHH3) predictive of pCR. Diagnostic agreement between CA and VA was better at lower staining scores but improved after optimal cut-off-based dichotomization.
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Affiliation(s)
- Tímea Tőkés
- 1st Department of Internal Medicine, Oncological Division, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, 1083, Hungary
| | - Anna-Mária Tőkés
- MTA-SE Tumor Progression Research Group, 2nd Department of Pahtology, Semmelweis University, Üllői út 93, Budapest, 1091, Hungary.,2nd Department of Pathology, Semmelweis University, Üllői út 93, Budapest, 1091, Hungary
| | - Gyöngyvér Szentmártoni
- 1st Department of Internal Medicine, Oncological Division, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, 1083, Hungary
| | - Gergő Kiszner
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - Lilla Madaras
- 2nd Department of Pathology, Semmelweis University, Üllői út 93, Budapest, 1091, Hungary
| | - Janina Kulka
- 2nd Department of Pathology, Semmelweis University, Üllői út 93, Budapest, 1091, Hungary
| | - Tibor Krenács
- MTA-SE Tumor Progression Research Group, 2nd Department of Pahtology, Semmelweis University, Üllői út 93, Budapest, 1091, Hungary.,1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - Magdolna Dank
- 1st Department of Internal Medicine, Oncological Division, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, 1083, Hungary.
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11
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Tőkés T, Kajáry K, Szentmártoni G, Lengyel Z, Györke T, Torgyík L, Somlai K, Tőkés AM, Kulka J, Dank M. Predictive and prognostic value of FDG-PET/CT imaging and different response evaluation criteria after primary systemic therapy of breast cancer. Breast Cancer 2016; 24:137-146. [PMID: 26979062 DOI: 10.1007/s12282-016-0685-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 07/07/2015] [Accepted: 03/04/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVES (1) To predict pathological complete remission (pCR) and survival after primary systemic therapy (PST) in patients diagnosed with breast cancer by using two different PET/CT based scores: a simplified PERCIST-based PET/CT score (Method 1) and a combined PET/CT score supplemented with the morphological results of the RECIST system (Method 2) and (2) to assess the effect of different breast carcinoma subtypes on tumor response and its evaluation. METHODS Eighty-eight patients were enrolled in the study who underwent PET/CT imaging before and after PST. PET/CTs were evaluated by changes in maximum Standardized Uptake Value (SUVmax) and tumor size. Method 1 and 2 were applied to predict pathological complete remission (pCR). Kaplan-Meier analyses for survival were performed. Classification into biological subtypes was performed based on the pre-therapeutic tumor characteristics. RESULTS A total of 30/88 patients showed pCR (34.1 %). Comparing pCR/non-pCR patient groups, significant differences were detected by changes in SUVmax (p < 0.001) and tumor size (p < 0.001) regarding the primary breast lesions. To predict pCR, Method 2 had higher sensitivity (72.4 % vs. 44.8 %) and negative predictive value (57.9 % vs. 45.8 %) with lower false negativity rate (16 vs. 32) than Method 1. pCR rate was higher in Her2-positive and triple negative tumors. Despite the significant differences detected between the biological subtypes regarding changes in primary tumor SUVmax (p = 0.007) and size (p = 0.015), the subtypes only had significant impact on response evaluation with Method 2 and not with Method 1. In our study, neither clinical nor pathological CR were predictors of longer progression-free survival. CONCLUSIONS Our results suggest that combined PET/CT criteria are more predictive of pCR. The effect of biological subtypes is significant on pCR rate as well as on the changes in FDG-uptake and morphological tumor response. Response evaluation with combined criteria was also able to reflect the differences between the biological behavior of breast tumor subtypes.
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Affiliation(s)
- Tímea Tőkés
- Oncological Division, 1st Department of Internal Medicine, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, 1083, Hungary
| | - Kornélia Kajáry
- Pozitron PET/CT Center, Hunyadi J. út 9, Budapest, 1117, Hungary
| | - Gyöngyvér Szentmártoni
- Oncological Division, 1st Department of Internal Medicine, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, 1083, Hungary
| | - Zsolt Lengyel
- Pozitron PET/CT Center, Hunyadi J. út 9, Budapest, 1117, Hungary
| | - Tamás Györke
- Department of Nuclear Medicine, Semmelweis University, Üllői út 78/A, Budapest, 1082, Hungary.,Scanomed Ltd, Laky Adolf utca 44, Budapest, 1145, Hungary
| | - László Torgyík
- Oncological Division, 1st Department of Internal Medicine, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, 1083, Hungary
| | - Krisztián Somlai
- Surgical Division of the St Margaret Hospital, Bécsi út 132, Budapest, 1032, Hungary
| | - Anna-Mária Tőkés
- MTA-SE Tumor Progression Research Group, 2nd Department of Pathology, Üllői út 93, Budapest, 1091, Hungary.,2nd Department of Pathology, Semmelweis University, Üllői út 93, Budapest, 1091, Hungary
| | - Janina Kulka
- MTA-SE Tumor Progression Research Group, 2nd Department of Pathology, Üllői út 93, Budapest, 1091, Hungary.,2nd Department of Pathology, Semmelweis University, Üllői út 93, Budapest, 1091, Hungary
| | - Magdolna Dank
- Oncological Division, 1st Department of Internal Medicine, Semmelweis University, Tömő utca 25-29, 4th floor, Budapest, 1083, Hungary.
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12
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Beaver K, Williamson S, Briggs J. Exploring patient experiences of neo-adjuvant chemotherapy for breast cancer. Eur J Oncol Nurs 2015; 20:77-86. [PMID: 26078034 DOI: 10.1016/j.ejon.2015.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [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: 02/25/2015] [Revised: 05/29/2015] [Accepted: 06/01/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Neo-adjuvant chemotherapy is recommended for 'inoperable' locally advanced and inflammatory breast cancers. For operable breast cancers, trials indicate no survival differences between chemotherapy given pre or post-surgery. Communicating evidence based information to patients is complex and studies examining patient experiences of neo-adjuvant chemotherapy are lacking. This study aims to explore the experiences of women who received neo-adjuvant chemotherapy for breast cancer. METHODS A qualitative approach using in-depth interviews with 20 women who had completed neo-adjuvant chemotherapy for breast cancer. Interview data were analysed using thematic analysis. RESULTS The sample included a relatively young group of women, with caring responsibilities. Five main themes emerged: coping with the rapid transition from 'well' to 'ill', information needs and decision making, needing support and empathy, impact on family, and creating a new 'normal'. More support was needed towards the end of chemotherapy, when side effects were at their most toxic, and decisions about forthcoming surgery were being made. Some women were referred to psychological services, but usually when a crisis point had been reached. CONCLUSION Information and support would have been beneficial at key time points. This information is vital in developing services and interventions to meet the complex needs of these patients and potentially prevent late referral to psychological services. Specialist oncology nurses are able to develop empathetic relationships with patients and have the experience, knowledge and skills to inform and support women experiencing neo-adjuvant chemotherapy. Targeting key time points and maintaining relationship throughout neo-adjuvant chemotherapy would be highly beneficial.
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Affiliation(s)
- Kinta Beaver
- School of Health, University of Central Lancashire, Preston, UK.
| | - Susan Williamson
- School of Health, University of Central Lancashire, Preston, UK.
| | - Jean Briggs
- Department of Clinical Psychology, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK.
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13
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Tőkés T, Torgyík L, Szentmártoni G, Somlai K, Tóth A, Kulka J, Dank M. Primary systemic therapy for breast cancer: Does the patient's involvement in decision-making create a new future? Patient Educ Couns 2015; 98:695-703. [PMID: 25749023 DOI: 10.1016/j.pec.2015.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 02/05/2015] [Accepted: 02/15/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Primary systemic therapy (PST) followed by surgery is the standard initial treatment for locally advanced breast cancer (LABC). However, some patients are averse to mastectomy or breast-conserving surgery and do not consent to these procedures. The reasons for this controversial decision, the factors influencing the decision-making and optimal solutions for decision aiding need to be investigated. METHODS We addressed these questions by a review of literature on the possibilities associated with different patient choices and subsequent treatment options in relation to LABC. RESULTS A total of 5 reviews and 22 clinical studies were summarized in relation to decision making and the most successful decision aids. A discussion is given of the issues of those few patients who cannot be convinced to undergo surgery. CONCLUSION Currently there is no guideline for the treatment of patients who reject the surgical procedures after PST. Medical oncologists should be able to apply decision aid modalities in a personalized manner to give all needed information to their patients thereby ensuring a deliberate decision-making process, facilitating acceptance of a need for surgery, and thus improving the chances of prolonged survival. PRACTICE IMPLICATIONS Currently multidisciplinary tumor boards are the most suitable decision aids in oncological practice.
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Affiliation(s)
- Tímea Tőkés
- Semmelweis University, 1st Department of Internal Medicine, Oncology Division, Budapest, Hungary.
| | - László Torgyík
- Semmelweis University, 1st Department of Internal Medicine, Oncology Division, Budapest, Hungary
| | - Gyöngyvér Szentmártoni
- Semmelweis University, 1st Department of Internal Medicine, Oncology Division, Budapest, Hungary
| | - Krisztián Somlai
- Semmelweis University, 1st Department of Internal Medicine, Oncology Division, Budapest, Hungary; St. Margaret Hospital, Surgical Division, Budapest, Hungary
| | - Andrea Tóth
- Semmelweis University, 1st Department of Internal Medicine, Oncology Division, Budapest, Hungary
| | - Janina Kulka
- Semmelweis University, 2nd Department of Pathology, Budapest, Hungary
| | - Magdolna Dank
- Semmelweis University, 1st Department of Internal Medicine, Oncology Division, Budapest, Hungary
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14
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Solá M, Margelí M, Castellá E, Cirauqui B, Mariscal A, Rull M, Julian JF, Luna M, Vallejo V, Fraile M. Detection of disseminated tumor cells in locally advanced breast cancer patients before primary systemic therapy. Breast 2013; 22:908-13. [PMID: 23683695 DOI: 10.1016/j.breast.2013.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [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: 10/08/2012] [Revised: 04/07/2013] [Accepted: 04/17/2013] [Indexed: 12/14/2022] Open
Abstract
AIM To assess the prevalence and prognostic power of disseminated tumor cells (DTC) in patients with locally advanced breast cancer (LABC) before primary systemic therapy (PST). MATERIALS AND METHODS LABC patients attending our Breast Unit were studied between 2002 and 2012, all of them being considered for PST. To determine the presence of DTC, posterior iliac crest aspirates were obtained and marrow samples were processed by gradient separation with Ficoll (Lymphoprep(®)) and immunohistochemical staining using the antiCK A45-B/B3 (EPIMET) antibody. Clinicopathologic variables were recorded before and after PST to assess response. Disease-free survival (DFS) and overall survival (OS) were determined after follow-up. The presence of DTC as a predictor of response to PST and as a prognostic tool for OS and DSF was evaluated. RESULTS DTC were observed in 26% of 47 patients included in the study. PST consisted of chemotherapy in 94% and hormone therapy in 6%. Breast-conserving therapy was attained in 33%. Mean follow-up was 68 months. Complete clinical response (CR) after PST was seen in 26%, disease recurrence in 38%, and cancer-related death in 8%; tumor size and negative estrogen receptors were significant predictors of CR and mastectomy was associated with DFS. Persistent axillary disease after PST and previous recurrence were predictive of OS. DTC were detected more often in patients who did not achieve CR and those who presented recurrence. DTC detection was a significant prognostic factor for a worse OS (OR = 7.62; CI95%: 1.46-39.61; p = 0.009) and a decreased survival time (62 versus 82 months, p = 0.004). CONCLUSION Presence of DTC before PST was found in a significant number of patients with LABC. DTC were found to be a significant prognostic factor for cancer-related death. DTC could be a surrogate predictor of response to PST and also of disease recurrence in LABC patients.
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Affiliation(s)
- Montserrat Solá
- Nuclear Medicine Department, Germans Trias i Pujol University Hospital, Carretera del Canyet, Badalona, Spain.
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15
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Alonso-Romero JL, Piñero-Madrona A. Past, present and future of primary systemic treatment in breast cancer. World J Obstet Gynecol 2013; 2:21-33. [DOI: 10.5317/wjog.v2.i2.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 02/12/2013] [Accepted: 04/11/2013] [Indexed: 02/05/2023] Open
Abstract
Primary systemic treatment is a fundamental part of breast cancer therapy, and it is applied to non-surgical and locally advanced tumours as well as surgical tumours to increase the likelihood of conservative treatment. Its aim is to achieve the best possible survival with better cosmetic results and with the lowest number of treatment-related secondary effects. Before treatment is started, it is necessary to attain the best knowledge of the biological features and locoregional extension of the tumour. To do so, it is necessary to obtain a biopsy of the lesion with a wide bore needle, as well as good radiological knowledge of the disease. Therefore, currently, the use of a dynamic magnetic resonance imaging (MRI) of the breast should be included in all cases. In addition, before it is started, especially in those tumours in which conservative treatment is considered, one or several radiopaque markers should be put into place to make it possible to locate the area to be treated if there is a considerable or complete response. Systemic treatment is mainly based on combined chemotherapy with anthracyclins and taxanes, in addition to some biological agents with demonstrated efficiency for increasing the likelihood of complete disease response (trastuzumab in patients with Her-2/neu overexpression). However, there is room for neoadjuvant hormone treatment, in patients with hormone receptor overexpression, especially in those cases in which chemotherapy is contraindicated as well as in elderly patients with a relatively short life expectancy. The assessment of preoperative treatment should be based on adequate radiological tests, and nowad these should include MRI before taking decisions about adequate surgical treatment. The objective of primary treatment is to be able to increase survival and improve the chances of local treatment in the case of locally advanced treatment, achieving results that are at least equal to those of adjuvant treatment in the case of surgical tumours, but with greater chances of conservative surgery. Although the objective is survival, achieving complete pathological response seems to be a reasonable related objective, although these are more closely linked in some tumour subtypes.
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16
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Kang E, Chung IY, Han SA, Kim SM, Jang M, Lyou CY, Park SY, Kim JH, Kim YJ, Kim SW. Feasibility of sentinel lymph node biopsy in breast cancer patients with initial axillary lymph node metastasis after primary systemic therapy. J Breast Cancer 2011; 14:147-52. [PMID: 21847411 PMCID: PMC3148541 DOI: 10.4048/jbc.2011.14.2.147] [Citation(s) in RCA: 14] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Accepted: 03/28/2011] [Indexed: 11/30/2022] Open
Abstract
Purpose Primary systemic therapy (PST) downstages up to 40% of initial documented axillary lymph node (ALN) metastases in breast cancer. The current surgical treatment after PST consists of breast tumor resection and axillary lymph node dissection (ALND). This strategy, however, does not eliminate unnecessary ALND in patients with complete remission of axillary metastases. The aim of this study was to examine the accuracy of sentinel lymph node biopsy (SLNB) after PST among patients with documented ALN metastasis at presentation and to identify the rate of pathologic complete-remission (CR) with ALN after PST. Methods We analyzed 66 patients with ALN metastasis that was pathologically proven preoperatively who underwent SLNB and concomitant ALND after PST. Axillary ultrasound (AUS) was used to evaluate the clinical response of initially documented ALN metastasis after PST. Intraoperative lymphatic mapping was performed using blue dye with or without radioisotope. Results After PST, 34.8% of patients had clinical CR of ALN on AUS and 28.8% patients had pathologic CR of ALN. The overall success rate of SLNB after PST was 87.9%, and the sentinel lymph node identification rate in patients with clinical CR was 95.7%. In patients with successful lymphatic mapping, 70.7% of patients had residual axillary metastases. The overall accuracy and false-negative rate were 87.9% and 17.1% in all patients: 95.5% and 10.0% in patients with clinical CR of ALN, and 83.3% and 19.4% in patients with residual axillary disease after PST. Conclusion Our findings suggest that SLNB may be feasible in patients with initial documented ALN metastasis who have clinical CR for metastatic ALN after PST. Further investigation in a prospective setting should be performed to confirm our results.
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Affiliation(s)
- Eunyoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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