Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial

Prognostic role of micrometastases in sentinel lymph node in patients with invasive breast cancer

BACKGROUND AND PURPOSE OF THE STUDY

Axillary lymph node status at the time of diagnosis remains one of the most important prognostic factors in women with breast cancer. Sentinel lymph node biopsy (SLNB) proved to be a reliable method for the evaluation of axillary nodal status in early-stage invasive breast cancer. The prognostic value and potential therapeutic consequences of SLN micrometastases remains a matter of great debate.

PATIENTS AND METHODS

From January 1998 to March 2011, 1,976 consecutive patients with non-metastatic invasive breast cancer underwent surgical treatment; 1,080 of them (54.6%) underwent SLNB. We collected data regarding demography, preoperative lymphoscintigraphy, type of surgery, histopathologic and immunohistochemical features and adjuvant treatment.

MAIN FINDINGS

A mean number of 2.1 ± 1.4 (range 1-13) SLN per patient were collected, a total of 2,294 nodes. SLNs were macrometastatic in 16.7% of patients and micrometastatic in 3.3%. Among the patients with positive SLN 93.6% underwent complete ALND. The overall survival (OS) and disease-free survival (DFS) of 72 patients with micrometastases in SLN at 60 months was 100%, similar to patients with negative SLN (98.7%), quite different from the DFS of N1-N3 patients (85.8%). Statistically significant differences in OS and DFS were observed between patients with N1mi and the group with N1-N3 sentinel node (p < 0.001 and p = 0.04) and also between patients with negative SLN and those with macrometastatic SLN (p < 0.001 for both).

CONCLUSION

SLN micrometastases could represents an epiphenomenon of peritumoral lymphovascular invasion which impacts independently on the survival of patients with invasive breast cancer.

Predicting the extent of nodal disease in early-stage breast cancer

BACKGROUND

The role of regional nodal ultrasound (US) has been questioned since publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 data. The goal of this study was to determine if imaging and clinicopathologic features could predict the extent of axillary nodal involvement in breast cancer.

STUDY DESIGN

Patients with T1-T2 tumors who underwent regional nodal US and axillary lymph node dissection from 2002 to 2012 were identified from a prospective database excluding those who received neoadjuvant chemotherapy. Patients whose metastases were identified by US confirmed by needle biopsy were compared with those identified by sentinel lymph node dissection (SLND) after a negative US.

RESULTS

Metastases were identified by US in 190 patients, and by SLND in 518 patients. SLND patients had fewer positive nodes (2.2 vs. 4.1; p < 0.0001), smaller metastases (5.3 vs. 13.8 mm; p < 0.0001), and a lower incidence of extranodal extension (24 vs. 53 %; p < 0.0001) than the US group. Even when US identified ≤2 abnormal nodes, patients were still more likely to have ≥3 positive nodes (45 %) than SLND patients (19 %; p < 0.001). After adjusting for tumor size, receptor status, and histology, multivariate analysis revealed that metastases identified by US [odds ratio (OR) 4.01; 95 % confidence interval (CI) 2.75-5.84] and lobular histology (OR 1.77; 95 % CI 1.06-2.95) predicted having ≥3 positive nodes.

CONCLUSIONS

Imaging and clinicopathologic features can be used to predict the extent of nodal involvement. Patients with US-detected metastases, even if small volume, have a higher burden of nodal involvement than patients with SLND-detected metastases and may not be comparable with patients in the ACOSOG Z0011 trial.

Clinical outcomes after sentinel lymph node biopsy in clinically node-negative breast cancer patients

Purpose

To evaluate non-sentinel lymph node (LN) status after sentinel lymph node biopsy (SNB) in patients with breast cancer and to identify the predictive factors for disease failure.

Materials and Methods

From January 2006 to December 2007, axillary lymph node (ALN) dissection after SNB was performed for patients with primary invasive breast cancer who had no clinical evidence of LN metastasis. A total of 320 patients were treated with breast-conserving surgery and radiotherapy.

Results

The median age of patients was 48 years, and the median follow-up time was 72.8 months. Close resection margin (RM) was observed in 13 patients. The median number of dissected SNB was two, and that of total retrieved ALNs was 11. Sentinel node accuracy was 94.7%, and the overall false negative rate (FNR) was 5.3%. Eleven patients experienced treatment failure. Local recurrence, regional LN recurrence, and distant metastasis were identified in 0.9%, 1.9%, and 2.8% of these patients, respectively. Sentinel LN status were not associated with locoregional recurrence (p > 0.05). Close RM was the only significant factor for disease-free survival (DFS) in univariate and multivariate analysis. The 5-year overall survival, DFS, and locoregional DFS were 100%, 96.8%, and 98.1%, respectively.

Conclusion

In this study, SNB was performed with high accuracy and low FNR and high locoregional control was achieved.

Relevance of the American College of Surgeons Oncology Group Z0011 Trial to breast cancer in the Australian setting

BACKGROUND

Conventional wisdom suggests that a patient with a positive sentinel node requires a completion axillary clearance to obtain full staging and durable regional control. However, this dictum has been challenged by the recent American College of Surgeons Oncology Group Z0011 Trial demonstrating that women with node-positive breast cancer who underwent sentinel node biopsy only, and were treated with breast conserving surgery and radiation, had equivalent locoregional recurrence and survival rates to those who had a completion axillary clearance. The aim of our study was to determine what the clinical impact of the Z0011 findings might be if patients were managed according to the Z0011 criteria in an Australian teaching hospital setting.

METHODS

We performed a retrospective review, using prospectively collected data, of all female patients with breast cancer assessed at the Westmead Breast Cancer Institute in 2010 and identified the subgroup who would potentially have fulfilled all Z0011 criteria. The characteristics and management of this group were compared with node-positive and to mastectomy patient subgroups.

RESULTS

A total of 280 patients with invasive breast cancer were identified. Twenty-six patients satisfied all Z0011 criteria, representing 9.3% of all patients and 21.5% of node-positive patients. Twenty-two (84.6%) patients had a subsequent axillary clearance, with six (27.3%) having additional positive nodes.

CONCLUSIONS

The Z0011 study is relevant to 9.3% of all breast cancer patients and 21.5% of node-positive breast cancer patients treated in a major Australian teaching hospital.

Management of operable primary breast cancer in older women

A considerable number of breast cancer diagnoses are made in older women. Differing physiological needs of older patients and biology of tumors compared with younger patients may alter treatment options between surgery and nonsurgical primary approaches. Adjuvant therapies may benefit these patients; however, concerns about toxicity and physical demands of treatment may affect patient choice regarding treatment. Furthermore, quality of life may be more important to the older individual than curative treatment alone. Growing evidence is emerging for employing Comprehensive Geriatric Assessment to determine other factors that may contribute to treatment decision-making in the older population. The way geriatric oncology is delivered varies, bringing the importance of the multidisciplinary team to the forefront of care delivery in this age group. Future research in this area should include combined consideration of tumor biology and geriatric needs.

Impact of sentinel node tumor burden on outcome of invasive breast cancer patients

BACKGROUND

The tumor status of the axillary lymph nodes is one of the most important prognostic factors in women with early breast cancer (BC). Sentinel lymph node (SLN) biopsy has become the standard staging procedure for patients with invasive BC, largely replacing axillary lymph nodes dissection (ALND). The exact impact on prognosis of SLN tumor burden is still object of controversy. The aim of this study was to correlate the tumor burden in the SLN with the outcome in a large cohort of women.

PATIENTS AND METHODS

1040 consecutive patients with clinical stage I-III invasive BC were prospectively collected on our Institutional BC database from January 2001 to January 2007. Patients were stratified into the following four groups based on the tumor burden of the SLN: macrometastases, tumor deposit ≥2 mm; micrometastases, tumor deposit ≥0.2 mm and <2 mm; isolated tumor cells (ITC), isolated tumor cells or tumor deposit <0.2 mm; negative, in case of patients with no evidence of tumor.

RESULTS

At a median follow-up of 8.5 years, the tumor burden of SLN metastases resulted significant predictor of DFS (P < 0.0001) and OS (P = 0.042). Multivariate analysis showed that the tumor burden of SLN metastases and Ki 67 proliferative index maintained the statistical significance.

CONCLUSION

Patients with SLN micrometastases or ITC, do not seem to have a worse DFS or OS compared with SLN negative cases. There is a significant decrease in DFS and OS in patients with macrometastatic disease in the SLN.

Main controversies in breast cancer

In this article, we have reviewed available evidence for diagnosis, treatment, and follow-up in female breast cancer (BC). Into daily clinical practice some controversies are occurred. Especially, in the diagnosis field, despite the fact that the optimal age in which screening mammography should start is a subject of intense controversy, there is a shift toward the beginning at the age of 40 although it is suggested that the net benefit is small for women aged 40 to 49 years. In addition, a promising tool in BC screening seems to be breast tomosynthesis. Other tools such as 3D ultrasound and shear wave elastography (SWE) are full of optimism in BC screening although ultrasonography is not yet a first-line screening method and there is insufficient evidence to recommend the systemic use of the SWE for BC screening. As for breast magnetic resonance imaging (MRI), even if it is useful in BC detection in women who have a strong family history of BC, it is not generally recommended as a screening tool. Moreover, based on the lack of randomized clinical trials showing a benefit of presurgical breast MRI in overall survival, it's integration into breast surgical operations remains debatable. Interestingly, in contrast to fine needle aspiration, core biopsy has gained popularity in presurgical diagnosis. Furthermore, after conservative surgery in patients with positive sentinel lymph nodes, the recent tendency is the shift from axillary dissection to axillary conserving strategies. While the accuracy of sentinel lymph node after neoadjuvant chemotherapy and second BC surgery remains controversial, more time is needed for evaluation and for determining the optimal interval between the two surgeries. Additionally, in the decision between immediate or delayed breast reconstruction, there is a tendency in the immediate use. In the prevention of BC, the controversial issue between tamoxifen and raloxifene becomes clear with raloxifene be more profitable through the toxicities of tamoxifen. However, the prevention of bone metastasis with bisphosphonates is still conflicting. Last but not least, in the follow-up of BC survivors, mammography, history and physical examination are the means of an early detection of BC recurrence. ed.

Extent of microinvasion in ductal carcinoma in situ is not associated with sentinel lymph node metastases

BACKGROUND

Ductal carcinoma in situ with microinvasion (DCISM) is a rare diagnosis with a good prognosis. Although nodal metastases are uncommon, sentinel lymph node biopsy (SLNB) remains standard care. Volume of disease in invasive breast cancer is associated with SLNB positivity, and, thus we hypothesized that in a large cohort of patients with DCISM, multiple foci of microinvasion might be associated with a higher risk of positive SLNB.

METHODS

Records from a prospective institutional database were reviewed to identify patients with DCISM who underwent SLNB between June 1997 and December 2010. Pathology reports were reviewed for number of microinvasive foci and categorized as 1 focus or ≥2 foci. Demographic, pathologic, treatment, and outcome data were obtained and analyzed.

RESULTS

Of 414 patients, 235 (57 %) had 1 focus of microinvasion and 179 (43 %) had ≥2 foci. SLNB macrometastases were found in 1.4 %, and micrometastases were found in 6.3 %; neither were significantly different between patients with 1 focus versus ≥2 foci (p = 1.0). Patients with positive SLNB or ≥2 foci of microinvasion were more likely to receive chemotherapy. At median 4.9 years (range 0-16.2 years) follow-up, 18 patients, all in the SLNB negative group, had recurred for an overall 5-year recurrence-free proportion of 95.9 %.

CONCLUSIONS

Even with large numbers, there was no higher risk of nodal involvement with ≥2 foci of microinvasion compared with 1 focus. Number of microinvasive foci and results of SLNB appear to be used in decision making for systemic therapy. Prognosis is excellent.

Advances in managing breast cancer: a clinical update

Although substantial progress has been made in the screening and management of breast cancer, globally it remains the most common cause of cancer and cancer death in women. While breast cancer is potentially curable when detected at an early stage, it remains incurable in the metastatic setting. Thus, given its high prevalence, improved prevention and treatment of metastases remains a clinically meaningful unmet need. We review here the advances made in the last several years in the screening and treatment of breast cancer and explore how our increased insight into the underlying biology of breast cancer has influenced our efforts to individualize patient care.

Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases: commentary on the IBCSG 23-01 Trial

Breast surgical oncologists have rapidly and successfully transitioned from the routine use of axillary lymph node dissection (ALND) to sentinel lymph node (SLN) biopsy for staging the axilla in clinically node negative patients. This approach limits the use of ALND to those patients with pathologically-proven axillary lymph node metastases and has prompted great current interest in whether or not all SLN-positive patients benefit from a completion ALND. Analysis of population-based data shows a decades-long trend towards omitting ALND in patients with low volume axillary disease. Thus, even prior to publication of the results of the ACOSOG Z0011 study and the IBCSG 23-01 study, completion ALND was being performed less frequently for selected patients with nodal micrometastases. Herein we review the contribution of the recently published IBCSG 23-01 study which provides additional data to confirm that for selected patients, mainly those with small, estrogen receptor-positive tumors with low nodal disease burden undergoing breast conservation with radiation and adjuvant systemic therapy, ALND might be avoided safely. This trial, which included small numbers of patients treated by mastectomy without radiation, and lumpectomy with partial breast irradiation, suggests interest in further clinical trials investigating these important patient populations. The study's short median follow-up however, cautions us to be clear in discussion, especially with younger patients who have otherwise biologically favorable tumors, that the long-term outcomes of SLN biopsy alone for low volume axillary disease remains unknown.

Does BMI affect the accuracy of preoperative axillary ultrasound in breast cancer patients?

INTRODUCTION

Obesity affects 36 % of American women and is a well-documented breast cancer risk factor. Preoperative axillary ultrasound (AUS) is used routinely for axillary staging in newly diagnosed breast cancer patients; However, the impact of obesity on the usefulness of AUS is unknown. Our aim was to evaluate the effect of body mass index (BMI) on the performance of AUS.

METHODS

From our prospective breast surgery database, we identified 1,510 consecutive invasive breast cancers in patients undergoing primary surgery, including axillary operation, from January 2010 to July 2013. Preoperative AUS was performed in 1,375 cases (91 %). We analyzed patient, pathology and imaging data.

RESULTS

Median BMI was 27.4 and 479 patients (36 %) were classified as obese (BMI ≥ 30). Most tumors were T1 (71 %) and estrogen receptor-positive (87 %). AUS was suspicious in 401 (29 %) patients, of whom 374 had ultrasound-guided lymph node fine-needle aspiration (FNA). Overall, 124 patients (33.2 %) were FNA positive. FNA identified disease preoperatively in 35.8 % of node-positive obese patients. For all BMI categories (normal, overweight, obese), AUS was predictive of pathologic nodal status (p < 0.0001). AUS sensitivity did not differ across BMI categories, while specificity and accuracy were better for overweight (p = 0.001 and 0.008, respectively) and obese (p = 0.007 and 0.02, respectively) patients, than for normal-BMI patients.

CONCLUSIONS

Despite theoretical concern regarding both potential technical challenges and obesity-related lymph node alterations, the sensitivity of preoperative AUS for detecting nodal metastasis was similar in obese and non-obese patients, while specificity was better in obese patients. Preoperative AUS is valuable for preoperative nodal staging of obese breast cancer patients.

Observational study of axilla treatment for breast cancer patients with 1-3 positive micrometastases or macrometastases in sentinel lymph nodes

Sentinel node biopsy is a standard procedure in clinically node-negative breast cancer patients. It has eliminated unnecessary axillary lymph node dissection in more than half of the early breast cancers. However, one of the unresolved issues in sentinel node biopsy is how to manage axilla surgery for sentinel node-positive patients and clinically node-negative patients. To evaluate the outcome of no axillary lymph node dissection in sentinel node-positive breast cancer, a prospective cohort study registering early breast cancer patients with positive sentinel nodes has been conducted (UMIN 000011782). Patients with 1-3 positive micrometastases or macrometastases in sentinel lymph nodes are eligible for the study. The primary endpoint is the recurrence rate of regional lymph nodes in patients treated with sentinel node biopsy. Patients treated with sentinel node biopsy followed by axillary lymph node dissection are also registered simultaneously to compare the prognosis. The propensity score matching is used to make the distributions of baseline risk factors comparable.

Prognostic relevance of peritumoral vascular invasion in immunohistochemically defined subtypes of node-positive breast cancer

Prognostic factors to better identify subcategories of node-positive breast cancer patients candidate to adjuvant chemotherapy are needed. The prognostic significance of the extent of peritumoral vascular invasion (PVI) in patients with positive axillary nodes is a matter of controversy. No data are available on the role of PVI within immunohistochemically defined subtypes. 3,729 consecutive patients with primary invasive breast cancer and positive axillary nodes were operated and referred for interdisciplinary evaluation from April 1997 to December 2005. Patients were classified as Luminal A, Luminal B(HER2 negative), Luminal B(HER2 positive), Triple Negative and HER-2 positive. The distribution of PVI was as follows: absent 2,010 (54 %), moderate/focal 963 (142 + 821) (26 %), and extensive 756 (20 %). Patients with extensive PVI were more likely to be Luminal B(HER2 negative) (49.3 %), younger (35-50 years), to have larger tumors (>pT2) with higher grade, a higher extent of node involvement (>4 nodes) and higher proliferative index, compared with patients with absence or moderate/focal PVI (p < 0.0001). In the multivariate analysis, extensive PVI (vs. absent) was correlated with a significant higher risk of local recurrence (HR 1.42, 95 %CI, 1.03-1.95, p = 0.0301). The immunohistochemically defined Luminal A-like subtype had a significant better outcome in terms of DFS, OS and reduced incidence of distant metastases when compared with the other subtypes. The occurrence of extensive PVI correlates with an increased risk of local recurrence. Luminal A tumors, classified according to the most recent St. Gallen recommendations, had an excellent outcome irrespective to the occurrence of extensive PVI or lymph node metastases and might be a good candidate to personalized adjuvant treatments.

Positive sentinel lymph node: the evolution of axillary surgery and intraoperative assessment of sentinel lymph nodes

SUMMARY 

Axillary lymph node dissection (ALND) has been the treatment for breast cancer in patients with sentinel lymph node (SLN) biopsy metastasis for prognostic information, local control and maybe for a small survival benefit. In recent years, clinicians have been questioning the need for axillary dissection in patients with positive SLN as the rate of axillary recurrences remains low when no ALND is performed in this group. Several variables incorporated in nomograms have been examined to predict axillary metastasis in patients with SLN metastasis and these nomograms have helped to determine which patients can spare the morbidity of the ALND. The combined multimodality in breast cancer treatments and the improvement in targeted therapies based in tumor biology have contributed to the low recurrence rates in early-stage breast cancer. As the multimodal treatment and the screening programs will improve, more patients with SLN metastasis will spare an ALND without compromising their oncologic outcome.

Impact of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial on clinical management of the axilla in older breast cancer patients: a SEER-medicare analysis

BACKGROUND

American College of Surgeons Oncology Group (ACOSOG) Z0011 demonstrated that eligible breast cancer patients with positive sentinel lymph nodes (SLN) could be spared an axillary lymph node dissection (ALND) without sacrificing survival or local control. Although heralded as a ‘‘practice-changing trial,’’ some argue that the stringent inclusion criteria limit the trial’s clinical significance. The objective was to assess the potential impact of ACOSOG Z0011 on axillary surgical management of Medicare patients and examine current practice patterns.

METHODS

Medicare beneficiaries aged C66 years with nonmetastatic invasive breast cancer diagnosed from 2001 to 2007 were identified from the Surveillance, Epidemiology and End Results-Medicare database (n = 59,431). Eligibility for ACOSOG Z0011 was determined: SLN mapping, tumor\5 cm, no neoadjuvant treatment, breast conservation; number of positive nodes was determined. Actual surgical axillary management for eligible patients was assessed.

RESULTS

Twelve percent (6,942/59,431) underwent SLN mapping and were node positive. Overall, 2,637 patients (4.4 % (2,637/59,431) of the total cohort, but 38 % (2,637/6,942) of patients with SLN mapping and positive nodes) met inclusion criteria for ACOSOG Z0011, had 1 or 2 positive lymph nodes, and could have been spared an ALND. Of these 2,637 patients, 46 % received a completion ALND and 54 % received only SLN biopsy.

CONCLUSIONS

Widespread implementation of ACOSOG Z0011 trial results could potentially spare 38 % of older breast cancer patients who undergo SLN mapping with positive lymph nodes an ALND. However, 54 % of these patients are already managed with SLN biopsy alone, lessening the impact of this trial on clinical practice in older breast cancer patients.

Mapping lymph nodes in cancer management - role of (99m)Tc-tilmanocept injection

Two decades ago, lymphatic mapping of sentinel lymph nodes (SLN) was introduced into surgical cancer management and was termed sentinel node navigated surgery. Although this technique is now routinely performed in the management of breast cancer and malignant melanoma, it is still under investigation for use in other cancers. The radioisotope technetium (^99mTc) and vital blue dyes are among the most widely used enhancers for SLN mapping, although near-infrared fluorescence imaging of indocyanine green is also becoming more commonly used. ^99mTc-tilmanocept is a new synthetic radioisotope with a relatively small molecular size that was specifically developed for lymphatic mapping. Because of its small size, ^99mTc-tilmanocept quickly migrates from its site of injection and rapidly accumulates in the SLN. The mannose moieties of ^99mTc-tilmanosept facilitate its binding to mannose receptors (CD206) expressed in reticuloendothelial cells of the SLN. This binding prevents transit to second-echelon lymph nodes. In Phase III trials of breast cancer and malignant melanoma, and Phase II trials of other malignancies, ^99mTc-tilmanocept had superior identification rates and sensitivity compared with blue dye. Trials comparing ^99mTc-tilmanocept with other ^99mTc-based agents are required before it can be routinely used in clinical settings.

Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials

BACKGROUND

Postmastectomy radiotherapy was shown in previous meta-analyses to reduce the risks of both recurrence and breast cancer mortality in all women with node-positive disease considered together. However, the benefit in women with only one to three positive lymph nodes is uncertain. We aimed to assess the effect of radiotherapy in these women after mastectomy and axillary dissection.

METHODS

We did a meta-analysis of individual data for 8135 women randomly assigned to treatment groups during 1964-86 in 22 trials of radiotherapy to the chest wall and regional lymph nodes after mastectomy and axillary surgery versus the same surgery but no radiotherapy. Follow-up lasted 10 years for recurrence and to Jan 1, 2009, for mortality. Analyses were stratified by trial, individual follow-up year, age at entry, and pathological nodal status.

FINDINGS

3786 women had axillary dissection to at least level II and had zero, one to three, or four or more positive nodes. All were in trials in which radiotherapy included the chest wall, supraclavicular or axillary fossa (or both), and internal mammary chain. For 700 women with axillary dissection and no positive nodes, radiotherapy had no significant effect on locoregional recurrence (two-sided significance level [2p]>0·1), overall recurrence (rate ratio [RR], irradiated vs not, 1·06, 95% CI 0·76-1·48, 2p>0·1), or breast cancer mortality (RR 1·18, 95% CI 0·89-1·55, 2p>0·1). For 1314 women with axillary dissection and one to three positive nodes, radiotherapy reduced locoregional recurrence (2p<0·00001), overall recurrence (RR 0·68, 95% CI 0·57-0·82, 2p=0·00006), and breast cancer mortality (RR 0·80, 95% CI 0·67-0·95, 2p=0·01). 1133 of these 1314 women were in trials in which systemic therapy (cyclophosphamide, methotrexate, and fluorouracil, or tamoxifen) was given in both trial groups and, for them, radiotherapy again reduced locoregional recurrence (2p<0·00001), overall recurrence (RR 0·67, 95% CI 0·55-0·82, 2p=0·00009), and breast cancer mortality (RR 0·78, 95% CI 0·64-0·94, 2p=0·01). For 1772 women with axillary dissection and four or more positive nodes, radiotherapy reduced locoregional recurrence (2p<0·00001), overall recurrence (RR 0·79, 95% CI 0·69-0·90, 2p=0·0003), and breast cancer mortality (RR 0·87, 95% CI 0·77-0·99, 2p=0·04).

INTERPRETATION

After mastectomy and axillary dissection, radiotherapy reduced both recurrence and breast cancer mortality in the women with one to three positive lymph nodes in these trials even when systemic therapy was given. For today's women, who in many countries are at lower risk of recurrence, absolute gains might be smaller but proportional gains might be larger because of more effective radiotherapy.

FUNDING

Cancer Research UK, British Heart Foundation, UK Medical Research Council.

[Sentinel node invasion: is it necessary to perform axillary lymph node dissection? Randomized trial SERC]

Contribution of axillary lymph node dissection (ALND) is questioned for positive sentinel node (SN), micro-metastasis and isolated tumor cells but also for macro-metastasis. The aim of this work is to precise why a prospective randomized trial is necessary and the design of this trial. Why? For positive SN, the scientific level evidence appears insufficient for validation of ALND omission as a new standard. Rational is presented with non-sentinel node involved rate and number of NSL involved at complementary ALND, axillary recurrence rate, disease free survival rate and adjuvant treatment decision impact. How? The proposed Sentinelle Envahi et Randomisation du Curage (SERC) trial will randomly assign to observation only or complementary ALND with positive SN. The aim is to demonstrate the non-inferiority of ALND omission versus ALND.

Is regional nodes radiotherapy an alternative to surgery?

Sentinel node biopsy (SN) in breast cancer treatment was introduced in the mid-1990s in order to be able to stage patients before decision of definitive surgery. Since then, both the pathological examinations of the SN and the systemic adjuvant treatment have improved and cause new challenges in the correct decision making regarding whether or not to radically treat the axilla in case of a positive SN. In SN positive patients, current St. Gallen guidelines support no completion ALND (axillary lymph node dissection) in clinically node-negative patients with 1-2 macrometastatic sentinel nodes operated with breast conservation and receiving tangential field adjuvant radiotherapy (RT). ALND is being questioned due to increased morbidity compared with SN biopsy alone, and to limited long term benefit on disease free survival in selected patients. An alternative to ALND is treating the axilla with nodal RT although this treatment is mostly used as adjuvant treatment after ALND in high risk patients. Few studies have investigated the benefit of nodal RT compared to ALND, and no consensus has yet been reached. Clinical decision making regarding treating the axilla should be based on relevant data, and in this review studies aiming at deciding whether or not and how the axilla should be treated in SN positive patients will be discussed. Furthermore treatment choice will be discussed, since besides ALND, both breast irradiation and nodal irradiation might cure residual disease after SN. Also the issue of improved systemic adjuvant treatment will be discussed in relation to eventually no regional axillary treatment.

[Impact of omission of axillary dissection on adjuvant therapy in patients with metastatic sentinel lymph nodes according to the ACOSOG Z0011 criteria]

OBJECTIVES

The results of the ACOSOG Z0011 questioned the usefulness of axillary lymph node dissection (ALND) in case of metastatic sentinel lymph node (SLN). The aim of our study was to assess the impact of the omission of ALND according to the inclusion criteria of the ACOSOG Z0011 study if SLN are metastatic but also the consequences on prescription of the application of a new standard of care for adjuvant treatment.

PATIENTS AND METHODS

This retrospective study included, between November 2007 and January 2012, patients with T1-T2N0 breast cancer and metastatic SLN meeting the criteria for omission of completion ALND according to the study of the ACOSOG Z0011. Patients were submitted anonymously and randomly in multidisciplinary meeting (MM) 3 times: with complete information including ALND (MM1), with information from SLN alone (MM2) and with complete information of ALND according to the current protocols in 2013 (MM3). During each presentation, we collected the decision of the different adjuvant treatments proposed: chemotherapy, hormonal therapy, radiotherapy (with radiation fields). Then, we compared therapeutic proposals of the 3 presentations.

RESULTS

Fifty-eight patients were eligible for inclusion criteria of the ACOSOG Z0011. Treatments actually proposed during MM1 consisted of 94.8 % of chemotherapy, 77.6 % of breast and lymph nodes radiotherapy and 91.4 % of hormone therapy. During the MM2, there was no significant difference compared to the decision taken during MM1. In fact, during MM2, we decided chemotherapy, radiotherapy and hormonotherapy respectively in 89.7, 79.3 and 91.4 % of the cases. During the MM3, it was shown a significant decrease in the indications of chemotherapy (82.8 %, P=0.03) and lymph nodes irradiation (56.9 %, P=0.02) compared to the therapeutic proposals of the MM1.

DISCUSSION AND CONCLUSION

The lack of information of ALND does not seem to significantly alter indications for adjuvant treatment. Otherwise, the evolution of our references causes a decrease in adjuvant therapy.

Tangential vs. defined radiotherapy in early breast cancer treatment without axillary lymph node dissection: a comparative study

PURPOSE

Recent studies have demonstrated low regional recurrence rates in early-stage breast cancer omitting axillary lymph node dissection (ALND) in patients who have positive nodes in sentinel lymph node dissection (SLND). This finding has triggered an active discussion about the effect of radiotherapy within this approach. The purpose of this study was to analyze the dose distribution in the axilla in standard tangential radiotherapy (SRT) for breast cancer and the effects on normal tissue exposure when anatomic level I-III axillary lymph node areas are included in the tangential radiotherapy field configuration.

PATIENTS AND METHODS

We prospectively analyzed the dosimetric treatment plans from 51 consecutive women with early-stage breast cancer undergoing radiotherapy. We compared and analyzed the SRT and the defined radiotherapy (DRT) methods for each patient. The clinical target volume (CTV) of SRT included the breast tissue without specific contouring of lymph node areas, whereas the CTV of DRT included the level I-III lymph node areas.

RESULTS

We evaluated the dose given in SRT covering the axillary lymph node areas of level I-III as contoured in DRT. The mean VD95% of the entire level I-III lymph node area in SRT was 50.28% (range, 37.31-63.24%), VD45 Gy was 70.1% (54.8-85.4%), and VD40 Gy was 83.5% (72.3-94.8%). A significant difference was observed between lung dose and heart toxicity in SRT vs. DRT. The V20 Gy and V30 Gy of the right and the left lung in DRT were significantly higher in DRT than in SRT (p<0.001). The mean heart dose in SRT was significantly lower (3.93 vs. 4.72 Gy, p=0.005).

CONCLUSION

We demonstrated a relevant dose exposure of the axilla in SRT that should substantially reduce local recurrences. Furthermore, we demonstrated a significant increase in lung and heart exposure when including the axillary lymph nodes regions in the tangential radiotherapy field set-up.

The need for axillary lymph node dissection in T1/T2 breast cancer surgery--counterpoint

For breast cancer patients, the role of the axillary lymph node dissection (ALND) in the management of clinically node negative breast cancer patient has shifted from routine, to selective, to increasingly rare. With the publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial results, some are ready to announce the time of death of this procedure. However, many questions remain regarding the design and statistical interpretation of the study, the treatments the patients actually received, and its applicability in clinical practice in light of other studies concerning regional management. Thus, the reports of the ALND's death may be greatly exaggerated. Careful acknowledgement of the study's strengths and shortcomings, and more recent trial data, suggest that although ALND may be safely avoided in a subset of sentinel lymph node positive, Z0011-eligible patients, others may require multidisciplinary review and consensus, and a careful conversation with the patient, before deciding it is not necessary.

It is not always necessary to do axillary dissection for T1 and T2 breast cancer--point

Axillary lymph node dissection (ALND) has been a part of breast cancer management since the 1900s. The idea that axillary metastases do not require surgical removal is a repudiation of the Halstedian concept of breast cancer biology, yet multiple prospective randomized studies show that the incidence of nodal recurrence in patients not having ALND is substantially lower than expected, based on the incidence of axillary metastases in patients having ALND, and survival does not differ based on axillary treatment. Avoidance of axillary dissection significantly reduces the morbidity of breast cancer surgery. As the use of systemic therapy has increased and targeted therapies have become available, the incidence of axillary recurrence in patients not having dissection has decreased to approximately 1% at 5 years, making routine axillary dissection difficult to justify. ALND is no longer standard management for patients with T1 and T2, clinically node-negative cancers undergoing breast-conserving therapy and found to have a positive sentinel node, and can also be avoided in patients with these tumor features having mastectomy if the need for postmastectomy radiotherapy is clear with the finding of a positive sentinel node.

In breast cancer patients sentinel lymph node metastasis characteristics predict further axillary involvement

The aim of the study was to correlate various primary tumor characteristics with lymph node status, to examine sentinel lymph node (SLN) metastasis size and non-SLN axillary involvement, to look for a cut-off size/number value possibly predicting additional axillary involvement with more accuracy and to examine the relationship of SLN metastasis size to overall survival. Of 301 patients who underwent SLN biopsy, 75 had positive SLNs. The size of the metastases was measured. For different size categories, association with the prevalence of non-SLN metastases was assessed. Associations between metastasis size and tumor characteristics and overall survival (OS) were studied. The prevalence of axillary lymph node (ALN) involvement was not significantly different between cases with micrometastasis or macrometastasis in SLNs (p = 0.124). However, for metastases larger than 6, 7, and 8 mm, the prevalence of ALN involvement was significantly higher (p = 0.046, 0.022, and 0.025). OS was significantly lower in SLN-positive than in SLN-negative cases (p = 0.0375). Primary tumor size larger than 20 mm was associated with a significantly higher incidence of SLN metastasis (p < 0.001), and primary tumor size over 26 mm was associated with additional positive non-SLN (p < 0.001). Higher mitotic index (≥ 7) in primary tumors was significantly (p < 0.001) associated with ALN involvement in SLN-positive cases, whereas higher Ki67 labeling index was not significantly correlated with SLN or ALN involvement. Lymphovascular invasion (LVI) in primary tumors was significantly correlated with SLN positivity (p < 0.001) but not with further ALN involvement or OS. Tumor size and LVI are predictive for SLN metastasis. Mitotic index, primary tumor size, and larger volume SLN involvement are determinants of further ALN involvement. SLN metastasis size over 6 mm is a strong predictor of further axillary involvement. OS is shorter in the presence of positive SLN.

Local treatment of the axilla in early breast cancer: concepts from the national surgical adjuvant breast and bowel project B-04 to the planned intergroup sentinel mamma trial

Local treatment of the axilla in clinically node-negative, early-stage breast cancer patients has been hotly debated after the release of the American College of Surgeons Oncology Group (ACOSOG) Z0011 findings. However, this review does not focus on the 'Z0011-eligible' patients alone, because this subgroup represents a minority of our patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB). The following topics are discussed: axillary diagnostics, timing of axillary procedures in the neoadjuvant setting, long-term follow-up of SLNB trials, omission of axillary surgery in randomized trials, management of the involved axilla with low tumor volume, positive sentinel lymph nodes and BCS, involved sentinel lymph nodes and mastectomy, and axillary radiotherapy. Finally, the current innovative study concepts (i.e. Sentinel Node versus Observation after Axillary Ultrasound (SOUND) and Intergroup Sentinel Mamma (INSEMA)) including patients with axillary observation alone in clinically node-negative women are presented.

Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Purpose

To provide evidence-based recommendations to practicing oncologists, surgeons, and radiation therapy clinicians to update the 2005 clinical practice guideline on the use of sentinel node biopsy (SNB) for patients with early-stage breast cancer.

Methods

The American Society of Clinical Oncology convened an Update Committee of experts in medical oncology, pathology, radiation oncology, surgical oncology, guideline implementation, and advocacy. A systematic review of the literature was conducted from February 2004 to January 2013 in Medline. Guideline recommendations were based on the review of the evidence by Update Committee.

Results

This guideline update reflects changes in practice since the 2005 guideline. Nine randomized clinical trials (RCTs) met systematic review criteria for clinical questions 1 and 2; 13 cohort studies informed clinical question 3.

Recommendations

Women without sentinel lymph node (SLN) metastases should not receive axillary lymph node dissection (ALND). Women with one to two metastatic SLNs planning to undergo breast-conserving surgery with whole-breast radiotherapy should not undergo ALND (in most cases). Women with SLN metastases who will undergo mastectomy should be offered ALND. These three recommendation are based on RCTs. Women with operable breast cancer and multicentric tumors, with ductal carcinoma in situ (DCIS) who will undergo mastectomy, who previously underwent breast and/or axillary surgery, or who received preoperative/neoadjuvant systemic therapy may be offered SNB. Women who have large or locally advanced invasive breast cancer (tumor size T3/T4), inflammatory breast cancer, or DCIS (when breast-conserving surgery is planned) or are pregnant should not undergo SNB. These recommendations are based on cohort studies and/or informal consensus. In some cases, updated evidence was insufficient to update previous recommendations.

Omission of axillary lymph node dissection for clinically node negative early-stage breast cancer patients

BACKGROUND

For clinically node negative (N0) breast cancer patients, sentinel node (SN) biopsy (SNB) is a standard technique and complete axillary lymph node dissection (ALND) remains the standard treatment when the SN is positive. However, the American College of Surgeons Oncology Group Z0011 trial and the International Breast Cancer Study Group 23-01 trial showed that SNB without ALND can offer excellent regional control and equal survival compared with ALND for limited macrometastatic and micrometastatic SN involvement, respectively. We retrospectively evaluated axillary control rates in clinically N0 patients who had no axillary surgical treatment.

METHODS

Data on 158 patients who underwent breast-conserving therapy without any axillary surgical procedure between 1994 and 2010 were extracted. The last follow-up was on May 2013, and the overall median follow-up period was 119.0 months.

RESULTS

Of all 158 patients, 10 (6.3 %) and 3 (1.9 %) developed locoregional and axillary recurrences, respectively. The 10-year locoregional and axillary recurrence rates were 5.8 and 2.1 %, respectively. The 5- and 10-year overall survival rates were 94.0 and 84.8 %, respectively. Cases with axillary recurrence tended to have common risk factors for recurrence.

CONCLUSION

Even if SNB and ALND were omitted, local and regional recurrence rates were very low among clinically N0 patients and were at the same levels shown in recent trials. This suggests that at least ALND might be safely avoided in clinically N0 patients without any obvious risk factors regardless of axillary nodal status after SNB.

Arm lymphoedema after axillary surgery in women with invasive breast cancer

BACKGROUND

The primary aim was to compare arm lymphoedema after sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND) in women with node-negative and node-positive breast cancer. The secondary aim was to examine the potential association between self-reported and objectively measured arm lymphoedema.

METHODS

Women who had surgery during 1999-2004 for invasive breast cancer in four centres in Sweden were included. The study groups were defined by the axillary procedure performed and the presence of axillary metastases: SLNB alone, ALND without axillary metastases, and ALND with axillary metastases. Before surgery, and 1, 2 and 3 years after operation, arm volume was measured and a questionnaire regarding symptoms of arm lymphoedema was completed. A mixed model was used to determine the adjusted mean difference in arm volume between the study groups, and generalized estimating equations were employed to determine differences in self-reported arm lymphoedema.

RESULTS

One hundred and forty women had SLNB alone, 125 had node-negative ALND and 155 node-positive ALND. Women who underwent SLNB had no increase in postoperative arm volume over time, whereas both ALND groups showed a significant increase. The risk of self-reported arm lymphoedema 1, 2 and 3 years after surgery was significantly lower in the SLNB group compared with that in both ALND groups. Three years after surgery there was a significant association between increased arm volume and self-reported symptoms of arm lymphoedema.

CONCLUSION

SLNB is associated with a minimal risk of increased arm volume and few symptoms of arm lymphoedema, significantly less than after ALND, regardless of lymph node status.

Management of the clinically node-negative axilla in primary and locally recurrent breast cancer

For patients with primary breast cancer, nodal status remains a key determinant for overall prognosis. Sentinel lymph node biopsy (SLNB) has become standard care for staging patients who have clinically node-negative disease. However, a new dilemma has arisen: how to manage the clinically negative axilla in patients with ipsilateral breast tumor recurrences (IBTRs). Are outcomes in these patients improved with repeat SLNB? Although observational studies suggest SLNB is feasible in patients with IBTR and a clinically node-negative axilla, the overall impact on morality and local recurrence is not yet known as no randomized trials have addressed this issue.

The classification of invasive carcinoma of the breast

The classification of invasive breast carcinoma assists diagnosis, allows for comparison of different patient groups in clinical trials and facilitates epidemiological analysis. For the individual patient, accurate tumor classification informs clinical decision-making with emphasis on assessment of prognosis and treatment formulation. Tumor grade is an independent prognostic indicator and is calculated by assessing specific tumor characteristics microscopically. The Tumor Node Metastasis staging system, produced by the American Joint Committee on Cancer Union for International Cancer Control, combines information about the primary tumor size, the status of the regional lymph nodes and the presence or absence of distant metastases at diagnosis to classify disease. In recent years, the use of gene expression profiling technology has led to the development of the molecular classification of breast cancer and has highlighted the importance of hormone receptor and HER2 oncogenic pathways, with particular reference to targeted chemotherapy. Tumor typing involves the identification of 'no special type' carcinoma with variable clinical, histological and molecular characteristics and 'special type' carcinomas that are usually associated with a particular set of prognostic and predictive indices. Some special type carcinomas have unique biological features that influence diagnostic investigation and clinical management.

A risk score model predictive of the presence of additional disease in the axilla in early-breast cancer patients with one or two metastatic sentinel lymph nodes

BACKGROUND

Axillary lymph node dissection (ALND) in early-breast cancer patients with positive sentinel node (SLN+) may not always be necessary.

AIMS

To predict the finding of ≥1 metastatic axillary node in addition to SLN+(s); to discriminate between patients who would or not benefit from ALND.

METHODS

Records of 397 consecutive patients with 1-2 SLN+s receiving ALND were reviewed. Clinico-pathological features were used in univariate and multivariate analyses to develop a logistic regression model predictive of the risk of ≥1 additional axillary node involved. The discrimination power of the model was quantified by the area under the receiver operating characteristic curve (AUC) and validated using an independent set of 83 patients.

RESULTS

In univariate analyses, the risk of ≥1 additional node involved was correlated with tumor size, grade, HER-2 and Ki-67 over-expression, number of SLN+s. All factors, but Ki-67, retained in multivariate regressions were used to generate a predictive model with good discriminating power on both the training and the validation sets (AUC 0.73 and 0.75, respectively). Three patient groups were defined based on their risk to present additional axillary burden.

CONCLUSIONS

The model identifies SLN+-patients at low risk (≤15%) who could reasonably be spared ALND and those at high risk (>75%) who should receive ALND. For patients at intermediate risk, ALND appropriateness could be individually evaluated based on other clinico-pathological parameters.

Detailed evaluation of one step nucleic acid (OSNA) molecular assay for intra-operative diagnosis of sentinel lymph node metastasis and prediction of non-sentinel nodal involvement: experience from a London teaching hospital

One step nucleic acid (OSNA) is a molecular diagnostic assay for intra-operative detection of sentinel node metastases. This study compared OSNA with standard histopathology in 283 nodes from 170 patients to evaluate sensitivity, specificity and concordance of the two methods. Additional analysis was done to investigate how cytokeratin 19 mRNA copy number affects prediction of non-sentinel node positivity. OSNA sensitivity was 93.2% and specificity 95.8%. Concordance between OSNA and histology was 95.6%. In the patients who had axillary clearance, the OSNA mRNA copy number on the sentinel node had 100% negative predictive value for histologically proven metastasis. mRNA copy numbers <1400 were not associated with histologically proven metastasis in subsequent nodes at axillary clearance. OSNA is a reliable method for the intra-operative evaluation of axillary lymph node metastasis even when half of the lymph node is used. Identification of mRNA copy number threshold predicting the positivity of non-sentinel axillary nodes seems to be feasible and would be clinically important.

Selective sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer: results of the GEICAM 2005-07 study

INTRODUCTION

A controversial aspect of breast cancer management is the use of sentinel lymph node biopsy (SLNB) in patients requiring neoadjuvant chemotherapy (NCT). This paper discusses the detection rate (DT) and false negatives (FN) of SLNB after NCT to investigate the influence of initial nodal disease and the protocols applied.

METHODS

Prospective observational multicenter study in women with breast cancer, treated with NCT and SLNB post-NCT with subsequent lymphadenectomy. DT and FN rates were calculated, both overall and depending on the initial nodal status or the use of diagnostic protocols pre-SLNB.

RESULTS

No differences in DT between initial node-negative cases and positive cases were found (89.8 vs. 84.4%, P=.437). Significant differences were found (94.1 vs. 56.5%, P=0,002) in the negative predictive value, which was lower when there was initial lymph node positivity, and a higher rate of FN, not significant (18.2 vs. 43.5%, P=.252) in the same cases. The axillary study before SLNB and after the NCT, significantly decreased the rate of FN in patients with initial involvement (55.6 vs 12.5, P=0,009).

CONCLUSIONS

NCT means less DT and a higher rate of FN in subsequent SLNB, especially if there is initial nodal involvement. The use of protocols in axillary evaluation after administering the NCT and before BSGC, decreases the FN rate in these patients.

Systematic review and meta-analysis of cytokeratin 19-based one-step nucleic acid amplification versus histopathology for sentinel lymph node assessment in breast cancer

Background

One-step nucleic acid amplification (OSNA) is a new rapid assay for detecting breast cancer metastases during surgery, saving a second procedure for patients requiring an axillary clearance. Many centres in the UK and abroad have adopted OSNA in place of routine histopathology, despite no published meta-analysis. The aim of this systematic review and meta-analysis was to determine whether intraoperative OSNA for lymph node assessment is comparable to routine histopathology in the detection of clinically relevant metastases.

Methods

PubMed, Embase, Web of Knowledge and regional databases were searched for relevant studies published before December 2012. Included studies compared OSNA and standard histology using fresh lymph nodes that were assessed in a clearly defined systematic manner in accordance with the index study.

Results

Twelve eligible studies were identified that included 5057 lymph nodes from 2192 patients. Although meta-analysis using a random-effects model showed a similar overall proportion of macrometastases detected (429 of 3234 versus 432 of 3234; odds ratio 0·99, 95 per cent confidence interval 0·86 to 1·15), analysis of concordance showed that the pooled positive predictive value for detecting macrometastases was 0·79. This suggests that up to 21 per cent of patients found to have macrometastases using OSNA would have an axillary clearance when histology would have classified the deposits as non-macrometastases. Furthermore, analysis of data from the index publication showed that the range of cytokeratin 19 titres for tumours of a given volume is too wide to predict tumour size.

Conclusion

OSNA has an unacceptably low positive predictive value, leading to axillary clearances that would not be recommended if standard histology had been used to assess the sentinel node.