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Reimer T, Stachs A, Veselinovic K, Kühn T, Heil J, Polata S, Marmé F, Müller T, Hildebrandt G, Krug D, Ataseven B, Reitsamer R, Ruth S, Denkert C, Bekes I, Zahm DM, Thill M, Golatta M, Holtschmidt J, Knauer M, Nekljudova V, Loibl S, Gerber B. Axillary Surgery in Breast Cancer - Primary Results of the INSEMA Trial. N Engl J Med 2024. [PMID: 39665649 DOI: 10.1056/nejmoa2412063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2024]
Abstract
BACKGROUND Whether surgical axillary staging as part of breast-conserving therapy can be omitted without compromising survival has remained unclear. METHODS In this prospective, randomized, noninferiority trial, we investigated the omission of axillary surgery as compared with sentinel-lymph-node biopsy in patients with clinically node-negative invasive breast cancer staged as T1 or T2 (tumor size, ≤5 cm) who were scheduled to undergo breast-conserving surgery. We report here the per-protocol analysis of invasive disease-free survival (the primary efficacy outcome). To show the noninferiority of the omission of axillary surgery, the 5-year invasive disease-free survival rate had to be at least 85%, and the upper limit of the confidence interval for the hazard ratio for invasive disease or death had to be below 1.271. RESULTS A total of 5502 eligible patients (90% with clinical T1 cancer and 79% with pathological T1 cancer) underwent randomization in a 1:4 ratio. The per-protocol population included 4858 patients; 962 were assigned to undergo treatment without axillary surgery (the surgery-omission group), and 3896 to undergo sentinel-lymph-node biopsy (the surgery group). The median follow-up was 73.6 months. The estimated 5-year invasive disease-free survival rate was 91.9% (95% confidence interval [CI], 89.9 to 93.5) among patients in the surgery-omission group and 91.7% (95% CI, 90.8 to 92.6) among patients in the surgery group, with a hazard ratio of 0.91 (95% CI, 0.73 to 1.14), which was below the prespecified noninferiority margin. The analysis of the first primary-outcome events (occurrence or recurrence of invasive disease or death from any cause), which occurred in a total of 525 patients (10.8%), showed apparent differences between the surgery-omission group and the surgery group in the incidence of axillary recurrence (1.0% vs. 0.3%) and death (1.4% vs. 2.4%). The safety analysis indicates that patients in the surgery-omission group had a lower incidence of lymphedema, greater arm mobility, and less pain with movement of the arm or shoulder than patients who underwent sentinel-lymph-node biopsy. CONCLUSIONS In this trial involving patients with clinically node-negative, T1 or T2 invasive breast cancer (90% with clinical T1 cancer and 79% with pathological T1 cancer), omission of surgical axillary staging was noninferior to sentinel-lymph-node biopsy after a median follow-up of 6 years. (Funded by the German Cancer Aid; INSEMA ClinicalTrials.gov number, NCT02466737.).
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Affiliation(s)
- Toralf Reimer
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Angrit Stachs
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Kristina Veselinovic
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Thorsten Kühn
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Jörg Heil
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Silke Polata
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Frederik Marmé
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Thomas Müller
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Guido Hildebrandt
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - David Krug
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Beyhan Ataseven
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Roland Reitsamer
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Sylvia Ruth
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Carsten Denkert
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Inga Bekes
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Dirk-Michael Zahm
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Marc Thill
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Michael Golatta
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Johannes Holtschmidt
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Michael Knauer
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Valentina Nekljudova
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Sibylle Loibl
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
| | - Bernd Gerber
- From the Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany (T.R., A.S., B.G.); University Hospital Ulm, Ulm, Germany (K.V., I.B.); Hospital Esslingen, Esslingen, Germany (T.K.); University Hospital Heidelberg, Heidelberg, Germany (J. Heil, M.G.); the Breast Unit, Sankt Elisabeth Hospital, Heidelberg, Germany (J. Heil, M.G.); Evang. Waldkrankenhaus Spandau, Berlin (S.P.); the Faculty of Medicine Mannheim, Department of Obstetrics and Gynecology, University of Heidelberg, Mannheim, Germany (F.M.); the Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany (T.M.); the Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany (G.H.); the Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany (D.K.); the Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany (D.K.); Medical School and University Medical Center OWL, Department of Gynecology and Obstetrics, Bielefeld University, Klinikum Lippe, Detmold, Germany (B.A.); Salzburg Regional Hospital, Salzburg, Austria (R.R.); Johanniter-Hospital Genthin-Stendal, Genthin, Germany (S.R.); the Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Marburg, Germany (C.D.); Breast Center St. Gallen, Kantonsspital, St. Gallen, Switzerland (I.B.); SRH Wald-Klinikum Gera, Gera, Germany (D.-M.Z.); the Department of Gynecology and Gynecologic Oncology, Agaplesion Markus Hospital, Frankfurt am Main, Germany (M.T.); the German Breast Group, Neu-Isenburg, Germany (J. Holtschmidt, V.N., S.L.); and the Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland (M.K.)
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Tian Y, Han L, Ma X, Guo R, GeSang Z, Zhai Y, Hu H. Comparison of the effect of ultrasounic-harmonic scalpel and electrocautery in the treatment of axillary lymph nodes during radical surgery for breast cancer. World J Surg Oncol 2024; 22:91. [PMID: 38600546 PMCID: PMC11007932 DOI: 10.1186/s12957-024-03381-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/06/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVE To compare the efficacy of ultrasounic-harmonic scalpel and electrocautery in the treatment of axillary lymph nodes during radical surgery for breast cancer. METHODS A prospective study was conducted in the Department of Breast Surgery, Zhongda Hospital Affiliated to Southeast University. A total of 128 patients with pathologically confirmed breast cancer who were treated by the same surgeon from July 2023 to November 2023 were included in the analysis. All breast operations were performed using electrocautery, and surgical instruments for axillary lymph nodes were divided into ultrasounic-harmonic scalpel group and electrocautery group using a random number table. According to the extent of lymph node surgery, it was divided into four groups: sentinel lymph node biopsy, lymph node at station I, lymph node at station I and II, and lymph node dissection at station I, II and III. Under the premise of controlling variables such as BMI, age and neoadjuvant chemotherapy, the effects of ultrasounic-harmonic scalpel and electrocautery in axillary surgery were compared. RESULTS Compared with the electrosurgical group, there were no significant differences in lymph node operation time, intraoperative blood loss, postoperative axillary drainage volume, axillary drainage tube indwelling time, postoperative pain score on the day after surgery, and the incidence of postoperative complications (p>0.05). CONCLUSION There is no significant difference between ultrasounic-harmonic scalpel and electrocautery in axillary lymph node treatment for breast cancer patients, which can provide a basis for the selection of surgical energy instruments.
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Affiliation(s)
- Yujia Tian
- School of Medicine, Southeast University, Nanjing, 210009, China
- Department of General Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
- Breast Disease Diagnosis and Treatment Center, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
| | - Lifei Han
- Department of General Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
- Breast Disease Diagnosis and Treatment Center, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
| | - Xiao Ma
- Department of General Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
- Breast Disease Diagnosis and Treatment Center, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
| | - Rui Guo
- School of Medicine, Southeast University, Nanjing, 210009, China
- Department of General Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
- Breast Disease Diagnosis and Treatment Center, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
| | - Zhuoga GeSang
- School of Medicine, Southeast University, Nanjing, 210009, China
- Department of General Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
- Breast Disease Diagnosis and Treatment Center, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
| | - Yabo Zhai
- School of Medicine, Southeast University, Nanjing, 210009, China
- Department of General Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
- Breast Disease Diagnosis and Treatment Center, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China
| | - Haolin Hu
- School of Medicine, Southeast University, Nanjing, 210009, China.
- Department of General Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China.
- Breast Disease Diagnosis and Treatment Center, Zhongda Hospital Affiliated to Southeast University, Nanjing, 210009, China.
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Weber WP, Davide Gentilini O, Morrow M, Montagna G, de Boniface J, Fitzal F, Wyld L, Rubio IT, Matrai Z, King TA, Saccilotto R, Galimberti V, Maggi N, Andreozzi M, Sacchini V, Castrezana López L, Loesch J, Schwab FD, Eller R, Heidinger M, Haug M, Kurzeder C, Di Micco R, Banys-Paluchowski M, Ditsch N, Harder Y, Paulinelli RR, Urban C, Benson J, Bjelic-Radisic V, Potter S, Knauer M, Thill M, Vrancken Peeters MJ, Kuemmel S, Heil J, Gulluoglu BM, Tausch C, Ganz-Blaettler U, Shaw J, Dubsky P, Poortmans P, Kaidar-Person O, Kühn T, Gnant M. Uncertainties and controversies in axillary management of patients with breast cancer. Cancer Treat Rev 2023; 117:102556. [PMID: 37126938 PMCID: PMC10752145 DOI: 10.1016/j.ctrv.2023.102556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/27/2023] [Accepted: 04/01/2023] [Indexed: 05/03/2023]
Abstract
The aims of this Oncoplastic Breast Consortium and European Breast Cancer Research Association of Surgical Trialists initiative were to identify uncertainties and controversies in axillary management of early breast cancer and to recommend appropriate strategies to address them. By use of Delphi methods, 15 questions were prioritized by more than 250 breast surgeons, patient advocates and radiation oncologists from 60 countries. Subsequently, a global virtual consensus panel considered available data, ongoing studies and resource utilization. It agreed that research should no longer be prioritized for standardization of axillary imaging, de-escalation of axillary surgery in node-positive cancer and risk evaluation of modern surgery and radiotherapy. Instead, expert consensus recommendations for clinical practice should be based on current evidence and updated once results from ongoing studies become available. Research on de-escalation of radiotherapy and identification of the most relevant endpoints in axillary management should encompass a meta-analysis to identify knowledge gaps, followed by a Delphi process to prioritize and a consensus conference to refine recommendations for specific trial designs. Finally, treatment of residual nodal disease after surgery was recommended to be assessed in a prospective register.
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Affiliation(s)
- Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | | | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Unit, Capio St Göran's Hospital, Stockholm, Sweden
| | - Florian Fitzal
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Austria; Austrian Breast and Colorectal Study Group ABCSG, Vienna, Austria
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Isabel T Rubio
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Madrid, Spain
| | - Zoltan Matrai
- Hamad Medical Corporation, Dept of Oncoplastic Breast Surgery, Doha, Qatar
| | - Tari A King
- Division of Breast Surgery, Brigham and Women's Hospital, Dana Farber/Brigham Cancer Center, Boston, MA, USA
| | - Ramon Saccilotto
- University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Mariacarla Andreozzi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Julie Loesch
- Gynecology Department, University Hospital Zurich, Zurich, Switzerland
| | - Fabienne D Schwab
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Ruth Eller
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Haug
- 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
| | - Rosa Di Micco
- Breast Surgery, San Raffaele University and Research Hospital, Milan, Italy
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Nina Ditsch
- Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Régis R Paulinelli
- Federal University of Goias, Goias, Brazil; Breast Unit, Araújo Jorge Hospital, Goias, Brazil
| | - Cicero Urban
- Breast Unit, Hospital Nossa Senhora Das Graças, Curitiba, Brazil
| | - John Benson
- Cambridge Breast Unit, Addenbrooke's Hospital Cambridge, Cambridge, UK; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation TRUST, School of Medicine, Anglia Ruskin University, Cambridge, UK
| | - Vesna Bjelic-Radisic
- Breast Unit, University Hospital Helios Wuppertal, University Witten/Herdecke, Wuppertal, Germany; Medical University Graz, Graz, Austria
| | | | - Michael Knauer
- Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Marc Thill
- Department of Gynaecology and Gynaecological Oncology, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Surgery, University Medical Center, Amsterdam, Netherlands
| | - Sherko Kuemmel
- Breast Unit, Hospital Essen-Mitte, Germany; Charité - Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Joerg Heil
- Department of Obstetrics and Gynecology, University of Heidelberg, Medical School, Heidelberg, Germany
| | | | | | | | - Jane Shaw
- Patient Advocacy Group, Oncoplastic Breast Consortium, Basel, Switzerland
| | - Peter Dubsky
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland; Breast Centre, Hirslanden Clinic St. Anna, Lucerne, Switzerland
| | - Philip Poortmans
- Iridium Netwerk and University of Antwerp, Wilrijk-Antwerpen, Belgium
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, at Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Dept. Radiation Oncologv (Maastro), Maastricht, Netherlands
| | - Thorsten Kühn
- Department of Gynecology, Hospital Esslingen, Esslingen, Germany
| | - Michael Gnant
- Austrian Breast and Colorectal Study Group ABCSG, Vienna, Austria; Comprehensive Cancer Center Medical University Vienna, Vienna, Austria
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Skarping I, Nilsson K, Dihge L, Fridhammar A, Ohlsson M, Huss L, Bendahl PO, Steen Carlsson K, Rydén L. The implementation of a noninvasive lymph node staging (NILS) preoperative prediction model is cost effective in primary breast cancer. Breast Cancer Res Treat 2022; 194:577-586. [PMID: 35790694 PMCID: PMC9287207 DOI: 10.1007/s10549-022-06636-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/13/2022] [Indexed: 11/29/2022]
Abstract
Purpose The need for sentinel lymph node biopsy (SLNB) in clinically node-negative (cN0) patients is currently questioned. Our objective was to investigate the cost-effectiveness of a preoperative noninvasive lymph node staging (NILS) model (an artificial neural network model) for predicting pathological nodal status in patients with cN0 breast cancer (BC). Methods A health-economic decision-analytic model was developed to evaluate the utility of the NILS model in reducing the proportion of cN0 patients with low predicted risk undergoing SLNB. The model used information from a national registry and published studies, and three sensitivity/specificity scenarios of the NILS model were evaluated. Subgroup analysis explored the outcomes of breast-conserving surgery (BCS) or mastectomy. The results are presented as cost (€) and quality-adjusted life years (QALYs) per 1000 patients. Results All three scenarios of the NILS model reduced total costs (–€93,244 to –€398,941 per 1000 patients). The overall health benefit allowing for the impact of SLNB complications was a net health gain (7.0–26.9 QALYs per 1000 patients). Sensitivity analyses disregarding reduced quality of life from lymphedema showed a small loss in total health benefits (0.4–4.0 QALYs per 1000 patients) because of the reduction in total life years (0.6–6.5 life years per 1000 patients) after reduced adjuvant treatment. Subgroup analyses showed greater cost reductions and QALY gains in patients undergoing BCS. Conclusion Implementing the NILS model to identify patients with low risk for nodal metastases was associated with substantial cost reductions and likely overall health gains, especially in patients undergoing BCS. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06636-x.
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Affiliation(s)
- Ida Skarping
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund, Sweden.
| | | | - Looket Dihge
- Division of Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | | | - Mattias Ohlsson
- Division of Computational Biology and Biological Physics, Department of Astronomy and Theoretical Physics, Lund University, Lund, Sweden
| | - Linnea Huss
- Division of Surgery, Department of Clinical Sciences Helsingborg, Lund University, Lund, Sweden.,Department of Surgery, Helsingborg General Hospital, Helsingborg, Sweden
| | - Pär-Ola Bendahl
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Katarina Steen Carlsson
- The Swedish Institute for Health Economics, Lund, Sweden.,Department of Clinical Sciences, Health Economics, Lund University, Malmö, Lund, Sweden
| | - Lisa Rydén
- Division of Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Surgery and Gastroenterology, Skåne University Hospital, Malmö, Sweden
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5
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Sentinel node involvement with or without completion axillary lymph node dissection: treatment and pathologic results of randomized SERC trial. NPJ Breast Cancer 2021; 7:133. [PMID: 34625562 PMCID: PMC8501060 DOI: 10.1038/s41523-021-00336-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 08/20/2021] [Indexed: 01/21/2023] Open
Abstract
Based on results of clinical trials, completion ALND (cALND) is frequently not performed for patients with breast conservation therapy and one or two involved sentinel nodes (SN) by micro- or macro-metastases. However, there were limitations despite a conclusion of non-inferiority for cALND omission. No trial had included patients with SN macro-metastases and total mastectomy or with >2 SN macro-metastases. The aim of the study was too analyze treatment delivered and pathologic results of patients included in SERC trial. SERC trial is a multicenter randomized non-inferiority phase-3 trial comparing no cALND with cALND in cT0-1-2, cN0 patients with SN ITC (isolated tumor cells) or micro-metastases or macro-metastases, mastectomy or breast conservative surgery. We randomized 1855 patients, 929 to receive cALND and 926 SLNB alone. No significant differences in patient’s and tumor characteristics, type of surgery, and adjuvant chemotherapy (AC) were observed between the two arms. Rates of involved SN nodes by ITC, micro-metastases, and macro-metastases were 5.91%, 28.12%, and 65.97%, respectively, without significant difference between two arms for all criteria. In multivariate analysis, two factors were associated with higher positive non-SN rate: no AC versus AC administered after ALND (OR = 3.32, p < 0.0001) and >2 involved SN versus ≤2 (OR = 3.45, p = 0.0258). Crude rates of positive NSN were 17.62% (74/420) and 26.45% (73/276) for patient’s eligible and non-eligible to ACOSOG-Z0011 trial. No significant differences in patient’s and tumor characteristics and treatment delivered were observed between the two arms. Higher positive-NSN rate was observed for patients with AC performed after ALND (17.65% for SN micro-metastases, 35.22% for SN macro-metastases) in comparison with AC administered before ALND.
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6
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Herrero M, Ciérvide R, Calle-Purón ME, Valero J, Buelga P, Rodriguez-Bertos I, Benassi L, Montero A. Macrometastasis at selective lymph node biopsy: A practical going-for-the-one clinical scoring system to personalize decision making. World J Clin Oncol 2021; 12:675-687. [PMID: 34513601 PMCID: PMC8394159 DOI: 10.5306/wjco.v12.i8.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/05/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Axillary sentinel lymph node biopsy (SLNB) is standard treatment for patients with clinically and pathological negative lymph nodes. However, the role of completion axillary lymph node dissection (cALND) following positive sentinel lymph node biopsy (SLNB) is debated.
AIM To identify a subgroup of women with high axillary tumor burden undergoing SLNB in whom cALND can be safely omitted in order to reduce the risk of long-term complications and create a Preoperative Clinical Risk Index (PCRI) that helps us in our clinical practice to optimize the selection of these patients.
METHODS Patients with positive SLNB who underwent a cALND were included in this study. Univariate and multivariate analysis of prognostic and predictive factors were used to create a PCRI for safely omitting cALND.
RESULTS From May 2007 to April 2014, we performed 1140 SLN biopsies, of which 125 were positive for tumor and justified to practice a posterior cALND. Pathologic findings at SLNB were micrometastases (mic) in 29 cases (23.4%) and macrometastasis (MAC) in 95 cases (76.6%). On univariate analysis of the 95 patients with MAC, statistically significant factors included: age, grade, phenotype, histology, lymphovascular invasion, lymph-node tumor size, and number of positive SLN. On multivariate analysis, only lymph-node tumor size (≤ 20 mm) and number of positive SLN (> 1) retained significance. A numerical tool was created giving each of the parameters a value to predict preoperatively which patients would not benefit from cALND. Patients with a PCRI ≤ 15 has low probability (< 10%) of having additional lymph node involvement, a PRCI between 15-17.6 has a probability of 43%, and the probability increases to 69% in patients with a PCRI > 17.6.
CONCLUSION The PCRI seems to be a useful tool to prospectively estimate the risk of nodal involvement after positive SLN and to identify those patients who could omit cALND. Further prospective studies are necessary to validate PCRI clinical generalization.
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Affiliation(s)
- Mercedes Herrero
- Department of Gynecology and Obstetrics, HM Hospitales, Madrid 28050, Spain
| | - Raquel Ciérvide
- Department of Radiation Oncology, HM Hospitales, Madrid 28050, Spain
| | - Maria Elisa Calle-Purón
- Department of Preventive Medicine and Public Health, Complutense University of Madrid, Madrid 28050, Spain
| | - Javier Valero
- Department of Gynecology and Obstetrics, HM Hospitales, Madrid 28050, Spain
| | - Paula Buelga
- Department of Gynecology and Obstetrics, HM Hospitales, Madrid 28050, Spain
| | | | - Leticia Benassi
- Department of Gynecology and Obstetrics, HM Hospitales, Madrid 28050, Spain
| | - Angel Montero
- Department of Radiation Oncology, HM Hospitales, Madrid 28050, Spain
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Keelan S, Flanagan M, Hill ADK. Evolving Trends in Surgical Management of Breast Cancer: An Analysis of 30 Years of Practice Changing Papers. Front Oncol 2021; 11:622621. [PMID: 34422626 PMCID: PMC8371403 DOI: 10.3389/fonc.2021.622621] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/19/2021] [Indexed: 01/12/2023] Open
Abstract
The management of breast cancer has evolved into a multidisciplinary evidence-based surgical speciality, with emphasis on conservative surgery. A number of landmark trials have established lumpectomy followed by radiation as the standard of care for many patients. The aim of this study is to construct a narrative review of recent developments in the surgical management of breast cancer and how such developments have impacted surgical practice. A comprehensive literature search of Pubmed was conducted. The latest search was performed on October 31st, 2020. Search terms “breast cancer” were used in combinations with specific key words and Boolean operators relating to surgical management. The reference lists of retrieved articles were comprehensively screened for additional eligible publications. Articles were selected and reviewed based on relevance. We selected publications in the past 10 years but did not exclude commonly referenced and highly regarded previous publications. Review articles and book chapters were also cited to provide reference on details not discussed in the academic literature. This article reviews the current evidence in surgical management of early-stage breast cancer, discusses recent trends in surgical practice for therapeutic and prophylactic procedures and provides commentary on implications and factors associated with these trends.
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Affiliation(s)
- Stephen Keelan
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,The Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Michael Flanagan
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,The Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Arnold D K Hill
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,The Department of Surgery, Beaumont Hospital, Dublin, Ireland
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Predictors of Sentinel Lymph Node Metastasis in Postoperatively Upgraded Invasive Breast Carcinoma Patients. Cancers (Basel) 2021; 13:cancers13164099. [PMID: 34439252 PMCID: PMC8392104 DOI: 10.3390/cancers13164099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
Sentinel lymph node (SLN) biopsy (SLNB) usually need not be simultaneously performed with breast-conserving surgery (BCS) for patients diagnosed with ductal carcinoma in situ (DCIS) by preoperative core needle biopsy (CNB), but must be performed once there is invasive carcinoma (IC) found postoperatively. This study aimed to investigate the factors contributing to SLN metastasis in underestimated IC patients with an initial diagnosis of DCIS by CNB. We retrospectively reviewed 1240 consecutive cases of DCIS by image-guided CNB from January 2010 to December 2017 and identified 316 underestimated IC cases with SLNB. Data on clinical characteristics, radiologic features, and final pathological findings were examined. Twenty-three patients (7.3%) had SLN metastasis. Multivariate analysis indicated that an IC tumor size > 0.5 cm (odds ratio: 3.11, p = 0.033) and the presence of lymphovascular invasion (odds ratio: 32.85, p < 0.0001) were independent risk predictors of SLN metastasis. In the absence of any predictors, the incidence of positive SLNs was very low (2.6%) in the total population and extremely low (1.3%) in the BCS subgroup. Therefore, omitting SLNB may be an acceptable option for patients who initially underwent BCS without risk predictors on final pathological assessment. Further prospective studies are necessary before clinical application.
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9
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Özler İ, Aydin H, Güler OC, Esen Bostancı I, Şahin Güner B, Karaman N, Doğan L, Özaslan C. Can preoperative axillary ultrasound and biopsy of suspicious lymph nodes be an alternative to sentinel lymph node biopsy in clinical node negative early breast cancer? Int J Clin Pract 2021; 75:e14332. [PMID: 33960070 DOI: 10.1111/ijcp.14332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/21/2021] [Accepted: 05/03/2021] [Indexed: 11/26/2022] Open
Abstract
AIM The aim of this study was to assess the efficacy of preoperative axillary ultrasonography (AUS) and preoperative axillary fine-needle aspiration biopsy (FNAB) from suspicious lymph nodes in clinically node-negative breast cancer to compare with radiologically positive and sentinel lymph node biopsy (SLNB) positive involvement. METHOD Clinically node-negative early-stage breast cancer patients were included in the study. These patients underwent preoperative AUS examination, suspicious lymph nodes were evaluated with FNAB. AUS-FNAB results were compared with those of SLNB or axillary dissection. RESULTS Of 181 patients undergoing AUS, 32 were reported to have axillary metastasis, 25 suspicious, and 124 benign nodes. The suspicious group underwent FNAB examination and metastasis was found in 9 of them. The sensitivity of AUS-FNAB was found to be 64.06%, specificity 100%, positive predictive value 100%, and negative predictive value (NPV) 83.5%. The false negativity rate (FN) of this method was 16,4%. Lymphovascular invasion and tumour size were found statistically significant factors for false negativity. CONCLUSION It was concluded that axillary AUS-FNAB with its high NPV, low FN rate, may be a clinical alternative to SLNB for early-stage breast cancer patients.
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Affiliation(s)
- İsmail Özler
- General Surgery Clinics of University of Health Sciences, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Hale Aydin
- Radiology Clinics of University of Health Sciences, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Onur Can Güler
- General Surgery Clinics of University of Health Sciences, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Işıl Esen Bostancı
- Radiology Clinics of University of Health Sciences, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Bahar Şahin Güner
- Radiology Clinics of University of Health Sciences, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Niyazi Karaman
- General Surgery Clinics of University of Health Sciences, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Lütfi Doğan
- General Surgery Clinics of University of Health Sciences, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Cihangir Özaslan
- General Surgery Clinics of University of Health Sciences, Ankara Oncology Education and Research Hospital, Ankara, Turkey
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10
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PET/MRI for Staging the Axilla in Breast Cancer: Current Evidence and the Rationale for SNB vs. PET/MRI Trials. Cancers (Basel) 2021; 13:cancers13143571. [PMID: 34298781 PMCID: PMC8303241 DOI: 10.3390/cancers13143571] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/05/2021] [Accepted: 07/12/2021] [Indexed: 01/03/2023] Open
Abstract
Simple Summary PET/MRI is a relatively new, hybrid imaging tool that allows practitioners to obtain both a local and systemic staging in breast cancer patients in a single exam. To date, the available evidence is not sufficient to determine the role of PET/MRI in breast cancer management. The aims of this paper are to provide an overview of the current literature on PET/MRI in breast cancer, and to illustrate two ongoing trials aimed at defining the eventual role of PET/MRI in axillary staging in two different settings: patients with early breast cancer and patients with positive axillary nodes that are candidates for primary systemic therapy. In both cases, findings from PET/MRI will be compared with the final pathology and could be helpful to better tailor axillary surgery in the future. Abstract Axillary surgery in breast cancer (BC) is no longer a therapeutic procedure but has become a purely staging procedure. The progressive improvement in imaging techniques has paved the way to the hypothesis that prognostic information on nodal status deriving from surgery could be obtained with an accurate diagnostic exam. Positron emission tomography/magnetic resonance imaging (PET/MRI) is a relatively new imaging tool and its role in breast cancer patients is still under investigation. We reviewed the available literature on PET/MRI in BC patients. This overview showed that PET/MRI yields a high diagnostic performance for the primary tumor and distant lesions of liver, brain and bone. In particular, the results of PET/MRI in staging the axilla are promising. This provided the rationale for two prospective comparative trials between axillary surgery and PET/MRI that could lead to a further de-escalation of surgical treatment of BC. • SNB vs. PET/MRI 1 trial compares PET/MRI and axillary surgery in staging the axilla of BC patients undergoing primary systemic therapy (PST). • SNB vs. PET/MRI 2 trial compares PET/MRI and sentinel node biopsy (SNB) in staging the axilla of early BC patients who are candidates for upfront surgery. Finally, these ongoing studies will help clarify the role of PET/MRI in BC and establish whether it represents a useful diagnostic tool that could guide, or ideally replace, axillary surgery in the future.
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11
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Keelan S, Heeney A, Downey E, Hegarty A, Roche T, Power C, Mhuircheartaigh NN, Duke D, Kerr J, Hambly N, Hill A. Breast cancer patients with a negative axillary ultrasound may have clinically significant nodal metastasis. Breast Cancer Res Treat 2021; 187:303-310. [PMID: 33837870 DOI: 10.1007/s10549-021-06194-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/12/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The non-invasive nature of the preoperative axillary ultrasound (AUS) fits the current trend of increasingly conservative axillary management. Recent publications suggest that early disease patients with clinically and radiologically negative axillae do not require sentinel lymph node biopsy (SLNB). This study aims to determine the true extent of axillary node disease in negative preoperative AUS patients. METHODS A 10-year breast cancer registry was reviewed to identify women with pathologically confirmed T1-2 invasive breast cancer and a negative preoperative AUS. Patients who received neoadjuvant chemotherapy were excluded. Combined positive lymph node count of SLNB ± ALND was used to determine total nodal burden (TNB). Axillae were classified into low nodal burden (LNB) defined as 1-2 positive nodes and high nodal burden (HNB) defined as ≥ 3 positive nodes. RESULTS 762 patients with negative AUS were included. There were 46.9% and 53.0% T1 and T2 tumours, respectively. 76.9% were node negative (0 LN +), 18.9% had LNB (1-2 LN +) and 4.2% had HNB (≥ 3LN +). Specifically, HNB disease was seen in 2% of T1 tumours and 6.2 % of T2 tumours with a negative AUS. In multivariate analysis, T2 strongly associated with ≥ 3 positive ALNs (OR 2.66 CI 1.09-6.51 p = 0.03) as did lymphovascular invasion (OR 3.56 CI 1.52-8.30 p = < 0.01). CONCLUSION This study shows that AUS in its current form cannot exclude HNB axillary metastasis to the extent of eliminating the need for surgical staging of the axilla. This may impact axillary local-regional recurrence and disease-free survival. We caution that a negative AUS has a rate of 4.2% of HNB. Therefore, in cases of negative AUS with a T2 tumour, we advocate continued use of SLNB.
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Affiliation(s)
- Stephen Keelan
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland. .,Department of Breast and Endocrine Surgery, Beaumont Hospital, Dublin, Ireland.
| | - Anna Heeney
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Breast and Endocrine Surgery, Beaumont Hospital, Dublin, Ireland
| | - Eithne Downey
- Department of Breast and Endocrine Surgery, Beaumont Hospital, Dublin, Ireland
| | - Aisling Hegarty
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Breast and Endocrine Surgery, Beaumont Hospital, Dublin, Ireland
| | - Trudi Roche
- Department of Breast and Endocrine Surgery, Beaumont Hospital, Dublin, Ireland
| | - Colm Power
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Breast and Endocrine Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Deirdre Duke
- Department of Radiology, Beaumont Hospital, Beaumont Hospital, Dublin, Ireland
| | - Jennifer Kerr
- Department of Radiology, Beaumont Hospital, Beaumont Hospital, Dublin, Ireland
| | - Niamh Hambly
- Department of Radiology, Beaumont Hospital, Beaumont Hospital, Dublin, Ireland
| | - Arnold Hill
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Breast and Endocrine Surgery, Beaumont Hospital, Dublin, Ireland
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12
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Di Micco R, Gentilini OD. Axillary observation alone versus sentinel node biopsy: past, present and future perspectives. MINERVA CHIR 2020; 75:392-399. [PMID: 33345525 DOI: 10.23736/s0026-4733.20.08528-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The evolution of axillary surgery in breast cancer has led from complete axillary dissection (AD) to sentinel node biopsy (SNB). It has not stopped yet but continues with a progressive de-escalation of surgical procedures aiming at axillary conservation. In parallel, the meaning of axillary surgery has changed as well. Over time, the dual role of both a therapeutic and a staging procedure has decreased leaving room to other modalities to treat and stage breast cancer. Although, the gold standard for axillary staging in early breast cancer remains SNB, the idea that axillary surgery could be even omitted has been proposed. The concept of abandoning axillary surgery is revolutionary but not new. Historical literature provides interesting data on patients who did not receive any axillary treatment at all with no impact on their survival. Starting from this, several ongoing trials are working to demonstrate that in selected breast cancer cohorts the information deriving from axillary surgery is superfluous and "axillary observation" alone is as effective as SNB. Whilst surgery has been de-escalated to less invasive procedures, systemic treatment, radiotherapy, multigene assays and advanced imaging modalities have gained ground in the management of breast cancer. New research is expected to help select the subgroups of patients for whom axillary surgery is not necessary anymore. This is a qualitative review reporting the most relevant literature data from historical trials on the omission of axillary surgery to the most recent and ongoing ones.
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Affiliation(s)
- Rosa Di Micco
- Breast Surgery Unit, IRCCS San Raffaele Hospital, Milan, Italy - .,Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy -
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13
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Kouloura A, Lanitis S, Filopoulos E, Angelopoulos MP, Kosmidis SP, Arkadopoulos N. Ongoing clinical trials on axillary management. MINERVA CHIR 2020; 75:408-418. [PMID: 33345527 DOI: 10.23736/s0026-4733.20.08490-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Within the last 50 years the management of patients with breast cancer has changed dramatically with a significant de-escalation of the role and magnitude of surgery, both for the management of the primary tumor and for the management of the axilla. In the management of the axilla of patients with early stage breast cancer (EBC) and clinically uninvolved axilla (cN0), axillary lymph node dissection (ALND) was gradually replaced by sentinel lymph node biopsy (SLNB) saving more than 60-70% of patients from an unnecessary dissection. Further studies confirmed that isolated tumor cells or micrometastases found on the SLN had no further benefit from ALND sparing even more patients from an unnecessary ALND. Eventually, the Z0011 and other studies showed that even patients with 1-2 positive SLN can be spared from ALND provided they fulfill certain criteria. Still though there were many flaws in these studies and further research was necessary to generalize the results of these studies to a wider target group. Meanwhile, there is a clear view that many low risk patients if they have their axilla evaluated via US and are not found to have suspicious nodes, it is highly unlikely to have involved axilla. This let to studies evaluating the non-surgical management of the axilla. Finally, in the post neoadjuvant setting 3 randomized controlled trials showed that under certain circumstances SLNB can be done after the NAC even in patients who initially had involved axilla and was converted to clinically uninvolved (cN1→cN0). EVIDENCE ACQUISITION PubMed, Medline, the Cochrane Library Controlled Trials Register as well as National Institutes of Health ClinicalTrials.Gov database have been consulted up to May 2020. EVIDENCE SYNTHESIS We studied and described the ongoing trials on patients not undergoing neoadjuvant chemotherapy and we discussed the eligibility criteria, the comparison arms and the expected outcomes. We further examined the ongoing trials on patients undergoing neoadjuvant chemotherapy in the same manner. CONCLUSIONS Although we have covered a long way in the journey of eliminating axillary surgery, there are still lots of questions to be answered and trials to be conducted. We anticipate the results of the ongoing trials to provide the necessary evidence to safely de-escalate more the axillary surgery, both in the non-neoadjuvant as well as in the neoadjuvant setting, hoping that in the not so far future the axillary surgery will eventually perish.
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Affiliation(s)
- Andriana Kouloura
- Department of Breast Surgery, Athens Euroclinic Hospital, Athens, Greece -
| | - Sophocles Lanitis
- Unit of Surgical Oncology, Second Surgical Department, Korgialenio - Benakio Hellenic Red Cross Hospital, Greece, Athens
| | | | | | | | - Nikolaos Arkadopoulos
- Fourth Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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14
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McEvoy AM, Poplack S, Nickel K, Olsen MA, Ademuyiwa F, Zoberi I, Odom E, Yu J, Chang SH, Gillanders WE. Cost-effectiveness analyses demonstrate that observation is superior to sentinel lymph node biopsy for postmenopausal women with HR + breast cancer and negative axillary ultrasound. Breast Cancer Res Treat 2020; 183:251-262. [PMID: 32651755 DOI: 10.1007/s10549-020-05768-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/22/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE To evaluate the cost-effectiveness of axillary observation versus sentinel lymph node biopsy (SLNB) after negative axillary ultrasound (AUS). In patients with clinical T1-T2 N0 breast cancer and negative AUS, SLNB is the current standard of care for axillary staging. However, SLNB is costly, invasive, decreasing in importance for medical decision-making, and is not considered therapeutic. Observation alone is currently being evaluated in randomized clinical trials, and is thought to be non-inferior to SLNB for patients with negative AUS. METHODS We performed cost-effectiveness analyses of observation versus SLNB after negative AUS in postmenopausal women with clinical T1-T2 N0, HR+/HER2- breast cancer. Costs at the 2016 price level were evaluated from a third-party commercial payer perspective using the MarketScan® Database. We compared cost, quality-adjusted life years (QALYs), and net monetary benefit (NMB). Multiple sensitivity analyses varying baseline probabilities, costs, utilities, and willingness-to-pay thresholds were performed. RESULTS Observation was superior to SLNB for patients with N0 and N1 disease, and for the entire patient population (NMB in US$: $655,659 for observation versus $641,778 for SLNB for the entire patient population). In the N0 and N1 groups, observation incurred lower cost and was associated with greater QALYs. SLNB was superior for patients with > 3 positive lymph nodes, representing approximately 5% of the population. Sensitivity analyses consistently demonstrated that observation is the optimal strategy for AUS-negative patients. CONCLUSION Considering both cost and effectiveness, observation is superior to SLNB in postmenopausal women with cT1-T2 N0, HR+/HER2- breast cancer and negative AUS.
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Affiliation(s)
- Aubriana M McEvoy
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Steven Poplack
- Department of Diagnostic Radiology, Section of Breast Imaging, Washington, University St. Louis, St. Louis, MO, USA
- Siteman Cancer Center, St. Louis, MO, USA
| | - Katelin Nickel
- Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA
| | - Margaret A Olsen
- Siteman Cancer Center, St. Louis, MO, USA
- Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA
| | - Foluso Ademuyiwa
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Medical Oncology, Washington, University St. Louis, St. Louis, MO, USA
| | - Imran Zoberi
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Radiation Oncology, Washington, University St. Louis, St. Louis, MO, USA
| | - Elizabeth Odom
- Division of Plastic Surgery, Washington, University St. Louis, St. Louis, MO, USA
| | - Jennifer Yu
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA
| | - Su-Hsin Chang
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA
| | - William E Gillanders
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA.
- Siteman Cancer Center, St. Louis, MO, USA.
- Department of Surgery, Washington University School of Medicine, Campus Box 8109, 4590 Children's Place, Suite 9600, St. Louis, MO, 63110, USA.
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15
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Central Review of Radiation Therapy Planning Among Patients with Breast-Conserving Surgery: Results from a Quality Assurance Process Integrated into the INSEMA Trial. Int J Radiat Oncol Biol Phys 2020; 107:683-693. [PMID: 32437921 DOI: 10.1016/j.ijrobp.2020.04.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE After publication of the radiation field design in the American College of Surgeons Oncology Group Z0011 trial, a radiation therapy quality assurance review was integrated into the Intergroup-Sentinel-Mamma (INSEMA) trial. We aimed to investigate the role of patient characteristics, extent of axillary surgery, and radiation techniques for dose distribution in ipsilateral axillary levels. METHODS AND MATERIALS INSEMA (NCT02466737) has randomized 5542 patients who underwent breast-conserving surgery. Of these, 276 patients from 108 radiation therapy facilities were included in the central review, using the planning records of the first 3 patients treated at each site. RESULTS Of the 276 patients, 41 had major deviations (ie, no axillary contouring or submission of insufficient records) leading to exclusion. A total of 235 (85.1%) radiation therapy planning records were delineated according to the INSEMA protocol, including 9 (3.8%) cases with minor deviations. At least 25% of INSEMA patients were unintentionally treated with ≥95% of the prescribed breast radiation dose in axillary level I. Approximately 50% of patients were irradiated with a median radiation dose of more than 85% of prescription dose in level I. Irradiated volumes and applied doses were significantly lower in levels II and III compared with level I. However, 25% of patients still received a median radiation dose of ≥75% of prescription dose to level II. Subgroup analysis revealed a significant association between incidental radiation dose in the axilla and obesity. Younger age, boost application, and fractionation schedule showed no impact on axillary dose distribution. CONCLUSIONS Assuming ≥80% of prescribed breast dose as the optimal dose for curative radiation of low-volume disease in axillary lymph nodes, at least 50% of reviewed INSEMA patients received an adequate dose in level I, even with contemporary 3-dimensional techniques. Dose coverage was much less in axillary levels II and III, and far below therapeutically relevant doses.
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16
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Bae MS. Using Deep Learning to Predict Axillary Lymph Node Metastasis from US Images of Breast Cancer. Radiology 2020; 294:29-30. [DOI: 10.1148/radiol.2019192339] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Min Sun Bae
- From the Department of Radiology, Inha University Hospital, 27 Inhang-ro, Jung-gu, Incheon 22332, Korea
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17
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A Radiation Oncologist’s Guide to Axillary Management in Breast Cancer: a Walk Through the Trials. CURRENT BREAST CANCER REPORTS 2019; 11:293-302. [DOI: 10.1007/s12609-019-00330-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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18
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Novikov S, Krzhivitskii P, Kanaev S, Krivorotko P, Ilin N, Melnik J, Popova N. SPECT-CT localization of axillary sentinel lymph nodes for radiotherapy of early breast cancer. Rep Pract Oncol Radiother 2019; 24:688-694. [PMID: 31754350 DOI: 10.1016/j.rpor.2019.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/07/2019] [Indexed: 01/02/2023] Open
Abstract
Purpose To evaluate the opportunities of single photon emission tomography/computerized tomography (SPECT-CT) for localization of axillary sentinel lymph nodes (ASLNs) and subsequent radiotherapy planning in women with early breast cancer. Material and methods Individual topography of ASLN was determined in 151 women with clinical T1-2N0M0 breast cancer. SPECT-CT visualization of ASLNs was initiated 120 min after intra-peritumoral injection of 99mTc-radiocolloids. Doses absorbed by virtual ASLNs after the whole breast irradiation with standard and extended tangential fields were calculated on a treatment planning station. Results SPECT-CT demonstrated a large variability of ASLN localization. They were detected in the central subgroup in 94 (61%) patients, in pectoral - in 77 (51%), and in interpectoral - in 4 (3%) patients. Sentinel lymph nodes "lying on the chest" were revealed in 35 (23%) cases.We found that with standard tangential fields coverage of ASLNs was obtained only in 20% of evaluated women. Extended tangential fields can effectively irradiate ASLNs localized in all axillary sub-regions with the exception of ASLNs "lying on the chest". Conclusion SPECT-CT mapping of ASLNs in women with cT1-2N0M0 breast cancer reveals their variable localization. This information can be important for planning of radiation treatment in women that underwent breast conserving surgery without an axillary surgery.
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Affiliation(s)
- Sergey Novikov
- Department of Radiotherapy and Nuclear Medicine, N.N. Petrov Institute Oncology, St Petersburg, Russia
| | - Pavel Krzhivitskii
- Department of Radiotherapy and Nuclear Medicine, N.N. Petrov Institute Oncology, St Petersburg, Russia
| | - Sergey Kanaev
- Department of Radiotherapy and Nuclear Medicine, N.N. Petrov Institute Oncology, St Petersburg, Russia
| | - Petr Krivorotko
- Surgery department, N.N. Petrov Institute Oncology, 197758, St Petersburg, Russia
| | - Nikolay Ilin
- Department of Radiotherapy and Nuclear Medicine, N.N. Petrov Institute Oncology, St Petersburg, Russia
| | - Julia Melnik
- Department of Radiotherapy and Nuclear Medicine, N.N. Petrov Institute Oncology, St Petersburg, Russia
| | - Nadejda Popova
- Department of Radiotherapy and Nuclear Medicine, N.N. Petrov Institute Oncology, St Petersburg, Russia
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19
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Garcia-Etienne CA, Ferrari A, Della Valle A, Lucioni M, Ferraris E, Di Giulio G, Squillace L, Bonzano E, Lasagna A, Rizzo G, Tancredi R, Scotti Foglieni A, Dionigi F, Grasso M, Arbustini E, Cavenaghi G, Pedrazzoli P, Filippi AR, Dionigi P, Sgarella A. Management of the axilla in patients with breast cancer and positive sentinel lymph node biopsy: An evidence-based update in a European breast center. Eur J Surg Oncol 2019; 46:15-23. [PMID: 31445768 DOI: 10.1016/j.ejso.2019.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/22/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023] Open
Abstract
The surgical approach to the axilla in breast cancer has been a controversial issue for more than three decades. Data from recently published trials have provided practice-changing recommendations in this scenario. However, further controversies have been triggered in the surgical community, resulting in heterogeneous diffusion of these recommendations. The development of clinical guidelines for the management of the axilla in patients with breast cancer is a work in progress. A multidisciplinary team discussion was held at the research hospital Policlinico San Matteo from the Università degli Studi di Pavia with the aim to update recommendations for the management of the axilla in patients with breast cancer. An evidence-based approach is presented. Our multidisciplinary panel determined that axillary dissection after a positive sentinel lymph node biopsy may be avoided in cN0 patients with micro/macrometastasis to ≤2 sentinel nodes, with age ≥40y, lesions ≤3 cm, who have not received neoadjuvant chemotherapy and have planned breast conservation (BCS) with whole breast radiotherapy (WBRT). Cases with gross (>2 mm) ECE in SLNs are evaluated on individual basis for completion ALND, axillary radiotherapy or omission of both. Patients fulfilling the criteria listed above who undergo mastectomy, may also avoid axillary dissection after multidisciplinary discussion of individual cases for consideration of axillary irradiation. Women 70 years or older with hormone receptors positive invasive lesions ≤3 cm, clinically negative nodes, and serious or multiple comorbidities who undergo BCS with WBRT, may forgo axillary staging/surgery (if mastectomy or larger tumor, comorbidities and life expectancy are taken into account).
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Affiliation(s)
- Carlos A Garcia-Etienne
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy.
| | - Alberta Ferrari
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Angelica Della Valle
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Marco Lucioni
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Elisa Ferraris
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giuseppe Di Giulio
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Luigi Squillace
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Elisabetta Bonzano
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Angioletta Lasagna
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Gianpiero Rizzo
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Richard Tancredi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Andrea Scotti Foglieni
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Francesca Dionigi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Maurizia Grasso
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Eloisa Arbustini
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giorgio Cavenaghi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Paolo Pedrazzoli
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Andrea R Filippi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Paolo Dionigi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Adele Sgarella
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
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20
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König L, Lang K, Heil J, Golatta M, Major G, Krug D, Hörner-Rieber J, Häfner MF, Koerber SA, Harrabi S, Bostel T, Debus J, Uhl M. Acute Toxicity and Early Oncological Outcomes After Intraoperative Electron Radiotherapy (IOERT) as Boost Followed by Whole Breast Irradiation in 157 Early Stage Breast Cancer Patients-First Clinical Results From a Single Center. Front Oncol 2019; 9:384. [PMID: 31165041 PMCID: PMC6536702 DOI: 10.3389/fonc.2019.00384] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/24/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Breast conserving surgery (BCS) followed by postoperative whole breast irradiation (WBI) is the current standard of care for early stage breast cancer patients. Boost to the tumor bed is recommended for patients with a higher risk of local recurrence and may be applied with different techniques. Intraoperative electron radiotherapy (IOERT) offers several advantages compared to other techniques, like direct visualization of the tumor bed, better skin sparing, less inter- and intrafractional motion, but also radiobiological effects may be beneficial. Objective of this retrospective analysis of IOERT as boost in breast cancer patients was to assess acute toxicity and early oncological outcomes. Material and Methods: All patients, who have been irradiated between 11/2014 and 01/2018 with IOERT during BCS were analyzed. IOERT was applied using the mobile linear accelerator Mobetron with a total dose of 10 Gy, prescribed to the 90% isodose. After ensured woundhealing, WBI followed with normofractionated or hypofractionated regimens. Patient reports, including diagnostic examinations and toxicity were analyzed after surgery and 6-8 weeks after WBI. Overall survival, distant progression-free survival, in-breast and contralateral breast local progression-free survival were calculated using the Kaplan-Meier method. Furthermore, recurrence patterns were assessed. Results: In total, 157 patients with a median age of 57 years were evaluated. Postoperative adverse events were mild with seroma and hematoma grade 1-2 in 26% and grade 3 in 0.6% of the patients. Wound infections grade 2-3 occurred in 2.2% and wound dehiscence grade 1-2 in 1.9% of the patients. Six to eight weeks after WBI radiotherapy-dependent acute dermatitis grade 1-2 was most common in 90.9% of the patients. Only 4.6% of the patients suffered from dermatitis grade 3. No grade 4 toxicities were documented after surgery or WBI. 2- and 3-year overall survival and distant progression-free survival, were 97.5 and 93.6, and 0.7 and 2.8%, respectively. In-breast recurrence and contralateral breast cancer rates after 3 years were 1.9 and 2.8%, respectively. Conclusion: IOERT boost during BCS is a safe treatment option with low acute toxicity. Short-term recurrence rates are comparable to previously published data and emphasize, that IOERT as boost is an effective treatment.
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Affiliation(s)
- Laila König
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jörg Heil
- Department of Gynecology and Obstetrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Golatta
- Department of Gynecology and Obstetrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Gerald Major
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Schleswig Holstein, Kiel, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Matthias F Häfner
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Stefan A Koerber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Tilman Bostel
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Mainz, Mainz, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Matthias Uhl
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
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21
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Wang J, Tang H, Li X, Song C, Xiong Z, Wang X, Xie X, Tang J. Is surgical axillary staging necessary in women with T1 breast cancer who are treated with breast-conserving therapy? Cancer Commun (Lond) 2019; 39:25. [PMID: 31068224 PMCID: PMC6505128 DOI: 10.1186/s40880-019-0371-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/25/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In the post-Z0011 trial era, the need to perform surgical axillary staging for early-stage breast cancer patients, who are treated with breast-conserving therapy (BCT), is being questioned. We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the safety of waiving surgical axillary staging in patients with T1 breast cancer treated with BCT. METHODS A total of 166,615 eligible patients diagnosed between 2000 and 2012 were divided into staging (sentinel lymph node biopsy or axillary lymph node dissection) and non-staging (no lymph node examined or only needle aspiration biopsy of lymph nodes) groups. Propensity score matching (PSM) was performed to balance disparities between the two groups. Multivariate analysis with the Cox proportional hazards model was used to assess factors related to breast cancer-specific survival (BCSS). RESULTS Although the tumor size at time of presentation was decreasing over years, the rate of surgical axillary staging increased from 93.3% to 96.9%. The 5-year BCSS rates of the whole cohort (before PSM) and matched cohort (after PSM) were 98.0% and 97.5%. Within the matched cohort, the BCSS was significantly longer in the staging group than in the non-staging group (P < 0.001). However, surgical axillary staging did not benefit patients who were 50-79 years old, had tumor size < 1 cm, histological grade I disease, or favorable histological types (tubular/mucinous/papillary) in stratified analyses (P > 0.05). Race, marital status, hormone receptors, and chemotherapy were not associated with the favorable impact of surgical axillary staging on BCSS (P > 0.05). CONCLUSION Although surgical axillary staging remains important for T1 breast cancer patients treated with BCT, it might be unnecessary for patients with old age, small tumor, grade I disease, or favorable histological types.
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Affiliation(s)
- Jin Wang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China.
| | - Hailin Tang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Xing Li
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Cailu Song
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Zhenchong Xiong
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Xi Wang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Xiaoming Xie
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Jun Tang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China.
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22
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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: 2.3] [Reference Citation Analysis] [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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23
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Gentilini OD, De Boniface J, Classe JM, Peintinger F, Reimer T, Reitsamer R, Rubio I, Smidt M, Kuehn T. A gap analysis of opportunities and priorities for breast surgical research. Lancet Oncol 2019; 20:e1. [PMID: 30614465 DOI: 10.1016/s1470-2045(18)30916-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/03/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Oreste D Gentilini
- Breast Surgery, San Raffaele University and Research Hospital, 20132, Milano, Italy.
| | - Jana De Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Unit, Goran's Hospital, Stockholm, Sweden
| | - Jean-Marc Classe
- Department of Surgical Oncology, Institut de Cancerologie du Ouest, Nantes, France
| | - Florentia Peintinger
- Institute of Pathology, Medical University Graz, Department for Gynecology and Obstetrics, General Hospital Leoben, Leoben, Austria
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Germany
| | - Roland Reitsamer
- Breast Center Salzburg, University Clinic Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Isabel Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Marjolein Smidt
- Department of Surgical Oncology GROW-School for Oncology & Developmental Biology Maastricht University Medical Centre, Netherlands
| | - Thorsten Kuehn
- Interdisciplinary Breast Center, Klinikum Esslingen, Germany
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Houvenaeghel G, Cohen M, Raro P, De Troyer J, de Lara CT, Gimbergues P, Gauthier T, Faure-Virelizier C, Vaini-Cowen V, Lantheaume S, Regis C, Darai E, Ceccato V, D'Halluin G, Del Piano F, Villet R, Jouve E, Beedassy B, Theret P, Gabelle P, Zinzindohoue C, Opinel P, Marsollier-Ferrer C, Dhainaut-Speyer C, Colombo PE, Lambaudie E, Tallet A, Boher JM. Overview of the pathological results and treatment characteristics in the first 1000 patients randomized in the SERC trial: axillary dissection versus no axillary dissection in patients with involved sentinel node. BMC Cancer 2018; 18:1153. [PMID: 30463611 PMCID: PMC6249981 DOI: 10.1186/s12885-018-5053-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/06/2018] [Indexed: 01/26/2023] Open
Abstract
Background Three randomized trials have concluded at non inferiority of omission of complementary axillary lymph node dissection (cALND) for patients with involved sentinel node (SN). However, we can outline strong limitations of these trials to validate this attitude with a high scientific level. We designed the SERC randomized trial (ClinicalTrials.gov, number NCT01717131) to compare outcomes in patients with SN involvement treated with ALND or no further axillary treatment. The aim of this study was to analyze results of the first 1000 patients included. Methods SERC trial is a multicenter non-inferiority phase 3 trial. Multivariate logistic regression analysis was used to identify independent factors associated with adjuvant chemotherapy administration and non-sentinel node (NSN) involvement. Results Of the 963 patients included in the analysis set, 478 were randomized to receive cALND and 485 SLNB alone. All patient demographics and tumor characteristics were balanced between the two arms. SN ITC was present in 6.3% patients (57/903), micro metastases in 33.0% (298), macro metastases in 60.7% (548) and 289 (34.2%) were non eligible to Z0011 trial criteria. Whole breast or chest wall irradiation was delivered in 95.9% (896/934) of patients, adjuvant chemotherapy in 69.5% (644/926), endocrine therapy in 89.6% (673/751) and the proportions were similar in the two arms. The overall rate of positive NSN was 19% (84/442) for patients with cALND. Crude rates of positive NSN according to SN status were 4.5% for ITC (1/22), 9.5% for micro metastases (13/137), 23.9% for macro metastases (61/255) and were respectively 29.36% (64/218), 9.33% (7/75) and 7.94% (10/126) when chemotherapy was administered after cALND, before cALND and for patients without chemotherapy. Conclusion The main objective of SERC trial is to demonstrate non inferiority of cALND omission. A strong interaction between timing of cALND and chemotherapy with positive NSN rate was observed. Trial registration This study is registered with ClinicalTrials.gov, number NCT01717131 October 19, 2012. Electronic supplementary material The online version of this article (10.1186/s12885-018-5053-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gilles Houvenaeghel
- Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd de Sainte Marguerite, 13009, Marseille, France. .,Department of surgery, Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France.
| | - Monique Cohen
- Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd de Sainte Marguerite, 13009, Marseille, France.,Department of surgery, Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France
| | - Pédro Raro
- Institut de Cancérologie de l'Ouest - Site Paul Papin, 15 rue André Boquel, 10059 49055, Angers Cedex 02, CS, France
| | - Jérémy De Troyer
- Polyclinique Urbain V, Chemin du Pont des Deux Eaux, 84000, Avignon, France
| | | | - Pierre Gimbergues
- Centre Jean Perrin, 58 rue Montalembert BP 392, 63011, Clermont Ferrand Cedex, France
| | - Tristan Gauthier
- HME CHU Dupuytren, 2 avenue Martin Luther King, 87000, Limoges, France
| | | | | | - Stéphane Lantheaume
- Clinique Pasteur, 294 boulevard Charles de Gaulle, 07500, Guilherand Granges, France
| | - Claudia Regis
- Centre Oscar Lambret, 3 rue F. Combemal, 59000, Lille, France
| | - Emile Darai
- Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France
| | - Vivien Ceccato
- Institut Jean Godinot, 1 rue du Général Koenig, 51056, Reims, France
| | - Gauthier D'Halluin
- Centre Clinical, 2 chemin Frégenueil CS 42510 Soyaux, 16025, Angoulème, France
| | | | - Richard Villet
- Groupe Hospitalier Des Diaconesses Croix Saint Simon, Site Reuilly, 18 rue Sergent Bauchat, 75012, Paris, France
| | - Eva Jouve
- Institut Universitaire du Cancer Toulouse, Oncopole, 1 avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - Bassoodéo Beedassy
- Hôpital Sainte Musse (CHITS), Service de chirurgie viscérale, Rue Henri Sainte-Claire Deville, 83056, Toulon, France
| | - Pierrick Theret
- CH Saint Quentin, 1 avenue Michel de l'Hospital, B.P. 608, 02321, Saint Quentin Cedex, France
| | - Philippe Gabelle
- GHM de Grenoble, La Clinique des Eaux Claires, 8 rue du Dr Calmette, 38028, Grenoble Cedex 1, France
| | | | - Pierre Opinel
- CHR du Pays d'Aix, Avenue des Tamaris, 13616, Aix en Provence Cedex 1, France
| | | | | | - Pierre-Emmanuel Colombo
- ICM - Institut Régional du Cancer Montpellier, 208 avenue des Apothicaires - Parc Euromédecine, 34298, Montpellier Cedex 5, France
| | - Eric Lambaudie
- Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd de Sainte Marguerite, 13009, Marseille, France.,Department of surgery, Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France
| | - Agnès Tallet
- Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd de Sainte Marguerite, 13009, Marseille, France.,Department of radiotherapy, Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France
| | - Jean-Marie Boher
- Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd de Sainte Marguerite, 13009, Marseille, France.,Department of biostatistics, Institut Paoli Calmettes & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France
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Reimer T, Engel J, Schmidt M, Offersen BV, Smidt ML, Gentilini OD. Is Axillary Sentinel Lymph Node Biopsy Required in Patients Who Undergo Primary Breast Surgery? Breast Care (Basel) 2018; 13:324-330. [PMID: 30498416 PMCID: PMC6257084 DOI: 10.1159/000491703] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated for various reasons: i) pN staging information may not be necessary for the postoperative treatment decision regarding adjuvant systemic therapy in the great majority of patients; ii) the SLNB-positive rate is declining below 20% in specialized breast centers; iii) albeit being a minimally invasive procedure, SLNB causes a significant reduction in quality of life in 23% of patients; and iv) previous randomized trials from the pre-SLNB era did not show a disadvantage for patients without axillary surgery with regard to overall survival. These data support the hypothesis that avoiding axillary treatment in patients with clinically and sonographically unsuspicious lymph nodes seems to be a safe option, although omitting axillary surgery may increase the risk of locoregional recurrence. Currently, the information regarding node-positive status is essential to guide postoperative treatment such as systemic or radiation therapies in a non-negligible minority of patients. Three ongoing prospective European trials (SOUND, INSEMA, BOOG 2013-08) with axillary observation alone versus SLNB in cN0 patients and primary breast-conserving surgery have the objective to evaluate oncologic safety when omitting SLNB.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Jutta Engel
- Munich Cancer Registry (MCR) of the Munich Tumour Centre, Institute of Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilians-University (LMU), Munich, Germany
| | - Marcus Schmidt
- Division of Molecular Medicine, Department of Obstetrics and Gynecology, Comprehensive Cancer Center, University Medical Center Mainz, Mainz, Germany
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology and Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Marjolein L. Smidt
- Division of Surgical Oncology, Maastricht University Medical Centre, Maastricht, Netherlands
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26
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Kim WH, Kim HJ, Lee SM, Cho SH, Shin KM, Lee SY, Lim JK, Lee WK. Preoperative axillary nodal staging with ultrasound and magnetic resonance imaging: predictive values of quantitative and semantic features. Br J Radiol 2018; 91:20180507. [PMID: 30059242 DOI: 10.1259/bjr.20180507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE: Although axillary imaging has recently received renewed interest for preoperative staging in tandem with the evolving minimally invasive surgical approaches, axillary imaging is limited by the lack of standardization in the interpretation. We aimed to classify imaging features in ultrasound and MRI into quantitative and semantic features and evaluate predictive value of each feature for predicting nodal metastases. METHODS: A total of 316 breast cancers patients who underwent ultrasound and MRI prior to axillary surgery were included. Retrospective reviews of our breastimaging database were done for the quantitative features [cortical thickness (CT) and CT-derived parameters, long diameter (LD), short diameter (SD), and LD/SD ratio] and semantic features (eccentricity, loss of fatty hilum, and irregularity) of the axillary lymph node in images. Odd ratios (ORs) for each imaging feature were calculated with adjustment for clinicopathological characteristics significantly associated with nodal metastases. RESULTS: All CT-derived parameters were significantly associated with nodal metastases in both ultrasound and MRI (OR, 3.3-3.5 for ultrasound and 3.3-3.9 for MRI, respectively; Ps < .05). For the ultrasound, LD/SD ratio (OR, 2.1), eccentricity (OR, 2.4), and fatty hilum loss (OR, 27.2) were significantly associated with nodal metastases (Ps < .05). For the MRI, SD (OR, 2.1) and eccentricity (OR, 3.0) were significantly associated with nodal metastases (Ps < .05). CONCLUSION: Among the quantitative features, all CT-derived parameters can be used for predicting nodal metastases. Significant predictors of semantic features were heterogeneous between ultrasound and MRI. ADVANCES IN KNOWLEDGE: (1) Imaging features of ultrasound and MRI for preoperative axillary nodal staging can be classified into quantitative and semantic features. (2) Predictive values of each imaging features are heterogeneous for predicting nodal metastases.
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Affiliation(s)
- Won Hwa Kim
- 1 Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital , Daegu , South Korea
| | - Hye Jung Kim
- 1 Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital , Daegu , South Korea
| | - So Mi Lee
- 1 Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital , Daegu , South Korea
| | - Seung Hyun Cho
- 1 Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital , Daegu , South Korea
| | - Kyung Min Shin
- 1 Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital , Daegu , South Korea
| | - Sang Yub Lee
- 1 Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital , Daegu , South Korea
| | - Jae Kwang Lim
- 1 Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital , Daegu , South Korea
| | - Won Kee Lee
- 2 Center of Biostatistics, School of Medicine, Kyungpook National University , Daegu , South Korea
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Cordoba O, Carrillo-Guivernau L, Reyero-Fernández C. Surgical Management of Breast Cancer Treated with Neoadjuvant Therapy. Breast Care (Basel) 2018; 13:238-243. [PMID: 30319325 PMCID: PMC6167713 DOI: 10.1159/000491760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Neoadjuvant therapy (NAT) allows downstaging in some cases of breast cancer. By consequence, it may enable a more conservative surgical approach or make surgery possible in cases ineligible for surgery before NAT. In this article, we review the evidence and management recommendations for optimal surgical treatment in this setting.
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Affiliation(s)
- Octavi Cordoba
- Obstetrics and Gynecology Department, Hospital Universitari Son Espases, Palma, Spain
| | - Lourdes Carrillo-Guivernau
- Breast Cancer Unit, Obstetrics and Gynecology Department, Hospital Universitari Son Espases, Palma, Spain
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The arrival of axilla conserving therapy (ACT). Is this the second revolution in locoregional management of breast cancer care? Radiother Oncol 2018; 128:591-592. [PMID: 29482843 DOI: 10.1016/j.radonc.2018.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 02/07/2018] [Accepted: 02/09/2018] [Indexed: 11/20/2022]
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29
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Yararbas U, Avci NC, Yeniay L, Argon AM. The value of 18F-FDG PET/CT imaging in breast cancer staging. Bosn J Basic Med Sci 2018; 18:72-79. [PMID: 28763628 DOI: 10.17305/bjbms.2017.2179] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/23/2017] [Accepted: 07/24/2017] [Indexed: 01/28/2023] Open
Abstract
The National Comprehensive Cancer Network (NCCN) guidelines recommend assessment with positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) in staging of breast cancer, starting from the stage IIIA. Previously, PET/CT contributed to the accurate staging from the stage IIB. Our aim is to evaluate the contribution of 18F-FDG PET/CT in staging of breast cancer patients. A total of 234 patients were retrospectively evaluated. PET/CT was performed preoperatively in 114/234 and postoperatively in 120/234 patients. Initial staging was performed based on histopathological results in 125/234 and clinical results in 109/234 patients, according to the American Joint Committee on Cancer (AJCC) classification. All patients had a normal abdominal ultrasound and chest x-ray. Following PET/CT imaging, modification in the staging was performed in patients with the metastatic findings. In 42/234 (17.9%) patients hypermetabolic extra-axillary regional lymph nodes and in 65/234 patients (27.7%) distant metastatic involvement were detected with PET/CT. Modification in the staging was applied in 82/234 (35%) patients. Patient management was changed in 69/234 (29.4%) cases. The percentage of patients with upstaging, according to each stage, was as follows: IIA: 18.6%, IIB: 30%, IIIA: 46.3%, IIIB: 68.8%, and IIIC: 20.8%. In 43/43 patients, 99mTc-methylene diphosphonate (MDP) bone scan did not show additional bone metastasis. In 5/32 patients, metastatic involvement was detected with sentinel lymph node biopsy (SLNB), but preoperative PET/CT scan did not reveal hypermetabolic lymph nodes. Although our study was limited by the referral bias and lack of homogeneity in the referral group, PET/CT still significantly contributed to the accurate staging and management of our breast cancer patients, starting from the stage IIA.
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Affiliation(s)
- Ulkem Yararbas
- Department of Nuclear Medicine, Ege University Medical Faculty, Izmir, Turkey.
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30
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Current Issues in the Overdiagnosis and Overtreatment of Breast Cancer. AJR Am J Roentgenol 2018; 210:285-291. [DOI: 10.2214/ajr.17.18629] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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32
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Stein RG, Fricker R, Rink T, Fitz H, Blasius S, Diessner J, Häusler SFM, Stüber TN, Andreas V, Wöckel A, Müller T. Evaluation of Sentinel Lymph Node Biopsy and Axillary Lymph Node Dissection for Breast Cancer Treatment Concepts - a Retrospective Study of 1,214 Breast Cancer Patients. Breast Care (Basel) 2017; 12:324-328. [PMID: 29234253 DOI: 10.1159/000477610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Most breast cancer patients require lumpectomy with axillary sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). The ACOSOG Z0011-trial failed to detect significant effects of ALND on disease-free and overall survival among patients with limited sentinel lymph node (SLN) metastases. Intense dose-dense chemotherapy and supraclavicular fossa radiation (SFR) are indicated for patients with extensive axillary metastases. In this multicentered study, we investigated the relevance of ALND after positive SLNB to determine adequate adjuvant therapy. Methods We retrospectively analyzed data from 1,214 patients with clinically nodal negative T1-T2 invasive breast cancer undergoing surgery at Hanau City Hospital Breast cancer center. Results 681 patients underwent ALND after SLNB. 20 patients (8.5%) from the group with 1 or 2 SLN metastases (n = 236) showed more than 3 lymph node metastases after ALND. 13 patients (31.7%) from the group with more than 2 SLN metastases (n = 41) were diagnosed with a minimum of 4 axillary lymph node metastases after ALND. Conclusions In 8.5% of the patients with 1 or 2 SLN metastases, ALND detected more than 3 macrometastases, setting the indication for intense dose-dense chemotherapy and SFR. More than 2 SLN metastases, T stage and grading predict lymph node metastases.
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Affiliation(s)
- Roland G Stein
- Department of Obstetrics and Gynecology, Würzburg University Hospital, Würzburg, Germany
| | - Roland Fricker
- Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany
| | - Thomas Rink
- Institute for Nuclear Medicine, Hanau City Hospital, Hanau, Germany
| | - Hartmut Fitz
- Institute for Pathology, Hanau City Hospital, Hanau, Germany
| | | | - Joachim Diessner
- Department of Obstetrics and Gynecology, Würzburg University Hospital, Würzburg, Germany
| | - Sebastian F M Häusler
- Department of Obstetrics and Gynecology, Würzburg University Hospital, Würzburg, Germany
| | - Tanja N Stüber
- Department of Obstetrics and Gynecology, Würzburg University Hospital, Würzburg, Germany
| | - Victoria Andreas
- Department of Obstetrics and Gynecology, Würzburg University Hospital, Würzburg, Germany
| | - Achim Wöckel
- Department of Obstetrics and Gynecology, Würzburg University Hospital, Würzburg, Germany
| | - Thomas Müller
- Department of Obstetrics and Gynecology, Hanau City Hospital, Hanau, Germany
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Esposito E, Di Micco R, Gentilini OD. Sentinel node biopsy in early breast cancer. A review on recent and ongoing randomized trials. Breast 2017; 36:14-19. [DOI: 10.1016/j.breast.2017.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/02/2017] [Accepted: 08/17/2017] [Indexed: 01/31/2023] Open
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Maráz R, Zombori T, Ambrózay É, Cserni G. The role of preoperative axillary ultrasound and fine-needle aspiration cytology in identifying patients with extensive axillary lymph node involvement. Eur J Surg Oncol 2017; 43:2021-2028. [DOI: 10.1016/j.ejso.2017.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 07/30/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022] Open
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Outcome following sentinel lymph node biopsy-guided decisions in breast cancer patients with conversion from positive to negative axillary lymph nodes after neoadjuvant chemotherapy. Breast Cancer Res Treat 2017; 166:473-480. [PMID: 28766131 DOI: 10.1007/s10549-017-4423-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 07/25/2017] [Indexed: 01/17/2023]
Abstract
PURPOSE Many breast cancer patients with positive axillary lymph nodes achieve complete node remission after neoadjuvant chemotherapy. The usefulness of sentinel lymph node biopsy in this situation is uncertain. This study evaluated the outcomes of sentinel biopsy-guided decisions in patients who had conversion of axillary nodes from clinically positive to negative following neoadjuvant chemotherapy. METHODS We reviewed the records of 1247 patients from five hospitals in Korea who had breast cancer with clinically axillary lymph node-positive status and negative conversion after neoadjuvant chemotherapy, between 2005 and 2012. Patients who underwent axillary operations with sentinel biopsy-guided decisions (Group A) were compared with patients who underwent complete axillary lymph node dissection without sentinel lymph node biopsy (Group B). Axillary node recurrence and distant recurrence-free survival were compared. RESULTS There were 428 cases in Group A and 819 in Group B. Kaplan-Meier analysis showed that recurrence-free survivals were not significantly different between Groups A and B (4-year axillary recurrence-free survival: 97.8 vs. 99.0%; p = 0.148). Multivariate analysis also indicated the two groups had no significant difference in axillary and distant recurrence-free survival. CONCLUSIONS For breast cancer patients who had clinical conversion of axillary lymph nodes from positive to negative following neoadjuvant chemotherapy, sentinel biopsy-guided axillary surgery, and axillary lymph node dissection without sentinel lymph node biopsy had similar rates of recurrence. Thus, sentinel biopsy-guided axillary operation in breast cancer patients who have clinically axillary lymph node positive to negative conversion following neoadjuvant chemotherapy is a useful strategy.
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Ahmed M, Jozsa F, Douek M. Is there a role for sentinel node biopsy in the pre-operative ultrasound positive axilla? Breast Cancer Res Treat 2017; 165:225-228. [PMID: 28597050 DOI: 10.1007/s10549-017-4313-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 05/23/2017] [Indexed: 11/29/2022]
Abstract
Axillary management in breast cancer is becoming increasingly conservative. This approach is based on the identification of low axillary burden on sentinel node biopsy (SNB). The modern practice of routine pre-operative axillary ultrasound has meant that patients are 'fast tracked' to axillary node clearance (ANC) in the presence of a histologically confirmed positive axilla. This practice reduces the number of patients undergoing SNB compared to the original trials, which evaluated the role of SNB, and those assessing safety of omission of ANC in low axillary burden. The risk of depriving patients with low axillary burden the opportunity to avoid ANC as a consequence of pre-operative ultrasound is discussed.
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Affiliation(s)
- M Ahmed
- Division of Cancer Studies, Research Oncology, King's College London, London, SE1 9RT, UK.
| | - F Jozsa
- Division of Cancer Studies, Research Oncology, King's College London, London, SE1 9RT, UK
| | - M Douek
- Division of Cancer Studies, Research Oncology, King's College London, London, SE1 9RT, UK
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Marrazzo A, Damiano G, Taormina P, Buscemi S, Lo Monte AI, Marrazzo E. Does Conservative Surgery for Breast Carcinoma Still Require Axillary Lymph Node Evaluation? A Retrospective Analysis of 1156 Consecutive Women With Early Breast Cancer. Clin Breast Cancer 2017; 17:e53-e57. [DOI: 10.1016/j.clbc.2016.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/06/2016] [Accepted: 10/12/2016] [Indexed: 02/05/2023]
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Abstract
Breast cancer is one of the three most common cancers worldwide. Early breast cancer is considered potentially curable. Therapy has progressed substantially over the past years with a reduction in therapy intensity, both for locoregional and systemic therapy; avoiding overtreatment but also undertreatment has become a major focus. Therapy concepts follow a curative intent and need to be decided in a multidisciplinary setting, taking molecular subtype and locoregional tumour load into account. Primary conventional surgery is not the optimal choice for all patients any more. In triple-negative and HER2-positive early breast cancer, neoadjuvant therapy has become a commonly used option. Depending on clinical tumour subtype, therapeutic backbones include endocrine therapy, anti-HER2 targeting, and chemotherapy. In metastatic breast cancer, therapy goals are prolongation of survival and maintaining quality of life. Advances in endocrine therapies and combinations, as well as targeting of HER2, and the promise of newer targeted therapies make the prospect of long-term disease control in metastatic breast cancer an increasing reality.
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Affiliation(s)
- Nadia Harbeck
- Breast Center, Department of Gynecology and Obstetrics, Comprehensive Cancer Center of the Ludwig-Maximilians-University, Munich, Germany.
| | - Michael Gnant
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Reimer T, Stachs A, Nekljudova V, Loibl S, Hartmann S, Wolter K, Hildebrandt G, Gerber B. Restricted Axillary Staging in Clinically and Sonographically Node-Negative Early Invasive Breast Cancer (c/iT1-2) in the Context of Breast Conserving Therapy: First Results Following Commencement of the Intergroup-Sentinel-Mamma (INSEMA) Trial. Geburtshilfe Frauenheilkd 2017; 77:149-157. [PMID: 28331237 DOI: 10.1055/s-0042-122853] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Axillary lymph node status remains an important prognostic factor in early breast cancer. It is regarded as an indicator for (neo)adjuvant systemic treatment and postoperative radiotherapy of the regional lymphatics. Commenced in September 2015, the INSEMA trial is investigating whether operative determination of nodal status as part of breast conserving therapy (BCT) for early stage breast cancer (c/iT1-2 c/iN0) can be avoided without reducing oncological safety. After inclusion of 1001 patients there was general acceptance of the complex study design by patients and study doctors so that recruitment for the first randomisation (axillary sentinel lymph node biopsy [SLNB]: yes or no) achieved predicted case numbers. The second randomisation however (SLNB alone versus complete axillary dissection when one or two macrometastases are present at SLNB) recruited fewer cases than expected for the following three reasons: a) the 13 % rate of one or two macrometastases after SLNB in the INSEMA trial collective was lower than expected; b) around 20 % of patients refused the second randomisation; c) there was delayed inclusion of the Austrian study centres, which only recruited for the second randomisation. Lack of knowledge of nodal status when SLNB is avoided represents a new challenge for the postoperative tumour board. In particular decisions on chemotherapy for luminal-like tumours and irradiation of the lymphatics (excluding axilla) must be guided by tumour biological parameters. The INSEMA trial does not provide answers to some important questions, e.g. it remains unclear whether patients without SLNB can be offered partial breast irradiation alone in low-risk situations and whether SLNB can also be avoided in patients with stage T1-2 tumours who have a mastectomy indication.
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Affiliation(s)
- T Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - A Stachs
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | | | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
| | - S Hartmann
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - K Wolter
- Department of Radiotherapy, University of Rostock, Rostock, Germany
| | - G Hildebrandt
- Department of Radiotherapy, University of Rostock, Rostock, Germany
| | - B Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
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Abstract
Breast cancer is the most common type of cancer diagnosed in women worldwide. Regional lymph node status is one of the strongest predictors of long-term prognosis in primary breast cancer. Sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection as the standard surgical procedure for staging clinically tumor-free regional nodes in patients with early-stage breast cancer. SLNB staging considerably reduces surgical morbidity in terms of shoulder dysfunction and lymphedema, without affecting diagnostic accuracy and prognostic information. Clinicians should not recommend axillary lymph node dissection for women with early-stage breast cancer who have tumor-free findings on SLNB because there is no advantage in terms of overall survival and disease-free survival. Starting from the early 1990s, SLNB has increasingly been used in breast cancer management, but its role is still debated under many clinical circumstances. Moreover, there is still a lack of standardization of the basic technical details of the procedure that is likely to be responsible for the variability found in the false-negative rate of the procedure (5.5-16.7%). In this article, we report the aspects of SLNB that are well established, those that are still debated, and the advancements that have taken place over the last 20 years. We have provided an update on the methodology from both a technical and a clinical point of view in the light of the most recent publications.
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Gerber B, Marx M, Untch M, Faridi A. Breast Reconstruction Following Cancer Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:286. [PMID: 26377531 DOI: 10.3238/arztebl.2015.0593] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND About 8000 breast reconstructions after mastectomy are per - formed in Germany each year. It has become more difficult to advise patients because of the wide variety of heterologous and autologous techniques that are now available and because of changes in the recommendations about radiotherapy. METHODS This article is based on a review of pertinent articles (2005-2014) that were retrieved by a selective search employing the search terms "mastectomy" and "breast reconstruction." RESULTS The goal of reconstruction is to achieve an oncologically safe and aestically satisfactory result for the patient over the long term. Heterologous, i.e., implant-based, breast reconstruction (IBR) and autologous breast reconstruction (ABR) are complementary techniques. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. If post-mastectomy radiotherapy (PMRT) is not indicated, implant-based reconstruction with or without a net/acellular dermal matrix (ADM) is a common option. Complications such as seroma formation, infection, and explantation are significantly more common when an ADM is used (15.3% vs. 5.4% ). If PMRT is performed, then the complication rate of implant-based breast reconstruction is 1 to 48% ; in particular, Baker grade III/IV capsular fibrosis occurs in 7 to 22% of patients, and the prosthesis must be explanted in 9 to 41% . Primary or, preferably, secondary autologous reconstruction is an alternative. The results of ABR are more stable over the long term, but the operation is markedly more complex. Autologous breast reconstruction after PMRT does not increase the risk of serious complications (20.5% vs. 17.9% without radiotherapy). CONCLUSION No randomized controlled trials have yet been conducted to compare the reconstructive techniques with each other. If radiotherapy will not be performed, immediate reconstruction with an implant is recommended. On the other hand, if post-mastectomy radiotherapy is indicated, then secondary autologous breast reconstruction is the procedure of choice. Future studies should address patients' quality of life and the long-term aesthetic results after breast reconstruction.
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Affiliation(s)
- Bernd Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Clinic for Plastic Surgery, Radebeul, Helios Klinikum Berlin Buch, Center for Breast Diseases, Vivantes Hospital am Urban, Berlin
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Stachs A, Thi ATH, Dieterich M, Stubert J, Hartmann S, Glass Ä, Reimer T, Gerber B. Assessment of Ultrasound Features Predicting Axillary Nodal Metastasis in Breast Cancer: The Impact of Cortical Thickness. Ultrasound Int Open 2016; 1:E19-24. [PMID: 27689144 DOI: 10.1055/s-0035-1555872] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To evaluate the accuracy of axillary ultrasound (AUS) in detecting nodal metastasis in patients with early-stage breast cancer and to identify AUS features with high predictive power. MATERIALS AND METHODS Prospective single-center preliminary study in 105 patients with a primary diagnosis of breast cancer and clinically negative axilla. AUS was performed using a 12 MHz linear-array transducer before ultrasound-guided needle biopsy. Nodal characteristics (shape, longitudinal-transverse [LT] axis ratio, margins, cortical thickness, hyperechoic hilum) were correlated with histopathological nodal status after SLNB or axillary lymph node dissection (ALND). RESULTS Nodal metastases were present in 42/105 patients (40.0%). Univariate analyses showed that absence of hyperechoic hilum, round shape, LT axis ratio<2, sharp margins and cortical thickness>3 mm were associated with lymph node metastasis. Multivariate logistic regression analysis revealed cortical thickness > 3 mm as an independent predictive parameter for nodal involvement. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 66.7, 74.6, 63.6, 77.0% and 71.4% respectively when cortical thickness > 3 mm was applied as the criterion for AUS positivity. Axillary tumor volume was low in patients with pT1/2 tumors and negative AUS, since only 3.2% of patients had > 2 metastatic lymph nodes. CONCLUSION Cortical thickness>3 mm is a reliable predictor of nodal metastatic involvement. Negative AUS does not exclude lymph node metastases, but extensive axillary tumor volume is rare.
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Affiliation(s)
- A Stachs
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - A Tra-Ha Thi
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - M Dieterich
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - J Stubert
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - S Hartmann
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Ä Glass
- Institute for Biostatistics, University of Rostock, Rostock, Germany
| | - T Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - B Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
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Van Berckelaer C, Huizing M, Van Goethem M, Vervaecke A, Papadimitriou K, Verslegers I, Trinh BX, Van Dam P, Altintas S, Van den Wyngaert T, Huyghe I, Siozopoulou V, Tjalma WAA. Preoperative ultrasound staging of the axilla make's peroperative examination of the sentinel node redundant in breast cancer: saving tissue, time and money. Eur J Obstet Gynecol Reprod Biol 2016; 206:164-171. [PMID: 27697620 DOI: 10.1016/j.ejogrb.2016.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 08/31/2016] [Accepted: 09/10/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the role of preoperative axillary staging with ultrasound (US) and fine needle aspiration cytology (FNAC). Can we avoid intraoperative sentinel lymph node (SLN) examination, with an acceptable revision rate by preoperative staging? DESIGN This study is based on the retrospective data of 336 patients that underwent US evaluation of the axilla as part of their staging. A FNAC biopsy was performed when abnormal lymph nodes were visualized. Patients with normal appearing nodes on US or a benign diagnostic biopsy had removal of the SLNs without intraoperative pathological examination. We calculated the sensitivity, specificity and accuracy of US/FNAC in predicting the necessity of an axillary lymphadenectomy. Subsequently we looked at the total cost and the operating time of 3 models. Model A is our study protocol. Model B is a theoretical protocol based on the findings of the Z0011 trial with only clinical preoperative staging and in Model C preoperative staging and intraoperative pathological examination were both theoretically done. sentinel node, staging, ultrasound, preoperative axillary staging, FNAC, axilla RESULTS: The sensitivity, specificity and accuracy are respectively 0.75 (0.66-0.82), 1.00 (0.99-1.00) and 0.92 (0.88-0.94). Only 26 out of 317 (8.2%) patients that successfully underwent staging needed a revision. The total cost of Model A was 1.58% cheaper than Model C and resulted in a decrease in operation time by 9,46%. The benefits compared with Model B were much smaller. CONCLUSION Preoperative US/FNAC staging of the axillary lymph nodes can avoid intraoperative examination of the sentinel node with an acceptable revision rate. It saves tissue, reduces operating time and decreases healthcare costs in general.
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Affiliation(s)
- Christophe Van Berckelaer
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Manon Huizing
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Mireille Van Goethem
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Andrew Vervaecke
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Konstantinos Papadimitriou
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Inge Verslegers
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Bich X Trinh
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Peter Van Dam
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Sevilay Altintas
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Tim Van den Wyngaert
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Ivan Huyghe
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Vasiliki Siozopoulou
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Wiebren A A Tjalma
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium.
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Sentinel Lymph Node Biopsy in Breast Cancer: Indications, Contraindications, and Controversies. Clin Nucl Med 2016; 41:126-33. [PMID: 26447368 DOI: 10.1097/rlu.0000000000000985] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Axillary lymph node status, a major prognostic factor in early-stage breast cancer, provides information important for individualized surgical treatment. Because imaging techniques have limited sensitivity to detect metastasis in axillary lymph nodes, the axilla must be explored surgically. The histology of all resected nodes at the time of axillary lymph node dissection (ALND) has traditionally been regarded as the most accurate method for assessing metastatic spread of disease to the locoregional lymph nodes. However, ALND may result in lymphedema, nerve injury, shoulder dysfunction, and other short-term and long-term complications limiting functionality and reducing quality of life. Sentinel lymph node biopsy (SLNB) is a less invasive method of assessing nodal involvement. The concept of SLNB is based on the notion that tumors drain in an orderly manner through the lymphatic system. Therefore, the SLN is the first to be affected by metastasis if the tumor has spread, and a tumor-free SLN makes it highly unlikely for other nodes to be affected. Sentinel lymph node biopsy has become the standard of care for primary treatment of early breast cancer and has replaced ALND to stage clinically node-negative patients, thus reducing ALND-associated morbidity. More than 20 years after its introduction, there are still aspects concerning SLNB and ALND that are currently debated. Moreover, SLNB remains an unstandardized procedure surrounded by many unresolved controversies concerning the technique itself. In this article, we review the main indications, contraindications, and controversies of SLNB in breast cancer in the light of the most recent publications.
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Wendler T, Paepke S. Axillary sentinel node aspiration biopsy: towards minimally invasive lymphatic staging in breast cancer. Clin Transl Imaging 2016. [DOI: 10.1007/s40336-016-0205-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tinterri C, Canavese G, Bruzzi P, Dozin B. SINODAR ONE, an ongoing randomized clinical trial to assess the role of axillary surgery in breast cancer patients with one or two macrometastatic sentinel nodes. Breast 2016; 30:197-200. [PMID: 27406897 DOI: 10.1016/j.breast.2016.06.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/14/2016] [Accepted: 06/15/2016] [Indexed: 12/15/2022] Open
Abstract
Sentinel lymph node biopsy alone is the current surgical axillary treatment for early-stage breast cancer patients with a negative sentinel lymph node (SLN). The possibility to omit axillary dissection also in presence of positive SLNs has been promoted by the American College of Surgeons Oncology Group (ASOCOG) Z0011 randomized trial. Several limitations and evidences of potential selection bias made this trial fairly controversial. Stronger evidence than currently available is needed on the safety of foregoing axillary dissection in well-defined populations of patients with positive SLNs. The Italian multicentre SINODAR ONE randomized trial here presented was designed with this aim.
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Affiliation(s)
- Corrado Tinterri
- Breast Unit, Cancer Center, IRCCS Clinical Institute Humanitas, Rozzano, MI, Italy
| | - Giuseppe Canavese
- Breast Unit, Cancer Center, IRCCS Clinical Institute Humanitas, Rozzano, MI, Italy
| | - Paolo Bruzzi
- Clinical Epidemiology, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Beatrice Dozin
- Clinical Epidemiology, IRCCS AOU San Martino-IST, Genoa, Italy.
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Omission of axillary dissection after a positive sentinel lymph-node: Implications in the multidisciplinary treatment of operable breast cancer. Cancer Treat Rev 2016; 48:1-7. [DOI: 10.1016/j.ctrv.2016.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/08/2016] [Accepted: 05/12/2016] [Indexed: 02/06/2023]
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Rautiainen S, Sudah M, Joukainen S, Sironen R, Vanninen R, Sutela A. Contrast-enhanced ultrasound -guided axillary lymph node core biopsy: Diagnostic accuracy in preoperative staging of invasive breast cancer. Eur J Radiol 2015; 84:2130-6. [DOI: 10.1016/j.ejrad.2015.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/09/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022]
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Sautter-Bihl ML, Sedlmayer F. Radiotherapy of the Lymphatic Pathways in Early Breast Cancer. Breast Care (Basel) 2015; 10:254-8. [PMID: 26600761 PMCID: PMC4608631 DOI: 10.1159/000438662] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
International guidelines reveal substantial differences regarding indications for regional nodal irradiation (RNI). Recently, several randomized studies provided new insights and these are discussed here. Patients with 1-3 positive nodes seem to profit from RNI compared to whole-breast (WBI) or chest-wall irradiation (CWI) alone, both with regard to locoregional control and disease-free survival. Irradiation of the regional lymphatics including axillary, supraclavicular and internal mammary nodes provided a small but significant survival benefit in recent randomized trials and 1 meta-analysis. Lymph node irradiation yields comparable tumor control in comparison to axillary lymph node dissection while reducing the rate of lymph edema. Data concerning the impact of 1-2 macroscopically affected sentinel nodes or microscopic metastases on prognosis are equivocal. Recent data suggest that the current restrictive use of RNI should be scrutinized, as the hazard-benefit relation appears to shift towards an improvement of outcome.
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Affiliation(s)
| | - Felix Sedlmayer
- Department of Radiotherapy and Radiation Oncology, LKH Salzburg, Paracelsus Medical University Hospital, Salzburg, Austria
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KOLACINSKA AGNIESZKA, CEBULA-OBRZUT BARBARA, PAKULA LUKASZ, CHALUBINSKA-FENDLER JUSTYNA, MORAWIEC-SZTANDERA ALINA, PAWLOWSKA ZOFIA, ZAWLIK IZABELA, MORAWIEC ZBIGNIEW, JESIONEK-KUPNICKA DOROTA, SMOLEWSKI PIOTR. Immune checkpoints: Cytotoxic T-lymphocyte antigen 4 and programmed cell death protein 1 in breast cancer surgery. Oncol Lett 2015; 10:1079-1086. [PMID: 26622629 PMCID: PMC4508983 DOI: 10.3892/ol.2015.3321] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 04/09/2015] [Indexed: 12/23/2022] Open
Abstract
Immune checkpoints refer to a plethora of inhibitory pathways built into the immune system, and recent studies have emphasized the role of these checkpoints in carcinogenesis. The aim of the present study was to evaluate two major immune checkpoints, the cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1), in the serum of 35 patients with stage I and II breast cancer. Serum concentrations of CTLA-4 and PD-1 were measured at three time points: i) Preoperatively; ii) during anesthesia following the harvesting of sentinel nodes (SNs); and iii) 24 h postoperatively. Control samples were obtained from 25 healthy, age-matched females. Assessment of CTLA-4 and PD-1 expression levels was conducted using flow cytometry. A statistically significant difference in PD-1 expression was identified between breast cancer patients preoperatively and healthy controls (26.31±11.87 vs. 12.72±8.15; P<0.0001). In addition, a statistically significant association was found between CTLA-4 and PD-1 levels prior to surgery (P=0.0084). In addition, CTLA-4 expression was associated with age (P=0.0453), with elevated levels of CTLA-4 detected in older breast cancer patients. Higher PD-1 expression levels were observed in T2 tumors compared with T1 tumors prior to surgery and intraoperatively; however, the differences were not statistically significant. Furthermore, a decrease in PD-1 levels was observed subsequent to harvesting SNs with metastasis, but not in SN-negative patients (P=0.05). A negative correlation was also observed between PD-1 expression and progesterone receptor (PR) status following surgery (P=0.024). These results provided a basis for further investigation of immune checkpoints in breast cancer. Breast cancer patients exhibit an altered profile of immune checkpoint markers, with higher concentrations of PD-1 observed in larger, PR-negative tumors.
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Affiliation(s)
- AGNIESZKA KOLACINSKA
- Department of Head and Neck Cancer Surgery, Medical University of Łódź, Łódź 93-509, Poland
- Department of Surgical Oncology, Cancer Center, Łódź 93-509, Poland
| | - BARBARA CEBULA-OBRZUT
- Department of Experimental Hematology, Medical University of Łódź, Łódź 93-510, Poland
| | - LUKASZ PAKULA
- Department of Anesthesiology, Copernicus Memorial Hospital, Łódź 93-509, Poland
| | | | | | - ZOFIA PAWLOWSKA
- Central Scientific Laboratory, Medical University of Łódź, Łódź 92-215, Poland
| | - IZABELA ZAWLIK
- Department of Medical Genetics, Institute of Nursing and Health Sciences, Faculty of Medicine, University of Rzeszów, Rzeszów 35-959, Poland
- Center for Innovative Research in Medical and Natural Sciences, Rzeszów 35-959, Poland
| | | | | | - PIOTR SMOLEWSKI
- Department of Experimental Hematology, Medical University of Łódź, Łódź 93-510, Poland
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