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Laws A, Specht MC. Leveraging Neoadjuvant Chemotherapy to Minimize the Burden of Axillary Surgery: a Review of Current Strategies and Surgical Techniques. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00388-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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García-Novoa A, Acea-Nebril B, Díaz Carballada C, Bouzón Alejandro A, Conde C, Cereijo Garea C, Varela JR, Santiago Freijanes P, Antolín Novoa S, Calvo Martínez L, Díaz I, Rodríguez Martínez S, Mosquera Oses J. Combining Wire Localization of Clipped Nodes with Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: Preliminary Results from a Prospective Study. Ann Surg Oncol 2020; 28:958-967. [PMID: 32725521 DOI: 10.1245/s10434-020-08925-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The ideal technique for lymph node staging for patients with pathologically confirmed node-positive breast cancer at diagnosis and neoadjuvant chemotherapy (NAC) is unclear. OBJECTIVE The aim of this study was to analyze the feasibility of wire/clip localization and sentinel lymph node biopsy (SLNB) for the axillary staging of these patients. METHODS We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and an SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an axillary lymph node dissection (ALND). The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS Forty-two patients met the inclusion criteria. We identified and extirpated the clip/wire-marked node in all patients (100%), with SLNB performed successfully in 95.3% of patients. The SLN and wire-marked node matched in 80% of patients; 73.8% of patients did not undergo ALND. DISCUSSION AND CONCLUSIONS Several studies have evaluated the efficacy of various procedures for lymph node marking for women with prechemotherapy lymph node involvement. Most of the studies reported high identification rates (> 94.8%), with false negative rates of < 7%. Similarly, our study allows us to conclude that combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and NAC offers a high identification rate (100%) and a high correlation between the wire-marked lymph node and the SLN (80%). This procedure has enabled the suppression of ALND for a significant number of patients (73%).
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Affiliation(s)
- Alejandra García-Novoa
- Breast Unit, Department of General Surgery, University Hospital Complex of A Coruña, A Coruña, Spain.
| | - Benigno Acea-Nebril
- Breast Unit, Department of General Surgery, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carlota Díaz Carballada
- Breast Unit, Department of Gynecology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Alberto Bouzón Alejandro
- Breast Unit, Department of General Surgery, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carmen Conde
- Breast Unit, Department of Gynecology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carmen Cereijo Garea
- Breast Unit, Case Manager Nurse, University Hospital Complex of A Coruña, A Coruña, Spain
| | - José Ramón Varela
- Breast Unit, Department of Radiology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Paz Santiago Freijanes
- Breast Unit, Department of Pathology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Silvia Antolín Novoa
- Breast Unit, Department of Oncology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Lourdes Calvo Martínez
- Breast Unit, Department of Oncology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Inma Díaz
- Breast Unit, Department of Radiation Therapy, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Sofia Rodríguez Martínez
- Breast Unit, Department of Nuclear Medicine, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Joaquin Mosquera Oses
- Breast Unit, Department of Radiology, University Hospital Complex of A Coruña, A Coruña, Spain
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Correlation Between Pathologic Complete Response in the Breast and Absence of Axillary Lymph Node Metastases After Neoadjuvant Systemic Therapy. Ann Surg 2020; 271:574-580. [PMID: 30557203 DOI: 10.1097/sla.0000000000003126] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim was to investigate whether pathologic complete response (pCR) in the breast is correlated with absence of axillary lymph node metastases at final pathology (ypN0) in patients treated with neoadjuvant systemic therapy (NST) for different breast cancer subtypes. BACKGROUND Pathologic complete response rates have improved on account of more effective systemic treatment regimens. Promising results in feasibility trials with percutaneous image-guided tissue sampling for the identification of breast pCR after NST raise the question whether breast surgery is a redundant procedure. Thereby, the need for axillary surgery should be reconsidered as well. METHODS Patients diagnosed with cT1-3N0-1 breast cancer and treated with NST, followed by surgery between 2010 and 2016, were selected from the Netherlands Cancer Registry. Patients were compared according to the pathologic response of the primary tumor with associated pathologic axillary outcome. Multivariable analysis was performed to determine clinicopathological variables correlated with ypN0. RESULTS A total of 4084 patients were included for analyses, of whom 986 (24.1%) achieved breast pCR. In clinically node negative patients (cN0), 97.7% (432/442) with breast pCR had ypN0 compared with 71.6% (882/1232) without breast pCR (P < 0.001). In clinically node positive patients (cN1), 45.0% (245/544) with breast pCR had ypN0 compared with 9.4% (176/1866) without breast pCR (P < 0.001). The odds of ypN0 was decreased in case of clinical T3 stage (OR 0.59, 95% CI 0.40-0.87), cN1 (OR 0.03, 95% CI 0.02-0.04) and ER+HER2- subtype (OR 0.30, 95% CI 0.20-0.44), and increased in case of breast pCR (OR 4.53, 95% CI 3.27-6.28). CONCLUSIONS Breast pCR achieved after NST is strongly correlated with ypN0 in cN0 patients, especially in ER+HER2+, ER-HER2+, and triple negative subtypes. These results provide data to proceed with future clinical trials to investigate if axillary surgery can be safely omitted in these selected patients when image-guided tissue sampling identifies a breast pCR.
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De-escalation of axillary surgery in breast cancer patients treated in the neoadjuvant setting: a Dutch population-based study. Breast Cancer Res Treat 2020; 180:725-733. [PMID: 32180074 PMCID: PMC7103007 DOI: 10.1007/s10549-020-05589-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/06/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE An overall trend is observed towards de-escalation of axillary surgery in patients with breast cancer. The objective of this study was to evaluate this trend in patients treated with neoadjuvant systemic therapy (NST). METHODS Patients with cT1-4N0-3 breast cancer treated with NST (2006-2016) were selected from the Netherlands Cancer Registry. Patients were classified by clinical node status (cN) and type of axillary surgery. Uni- and multivariable logistic regression analyses were performed to determine the clinicopathological factors associated with performing ALND in cN+ patients. RESULTS A total of 12,461 patients treated with NST were identified [5830 cN0 patients (46.8%), 6631 cN+ patients (53.2%)]. In cN0 patients, an overall increase in sentinel lymph node biopsy (SLNB) only (not followed by ALND) was seen from 11% in 2006 to 94% in 2016 (p < 0.001). SLNB performed post-NST increased from 33 to 62% (p < 0.001). In cN+ patients, an overall decrease in ALND was seen from 99% in 2006 to 53% in 2016 (p < 0.001). Age (OR 1.01, CI 1.00-1.02), year of diagnosis (OR 0.47, CI 0.44-0.50), HER2-positive disease (OR 0.62, CI 0.52-0.75), clinical tumor stage (T2 vs. T1 OR 1.32, CI 1.06-1.65, T3 vs. T1 OR 2.04, CI 1.58-2.63, T4 vs. T1 OR 6.37, CI 4.26-9.50), and clinical nodal stage (N3 vs. N1 OR 1.65, CI 1.28-2.12) were correlated with performing ALND in cN+ patients. CONCLUSIONS ALND decreased substantially over the past decade in patients treated with NST. Assessment of long-term prognosis of patients in whom ALND is omitted after NST is urgently needed.
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Combined positive axillary lymph node marking with iodine-125 seeds and sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2020. [DOI: 10.1016/j.remnie.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lim GH, Teo SY, Gudi M, Ng RP, Pang J, Tan YS, Lee YS, Allen JC, Leong LCH. Initial results of a novel technique of clipped node localization in breast cancer patients postneoadjuvant chemotherapy: Skin Mark clipped Axillary nodes Removal Technique (SMART trial). Cancer Med 2020; 9:1978-1985. [PMID: 31970894 PMCID: PMC7064023 DOI: 10.1002/cam4.2848] [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: 08/04/2019] [Revised: 12/21/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose Removal of clipped nodes can improve sentinel node biopsy accuracy in breast cancer patients post neoadjuvant chemotherapy (NACT). However, the current methods of clipped node localization have limitations. We evaluated the feasibility of a novel clipped node localization and removal technique by preoperative skin marking of clipped nodes and removal by the Skin Mark clipped Axillary nodes Removal Technique (SMART), with the secondary aim of assessing the ultrasound visibility of the various clips in the axillary nodes after NACT. Methods Invasive breast cancer patients with histologically metastatic axillary nodes, going for NACT, and ≤3 sonographically abnormal axillary nodes were recruited. All abnormal nodes had clips inserted. Patients with M1 disease were excluded. Post‐NACT, patients underwent SMART and axillary lymph node dissection. Specimen radiography and pathological analyses were performed to confirm the clipped node presence. Success, complication rates of SMART, and ultrasound visibility of the various clips were assessed. Results Twenty‐five clipped nodes in 14 patients underwent SMART without complications. The UltraCor Twirl, hydroMARK, UltraClip Dual Trigger, and UltraClip were removed in 13/13 (100%), 7/9 (77.8%), 1/2 (50.0%), and 0/1 (0%), respectively (P = .0103) with UltraCor Twirl having the best ultrasound visibility and removal rate. Removal of three clipped nodes in the same patient (P = .0010) and deeply seated clipped nodes (P = .0167) were associated with SMART failure. Conclusion Skin Mark clipped Axillary nodes Removal Technique is feasible for removing clipped nodes post‐NACT, with 100% observed success rate, using the UltraCor Twirl marker in patients with <3 not deeply seated clipped nodes. Larger studies are needed for validation.
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Affiliation(s)
- Geok Hoon Lim
- Breast Department, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Sze Yiun Teo
- Department of Diagnostic & Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
| | - Mihir Gudi
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Ruey Pyng Ng
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jinnie Pang
- Breast Department, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yia Swam Tan
- Breast Department, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yien Sien Lee
- Department of Diagnostic & Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
| | - John C Allen
- Duke-NUS Medical School, Centre for Quantitative Medicine, Singapore, Singapore
| | - Lester Chee Hao Leong
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
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Banys-Paluchowski M, Gruber IV, Hartkopf A, Paluchowski P, Krawczyk N, Marx M, Brucker S, Hahn M. Axillary ultrasound for prediction of response to neoadjuvant therapy in the context of surgical strategies to axillary dissection in primary breast cancer: a systematic review of the current literature. Arch Gynecol Obstet 2020; 301:341-353. [PMID: 31897672 DOI: 10.1007/s00404-019-05428-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Data on the optimal treatment strategy for patients undergoing neoadjuvant therapy (NAT) who initially presented with metastatic nodes and convert to node-negative disease (cN+ → ycN0) are limited. Since NAT leads to axillary downstaging in 20-60% of patients, the question arises whether these patients might be offered less-invasive procedures than axillary dissection, such as sentinel node biopsy or targeted removal of lymph nodes marked before therapy. METHODS We performed a systematic review of clinical studies on the use of axillary ultrasound for prediction of response to NAT and ultrasound-guided marking of metastatic nodes for targeted axillary dissection. RESULTS The sensitivity of ultrasound for prediction of residual node metastasis was higher than that of clinical examination and MRI/PET in most studies; specificity ranged in large trials from 37 to 92%. The diagnostic performance of ultrasound after NAT seems to be associated with tumor subtype: the positive predictive value was highest in luminal, the negative in triple-negative tumors. Several trials evaluated the usefulness of ultrasound for targeted axillary dissection. Before NAT, nodes were most commonly marked using ultrasound-guided clip placement, followed by ultrasound-guided placement of a radioactive seed. After chemotherapy, the clip was detected on ultrasound in 72-83% of patients; a comparison of sonographic visibility of different clips is lacking. Detection rate after radioactive seed placement was ca. 97%. CONCLUSION In conclusion, ultrasound improves prediction of axillary response to treatment in comparison to physical examination and serves as a reliable guiding tool for marking of target lymph nodes before the start of treatment. High quality and standardization of the examination is crucial for selection of patients for less-invasive surgery.
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Affiliation(s)
| | - Ines Verena Gruber
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Andreas Hartkopf
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics, Regio Klinikum Pinneberg, Pinneberg, Germany
| | - Natalia Krawczyk
- Department of Obstetrics and Gynecology, University of Düsseldorf, Düsseldorf, Germany
| | - Mario Marx
- Department for Women's Health, University of Tübingen, Tübingen, Germany.,Department of Plastic, Reconstructive and Breast Surgery, Elblandklinikum Radebeul, Radebeul, Germany
| | - Sara Brucker
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Markus Hahn
- Department for Women's Health, University of Tübingen, Tübingen, Germany
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Reply to: Sentinel node biopsy after neoadjuvant chemotherapy for breast cancer in patients with pre-treatment node-positive: Recommendation to optimize the performance. Eur J Surg Oncol 2020; 46:218-219. [DOI: 10.1016/j.ejso.2019.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 11/16/2022] Open
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Simons J, Maaskant-Braat A, Luiten E, Leidenius M, van Nijnatten T, Boelens P, Koppert L, van der Pol C, van de Velde C, Audisio R, Smidt M. Patterns of axillary staging and management in clinically node positive breast cancer patients treated with neoadjuvant systemic therapy: Results of a survey amongst breast cancer specialists. Eur J Surg Oncol 2020; 46:53-58. [DOI: 10.1016/j.ejso.2019.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/03/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022] Open
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61
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Kanesalingam K, Sriram N, Heilat G, Ng EE, Meybodi F, Elder E, Brennan M, French J. Targeted axillary dissection after neoadjuvant systemic therapy in patients with node-positive breast cancer. ANZ J Surg 2019; 90:332-338. [PMID: 31845501 DOI: 10.1111/ans.15604] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 11/02/2019] [Accepted: 11/08/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Over the last decade, neoadjuvant systemic therapy (NAST) has gained considerable popularity and its use has been extended to include breast cancer patients with operable node-positive disease. It may no longer be necessary to commit patients who are node-positive at presentation to axillary dissection if they become clinically node-negative after completing NAST. Targeted axillary dissection (TAD) is a technique where the marked pre-NAST positive node is excised along with the sentinel nodes and its response to chemotherapy is assessed and thus helps guide further treatment to the axilla. METHODS The aim of this study was to determine the feasibility of marking positive axillary nodes with a clip and removing the clipped node after neoadjuvant treatment. We also assessed the concordance of the sentinel node with the clipped node. RESULTS We prospectively evaluated 37 clinically and/or radiologically node-positive patients who underwent NAST. The overall identification rate of the clipped node was 78%. The identification rate was 100% if the clipped node was localized preoperatively and was much lower at 68% in patients who did not have the clipped node localized. The clipped node was not retrieved as the sentinel node in 14% of patients. CONCLUSION We present the first Australian series on the feasibility of TAD. TAD is a feasible option in patients having NAST and with every new technique there is a learning curve. With the increasing experience globally and the refinement in marking and localization techniques, the accuracy of performing TAD will likely continue to improve.
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Affiliation(s)
- Kavitha Kanesalingam
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nina Sriram
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ghaith Heilat
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - E-Ern Ng
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Farid Meybodi
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Elisabeth Elder
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Meagan Brennan
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - James French
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer: A Systematic Review and Meta-analysis. Ann Surg 2019; 269:432-442. [PMID: 30312200 PMCID: PMC6369968 DOI: 10.1097/sla.0000000000003075] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective: The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND. Summary of Background Data: Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity. Methods: PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV). Results: Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%. Conclusion: Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.
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Samiei S, van Nijnatten TJA, van Beek HC, Polak MPJ, Maaskant-Braat AJG, Heuts EM, van Kuijk SMJ, Schipper RJ, Lobbes MBI, Smidt ML. Diagnostic performance of axillary ultrasound and standard breast MRI for differentiation between limited and advanced axillary nodal disease in clinically node-positive breast cancer patients. Sci Rep 2019; 9:17476. [PMID: 31767929 PMCID: PMC6877558 DOI: 10.1038/s41598-019-54017-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/07/2019] [Indexed: 01/13/2023] Open
Abstract
Preoperative differentiation between limited (pN1; 1-3 axillary metastases) and advanced (pN2-3; ≥4 axillary metastases) nodal disease can provide relevant information regarding surgical planning and guiding adjuvant radiation therapy. The aim was to evaluate the diagnostic performance of preoperative axillary ultrasound (US) and breast MRI for differentiation between pN1 and pN2-3 in clinically node-positive breast cancer. A total of 49 patients were included with axillary metastasis confirmed by US-guided tissue sampling. All had undergone breast MRI between 2008-2014 and subsequent axillary lymph node dissection. Unenhanced T2-weighted MRI exams were reviewed by two radiologists independently. Each lymph node on the MRI exams was scored using a confidence scale (0-4) and compared with histopathology. Diagnostic performance parameters were calculated for differentiation between pN1 and pN2-3. Interobserver agreement was determined using Cohen's kappa coefficient. At final histopathology, 67.3% (33/49) and 32.7% (16/49) of patients were pN1 and pN2-3, respectively. Breast MRI was comparable to US in terms of accuracy (MRI reader 1 vs US, 71.4% vs 69.4%, p = 0.99; MRI reader 2 vs US, 73.5% vs 69.4%, p = 0.77). In the case of 1-3 suspicious lymph nodes, pN2-3 was observed in 30.4% on US (positive predictive value (PPV) 69.6%) and in 22.2-24.3% on MRI (PPV 75.7-77.8%). In the case of ≥4 suspicious lymph nodes, pN1 was observed in 33.3% on US (negative predictive value (NPV) 66.7%) and in 38.5-41.7% on MRI (NPV 58.3-61.5%). Interobserver agreement was considered good (k = 0.73). In clinically node-positive patients, the diagnostic performance of axillary US and breast MRI is comparable and limited for accurate differentiation between pN1 and pN2-3. Therefore, there seems no added clinical value of preoperative breast MRI regarding nodal staging in patients with positive axillary US.
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Affiliation(s)
- S Samiei
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands.
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - H C van Beek
- Department of Radiology, Maxima Medical Centre, Eindhoven, The Netherlands
| | - M P J Polak
- Department of Radiology, Maxima Medical Centre, Eindhoven, The Netherlands
| | | | - E M Heuts
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - R J Schipper
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M L Smidt
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Custodio Rebollo Aguirre A, Sánchez Sánchez R, González Jiménez AD, Culiañez Casas M, Mendoza Arnau I, Rashki M, Rudolphi Solero T, Martínez Meca S. Combined procedure of marking axillary positive node with iodine-125 seed and sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2019; 39:75-83. [PMID: 31759957 DOI: 10.1016/j.remn.2019.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present our initial experience in the combined procedure of intraoperative detection of axillary positive node marked with 125I seed (ML) and sentinel node biopsy (SLN) after neoadjuvant chemotherapy (NACT), in breast cancer patients. MATERIAL AND METHODS Prospective study, January 2017 - March 2019, 16 breast cancer patients T1-3N1. TNM stage: IIA: 3, IIB: 10, IIIA: 3. Histological type ductal invasive: 14. Molecular subtype: luminal A: 3, luminal B: 9, HER2: 3, basal like: 1. The ML was marked 227±36 days before neoadjuvant chemotherapy (n: 10), or 1-6 days before surgery, on previously identified node by ultrasound visibility marker, hydrogel (n: 3) or three dimensional-3D (n: 3). Axillary lymphadenectomy was undertaken in 10 patients. RESULTS ML and SLN were identified in the surgery in 93.7% (15/16) of the cases, in 33.3% (5/15) ML was not among SLN, and in only one patient (1/5) was there a discrepancy between the result of ML and SLN (macrometastases vs. negative 0/2). Median number of lymph nodes SLN: 2.2±0.9 (range 1-3) and AD: 13.5±5.2 (range 7-23). In all cases, histopathological analysis of ML, 125I seed and/or marker within, correctly predicted axillary status after neoadjuvant chemotherapy. In all patients the 125I radioactive seed was recovered. CONCLUSIONS Placing of 125I seeds is a feasible technique for intraoperative location of axillary positive node combined with SLN. The histopathological result of ML allows the axillary status to be determined after neoadjuvant chemotherapy.
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Affiliation(s)
| | - R Sánchez Sánchez
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - A D González Jiménez
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Culiañez Casas
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - I Mendoza Arnau
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Rashki
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - T Rudolphi Solero
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - S Martínez Meca
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
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65
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Montagna G, Ritter M, Weber WP. News in surgery of patients with early breast cancer. Breast 2019; 48 Suppl 1:S2-S6. [DOI: 10.1016/s0960-9776(19)31114-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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66
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Elena GG, Pilar PB. Radioguided surgery of non palpable lesions: we have much to sow. Rev Esp Med Nucl Imagen Mol 2019. [DOI: 10.1016/j.remnie.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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67
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Gironés EG, Barranco PP. Cirugía radioguiada de lesiones ocultas: tenemos mucho que sembrar. Rev Esp Med Nucl Imagen Mol 2019; 38:341-342. [DOI: 10.1016/j.remn.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 11/28/2022]
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68
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Simons JM, van Pelt MLMA, Marinelli AWKS, Straver ME, Zeillemaker AM, Pereira Arias‐Bouda LM, van Nijnatten TJA, Koppert LB, Hunt KK, Smidt ML, Luiten EJT, van der Pol CC. Excision of both pretreatment marked positive nodes and sentinel nodes improves axillary staging after neoadjuvant systemic therapy in breast cancer. Br J Surg 2019; 106:1632-1639. [PMID: 31593294 PMCID: PMC6856822 DOI: 10.1002/bjs.11320] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/10/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Marking the axilla with radioactive iodine seed and sentinel lymph node (SLN) biopsy have been proposed for axillary staging after neoadjuvant systemic therapy in clinically node-positive breast cancer. This study evaluated the identification rate and detection of residual disease with combined excision of pretreatment-positive marked lymph nodes (MLNs) together with SLNs. METHODS This was a multicentre retrospective analysis of patients with clinically node-positive breast cancer undergoing neoadjuvant systemic therapy and the combination procedure (with or without axillary lymph node dissection). The identification rate and detection of axillary residual disease were calculated for the combination procedure, and for MLNs and SLNs separately. RESULTS At least one MLN and/or SLN(s) were identified by the combination procedure in 138 of 139 patients (identification rate 99·3 per cent). The identification rate was 92·8 per cent for MLNs alone and 87·8 per cent for SLNs alone. In 88 of 139 patients (63·3 per cent) residual axillary disease was detected by the combination procedure. Residual disease was shown only in the MLN in 20 of 88 patients (23 per cent) and only in the SLN in ten of 88 (11 per cent), whereas both the MLN and SLN contained residual disease in the remainder (58 of 88, 66 per cent). CONCLUSION Excision of the pretreatment-positive MLN together with SLNs after neoadjuvant systemic therapy in patients with clinically node-positive disease resulted in a higher identification rate and improved detection of residual axillary disease.
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Affiliation(s)
- J. M. Simons
- Department of Surgical OncologyErasmus Medical Centre RotterdamRotterdamthe Netherlands
- Department of Surgical OncologyUniversity Medical Centre Utrecht, Utrecht UniversityUtrechtthe Netherlands
| | - M. L. M. A. van Pelt
- Department of Surgical OncologyHaaglanden Medical CentreThe Haguethe Netherlands
| | | | - M. E. Straver
- Department of Surgical OncologyHaaglanden Medical CentreThe Haguethe Netherlands
| | - A. M. Zeillemaker
- Department of Surgical OncologyAlrijne HospitalLeiderdorpthe Netherlands
| | - L. M. Pereira Arias‐Bouda
- Department of Nuclear MedicineAlrijne HospitalLeiderdorpthe Netherlands
- Section of Nuclear Medicine, Department of RadiologyLeiden University Medical CentreLeidenthe Netherlands
| | - T. J. A. van Nijnatten
- Department of Radiology and Nuclear MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - L. B. Koppert
- Department of Surgical OncologyErasmus Medical Centre RotterdamRotterdamthe Netherlands
| | - K. K. Hunt
- Department of Breast Surgical OncologyUniversity of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - M. L. Smidt
- Department of Surgical OncologyMaastricht University Medical Centre+Maastrichtthe Netherlands
- GROW – School for Oncology and Developmental BiologyMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - E. J. T. Luiten
- Department of Surgical OncologyAmphia HospitalBredathe Netherlands
| | - C. C. van der Pol
- Department of Surgical OncologyUniversity Medical Centre Utrecht, Utrecht UniversityUtrechtthe Netherlands
- Department of Surgical OncologyAlrijne HospitalLeiderdorpthe Netherlands
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69
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Gandhi A, Doughty J. Comment on: Management of the axilla following neoadjuvant chemotherapy for breast cancer. Br J Surg 2019; 106:1705. [PMID: 31639210 DOI: 10.1002/bjs.11415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 11/08/2022]
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70
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Vrancken Peeters MTFD. Management of the axilla after neoadjuvant chemotherapy for breast cancer. Br J Surg 2019; 106:1571-1573. [DOI: 10.1002/bjs.11397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 11/07/2022]
Abstract
Minor international differences
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Affiliation(s)
- M T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
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71
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Glaeser A, Sinn HP, Garcia-Etienne C, Riedel F, Hug S, Schaefgen B, Golatta M, Hennigs A, Feisst M, Sohn C, Heil J. Heterogeneous Responses of Axillary Lymph Node Metastases to Neoadjuvant Chemotherapy are Common and Depend on Breast Cancer Subtype. Ann Surg Oncol 2019; 26:4381-4389. [PMID: 31605339 DOI: 10.1245/s10434-019-07915-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The objective of this study was to analyze heterogeneous responses of axillary lymph node metastasis to neoadjuvant chemotherapy and to determine to what extent they differ between tumor subtypes (TN, HER2+, HR+/HER2-). METHODS This retrospective, monocenter study included 72 consecutive, histologically node-positive breast cancers (cT1-4 cN1-3 cM0) diagnosed in the period from January 2015 to December 2016, who had received axillary lymph node dissection following neoadjuvant chemotherapy. All individual lymph node specimens were re-evaluated for the presence of tumor cells and chemotherapy effects to assess their response to neoadjuvant chemotherapy on an individual lymph node level according to the Sataloff classification. RESULTS Heterogeneous axillary responses to neoadjuvant chemotherapy occurred in 47.2% of the included 72 patients. The partial response rate was significantly higher in HR+/HER2- tumors (74.2%) than in TN (28.6%) and HER2+ tumors (25.0%) (p < 0.001). The presence of at least one negative, completely responding lymph node in the axillary lymph node dissection specimen had a false-negative rate of 48.8% in predicting ypN0. It dropped below 10% if at least four completely responding negative lymph nodes were identified. CONCLUSIONS Our study shows that axillary heterogeneous response rates differ significantly between tumor subtypes.
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Affiliation(s)
- Antonia Glaeser
- Department of Obstetrics and Gynecology, University Breast Unit, University Women's Hospital Heidelberg, Heidelberg, Germany
| | - Hans-Peter Sinn
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Carlos Garcia-Etienne
- Department of Breast Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, PV, Italy
| | - Fabian Riedel
- Department of Obstetrics and Gynecology, University Breast Unit, University Women's Hospital Heidelberg, Heidelberg, Germany
| | - Sarah Hug
- Department of Obstetrics and Gynecology, University Breast Unit, University Women's Hospital Heidelberg, Heidelberg, Germany
| | - Benedikt Schaefgen
- Department of Obstetrics and Gynecology, University Breast Unit, University Women's Hospital Heidelberg, Heidelberg, Germany
| | - Michael Golatta
- Department of Obstetrics and Gynecology, University Breast Unit, University Women's Hospital Heidelberg, Heidelberg, Germany
| | - Andre Hennigs
- Department of Obstetrics and Gynecology, University Breast Unit, University Women's Hospital Heidelberg, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Christof Sohn
- Department of Obstetrics and Gynecology, University Breast Unit, University Women's Hospital Heidelberg, Heidelberg, Germany
| | - Joerg Heil
- Department of Obstetrics and Gynecology, University Breast Unit, University Women's Hospital Heidelberg, Heidelberg, Germany.
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Beniey M, Boulva K, Kaviani A, Patocskai E. Novel Uses of Radioactive Seeds in Surgical Oncology: A Case Series. Cureus 2019; 11:e5706. [PMID: 31720174 PMCID: PMC6823086 DOI: 10.7759/cureus.5706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The localization of nonpalpable axillary metastatic lymph nodes has been achieved using several techniques in the past. Amongst these techniques, the use of radioactive iodine seeds is increasingly spread, and was initially reserved to breast-conserving surgery. Many studies have assessed the use of radioactive seed localization for the surgical management of breast cancer patients diagnosed with lymph node metastases. However, few articles have reported their utilization in other cancer subtypes and in complex clinical situations. This case series describes the innovative use of radioactive seeds in the axilla in five patients, including one case of squamous cell carcinoma skin cancer, one case of malignant melanoma, and three cases of invasive breast cancer.
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Affiliation(s)
- Michèle Beniey
- Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Kerianne Boulva
- Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Ahmad Kaviani
- Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Erica Patocskai
- Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
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73
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Beek MA, Gobardhan PD, Klompenhouwer EG, Menke-Pluijmers MB, Steenvoorde P, Merkus JW, Rutten HJ, Voogd AC, Luiten EJ. A patient- and assessor-blinded randomized controlled trial of axillary reverse mapping (ARM) in patients with early breast cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 46:59-64. [PMID: 31402072 DOI: 10.1016/j.ejso.2019.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/01/2019] [Accepted: 08/04/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Axillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement. METHODS Peroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomized study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk. RESULTS No significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p < 0.05). No axillary recurrence was found in both groups. CONCLUSIONS In contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity.
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Affiliation(s)
- Martinus A Beek
- Department of Surgery, Amphia Hospital, Breda, the Netherlands.
| | | | | | | | - Pascal Steenvoorde
- Department of Surgery, Medisch Spectrum Twente Hospital, Twente, the Netherlands
| | - Jos Ws Merkus
- Department of Surgery, Haga Hospital, The Hague, the Netherlands
| | - Harm Jt Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; Department of Surgery, Maastricht University, Maastricht, the Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Faculty of Health Medicine and Life Sciences, Research Institute Growth and Development (GROW), Maastricht University, Maastricht, the Netherlands; Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
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74
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Racz JM, Caudle AS. Sentinel Node Lymph Node Surgery After Neoadjuvant Therapy: Principles and Techniques. Ann Surg Oncol 2019; 26:3040-3045. [PMID: 31342394 DOI: 10.1245/s10434-019-07591-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Indexed: 02/05/2023]
Abstract
Surgical management of the axilla in breast cancer has been a topic of great interest. While sentinel lymph node biopsy (SLNB) is an established approach for patients undergoing surgical treatment as the first element of their care, there is continued debate regarding surgical management of the axilla in patients receiving neoadjuvant chemotherapy (NAC). In clinically node-negative patients, it has been debated whether or not SLNB should be performed before chemotherapy to accurately determine the clinical stage, or after chemotherapy, thus prioritizing the response to therapy and potentially minimizing axillary surgery. Node-positive patients have undergone axillary lymph node dissection in the past, however this paradigm has been challenged in recent years. Thus, surgeons must understand the importance of accurate axillary information both before and after NAC, and its role in multidisciplinary planning. We present a summary of the data surrounding axillary management in patients receiving NAC, and recommendations for surgical technique.
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Affiliation(s)
| | - Abigail S Caudle
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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75
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Wong SM, Weiss A, Mittendorf EA, King TA, Golshan M. Surgical Management of the Axilla in Clinically Node-Positive Patients Receiving Neoadjuvant Chemotherapy: A National Cancer Database Analysis. Ann Surg Oncol 2019; 26:3517-3525. [PMID: 31342389 DOI: 10.1245/s10434-019-07583-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The feasibility of sentinel lymph node biopsy (SLNB) in patients with clinically node-positive (cN+) disease who convert to clinically node-negative (cN0) disease following neoadjuvant chemotherapy (NAC) has been evaluated in several large clinical trials, but it remains unclear whether the approach has been broadly adopted in the United States. METHODS The National Cancer Database was used to identify women diagnosed with cN+ breast cancer who received NAC followed by surgery between 2012 and 2015. Trends in axillary surgery were evaluated and multivariable logistic regression analyses performed to determine factors associated with receipt of SLNB. RESULTS Of 12,965 women cN+ at baseline, the use of SLNB increased from 31.8% in 2012 to 49% in 2015 (p < 0.001). Using axillary pCR as a surrogate for patients who convert to cN0 following NAC, among 5127 (39.5%) ypN0 patients, SLNB increased from 38.2 to 58.4% over the study period (p < 0.001), resulting in avoidance of axillary dissection in 42.2% of ypN0 patients by 2015. In adjusted analyses, factors significantly associated with SLNB attempt included cN1 disease, age < 45 years, treatment facility type, triple-negative and HER2-positive subtypes, and year of diagnosis. In women with residual isolated tumor cells (ITCs), micrometastases, and ypN1 disease, SLNB was the only axillary procedure performed in 36.9%, 23.6%, and 13.0% of cases. CONCLUSIONS The use of SLNB in cN+ patients receiving NAC increased significantly between 2012 and 2015. SLNB alone was performed in more than 10% of patients with ypN1 disease, 20% with micrometastases, and 35% with ITCs; the oncologic safety of omitting axillary dissection in these patients requires further evaluation.
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Affiliation(s)
- Stephanie M Wong
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Anna Weiss
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Mehra Golshan
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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Woods RW, Camp MS, Durr NJ, Harvey SC. A Review of Options for Localization of Axillary Lymph Nodes in the Treatment of Invasive Breast Cancer. Acad Radiol 2019; 26:805-819. [PMID: 30143401 DOI: 10.1016/j.acra.2018.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 02/09/2023]
Abstract
Invasive breast cancer is a common disease, and the most common initial site of metastatic disease are the axillary lymph nodes. As the standard of care shifts towards less invasive surgery in the axilla for patients with invasive breast cancer, techniques have been developed for axillary node localization that allow targeted dissection of specific lymph nodes without requiring full axillary lymph node dissection. Many of these techniques have been adapted from technologies developed for localization of lesions within the breast and include marker clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive seeds, magnetic seeds, radar reflectors, and radiofrequency identification devices.The purpose of this article is to summarize these methods and describe benefits and drawbacks of each method for performing localization of lymph nodes in the axilla.
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Patel R, MacKerricher W, Tsai J, Choy N, Lipson J, Ikeda D, Pal S, De Martini W, Allison KH, Wapnir IL. Pretreatment Tattoo Marking of Suspicious Axillary Lymph Nodes: Reliability and Correlation with Sentinel Lymph Node. Ann Surg Oncol 2019; 26:2452-2458. [PMID: 31087176 DOI: 10.1245/s10434-019-07419-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Tattooing is an alternative method for marking biopsied axillary lymph nodes (ALNs) before initiation of treatments for newly diagnosed breast cancer. Detection of black ink-stained nodes is performed under direct visualization at surgery and is combined with sentinel node (SLN) mapping procedures. METHODS Women with newly diagnosed breast cancer who underwent fine or core-needle biopsy of suspicious ALNs were recruited. The nodal cortex and perinodal soft tissue was injected with 0.1-1.0 ml of Spot™ (GI Supply) black ink under ultrasound guidance. Intraoperatively, black stained nodes were removed along with SLNs, noting concordance between the two. RESULTS Sixty-six evaluable patients were enrolled (2013-2017). Nineteen received surgery first (Group 1) and 47 neoadjuvant therapy (NAT, Group 2). The average number of nodes tattooed was 1.16 for Group 1 and 1.04 for Group 2. The average interval from tattoo to surgery was 21 days (range 1-62) for Group 1 and 148 days (range 71-257) for Group 2. The tattooed node(s) were visually identified at surgery and corresponded to the sentinel lymph node(s) in 98.5% of cases (18/19 in Group 1 and 47/47 in Group 2). Of the 14 patients in Group 2 whose nodes remained positive following NAT, the tattooed node was the SLN associated with carcinoma. CONCLUSIONS Tattooing is an alternative method for marking biopsied ALNs. Tattooed nodes coincided with SLNs in 98.5% of cases. This technique is advantageous, because it allows for fewer procedures and lower costs compared with other methods.
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Affiliation(s)
- Rupa Patel
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Wendy MacKerricher
- Department of Pathology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Jacqueline Tsai
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Nicole Choy
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Jafi Lipson
- Department of Radiology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Debra Ikeda
- Department of Radiology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Sunita Pal
- Department of Radiology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Wendy De Martini
- Department of Radiology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Irene L Wapnir
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA.
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78
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Caudle AS, Kuerer HM, Krishnamurthy S, Shin K, Hobbs BP, Ma J, Mittendorf EA, Washington AC, DeSnyder SM, Black DM, Hunt KK, Yang WT. Feasibility of fine-needle aspiration for assessing responses to chemotherapy in metastatic nodes marked with clips in breast cancer: A prospective registry study. Cancer 2018; 125:365-373. [PMID: 30359480 DOI: 10.1002/cncr.31825] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/13/2018] [Accepted: 10/01/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Clips are often placed to mark axillary nodes with biopsy-confirmed metastases in patients with breast cancer. The evaluation of clipped nodes after chemotherapy can identify patients who have eradication of nodal disease. The goal of this study was to determine whether preoperative fine-needle aspiration (FNA) of clipped nodes after neoadjuvant chemotherapy (NAC) could predict the presence of residual disease. METHODS This prospective registry study enrolled 50 patients with a clip placed to mark nodes with biopsy-confirmed metastases who had completed NAC. Participants underwent FNA of the clipped node before seed-localized lymph node excision. FNA pathology was compared with surgical pathology. RESULTS There were 36 patients (72%) with residual disease on surgical pathology: 3 (8%) had a nondiagnostic aspirate, carcinoma was seen in 14 (39%), and 19 (53%) had a false-negative result. The sensitivity of FNA was 42.4%, its specificity was 100%, and its negative predictive value was 40.6%. In a univariate analysis, the odds of a true-positive result increased significantly with the mean initial size of the clipped node (odds ratio [OR], 4.3; P = .004) and the size of the metastatic focus after NAC (OR, 1.3; P = 0.003), whereas normalization of nodes after chemotherapy (OR, 0.1) and a lack of response on ultrasound (OR, 0.11) were associated with a false-negative result (P = .01). CONCLUSIONS FNA of marked nodes after chemotherapy has a high false-negative rate. This highlights the need for surgical staging of the axilla after NAC to assess the response.
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Affiliation(s)
- Abigail S Caudle
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Savitri Krishnamurthy
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kyungmin Shin
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Junsheng Ma
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth A Mittendorf
- Department of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Ashley C Washington
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah M DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dalliah M Black
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wei T Yang
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
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79
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Park KU, Caudle A. Management of the Axilla in the Patient with Breast Cancer. Surg Clin North Am 2018; 98:747-760. [DOI: 10.1016/j.suc.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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80
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Caudle AS. Intraoperative Pathologic Evaluation with Targeted Axillary Dissection. Ann Surg Oncol 2018; 25:3112-3114. [DOI: 10.1245/s10434-018-6666-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Indexed: 11/18/2022]
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81
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Taback B, Jadeja P, Ha R. Enhanced Axillary Evaluation Using Reflector-Guided Sentinel Lymph Node Biopsy: A Prospective Feasibility Study and Comparison With Conventional Lymphatic Mapping Techniques. Clin Breast Cancer 2018; 18:e869-e874. [PMID: 29544701 DOI: 10.1016/j.clbc.2018.02.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/04/2018] [Accepted: 02/05/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recently there are efforts to use sentinel lymph node biopsy (SLNB) techniques after neoadjuvant chemotherapy (NAC) to minimize axillary surgery. However, studies have shown higher false negative rates in this scenario, which might result in inaccurate assessment of treatment response and patient prognosis as well as leaving residual disease behind. In this study, we describe the use of reflector-guided excision of the percutaneously biopsied node (PBN) as an aid to conventional SLNB and its predictor of the axillary status after NAC. PATIENTS AND METHODS This was a single-institution analysis of patients who underwent axillary fiducial-reflector placement and subsequent SLNB compared with conventional SLNB. RESULTS Nineteen patients in the reflector group were matched with 19 patients who underwent conventional SLNB (conventional group). The PBN was identified in the SLNB in 19 patients (100%) in the reflector group and in 9 patients (47.3%) in the conventional group (P = .002). In the remaining 10 patients in the conventional group, the PBN was identified in the axillary lymph node dissection specimen in 4 patients (21%) and not identified in 6 patients (31.7%). Among the 38 patients, traditional mapping failed to identify the PBN in 13 patients (34.2%). The PBN was negative in 10 patients (36%) and positive in 18 patients (64%); no additional positive nodes were identified among patients with a negative PBN, correctly reflecting the status of the axilla in 100% of cases. CONCLUSION Mapping failure after NAC might compromise SLNB. Reflector-guided excision of the PBN is not only facile and feasible, but more accurately reflects the status of the axilla after NAC.
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Affiliation(s)
- Bret Taback
- Department of Breast Surgery, Columbia University Medical Center, New York, NY.
| | - Priya Jadeja
- Department of Breast Surgery, Columbia University Medical Center, New York, NY
| | - Richard Ha
- Department of Breast Imaging, Columbia University Medical Center, New York, NY
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Goñi Gironés E. New approaches in radioguided surgery. Rev Esp Med Nucl Imagen Mol 2018. [DOI: 10.1016/j.remnie.2017.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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83
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Goñi Gironés E. New approaches in radioguided surgery. Rev Esp Med Nucl Imagen Mol 2017; 37:1-2. [PMID: 29137876 DOI: 10.1016/j.remn.2017.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
Affiliation(s)
- E Goñi Gironés
- Grupo de Trabajo de Cirugía Radioguiada de la Sociedad Española de Medicina Nuclear.
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