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Pop CF, Nziki LD, El Helou E, Moreau M, Radermecker M, Larsimont D, Veys I, De Neubourg F. Axillary Surgical Attitude Changing with Retrospective Application of ACOSOG Z0011 Eligible Criteria: An Institutional Evaluation. Eur J Breast Health 2023; 19:318-324. [PMID: 37795004 PMCID: PMC10546802 DOI: 10.4274/ejbh.galenos.2023.2023-6-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/14/2023] [Indexed: 10/06/2023]
Abstract
Objective Sentinel lymph node biopsy (SLNB) represents the gold standard for axillary surgical staging. The aim of this study was to assess the proportion of axillary lymph node dissection (ALND) that could be avoided after retrospective application of the ACOSOG Z0011 criteria and to evaluate the shortterm complications associated with axillary surgery. Materials and Methods We reviewed breast cancer (BC) patients treated by primary breast-conserving surgery from 2012 to 2015. The percentage of SLNB vs ALND performed before and after the application of the ACOSOG Z0011 criteria was calculated. Complications were analyzed using crosstabs, with p<0.05 considered significant. Results Two hundred fifty one patients with a median age of 59.3 years were included. BC tumors had a median size of 13 mm and were mostly unifocal (83.9%). There were 30.3% with 1-2 metastatic lymph nodes (MLN). ALND was performed in 44.2%. The patients with 1-2 MLN, had only SLNB in 14.5% of cases. By applying the ACOSOG Z0011 criteria, ALND would have been avoided in 40.2% of patients. At least one postoperative complication was reported after SLNB or ALND for 45.7% and 74.7% of patients respectively. Seroma was the most frequent complication, and occurred in 29.3% of cases after SLNB and in 59.5% after ALND. Conclusion SNLB is the most commonly used axillary surgical staging procedure in this series (55.8%). With a retrospective application of the ACOSOG Z0011 criteria in our population, ALND could have been avoided for 40.2% patients. Post-operative complications rate was higher after ALND, with a seroma rate at 59.5%.
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Affiliation(s)
- C. Florin Pop
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Lea Datin Nziki
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Etienne El Helou
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Michel Moreau
- Data Centre and Statistics, Institut Jules Bordet, ULB, Brussels, Belgium
| | | | - Denis Larsimont
- Department of Pathology, Institut Jules Bordet, ULB, Brussels, Belgium
| | - Isabelle Veys
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Filip De Neubourg
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Jankowski P, Findeklee S, Georgescu MT, Sima RM, Nigdelis MP, Solomayer EF, Klamminger GG, Hamoud BH. The Therapy of Vulvar Carcinoma-Evaluation of Surgical Options in a Retrospective Monocentric Study. Life (Basel) 2023; 13:1973. [PMID: 37895358 PMCID: PMC10608767 DOI: 10.3390/life13101973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/21/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Background: Surgical-oncological treatment methods are continuously put to the test in times of evidence-based medicine-notably, a constant reevaluation remains key, especially for tumor entities with increasing incidence such as vulvar carcinoma. (2) Methods: In order to determine the postoperative clinical course of different methods of vulvar excision (vulvectomy, hemivulvectomy) as well as inguinal lymph node removal (lymphadenectomy, sentinel lymph node biopsy) with regard to postoperative wound-healingprocess, perioperative hemorrhage, and re-resection rates, we retrospectively analyzed surgical, morphological and laboratory data of 76 patients with a pathological diagnosed vulvar cancer. (3) Results: Analysis of our data from a single center revealed a comparable perioperative clinical course regardless of the chosen method of vulvar excision and inguinal lymph node removal. (4) Conclusions: Thus, our results emphasize the current multimodality in surgical therapy of vulvar carcinoma, in which consideration of known prognostic factors together with the individual patient's clinical situation allow guideline-based therapy aimed at maximizing surgical safety.
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Affiliation(s)
- Peter Jankowski
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Sebastian Findeklee
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Mihai-Teodor Georgescu
- Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- “Prof. Dr. Alexandru Trestioreanu” Oncology Institute, 022328 Bucharest, Romania
| | - Romina Marina Sima
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- The “Bucur” Maternity, ‘Saint John’ Hospital, 040294 Bucharest, Romania
| | - Meletios P. Nigdelis
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Papageorgiou General Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece
| | - Erich-Franz Solomayer
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Gilbert Georg Klamminger
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Bashar Haj Hamoud
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
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53
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Ji H, Hu C, Yang X, Liu Y, Ji G, Ge S, Wang X, Wang M. Lymph node metastasis in cancer progression: molecular mechanisms, clinical significance and therapeutic interventions. Signal Transduct Target Ther 2023; 8:367. [PMID: 37752146 PMCID: PMC10522642 DOI: 10.1038/s41392-023-01576-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 07/04/2023] [Accepted: 07/26/2023] [Indexed: 09/28/2023] Open
Abstract
Lymph nodes (LNs) are important hubs for metastatic cell arrest and growth, immune modulation, and secondary dissemination to distant sites through a series of mechanisms, and it has been proved that lymph node metastasis (LNM) is an essential prognostic indicator in many different types of cancer. Therefore, it is important for oncologists to understand the mechanisms of tumor cells to metastasize to LNs, as well as how LNM affects the prognosis and therapy of patients with cancer in order to provide patients with accurate disease assessment and effective treatment strategies. In recent years, with the updates in both basic and clinical studies on LNM and the application of advanced medical technologies, much progress has been made in the understanding of the mechanisms of LNM and the strategies for diagnosis and treatment of LNM. In this review, current knowledge of the anatomical and physiological characteristics of LNs, as well as the molecular mechanisms of LNM, are described. The clinical significance of LNM in different anatomical sites is summarized, including the roles of LNM playing in staging, prognostic prediction, and treatment selection for patients with various types of cancers. And the novel exploration and academic disputes of strategies for recognition, diagnosis, and therapeutic interventions of metastatic LNs are also discussed.
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Affiliation(s)
- Haoran Ji
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Chuang Hu
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Xuhui Yang
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Yuanhao Liu
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Guangyu Ji
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Shengfang Ge
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Xiansong Wang
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Mingsong Wang
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
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Alkner S, de Boniface J, Lundstedt D, Mjaaland I, Ryden L, Vikstrom J, Bendahl PO, Holmberg E, Sackey H, Wieslander E, Karlsson P. Protocol for the T-REX-trial: tailored regional external beam radiotherapy in clinically node-negative breast cancer patients with 1-2 sentinel node macrometastases - an open, multicentre, randomised non-inferiority phase 3 trial. BMJ Open 2023; 13:e075543. [PMID: 37751948 PMCID: PMC10533703 DOI: 10.1136/bmjopen-2023-075543] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Modern systemic treatment has reduced incidence of regional recurrences and improved survival in breast cancer (BC). It is thus questionable whether regional radiotherapy (RT) is still beneficial in patients with sentinel lymph node (SLN) macrometastasis. Postoperative regional RT is associated with an increased risk of arm morbidity, pneumonitis, cardiac disease and secondary cancer. Therefore, there is a need to individualise regional RT in relation to the risk of recurrence. METHODS AND ANALYSIS In this multicentre, prospective randomised trial, clinically node-negative patients with oestrogen receptor-positive, HER2-negative BC and 1-2 SLN macrometastases are eligible. Participants are randomly assigned to receive regional RT (standard arm) or not (intervention arm). Regional RT includes the axilla level I-III, the supraclavicular fossa and in selected patients the internal mammary nodes. Both groups receive RT to the remaining breast. Chest-wall RT after mastectomy is given in the standard arm, but in the intervention arm only in cases of widespread multifocality according to national guidelines. RT quality assurance is an integral part of the trial.The trial aims to include 1350 patients between March 2023 and December 2028 in Sweden and Norway. Primary outcome is recurrence-free survival (RFS) at 5 years. Non-inferiority will be declared if outcome in the de-escalation arm is not >4.5 percentage units below that with regional RT, corresponding to an HR of 1.41 assuming 88% 5-year RFS with standard treatment. Secondary outcomes include locoregional recurrence, overall survival, patient-reported arm morbidity and health-related quality of life. Gene expression analysis and tumour tissue-based studies to identify prognostic and predictive markers for benefit of regional RT are included. ETHICS AND DISSEMINATION The trial protocol is approved by the Swedish Ethics Authority (Dnr-2022-02178-01, 2022-05093-02, 2023-00826-02, 2023-03035-02). Results will be presented at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05634889.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Ingvil Mjaaland
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Lisa Ryden
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Johan Vikstrom
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Pär-Ola Bendahl
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Helena Sackey
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Elinore Wieslander
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
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Verreck EEF, van Steenhoven JEC, Kuijer A, van Maaren MC, Simons JM, Siesling S, van Dalen T. Trends of Axillary Treatment in Sentinel Node-Positive Breast Cancer Patients Undergoing Mastectomy. Ann Surg Oncol 2023; 30:5623-5632. [PMID: 37225832 PMCID: PMC10409658 DOI: 10.1245/s10434-023-13568-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The ACOSOG-Z0011- and the AMAROS-trial obviated the need for axillary surgery in most sentinel node-positive (SLN+) breast cancer patients undergoing breast-conserving surgery (BCS). Data for patients who undergo mastectomy is scarce. The purpose of this study was to investigate patterns of axillary treatment in SLN+ patients treated by mastectomy in the years after the publication of landmark studies regarding axillary treatment in SLN+ breast cancer patients undergoing BCS. METHODS This was a population-based study in cT1-3N0M0 breast cancer patients treated by mastectomy and staged as SLN+ between 2009 and 2018. The performance of an axillary lymph node dissection (ALND) and/or administration of postmastectomy radiotherapy (PMRT) were primary outcomes and were studied over time. RESULTS The study included 10,633 patients. The frequency of ALND performance decreased from 78% in 2009 to 10% in 2018, whereas PMRT increased from 4 to 49% (P < 0.001). In ≥N1a patients, ALND performance decreased from 93 to 20%, whereas PMRT increased to 70% (P < 0.001). In N1mi and N0itc patients, ALND was abandoned during the study period, whereas PMRT increased to 38% and 13% respectively (P < 0.001), respectively. Age, tumor subtype, N-stage, and hospital type affected the likelihood that patients underwent ALND. CONCLUSIONS In this study in SLN+ breast cancer patients undergoing mastectomy, use of ALND decreased drastically over time. By the end of 2018 most ≥N1a patients received PMRT as the only adjuvant axillary treatment, whereas the majority of N1mi and N0itc patients received no additional treatment.
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Affiliation(s)
| | - Julia E C van Steenhoven
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Anne Kuijer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marissa C van Maaren
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Janine M Simons
- Department of Radiotherapy, Erasmus MC, Rotterdam, The Netherlands
- GROW school for oncology and reproduction, MUMC+, Maastricht, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Thijs van Dalen
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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56
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Leem C, Wang Y, Kirkpatrick J, Juhasz E. Selective use of radiological staging in node-positive stage II breast cancer patients may have a role in treatment. ANZ J Surg 2023; 93:2203-2207. [PMID: 37439515 DOI: 10.1111/ans.18605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/01/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Advanced-staging radiography is used inconsistently for patients with early-stage (stage I + II) breast cancer. However, accurate and appropriate staging of newly diagnosed breast cancer may significantly impact treatment decisions. METHODS Four hundred and ninety-nine patients with stages II and III breast cancer were seen in the breast service at Waitemata DHB, New Zealand from 2013 to 2018 were enrolled in the study and audited for radiological staging. RESULTS One hundred and two stage II patients had computed tomography (CT) at baseline; 88 of 102 (86%) of stage II patients were node-positive (≥N1) with six patients (6.8%) having distant metastatic disease, and were upstaged to stage IV. Fifty-two stage III patients out of 72 (72%) had baseline staging CTs. Nine out of 52 patients (17%) of stage III patients were upstaged to stage IV. Despite guideline recommendations, baseline staging for T4 disease (stage IIIB) was poor, with only 7 out of 13 patients with stage IIIB disease radiologically staged. CONCLUSION Consideration for baseline radiological staging should be given to stages II and III, cN1 breast cancer patients, in which diagnosis of distant metastatic disease would change the treatment plan. Regional guidelines for baseline radiological staging for breast cancer patients may have an impact on patient management in breast cancer patients.
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Affiliation(s)
- Chaey Leem
- Department of General Surgery, North Shore Hospital, Auckland, New Zealand
| | - Yijiao Wang
- Department of General Surgery, North Shore Hospital, Auckland, New Zealand
| | - Joshua Kirkpatrick
- Department of General Surgery, North Shore Hospital, Auckland, New Zealand
| | - Eva Juhasz
- Department of General Surgery, North Shore Hospital, Auckland, New Zealand
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Bollet MA, Racadot S, Rivera S, Arnaud A, Bourgier C. [Breast cancer radiation therapy: Current questions in 2023]. Cancer Radiother 2023; 27:524-530. [PMID: 37541797 DOI: 10.1016/j.canrad.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 08/06/2023]
Abstract
Radiation therapy is a corner stone of breast cancer treatment as it has been shown postoperatively that it improves local control and overall survival. In recent years, multidisciplinary therapeutic strategies have evolved considerably for early-stage breast cancer, both surgically and in terms of systemic treatments or radiation therapy. Each of these developments affects other treatment components and open up new questions allowing even more personalized treatments. Essentially normofractionated a few years ago, breast radiation therapy is today very largely moderately or even ultra hypofractionated. De-escalation of the surgery of the axilla has changed the indications for lymph node radiation therapy keeping similar efficacy with reduced toxicity. Indications for radiation therapy after neoadjuvant chemotherapy remain based on pre-chemotherapy staging pending the results of ongoing randomized studies. The addition of a boost to the tumor bed significantly reduces the risk of local recurrence, but the magnitude of this benefit decreases with increasing age. The main risk factors for local recurrence are young age, the associated extended ductal in situ component, hormone receptor negative and high-grade status. The results of the simultaneous integrated boost (SIB) seem similar with normo- or moderately hypofractionated radiation therapy regimen.
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Affiliation(s)
- M A Bollet
- Institut de radiothérapie Hartmann, 4, rue Kléber, 92300 Levallois-Perret, France; Institut français du sein, 15, rue Jean-Nicot, 75007 Paris, France
| | - S Racadot
- Département d'oncologie radiothérapie, centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - S Rivera
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; UMR 1030, université Paris-Saclay, Gustave-Roussy, 94805 Villejuif, France.
| | - A Arnaud
- Institut du cancer Sainte-Catherine, Avignon, France
| | - C Bourgier
- Fédération universitaire d'oncologie radiothérapie de Méditerranée Occitanie, Institut du cancer de Montpellier (ICM), université de Montpellier, Inserm U1194, IRCM, Montpellier, France
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Leonard LD, de Araujo TB, Quinn C, Thomas MB, Beaty L, Mott NM, Colborn K, Heelan AA, Tevis SEA, Christian N, Arhendt G, Gleisner AL. De-implementation of Axillary Dissection in Women Undergoing Mastectomy for Breast Cancer. Ann Surg Oncol 2023; 30:5692-5702. [PMID: 37326811 DOI: 10.1245/s10434-023-13698-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Completion axillary lymph node dissection (cALND) was standard treatment for breast cancer with positive sentinel lymph nodes (SLNs) until 2011, when data from the Z11 and AMAROS trials challenged its survival benefit in early stage breast cancer. We assessed the contribution of patient, tumor, and facility factors on cALND use in patients undergoing mastectomy and SLN biopsy. PATIENTS AND METHODS Using the National Cancer Database, patients diagnosed from 2012 to 2017 who underwent upfront mastectomy and SLN biopsy with at least one positive SLN were included. A multivariable mixed effects logistic regression model was used to determine the effect of patient, tumor, and facility variables on cALND use. Reference effect measures (REM) were used to compare the contribution of general contextual effects (GCE) to variation in cALND use. RESULTS From 2012 to 2017, the overall use of cALND decreased from 81.3% to 68.0%. Overall, younger patients, larger tumors, higher grade tumors, and tumors with lymphovascular invasion were more likely to undergo cALND. Facility variables, including higher surgical volume and facility location in the Midwest, were associated with increased use of cALND. However, REM results showed that the contribution of GCE to the variation in cALND use exceeded that of the measured patient, tumor, facility, and time variables. CONCLUSIONS There was a decrease in cALND use during the study period. However, cALND was frequently performed in women after mastectomy found to have a positive SLN. There is high variability in cALND use, mainly driven by interfacility practice variation rather than specific high-risk patient and/or tumor characteristics.
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Affiliation(s)
- Laura D Leonard
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Thiago B de Araujo
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christopher Quinn
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Madeline B Thomas
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Laurel Beaty
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nicole M Mott
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kathryn Colborn
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Alicia A Heelan
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Sarah E A Tevis
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nicole Christian
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gretchen Arhendt
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ana L Gleisner
- Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Zaveri S, Lillemoe HA, Teshome M, Reyna CR, Vreeland TJ, Francescatti AB, Zheng L, Hunt KK, Katz MHG, Kilgore LJ. Operative standards for sentinel lymph node biopsy and axillary lymphadenectomy for breast cancer: review of the American College of Surgeons commission on cancer standards 5.3 and 5.4. Surgery 2023; 174:717-721. [PMID: 37202308 DOI: 10.1016/j.surg.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/06/2023] [Accepted: 04/09/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Shruti Zaveri
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX. https://twitter.com/shrutizaveriMD
| | - Heather A Lillemoe
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX. https://twitter.com/hillemoe
| | - Mediget Teshome
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL. https://twitter.com/drmediget
| | - Chantal R Reyna
- Department of Surgery, Crozer Health, Upland, PA. https://twitter.com/kprgrl3
| | - Timothy J Vreeland
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX; Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL. https://twitter.com/vreelant
| | | | - Linda Zheng
- Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL. https://twitter.com/lindazheng_ACS
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL. https://twitter.com/kellykhunt
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL. https://twitter.com/mkatzmd
| | - Lyndsey J Kilgore
- Department of Surgery, Division of Breast Surgical Oncology, University of Kansas Cancer Center, Kansas City, KS.
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Pesapane F, Mariano L, Magnoni F, Rotili A, Pupo D, Nicosia L, Bozzini AC, Penco S, Latronico A, Pizzamiglio M, Corso G, Cassano E. Future Directions in the Assessment of Axillary Lymph Nodes in Patients with Breast Cancer. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1544. [PMID: 37763661 PMCID: PMC10534800 DOI: 10.3390/medicina59091544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Breast cancer (BC) is a leading cause of morbidity and mortality worldwide, and accurate assessment of axillary lymph nodes (ALNs) is crucial for patient management and outcomes. We aim to summarize the current state of ALN assessment techniques in BC and provide insights into future directions. Materials and Methods: This review discusses various imaging techniques used for ALN evaluation, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. It highlights advancements in these techniques and their potential to improve diagnostic accuracy. The review also examines landmark clinical trials that have influenced axillary management, such as the Z0011 trial and the IBCSG 23-01 trial. The role of artificial intelligence (AI), specifically deep learning algorithms, in improving ALN assessment is examined. Results: The review outlines the key findings of these trials, which demonstrated the feasibility of avoiding axillary lymph node dissection (ALND) in certain patient populations with low sentinel lymph node (SLN) burden. It also discusses ongoing trials, including the SOUND trial, which investigates the use of axillary ultrasound to identify patients who can safely avoid sentinel lymph node biopsy (SLNB). Furthermore, the potential of emerging techniques and the integration of AI in enhancing ALN assessment accuracy are presented. Conclusions: The review concludes that advancements in ALN assessment techniques have the potential to improve patient outcomes by reducing surgical complications while maintaining accurate disease staging. However, challenges such as standardization of imaging protocols and interpretation criteria need to be addressed. Future research should focus on large-scale clinical trials to validate emerging techniques and establish their efficacy and cost-effectiveness. Over-all, this review provides valuable insights into the current status and future directions of ALN assessment in BC, highlighting opportunities for improving patient care.
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Affiliation(s)
- Filippo Pesapane
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Luciano Mariano
- Breast Imaging Division, AOU Città della Scienza e della Salute di Torino, 10126 Turin, Italy;
| | - Francesca Magnoni
- Division of Breast Surgery, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (F.M.); (G.C.)
- European Cancer Prevention Organization (ECP), 20122 Milan, Italy
| | - Anna Rotili
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Davide Pupo
- Radiology Division, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy;
| | - Luca Nicosia
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Anna Carla Bozzini
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Silvia Penco
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Antuono Latronico
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Maria Pizzamiglio
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Giovanni Corso
- Division of Breast Surgery, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (F.M.); (G.C.)
- European Cancer Prevention Organization (ECP), 20122 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Enrico Cassano
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
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Garcia-Tejedor A, Ortega-Exposito C, Salinas S, Luzardo-González A, Falo C, Martinez-Pérez E, Pérez-Montero H, Soler-Monsó MT, Bajen MT, Benitez A, Ortega R, Petit A, Guma A, Campos M, Plà MJ, Pernas S, Peñafiel J, Yeste C, Gil-Gil M, Guedea F, Ponce J, Laplana M. Axillary lymph node dissection versus radiotherapy in breast cancer with positive sentinel nodes after neoadjuvant therapy (ADARNAT trial). Front Oncol 2023; 13:1184021. [PMID: 37621686 PMCID: PMC10446877 DOI: 10.3389/fonc.2023.1184021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/04/2023] [Indexed: 08/26/2023] Open
Abstract
Introduction Breast cancer surgery currently focuses on de-escalating treatment without compromising patient survival. Axillary radiotherapy (ART) now replaces axillary lymph node dissection (ALND) in patients with limited sentinel lymph node (SLN) involvement during the primary surgery, and this has significantly reduced the incidence of lymphedema without worsening the prognosis. However, patients treated with neoadjuvant systemic treatment (NST) cannot benefit from this option despite the low incidence of residual disease in the armpit in most cases. Data regarding the use of radiotherapy instead of ALND in this population are lacking. This study will assess whether ART is non-inferior to ALND in terms of recurrence and overall survival in patients with positive SLN after NST, including whether it reduces surgery-related adverse effects. Methods and analyses This multicenter, randomized, open-label, phase 3 trial will enroll 1660 patients with breast cancer and positive SLNs following NST in approximately 50 Spanish centers over 3 years. Patients will be stratified by NST regimen and nodal involvement (isolated tumoral cells or micrometastasis versus macrometastasis) and randomly assigned 1:1 to ART without ALND (study arm) or ALND alone (control arm). Level 3 and supraclavicular radiotherapy will be added in both arms. The primary outcome is the 5-year axillary recurrence determined by clinical and radiological examination. The secondary outcomes include lymphedema or arm dysfunction, quality of life based (EORTC QLQ-C30 and QLQ-BR23 questionnaires), disease-free survival, and overall survival. Discussion This study aims to provide data to confirm the efficacy and safety of ART over ALND in patients with a positive SLN after NST, together with the impact on morbidity. Ethics and dissemination The Research Ethics Committee of Bellvitge University Hospital approved this trial (Protocol Record PR148/21, version 3, 1/2/2022) and all patients must provide written informed consent. The involvement of around 50 centers across Spain will facilitate the dissemination of our results. Trial registration ClinicalTrials.gov, identifier number NCT04889924.
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Affiliation(s)
- Amparo Garcia-Tejedor
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Carlos Ortega-Exposito
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Sira Salinas
- Rehabilitation Service, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Ana Luzardo-González
- Rehabilitation Service, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Catalina Falo
- Department of Medical Oncology, Multidisciplinary Breast Cancer Unit, Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Evelyn Martinez-Pérez
- Department of Radiation Oncology, Multidisciplinary Breast Cancer Unit. Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Héctor Pérez-Montero
- Department of Radiation Oncology, Multidisciplinary Breast Cancer Unit. Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - M. Teresa Soler-Monsó
- Department of Pathology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Maria-Teresa Bajen
- Department of Nuclear Medicine, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Ana Benitez
- Department of Nuclear Medicine, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Raul Ortega
- Department of Radiology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Anna Petit
- Department of Pathology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Anna Guma
- Department of Radiology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Miriam Campos
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Maria J. Plà
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Sonia Pernas
- Department of Medical Oncology, Multidisciplinary Breast Cancer Unit, Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Judith Peñafiel
- Biostatistics Unit, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Carlos Yeste
- Degree in Biology, Monitoring, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Miguel Gil-Gil
- Department of Medical Oncology, Multidisciplinary Breast Cancer Unit, Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Ferran Guedea
- Department of Radiation Oncology, Multidisciplinary Breast Cancer Unit. Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Jordi Ponce
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Maria Laplana
- Department of Radiation Oncology, Multidisciplinary Breast Cancer Unit. Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
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Giannakou A, Gooch J, Gergelis KR, Weiss A. De-escalation of axillary surgery in patients outside Z0011 criteria. Surgery 2023; 174:416-418. [PMID: 37156648 DOI: 10.1016/j.surg.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/14/2023] [Accepted: 03/30/2023] [Indexed: 05/10/2023]
Abstract
Over the past 2 decades, axillary surgical management for breast cancer patients has been reshaped after several practice-changing randomized clinical trials provided evidence to support the de-escalation of axillary surgery, specifically the omission of axillary lymph node dissection, for patients with positive axillary lymph nodes. One such practice-changing trial was the American College of Surgeons Oncology Group Z0011 trial, which showed that patients with clinical T1-2 breast tumors and limited nodal disease (1-2 positive sentinel lymph nodes) who underwent upfront breast-conserving therapy could be safely spared the morbidity of axillary lymph node dissection. American College of Surgeons Oncology Group Z0011 has been criticized as several important groups were excluded, such as patients who underwent a mastectomy, patients with >2 positive sentinel lymph nodes, or patients with imaging-detected lymph node metastases. These exclusions have led to unclear guidelines and very difficult management decisions for many patients with breast cancer who are just outside the Z0011 criteria. Several subsequent trials that investigated sentinel lymph node biopsy alone or sentinel lymph node biopsy plus axillary radiation versus axillary lymph node dissection enrolled patients with higher volumes of disease than American College of Surgeons Oncology Group Z0011, such as mastectomy patients or patients with >2 positive sentinel lymph nodes. The goal of this review is to describe the findings of these trials and to discuss the current best practices regarding axillary management in patients who are candidates for upfront surgery but were excluded from American College of Surgeons Oncology Group Z0011, with a particular focus on patients undergoing mastectomy, patients with >2 positive sentinel lymph nodes, patients with large or multifocal tumors, and patients with imaging-detected biopsy-proven lymph node metastases.
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Affiliation(s)
- Andreas Giannakou
- Department of Surgery, Division of Surgical Oncology, University of Rochester School of Medicine and Dentistry, NY
| | - Jessica Gooch
- Department of Surgery, Division of Surgical Oncology, University of Rochester School of Medicine and Dentistry, NY; Wilmot Cancer Center, University of Rochester Medical Center, NY
| | - Kimberly R Gergelis
- Wilmot Cancer Center, University of Rochester Medical Center, NY; Department of Radiation Oncology, University of Rochester School of Medicine and Dentistry, NY
| | - Anna Weiss
- Department of Surgery, Division of Surgical Oncology, University of Rochester School of Medicine and Dentistry, NY; Wilmot Cancer Center, University of Rochester Medical Center, NY.
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Cebrecos I, Mension E, Alonso I, Castillo H, Sanfeliu E, Vidal-Sicart S, Ganau S, Vidal M, Schettini F. Nonsentinel Axillary Lymph Node Status in Clinically Node-Negative Early Breast Cancer After Primary Systemic Therapy and Positive Sentinel Lymph Node: A Predictive Model Proposal. Ann Surg Oncol 2023; 30:4657-4668. [PMID: 36809608 PMCID: PMC10319670 DOI: 10.1245/s10434-023-13231-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/24/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND In clinically node-negative (cN0) early stage breast cancer (EBC) undergoing primary systemic treatment (PST), post-treatment positive sentinel lymph node (SLN+) directs axillary lymph node dissection (ALND), with uncertain impacts on outcomes and increased morbidities. PATIENTS AND METHODS We conducted an observational study on imaging-confirmed cN0 EBC, who underwent PST and breast surgery that resulted in SLN+ and underwent ALND. The association among baseline/postsurgical clinic-pathological factors and positive nonsentinel additional axillary lymph nodes (non-SLN+) was analyzed with logistic regression. LASSO regression (LR) identified variables to include in a predictive score of non-SLN+ (ALND-predict). The accuracy and calibration were assessed, an optimal cut-point was then identified, and in silico validation with bootstrap was undertaken. RESULTS Non-SLN+ were detected in 22.2% cases after ALND. Only progesterone receptor (PR) levels and macrometastatic SLN+ were independently associated to non-SLN+. LR identified PR, Ki67, and type and number of SLN+ as the most efficient covariates. The ALND-predict score was built based on their LR coefficients, showing an area under the curve (AUC) of 0.83 and an optimal cut-off of 63, with a negative predictive value (NPV) of 0.925. Continuous and dichotomic scores had a good fit (p = 0.876 and p = 1.00, respectively) and were independently associated to non-SLN+ [adjusted odds ratio (aOR): 1.06, p = 0.002 and aOR: 23.77, p < 0.001, respectively]. After 5000 bootstrap-adjusted retesting, the estimated bias-corrected and accelerated 95%CI included the aOR. CONCLUSIONS In cN0 EBC with post-PST SLN+, non-SLN+ at ALND are infrequent (~22%) and independently associated to PR levels and macrometastatic SLN. ALND-predict multiparametric score accurately predicted absence of non-SLN involvement, identifying most patients who could be safely spared unnecessary ALND. Prospective validation is required.
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Affiliation(s)
- Isaac Cebrecos
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Eduard Mension
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Inmaculada Alonso
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Helena Castillo
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Esther Sanfeliu
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Department of Pathology, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Diagnosis Imaging Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergi Ganau
- Department of Radiology, Diagnosis Imaging Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Maria Vidal
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Medical Oncology Department, Hospital Clinic of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francesco Schettini
- Faculty of Medicine, University of Barcelona, Barcelona, Spain.
- Medical Oncology Department, Hospital Clinic of Barcelona, Barcelona, Spain.
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
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Höller A, Nguyen-Sträuli BD, Frauchiger-Heuer H, Ring A. "Diagnostic and Prognostic Biomarkers of Luminal Breast Cancer: Where are We Now?". BREAST CANCER (DOVE MEDICAL PRESS) 2023; 15:525-540. [PMID: 37533589 PMCID: PMC10392911 DOI: 10.2147/bctt.s340741] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/12/2023] [Indexed: 08/04/2023]
Abstract
Luminal breast cancers are hormone receptor (estrogen and/or progesterone) positive that are further divided into HER2-negative luminal A and HER2-positive luminal B subtypes. According to currently accepted convention, they represent the most common subtypes of breast cancer, accounting for approximately 70% of cases. Biomarkers play a critical role in the functional characterization, prognostication, and therapeutic prediction, rendering them indispensable for the clinical management of invasive breast cancer. Traditional biomarkers include clinicopathological parameters, which are increasingly extended by genetic and other molecular markers, enabling the comprehensive characterization of patients with luminal breast cancer. Liquid biopsies capturing and analyzing circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA) are emerging technologies that envision personalized management through precision oncology. This article reviews key biomarkers in luminal breast cancer and ongoing developments.
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Affiliation(s)
- Anna Höller
- Department of Gynecology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bich Doan Nguyen-Sträuli
- Department of Gynecology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
| | - Heike Frauchiger-Heuer
- Department of Gynecology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Alexander Ring
- Department of Gynecology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
- Department of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Fan YJ, Li JC, Zhu DM, Zhu HL, Zhao Y, Zhu XB, Wu G, Bai TT. Efficacy and safety comparison between axillary lymph node dissection with no axillary surgery in patients with sentinel node-positive breast cancer: a systematic review and meta-analysis. BMC Surg 2023; 23:209. [PMID: 37495945 PMCID: PMC10369839 DOI: 10.1186/s12893-023-02101-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 07/07/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND This systematic review and meta-analysis aimed to study the evidence on the efficacy and safety of omitting axillary lymph node dissection (ALND) for patients with clinically node-negative but sentinel lymph node (SLN)-positive breast cancer using all the available evidence. METHODS The Embase, Medline, and Cochrane Library databases were searched through February 25, 2023. Original trials that compared only the sentinel lymph node biopsy (SLNB) with ALND as the control group for patients with clinically node-negative but SLN-positive breast cancer were included. The primary outcomes were axillary recurrence rate, total recurrence rate, disease-free survival (DFS), and overall survival (OS). Meta-analyses were performed to compare the odds ratio (OR) in rates and the hazard ratios (HR) in time-to-event outcomes between both interventions. Based on different study designs, tools in the revised Cochrane risk of bias tool were used for randomized trials and the risk of bias in nonrandomized studies of interventions to assess the risk of bias for each included article. Funnel plots and Egger's test were used for the publication's bias assessment. RESULTS In total, 30 reports from 26 studies were included in the systematic review (9 reports of RCTs, 21 reports of retrospective cohort studies). According to our analysis, omitting ALND in patients with clinically node-negative but SLN-positive breast cancer had a similar axillary recurrence rate (OR = 0.95, 95% confidence interval (CI): 0.76-1.20), DFS (HR = 1.02, 95% CI: 0.89-1.16), and OS (HR = 0.97, 95% CI: 0.92-1.03), but caused a significantly lower incidence of adverse events and benefited in locoregional recurrence rate (OR = 0.76, 95% CI: 0.59-0.97) compared with ALND. CONCLUSION For patients with clinically node-negative but SLN-positive breast cancer (no matter the number of the positive SLN), this review showed that SLNB alone had a similar axillary recurrence rate, DFS, and OS, but caused a significantly lower incidence of adverse events and showed a benefit for the locoregional recurrence compared with ALND. An OS benefit was found in the Macro subset that used SLNB alone versus complete ALND. Therefore, omitting ALND is feasible in this setting. TRIAL REGISTRATION CRD 42023397963.
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Affiliation(s)
- Yu-Jia Fan
- Thyroid & Breast Surgery Department,, Liaocheng People's Hospital, Liaocheng, 252000, Shandong Province, P. R. China
| | - Jin-Cheng Li
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China.
| | - De-Miao Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Hai-Long Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Yi Zhao
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Xin-Bing Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Gang Wu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Ting-Ting Bai
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
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Luo S, Fu W, Lin J, Zhang J, Song C. Prognosis and local treatment strategies of breast cancer patients with different numbers of micrometastatic lymph nodes. World J Surg Oncol 2023; 21:202. [PMID: 37430331 DOI: 10.1186/s12957-023-03082-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/17/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Lymph node micrometastasis is an important prognostic factor in breast cancer, but patients with different numbers of involved lymph nodes are all divided into the same N1mi stage without distinction. We designed this study to compare the prognosis and local treatment recommendations of N1mi breast cancer patients with different numbers of micrometastatic lymph nodes. PATIENTS AND METHODS A total of 27,032 breast cancer patients with T1-2N1miM0 stage from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2019) who underwent breast surgery were included in this retrospective study. Patients were divided into three groups for prognosis comparison according to the number of micrometastatic lymph nodes: N1mi with 1 (Nmi = 1), 2 (Nmi = 2), or more (Nmi ≥ 3) involved lymph nodes. We explored the characteristics and survival outcomes of the population receiving different local treatments, including different axillary surgery types and whether receiving radiotherapy or not. Univariate and multivariate Cox proportional hazards regression analysis were used to compare the overall survival (OS) and breast cancer-specific survival (BCSS) in different groups. Stratified analyses and interaction analyses were also applied to explore the predictive significance of different involved lymph nodes numbers. Propensity score matching (PSM) method was utilized to balance the differences between groups. RESULTS Univariate and multivariate Cox regression analysis indicated that nodal status was an independent prognostic factor. After adjustment for other prognostic factors, there was a significant difference in prognosis between Nmi = 1 group and Nmi = 2 group [adjusted hazard ratio (HR) 1.145, 95% confidence interval (CI): 1.047-1.251, P = 0.003], and patients with Nmi ≥ 3 group had a significantly poorer prognosis (adjusted HR 1.679, 95% CI 1.589-2.407; P < 0.001). The proportion of N1mi patients only underwent sentinel lymph nodes biopsy (SLNB) gradually increased from 2010 (Ptrend < 0.001). After adjusting for other factors, N1mi patients who underwent axillary lymph nodes dissection (ALND) was associated with significant survival benefit than SLNB (adjusted HR 0.932, 95%CI 0.874-0.994; P = 0.033), the same goes for receiving radiotherapy (adjusted HR 1.107, 95%CI 1.030-1.190; P = 0.006). Further stratified analysis showed that in the SLNB subgroup, radiotherapy was associated with a significant survival benefit (HR 1.695, 95%CI 1.534-1.874; P < 0.001), whereas in the ALND subgroup, there was no significant prognostic difference with or without radiotherapy (HR 1.029, 95%CI 0.933-1.136; P = 0.564). CONCLUSION Our study indicates that the increasing number of lymph node micrometastases was associated a worse prognosis of N1mi breast cancer patients. In addition, ALND does provide a significant survival benefit for these patients, while the benefit from local radiotherapy may be of even greater importance.
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Affiliation(s)
- Shiping Luo
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Wenfen Fu
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Jingyi Lin
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Jie Zhang
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
| | - Chuangui Song
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
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Del Castillo A, Gomez-Modet S, Mata JM, Tejedor L. Targeted axillary dissection using Radioguided Occult Lesion Localization technique in the clinically negative marked lymph node after neoadjuvant treatment in breast cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1184-1188. [PMID: 36958951 DOI: 10.1016/j.ejso.2023.03.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/27/2022] [Accepted: 03/09/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE To be aware of the feasibility of targeted axillary dissection (TAD) injecting 99mTechnetium-labeled macroaggregated albumin (99mTc-MAA) preoperatively into the clipped lymph node of patients with axillary complete clinical response (ycN0), after neoadjuvant chemotherapy (NAC) for breast cancer. PATIENTS AND METHODS A retrospective observational study was performed on N1 patients with a clipped positive node and a clinically negative axilla (ycN0) after NAC in one center. The pretreatment positive lymph node was injected with 99mTc-MAA the day before surgery and identified intraoperatively with a radioguided occult lesion localization (ROLL) technique. Patients were subjected to a TAD with the intent of identifying the clipped node and other/s sentinel nodes through a standard sentinel lymph node biopsy (SLNB). RESULTS 54 patients and 55 axillary clipped nodes were included. The clip was intraoperatively encountered in every patient, accomplishing a 100% detection rate, although in one case no lymphatic tissue could be found in the intraoperative frozen section. An axillary lymph node dissection (ALND) was avoided in 62.9% of the cases (34/54). CONCLUSION The use of the ROLL technique is a highly valuable tool since it allows a 100% success rate in retrieving the marker (and a 98.1% rate in detecting the clipped lymph node) in ycN0 breast cancer patients.
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Affiliation(s)
- Ana Del Castillo
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - Susana Gomez-Modet
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - José María Mata
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - Luis Tejedor
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
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Campbell I, Wetzig N, Ung O, Espinoza D, Farshid G, Collins J, Kollias J, Gebski V, Mister R, Simes RJ, Stockler MR, Gill G. 10-Year axillary recurrence in the RACS SNAC1 randomised trial of sentinel lymph node-based management versus routine axillary lymph node dissection. Breast 2023; 70:70-75. [PMID: 37393644 DOI: 10.1016/j.breast.2023.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Sentinel node-based management (SNBM) is the international standard of care for early breast cancer that is clinically node-negative based on randomised trials comparing it with axillary lymph node dissection (ALND) and reporting similar rates of axillary recurrence (AR) without distant disease. We report all ARs, overall survival, and breast cancer-specific survival at 10-years in SNAC1. METHODS 1.088 women with clinically node-negative, unifocal breast cancers 3 cm or less in diameter were randomly assigned to either SNBM with ALND if the sentinel node (SN) was positive, or to SN biopsy followed by ALND regardless of SN involvement. RESULTS First ARs were more frequent in those assigned SNBM rather than ALND (11 events, cumulative risk at 10-years 1·85%, 95% CI 0·95-3.27% versus 2 events, 0·37%, 95% CI 0·08-1·26%; HR 5·47, 95% CI 1·21-24·63; p = 0·013). Disease-free survival, breast cancer-specific survival, and overall survival were similar in those assigned SNBM versus ALND. Lymphovascular invasion was an independent predictor of AR (HR 6·6, 95% CI 2·25-19·36, p < 0·001). CONCLUSION First ARs were more frequent with SNBM than ALND in women with small, unifocal breast cancers when all first axillary events were considered. We recommend that studies of axillary treatment should report all ARs to give an accurate indication of treatment effects. The absolute frequency of AR was low in women meeting our eligibility criteria, and SNBM should remain the treatment of choice in this group. However, for those with higher-risk breast cancers, further study is needed because the estimated risk of AR might alter their choice of axillary surgery.
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Affiliation(s)
- Ian Campbell
- Department of Surgery, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand; Waikato Hospital, Hamilton, New Zealand.
| | - Neil Wetzig
- Princess Alexandra Hospital, Brisbane, Australia
| | - Owen Ung
- Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - David Espinoza
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Gelareh Farshid
- South Australian Pathology, Royal Adelaide Hospital, Adelaide, Australia
| | - John Collins
- University of Melbourne, Department of Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - James Kollias
- Department of Surgery, University of Adelaide, Adelaide, Australia; Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Val Gebski
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Rebecca Mister
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - R John Simes
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Martin R Stockler
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Grantley Gill
- Emeritus Professor, University of Adelaide, Adelaide, Australia
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69
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Izzo P, De Intinis C, Sibio S, Basso L, Polistena A, Gabriele R, Codacci-Pisanelli M, Izzo L, Izzo S. Sentinel Lymph Node Detection in Breast Cancer: An Innovative Technique. Diagnostics (Basel) 2023; 13:2030. [PMID: 37370925 DOI: 10.3390/diagnostics13122030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: Sentinel lymph node biopsy is important in the search for metastases, especially in patients with malignant breast disease. Our study proposed new techniques to prevent complications such as possible postoperative seroma formation, pain or hypoesthesia of the axillary cord and medial arm surface, as well as motor deficits, to avoid disabling outcomes and presents initial data from our experience with the sentinel lymph node biopsy technique. (2) Methods: We mainly used two radioactive tracer detection techniques and a new technique using a radiotracer called Sentimag-magtrace. The positive lymph node was located and removed to perform histologic analysis. In our study, we evaluate 100 patients who underwent breast cancer surgery. (3) Results: We calculated the identification rates of the different methods of sentinel lymph node detection and found that it was 88.9% using radioactive tracers vs. 89.5% using the magnetic tracer technology (Sentimag). (4) Conclusions: Thus, this technique avoids radiation exposure for both patients and health care providers, and can reduce costs and time.
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Affiliation(s)
- Paolo Izzo
- Department of Surgery "Pietro Valdoni", Policlinico "Umberto I", Rome "Sapienza" University of Rome, 00128 Rome, Italy
| | - Claudia De Intinis
- Department of Surgery "Pietro Valdoni", Policlinico "Umberto I", Rome "Sapienza" University of Rome, 00128 Rome, Italy
| | - Simone Sibio
- Department of Surgery "Pietro Valdoni", Policlinico "Umberto I", Rome "Sapienza" University of Rome, 00128 Rome, Italy
| | - Luigi Basso
- Department of Surgery "Pietro Valdoni", Policlinico "Umberto I", Rome "Sapienza" University of Rome, 00128 Rome, Italy
| | - Andrea Polistena
- Department of Surgery "Pietro Valdoni", Policlinico "Umberto I", Rome "Sapienza" University of Rome, 00128 Rome, Italy
| | - Raimondo Gabriele
- Department of Surgery "Pietro Valdoni", Policlinico "Umberto I", Rome "Sapienza" University of Rome, 00128 Rome, Italy
| | - Massimo Codacci-Pisanelli
- Department of Surgery "Pietro Valdoni", Policlinico "Umberto I", Rome "Sapienza" University of Rome, 00128 Rome, Italy
| | - Luciano Izzo
- Department of Surgery "Pietro Valdoni", Policlinico "Umberto I", Rome "Sapienza" University of Rome, 00128 Rome, Italy
| | - Sara Izzo
- Unit of Colorectal Surgery, Department of Medical, Surgical, Neurologic, Metabolic and Ageing Sciences, University of Campania "Luigi Vanvitelli", 81100 Caserta, Italy
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Weber WP, Davide Gentilini O, Morrow M, Montagna G, de Boniface J, Fitzal F, Wyld L, Rubio IT, Matrai Z, King TA, Saccilotto R, Galimberti V, Maggi N, Andreozzi M, Sacchini V, Castrezana López L, Loesch J, Schwab FD, Eller R, Heidinger M, Haug M, Kurzeder C, Di Micco R, Banys-Paluchowski M, Ditsch N, Harder Y, Paulinelli RR, Urban C, Benson J, Bjelic-Radisic V, Potter S, Knauer M, Thill M, Vrancken Peeters MJ, Kuemmel S, Heil J, Gulluoglu BM, Tausch C, Ganz-Blaettler U, Shaw J, Dubsky P, Poortmans P, Kaidar-Person O, Kühn T, Gnant M. Uncertainties and controversies in axillary management of patients with breast cancer. Cancer Treat Rev 2023; 117:102556. [PMID: 37126938 PMCID: PMC10752145 DOI: 10.1016/j.ctrv.2023.102556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/27/2023] [Accepted: 04/01/2023] [Indexed: 05/03/2023]
Abstract
The aims of this Oncoplastic Breast Consortium and European Breast Cancer Research Association of Surgical Trialists initiative were to identify uncertainties and controversies in axillary management of early breast cancer and to recommend appropriate strategies to address them. By use of Delphi methods, 15 questions were prioritized by more than 250 breast surgeons, patient advocates and radiation oncologists from 60 countries. Subsequently, a global virtual consensus panel considered available data, ongoing studies and resource utilization. It agreed that research should no longer be prioritized for standardization of axillary imaging, de-escalation of axillary surgery in node-positive cancer and risk evaluation of modern surgery and radiotherapy. Instead, expert consensus recommendations for clinical practice should be based on current evidence and updated once results from ongoing studies become available. Research on de-escalation of radiotherapy and identification of the most relevant endpoints in axillary management should encompass a meta-analysis to identify knowledge gaps, followed by a Delphi process to prioritize and a consensus conference to refine recommendations for specific trial designs. Finally, treatment of residual nodal disease after surgery was recommended to be assessed in a prospective register.
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Affiliation(s)
- Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | | | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Unit, Capio St Göran's Hospital, Stockholm, Sweden
| | - Florian Fitzal
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Austria; Austrian Breast and Colorectal Study Group ABCSG, Vienna, Austria
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Isabel T Rubio
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Madrid, Spain
| | - Zoltan Matrai
- Hamad Medical Corporation, Dept of Oncoplastic Breast Surgery, Doha, Qatar
| | - Tari A King
- Division of Breast Surgery, Brigham and Women's Hospital, Dana Farber/Brigham Cancer Center, Boston, MA, USA
| | - Ramon Saccilotto
- University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Mariacarla Andreozzi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Julie Loesch
- Gynecology Department, University Hospital Zurich, Zurich, Switzerland
| | - Fabienne D Schwab
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Ruth Eller
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Haug
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Christian Kurzeder
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Rosa Di Micco
- Breast Surgery, San Raffaele University and Research Hospital, Milan, Italy
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Nina Ditsch
- Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Régis R Paulinelli
- Federal University of Goias, Goias, Brazil; Breast Unit, Araújo Jorge Hospital, Goias, Brazil
| | - Cicero Urban
- Breast Unit, Hospital Nossa Senhora Das Graças, Curitiba, Brazil
| | - John Benson
- Cambridge Breast Unit, Addenbrooke's Hospital Cambridge, Cambridge, UK; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation TRUST, School of Medicine, Anglia Ruskin University, Cambridge, UK
| | - Vesna Bjelic-Radisic
- Breast Unit, University Hospital Helios Wuppertal, University Witten/Herdecke, Wuppertal, Germany; Medical University Graz, Graz, Austria
| | | | - Michael Knauer
- Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Marc Thill
- Department of Gynaecology and Gynaecological Oncology, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Surgery, University Medical Center, Amsterdam, Netherlands
| | - Sherko Kuemmel
- Breast Unit, Hospital Essen-Mitte, Germany; Charité - Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Joerg Heil
- Department of Obstetrics and Gynecology, University of Heidelberg, Medical School, Heidelberg, Germany
| | | | | | | | - Jane Shaw
- Patient Advocacy Group, Oncoplastic Breast Consortium, Basel, Switzerland
| | - Peter Dubsky
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland; Breast Centre, Hirslanden Clinic St. Anna, Lucerne, Switzerland
| | - Philip Poortmans
- Iridium Netwerk and University of Antwerp, Wilrijk-Antwerpen, Belgium
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, at Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Dept. Radiation Oncologv (Maastro), Maastricht, Netherlands
| | - Thorsten Kühn
- Department of Gynecology, Hospital Esslingen, Esslingen, Germany
| | - Michael Gnant
- Austrian Breast and Colorectal Study Group ABCSG, Vienna, Austria; Comprehensive Cancer Center Medical University Vienna, Vienna, Austria
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71
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Beck AC, Morrow M. Axillary lymph node dissection: Dead or still alive? Breast 2023; 69:469-475. [PMID: 36702672 PMCID: PMC10300611 DOI: 10.1016/j.breast.2023.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 01/24/2023] Open
Abstract
Although sentinel lymph node biopsy is now the primary method of axillary staging and is therapeutic for patients with limited nodal disease, axillary lymph node dissection (ALND) is still necessary for staging in groups where sentinel lymph node biopsy has not been proven to be accurate and to maintain local control in those with a heavy axillary tumor burden. Additionally, newer approaches to systemic therapy tailored to risk level sometimes necessitate knowledge of the number of involved axillary nodes which can only be obtained with ALND. Ongoing trials will address whether there are additional circumstances where radiotherapy can replace ALND.
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Affiliation(s)
- Anna C Beck
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
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72
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Li B, Wang G, Miao K, Zhang A, Sun L, Yu X, Lei JH, Xie L, Yan J, Li W, Deng CX, Dai Y. Fueling sentinel node via reshaping cytotoxic T lymphocytes with a flex-patch for post-operative immuno-adjuvant therapy. Nat Commun 2023; 14:2518. [PMID: 37130873 PMCID: PMC10154421 DOI: 10.1038/s41467-023-38245-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 04/17/2023] [Indexed: 05/04/2023] Open
Abstract
Clinical updates suggest conserving metastatic sentinel lymph nodes (SLNs) of breast cancer (BC) patients during surgery; however, the immunoadjuvant potential of this strategy is unknown. Here we leverage an immune-fueling flex-patch to animate metastatic SLNs with personalized antitumor immunity. The flex-patch is implanted on the postoperative wound and spatiotemporally releases immunotherapeutic anti-PD-1 antibodies (aPD-1) and adjuvants (magnesium iron-layered double hydroxide, LDH) into the SLN. Genes associated with citric acid cycle and oxidative phosphorylation are enriched in activated CD8+ T cells (CTLs) from metastatic SLNs. Delivered aPD-1 and LDH confer CTLs with upregulated glycolytic activity, promoting CTL activation and cytotoxic killing via metal cation-mediated shaping. Ultimately, CTLs in patch-driven metastatic SLNs could long-termly maintain tumor antigen-specific memory, protecting against high-incidence BC recurrence in female mice. This study indicates a clinical value of metastatic SLN in immunoadjuvant therapy.
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Affiliation(s)
- Bei Li
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Guohao Wang
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Kai Miao
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Aiping Zhang
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Liangyu Sun
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
| | - Xinwang Yu
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Josh Haipeng Lei
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Lisi Xie
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Jie Yan
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Wenxi Li
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China
| | - Chu-Xia Deng
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China.
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China.
| | - Yunlu Dai
- Cancer Centre and Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau SAR, 999078, China.
- MoE Frontiers Science Center for Precision Oncology, University of Macau, Macau SAR, 999078, China.
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Xu Q, Wang J, Wang J, Guo R, Qian Y, Liu F. The effectiveness of ultrasound-guided core needle biopsy in detecting lymph node metastases in the axilla in patients with breast cancer: systematic review and meta-analysis. Clinics (Sao Paulo) 2023; 78:100207. [PMID: 37141768 PMCID: PMC10176171 DOI: 10.1016/j.clinsp.2023.100207] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVE This study aimed to perform a meta-analysis to investigate the diagnostic safety and accuracy of Ultrasound-Guided Core Needle Biopsy (US-CNB) Axillary Lymph Nodes (ALNs) region in patients with Breast Cancer (BC). METHODS The authors searched the electronic databases PubMed, Scopus, Embase, and Web of Science for clinical trials about US-CNB for the detection of ALNs in breast cancer patients. The authors extracted and pooled raw data from the included studies and performed statistical analyses using Meta-DiSc 1.4 and Review Manager 5.3 software. A random effects model was used to calculate the data. At the same time, data from the Ultrasound-guided Fine-Needle Aspiration (US-FNA) were introduced for comparison with the US-CNB. In addition, the subgroup was performed to explore the causes of heterogeneity. (PROSPERO ID: CRD42022369491). RESULTS In total, 18 articles with 2521 patients were assessed as meeting the study criteria. The overall sensitivity was 0.90 (95% CI [Confidence Interval], 0.87‒0.91; p = 0.00), the overall specificity was 0.99 (95% CI 0.98‒1.00; p = 0.62), the overall area under the curve (AUC) was 0.98. Next, in the comparison of US-CNB and US-FNA, US-CNB is better than US-FNA in the diagnosis of ALNs metastases. The sensitivity was 0.88 (95% CI 0.84‒0.91; p = 0.12) vs. 0.73 (95% CI 0.69‒0.76; p = 0.91), the specificity was 1.00 (95% CI 0.99‒1.00; p = 1.00) vs. 0.99 (95% CI 0.67‒0.74; p = 0.92), and the AUC was 0.99 vs. 0.98. Subgroup analysis showed that heterogeneity may be related to preoperative Neoadjuvant Chemotherapy (NAC) treatment, region, size of tumor diameter, and the number of punctures. CONCLUSION US-CNB has a satisfactory diagnostic performance with good specificity and sensitivity in the preoperative diagnosis of ALNs in BC patients.
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Affiliation(s)
- Qi Xu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jiale Wang
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jing Wang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Runzhao Guo
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yao Qian
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Feng Liu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China.
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74
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García Chiloeches A, González Barranquero A, Juéz Sáez LD, Corral Moreno S, Rivas Fidalgo S, Pastor Peinado P, Cabañas Montero LJ, Fernández Cebrián JM. Intraoperative sentinel node biopsy, is it worth the wait? Cir Esp 2023; 101:325-332. [PMID: 36152966 DOI: 10.1016/j.cireng.2022.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/01/2022] [Indexed: 05/16/2023]
Abstract
INTRODUCTION In our institution, the study of selective sentinel node biopsy (SLNB) is performed intraoperatively. The main objective of our study is to know the proportion of patients who benefits from the waiting of the results of SLNB. METHODS A retrospective analysis of patients operated on our center between January 1st, 2018 and June 30, 2019 was carried out. We included women diagnosed with T1-T2 tumors, treated by lumpectomy and SLNB studied using OSNA method. RESULTS Our study included 149 women. There were not statistically significant differences in terms of demographic data between the group treated with axillary lymph node dissection (ALND) and exclusively SLNB group. After analysis of SLN intraoperatively, there were performed 18 axillary lymphadenectomies. Only in six of this 18 cases, three or more sentinel nodes were founded. The location of the tumor, the presence of lymphovascular permeation and the total tumor load (TTL) showed statistically significant differences between groups. Only the TTL was established as the independent factor of the need for ALND. DISCUSSION Obtaining a deferred result of the SLNB allowed reducing the time of anesthesia and occupation of the operating room, since in a high percentage of cases an additional procedure is not performed.
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Affiliation(s)
- Alba García Chiloeches
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | | | - Luz Divina Juéz Sáez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Sara Corral Moreno
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Sonia Rivas Fidalgo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Paula Pastor Peinado
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
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75
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Woodward SG, Fayanju OM. Optimizing Sentinel Node Biopsy After Neoadjuvant Therapy: Striving to Know What We Do Not Know. Ann Surg Oncol 2023; 30:1943-1944. [PMID: 36662332 PMCID: PMC10187972 DOI: 10.1245/s10434-022-12942-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/01/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Steven G Woodward
- Division of Breast Surgery, Department of Surgery, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Oluwadamilola M Fayanju
- Division of Breast Surgery, Department of Surgery, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA.
- Rena Rowan Breast Center, Abramson Cancer Center, Philadelphia, PA, USA.
- Penn Center for Cancer Care Innovation (PC3I), The University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics (LDI), The University of Pennsylvania, Philadelphia, PA, USA.
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van Steenhoven JEC, van Maaren MC, Verreck EEF, Schipper RJ, Nieuwenhuijzen GAP, Kuijer A, Siesling S, van Dalen T. Inequalities in the omission of axillary dissection in sentinel lymph node positive patients in the Netherlands: Innovative hospitals are early adopters of a de-escalating approach. Int J Cancer 2023; 152:1378-1387. [PMID: 36522834 PMCID: PMC10108210 DOI: 10.1002/ijc.34400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 12/23/2022]
Abstract
During the last decade completion axillary lymph node dissection (cALND) was gradually omitted in sentinel lymph node positive (SLN+) breast cancer patients. However, adoption varies among hospitals. We analyzed factors associated with the omission of cALND in all Dutch SLN+ patients. As one of the focus hospital-related factors we defined "innovative" as the percentage of gene-expression profile (GEP) deployment within the indicated group of patients per hospital as a proxy for early adoption of innovations. cT1-2N0M0 SLN+ patients treated between 2011 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were defined to be innovative based on their GEP use. Multivariable logistic regression (MLR) was performed to assess the relationship between innovative capacity, patient-, treatment- and hospital-related characteristics and cALND performance. 14 317 patients were included. Treatment in a hospital with high innovative capacity was associated with a lower probability of receiving cALND (OR 0.69, OR 0.46 and OR 0.35 in modestly, fairly and very innovative, respectively). Other factors associated with a lower probability of receiving a cALND were age 70 and 79 years and ≥79 years (ORs 0.59 [95% CI: 0.50-0.68] and 0.21 [95% CI: 0.17-0.26]) and treatment in an academic hospital (OR 0.41 [95% CI: 0.33-0.51]). Factors associated with an increased probability of undergoing cALND were HR-/HER2- tumors (OR 1.46 [95% CI: 1.19-1.80]), macrometastatic lymph node involvement (OR 6.37 [95% CI: 5.70-7.13]) and mastectomy (OR 4.57 [95% CI: 4.09-5.10]). Patients treated in a hospital that early adopted innovations were less likely to receive cALND. Our findings endorse the need for studies on barriers and facilitators of implementing innovations.
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Affiliation(s)
- Julia E C van Steenhoven
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands.,Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marissa C van Maaren
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | | | - Robert J Schipper
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Anne Kuijer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Thijs van Dalen
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
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Li P, Yang C, Zhang J, Chen Y, Zhang X, Liang M, Huang N, Chen Y, Wang K. Survival After Sentinel Lymph Node Biopsy Compared with Axillary Lymph Node Dissection for Female Patients with T3-4c Breast Cancer. Oncologist 2023:7079822. [PMID: 36929946 PMCID: PMC10400163 DOI: 10.1093/oncolo/oyad038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/03/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND For patients with cN0 and T1-2 breast cancer, sentinel lymph node biopsy (SLNB) can provide survival results equivalent to axillary lymph node dissection (ALND). However, whether it can be performed on T3-4c patients is still controversial. MATERIALS AND METHODS Female patients diagnosed with cN0, T3-4c, and M0 breast cancer from 2004 to 2019 were identified using the surveillance, epidemiology and end results (SEER) database and divided into 2 groups, the SLNB group (1-5 regional lymph nodes examined) and the ALND group (≥10 regional lymph nodes examined). Finally, only those with pN0 disease were included in the SLNB group. The baseline differences in clinicopathological characteristics between groups were eliminated by propensity score matching (PSM). We also conducted subgroup analyses according to age, overall TNM stage, breast cancer subtypes, surgical approaches, radiation therapy, and chemotherapy. The primary endpoint was survival. RESULTS With a mean follow-up of 75 months, a total of 186 deaths were reported among 864 patients. The overall survival (OS) and breast cancer-specific survival (BCSS) in the SLNB group were 78.2% and 87.5%, respectively, and that in the ALND group were 78.7% and 87.3%, respectively. The unadjusted hazard ratio (HR) for OS and BCSS in the SLNB group (vs. the ALND group) was 0.922 (95% CI, 0.691-1.230, P = .580) and 0.874 (95% CI, 0.600-1.273, P = .481), respectively. Besides, the OS and BCSS between the 2 groups were also similar in all subgroup analyses. CONCLUSIONS SLNB may be performed on female patients with cN0, T3-4c, and M0 breast cancer.
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Affiliation(s)
- Peiyong Li
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangdong Medical University, Guangzhou, People's Republic of China
| | - Ciqiu Yang
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Junsheng Zhang
- Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Yitian Chen
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Xiaoqi Zhang
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Minting Liang
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Shantou University Medical College, Guangzhou, People's Republic of China
| | - Na Huang
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Yilin Chen
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), South China University of Technology, Guangzhou, People's Republic of China
| | - Kun Wang
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangdong Medical University, Guangzhou, People's Republic of China
- Department of Breast Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
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78
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Lei H, Yuan P, Guo C, Ying J. Development and validation of nomograms for predicting axillary non-SLN metastases in breast cancer patients: A retrospective analysis. Front Oncol 2023; 13:1096589. [PMID: 36969057 PMCID: PMC10036576 DOI: 10.3389/fonc.2023.1096589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/16/2023] [Indexed: 03/12/2023] Open
Abstract
PurposeThe aim of this study was to develop a nomogram for predicting positive non-sentinel lymph nodes (non-SLNs) in positive SLN breast cancer patients and validate the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram for non-SLN metastasis in Chinese patients.MethodsThe pathological features of 2,561 breast cancer patients were retrospectively reviewed, and the patients were divided into training and validation cohorts. Positive non-SLN predictors were identified using univariate and multivariate analyses and used to construct the nomogram. In patients with positive SLNs, the MSKCC nomogram was used to calculate the probability of non-SLN metastasis. The area under the receiver operating characteristic curve (AUC) was calculated to assess the accuracy of this model and the MSKCC nomogram.ResultsAccording to multivariate logistic regression analysis, the number of positive and negative SLNs, tumor stage, lymphovascular invasion, perineural invasion, and extracapsular extension were independent predictive factors for non-SLN metastasis and were selected to establish the nomogram for predicting positive non-SLNs. This nomogram performed favorably in predicting positive non-SLNs, with AUCs of 0.765 and 0.741 for the training and validation cohorts, respectively. The MSKCC nomogram predicted non-SLN metastasis with an AUC of 0.755.ConclusionA nomogram was developed and validated to assist clinicians in evaluating the likelihood of positive non-SLN. For Chinese patients with a known ER status before surgery, the MSKCC nomogram can be used to predict non-SLN metastases.
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Nguyen HT, De Allegri M, Heil J, Hennigs A. Population-Level Impact of Omitting Axillary Lymph Node Dissection in Early Breast Cancer Women: Evidence from an Economic Evaluation in Germany. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:275-287. [PMID: 36409454 PMCID: PMC9676848 DOI: 10.1007/s40258-022-00771-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The American College of Surgeons Oncology Group Z0011 trial showed that complete axillary lymph node dissection (cALND) did not improve survival benefits in patients with one or two tumour-involved sentinel lymph nodes and undergoing breast conservation. Still, a considerable number of the Z0011-eligible patients continue to be treated with cALND in various countries. Given the potential economic gain from implementation of the Z0011 recommendations, we quantified population-level impacts of omitting cALND among Z0011-eligible patients in clinical practice. METHODS This 2-year economic analysis adopted both the perspective of patients under statutory insurance and the societal perspective, using data collected prospectively from 179 German breast cancer units between 2008 and 2015. The estimation of cost savings and health gain relied on a single decision tree, which considered three scenarios: clinical practice at the baseline; actual implementation in routine care; and hypothetical full implementation in all eligible patients. RESULTS Data for 188,909 patients with primary breast cancer were available, 13,741 (7.3%) of whom met the Z0011 inclusion criteria. The use of cALND decreased from 94.3% in 2010 to 46.9% in 2015, resulting in a gain of 335 quality-adjusted life-years and a saving of EUR50,334,756 for the society. Had cALND been omitted in all eligible patients, the total gain would have been more than double. CONCLUSIONS The implementation of the Z0011 recommendations resulted in substantial savings and health gain in Germany. Our findings suggest that it is beneficial to introduce additional policy measures to promote further uptake of the Z0011 recommendations in clinical practice.
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Affiliation(s)
- Hoa Thi Nguyen
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany.
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany
| | - Jörg Heil
- Breast Unit, University Hospital, Heidelberg University, Heidelberg, Germany
- Breast Unit, Klinik St. Elisabeth, Heidelberg, Germany
| | - André Hennigs
- Breast Unit, University Hospital, Heidelberg University, Heidelberg, Germany
- Breast Unit, Klinik St. Elisabeth, Heidelberg, Germany
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Lin F, Li Q, Wang Z, Shi Y, Ma H, Zhang H, Zhang K, Yang P, Zhang R, Duan S, Gu Y, Mao N, Xie H. Intratumoral and peritumoral radiomics for preoperatively predicting the axillary non-sentinel lymph node metastasis in breast cancer on the basis of contrast-enhanced mammography: a multicenter study. Br J Radiol 2023; 96:20220068. [PMID: 36542866 PMCID: PMC9975381 DOI: 10.1259/bjr.20220068] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 11/07/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To develop and test a contrast-enhanced mammography (CEM)-based radiomics model using intratumoral and peritumoral regions to predict non-sentinel lymph node (NSLN) metastasis in breast cancer before surgery. METHODS This multicenter study included 365 breast cancer patients with sentinel lymph node metastasis. Intratumoral regions of interest (ROIs) were manually delineated, and peritumoral ROIs (5 and 10 mm) were automatically obtained. Five models, including intratumoral model, peritumoral (5 and 10 mm) models, and intratumoral+peritumoral (5 and 10 mm) models, were constructed by support vector machine classifier on the basis of optimal features selected by variance threshold, SelectKbest, and least absolute shrinkage and selection operator algorithms. The predictive performance of radiomics models was evaluated by receiver operating characteristic curves. An external testing set was used to test the model. The Memorial Sloan Kettering Cancer Center (MSKCC) model was used to compare the predictive performance with radiomics model. RESULTS The intratumoral ROI and intratumoral+peritumoral 10-mm ROI-based radiomics model achieved the best performance with an area under the curve (AUC) of 0.8000 (95% confidence interval [CI]: 0.6871-0.8266) in the internal testing set. In the external testing set, the AUC of radiomics model was 0.7567 (95% CI: 0.6717-0.8678), higher than that of MSKCC model (AUC = 0.6681, 95% CI: 0.5148-0.8213) (p = 0.361). CONCLUSIONS The intratumoral and peritumoral radiomics based on CEM had an acceptable predictive performance in predicting NSLN metastasis in breast cancer, which could be seen as a supplementary predicting tool to help clinicians make appropriate surgical plans. ADVANCES IN KNOWLEDGE The intratumoral and peritumoral CEM-based radiomics model could noninvasively predict NSLN metastasis in breast cancer patients before surgery.
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Affiliation(s)
- Fan Lin
- Department of Radiology, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, China
| | - Qin Li
- Department of Radiology, WeiFang Traditional Chinese Hospital, Weifang, China
| | - Zhongyi Wang
- Department of Radiology, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, China
| | - Yinghong Shi
- Department of Radiology, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, China
| | - Heng Ma
- Department of Radiology, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, China
| | - Haicheng Zhang
- Big Data and Artificial Intelligence Laboratory, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, China
| | - Kun Zhang
- Department of Breast Surgery, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, China
| | - Ping Yang
- Department of Pathology, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, China
| | - Ran Zhang
- Huiying Medical Technology, Beijing, China
| | | | - Yajia Gu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | | | - Haizhu Xie
- Department of Radiology, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, China
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Machado LB, Brody MB, Rotenberg SE, Stachelek GC, Fernandez JG. Breast Cancer Tumor Board: A Radiologist's Guide to Postmastectomy Radiation Therapy. Radiographics 2023; 43:e220086. [PMID: 36795596 DOI: 10.1148/rg.220086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Radiation therapy represents a pillar in the current management of breast cancer. Historically, postmastectomy radiation therapy (PMRT) has been administered only in patients with locally advanced disease and a poor prognosis. These included patients with large primary tumors at diagnosis and/or more than three metastatic axillary lymph nodes. However, during the past few decades, several factors have prompted a shift in perspective, and recommendations for PMRT have become more fluid. Guidelines for PMRT in the United States are outlined by the National Comprehensive Cancer Network and the American Society for Radiation Oncology. Because evidence to support performing PMRT is frequently discordant, the decision to offer radiation therapy often requires team discussion. These discussions are usually held in multidisciplinary tumor board meetings in which radiologists play a pivotal role by providing critical information such as the location and extent of disease. Breast reconstruction after mastectomy is optional and is safe in cases in which the patient's clinical status allows it. The preferred method in the setting of PMRT is autologous reconstruction. If this is not possible, then a two-step implant-based reconstruction is recommended. Radiation therapy does involve a risk of toxicity. Complications can be seen in acute and chronic settings and range from fluid collections and fractures to radiation-induced sarcomas. Radiologists have a key role in detecting these and other clinically relevant findings and should be prepared to recognize, interpret, and address them. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Laura B Machado
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
| | - Marion B Brody
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
| | - Scott E Rotenberg
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
| | - Gregory C Stachelek
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
| | - John G Fernandez
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
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Park Y, Shin YS, Kim K, Shin KH, Chang JH, Kim SS, Jung JH, Park W, Kim H, Kim YB, Ahn SJ, Kim M, Kim JH, Cha HJ, Kim TG, Park HJ, Lee SY. Omission of axillary lymph node dissection in patients with ypN+ breast cancer after neoadjuvant chemotherapy: A retrospective multicenter study (KROG 21-06). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:589-596. [PMID: 36470801 DOI: 10.1016/j.ejso.2022.11.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/11/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND We evaluated the impact of omitting axillary lymph node dissection (ALND) on oncological outcomes in breast cancer patients with residual nodal disease after neoadjuvant chemotherapy (NAC). METHODS The medical records of patients who underwent NAC followed by surgical resection and had residual nodal disease were retrospectively reviewed. In total, 1273 patients from 12 institutions were included; all underwent postoperative radiotherapy. Axillary surgery consisted of ALND in 1103 patients (86.6%) and sentinel lymph node biopsy (SLNBx) alone in 170 (13.4%). Univariate and multivariate analyses of disease-free survival (DFS) and overall survival (OS) were performed before and after propensity score matching (PSM). RESULTS The median follow-up was 75.3 months (range, 2.5-182.7). Axillary recurrence rates were 4.8% in the ALND group (n = 53) and 4.7% in the SLNBx group (n = 8). Before PSM, univariate analysis indicated that the 5-year OS rate was inferior in the ALND group compared to the SLNBx group (86.6% vs. 93.3%, respectively; P = 0.002); multivariate analysis did not show a difference between groups (P = 0.325). After PSM, 258 and 136 patients were included in the ALND and SLNBx groups, respectively. There were no significant differences between the ALND and SLNBx groups in DFS (5-year rate, 75.8% vs. 76.9%, respectively; P = 0.406) or OS (5-year rate, 88.7% vs. 93.1%, respectively; P = 0.083). CONCLUSIONS SLNBx alone did not compromise oncological outcomes in patients with residual nodal disease after NAC. The omission of ALND might be a possible option for axillary management in patients treated with NAC and postoperative radiotherapy.
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Affiliation(s)
- Younghee Park
- Department of Radiation Oncology, Ewha Womans University College of Medicine, South Korea
| | - Young Seob Shin
- Department of Radiation Oncology, University of Ulsan College of Medicine, South Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, South Korea.
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, South Korea.
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University College of Medicine, South Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine, South Korea
| | - Jin Hong Jung
- Department of Radiation Oncology, University of Ulsan College of Medicine, South Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, South Korea
| | - Sung Ja Ahn
- Department of Radiation Oncology, Chonnam National University Medical School, South Korea
| | - Myungsoo Kim
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, South Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Keimyung University School of Medicine, South Korea
| | - Hye Jung Cha
- Department of Radiation Oncology, Yonsei University Wonju College of Medicine, South Korea
| | - Tae Gyu Kim
- Department of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, South Korea
| | - Hae Jin Park
- Department of Radiation Oncology, Hanyang University College of Medicine, South Korea
| | - Sun Young Lee
- Department of Radiation Oncology, Jeonbuk National University School of Medicine, South Korea
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Thompson JL, Wright GP. Contemporary approaches to the axilla in breast cancer. Am J Surg 2023; 225:583-587. [PMID: 36522219 DOI: 10.1016/j.amjsurg.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Over the past decade, axillary management in breast cancer has fundamentally shifted. The former notion that any degree of axillary nodal involvement warrants axillary lymph node dissection (ALND) has been challenged. Following publication of the ACOSOG Z0011 trial, national trends demonstrated significant reductions in ALND performance. Axillary radiotherapy in lieu of ALND is a consideration for select patients with a positive sentinel lymph node, while ongoing studies are investigating the role of adjuvant regional radiotherapy in women with positive nodes prior to neoadjuvant chemotherapy. Efforts toward de-escalation of axillary surgery continue to evolve, as do the indications for sentinel node biopsy omission in select subsets of patients. This review highlights the recent advances and neoteric approaches to local therapy of the axilla in breast cancer.
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Affiliation(s)
- Jessica L Thompson
- Spectrum Health Medical Group Comprehensive Breast Clinic, 145 Michigan Street NE, Suite 4400, Grand Rapids, MI, 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 15 Michigan Street NE, Grand Rapids, MI, 49503, USA.
| | - G Paul Wright
- Spectrum Health Medical Group Comprehensive Breast Clinic, 145 Michigan Street NE, Suite 4400, Grand Rapids, MI, 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 15 Michigan Street NE, Grand Rapids, MI, 49503, USA; Spectrum Health Medical Group, Division of Surgical Oncology, 145 Michigan Street NE, Suite 5500, Grand Rapids, MI, 49503, USA.
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Knape N, Park JH, Agala CB, Spanheimer P, Morrow M, Downs-Canner S, Baldwin XL. Can We Forgo Sentinel Lymph Node Biopsy in Women Aged ≥ 50 Years with Early-Stage Hormone-Receptor-Positive HER2-Negative Special Histologic Subtype Breast Cancer? Ann Surg Oncol 2023; 30:1042-1050. [PMID: 36217063 DOI: 10.1245/s10434-022-12626-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Breast cancer has significant biologic heterogeneity, which influences treatment decisions. We hypothesized that in postmenopausal women (≥ 50 years) with clinical T1-2, N0, hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer of special histology (mucinous, tubular, cribriform, papillary), information from sentinel lymph node biopsy (SLNB) may not change adjuvant therapy recommendations. PATIENTS AND METHODS We constructed a cohort from the National Cancer Database of women aged ≥ 18 years with cT1-2 N0 HR+ HER2- invasive breast cancer. We calculated the frequency of nodal positivity by histology. We measured the frequency of N2/N3 disease, the distribution of Oncotype DX 21-gene assay recurrence score (ODX RS) across special histology by nodal status, and frequency of chemotherapy use by ODX RS and pathologic N stage. RESULTS In women with cN0 HR+/HER2- special histologic subtype breast cancer, the likelihood of pathologic nodal positivity is less than 5%, and 99.7% of patients had N0 or N1 disease. Among women aged ≥ 50 years with HR+/HER2- special histologic subtype breast cancer, there was low prevalence of high ODX RS > 25 in both N0 and N1 patients (7% overall). Receipt of chemotherapy correlated with Oncotype DX scores as anticipated, with the lowest use in women with a low/intermediate RS (from 2 to 6% for N0 and 6-24% for N1) and the highest use in women with high risk Oncotype scores (from 74 to 92%). CONCLUSIONS Our study suggests that SLNB could potentially be omitted in select postmenopausal women with cT1-2 N0 HR+/HER2- special histologic subtype breast cancer when ODX RS is available.
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Affiliation(s)
- Nicole Knape
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Ji-Hye Park
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chris B Agala
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Philip Spanheimer
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Monica Morrow
- Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Xavier L Baldwin
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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85
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Houvenaeghel G, de Nonneville A, Chopin N, Classe JM, Mazouni C, Chauvet MP, Reyal F, Tunon de Lara C, Jouve E, Rouzier R, Daraï E, Gimbergues P, Coutant C, Azuar AS, Villet R, Crochet P, Rua S, Bannier M, Cohen M, Boher JM. The need to tailor the omission of axillary lymph node dissection to patients with good prognosis and sentinel node micro-metastases. Cancer Med 2023; 12:4023-4032. [PMID: 36127853 PMCID: PMC9972015 DOI: 10.1002/cam4.5257] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Results of IBCSG-23-01-trial which included breast cancer patients with involved sentinel nodes (SN) by isolated-tumor-cells or micro-metastases supported the non-inferiority of completion axillary-lymph-node-dissection (cALND) omission. However, current data are considered insufficient to avoid cALND for all patients with SN-micro-metastases. METHODS To investigate the impact of cALND omission on disease-free-survival (DFS) and overall survival (OS), we analyzed a cohort of 1421 patients <75 years old with SN-micro-metastases who underwent breast conservative surgery (BCS). We used inverse probability of treatment weighting (IPTW) to obtain adjusted Kaplan-Meier estimators representing the experience in the analysis cohort, based on whether all or none had been subject to cALND omission. RESULTS Weighted log-rank tests comparing adjusted Kaplan-Meier survival curves showed significant differences in OS (p-value = 0.002) and borderline significant differences in DFS (p-value = 0.090) between cALND omission versus cALND. Cox's regression using stabilized IPTW evidenced an average increase in the risk of death associated with cALND omission (HR = 2.77, CI95% = 1.36-5.66). Subgroup analyses suggest that the rates of recurrence and death associated with cALND omission increase substantially after a large period of time in the half sample of women less likely to miss cALND. CONCLUSIONS Using IPTW to estimate the causal treatment effect of cALND in a large retrospective cohort, we concluded cALND omission is associated with an increased risk of recurrence and death in women of <75 years old treated by BCS in the absence of a large consensus in favor of omitting cALND. These results are particularly contributive for patients treated by BCS where cALND omission rates increase over time.
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Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Alexandre de Nonneville
- Department of Medical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | | | - Jean-Marc Classe
- Institut René Gauducheau, Site hospitalier Nord, St Herblain, France
| | | | | | | | | | - Eva Jouve
- Centre Claudius Regaud, Toulouse, France
| | | | | | | | | | | | | | | | - Sandrine Rua
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Marie Bannier
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Monique Cohen
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Jean-Marie Boher
- Department of Biostatistics and Methodology, Institut Paoli Calmettes, 13009 and Aix-Marseille University, Unité Mixte de Recherche S1252, Institut de Recherche pour le Développement, Marseille, France
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86
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Clinical Trials in Breast Cancer. Surg Clin North Am 2023; 103:17-33. [DOI: 10.1016/j.suc.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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87
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Cobb A, DeSnyder SM. Risk Factors for Breast Cancer-Related Lymphedema, Risk Reduction, and Myths about Precautionary Behaviors. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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88
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Krecko LK, Lautner MA, Wilke LG. Clinical Trials That Have Informed the Modern Management of Breast Cancer. Surg Oncol Clin N Am 2023; 32:27-46. [PMID: 36410920 DOI: 10.1016/j.soc.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Randomized controlled trials have informed the historical evolution of breast cancer management, distilling operative and nonoperative treatments to achieve disease control and improve survival while maximizing quality of life and minimizing complications. The authors describe landmark trials investigating and influencing the following aspects of breast cancer care: extent of breast surgery; axillary management; neoadjuvant and adjuvant therapies; and selection of chemotherapy versus endocrine therapy via application of genomic assays.
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Affiliation(s)
- Laura K Krecko
- Department of Surgery, University of Wisconsin Hospital and Clinics, 600 Highland Avenue K4/642, Madison, WI 53792, USA. https://twitter.com/LauraKrecko
| | - Meeghan A Lautner
- Department of Surgery, University of Wisconsin Hospital and Clinics, 600 Highland Avenue K4/624, Madison, WI 53792, USA. https://twitter.com/mlautnermd
| | - Lee G Wilke
- Department of Surgery, University of Wisconsin Hospital and Clinics, 600 Highland Avenue K4/624, Madison, WI 53792, USA.
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89
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Zhu Y, Jia Y, Pang W, Duan Y, Chen K, Nie F. Ultrasound contrast-enhanced patterns of sentinel lymph nodes: predictive value for nodal status and metastatic burden in early breast cancer. Quant Imaging Med Surg 2023; 13:160-170. [PMID: 36620166 PMCID: PMC9816714 DOI: 10.21037/qims-22-234] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 10/07/2022] [Indexed: 11/21/2022]
Abstract
Background In the post-Z0011 era, sentinel lymph node (SLN) status and metastatic burden determine whether axillary management entails conservative sentinel lymph node biopsy (SLNB) or radical axillary lymph node dissection (ALND) in breast cancer patients. However, SLN status and metastatic burden cannot be evaluated preoperatively in clinical practice. This study explored the predictive value of contrast-enhanced ultrasound (CEUS) patterns of SLN to assess the nodal status and metastatic burden in early breast cancer patients. Methods A retrospective study was conducted on 88 consecutive patients who were diagnosed with clinical T1-2N0 breast cancer between December 2020 and November 2021 at the Lanzhou University Second Hospital and scheduled for SLNB. Preoperative CEUS was performed to confirm the location and enhancement pattern of the SLN, and the conventional ultrasonic characteristics of the primary breast lesions and SLN were recorded. Intraoperative localized SLN and postoperative pathological results were used as the gold standard for comparison with preoperative ultrasound findings. Results CEUS successfully identified at least 1 SLN in 88 patients, with a total of 118 SLNs identified in the entire cohort. Univariate analysis showed that lesion size, blood flow grade, SLN longitudinal diameter, cortical thickness, and enhancement pattern were significant predictive features of SLN metastasis. Further multiple regression analysis indicated that the enhancement pattern of the SLN was an independent risk factor for SLN metastasis, with a sensitivity and a specificity of 84.2% (32/38) and 80.0% (40/50), respectively. Meanwhile, the SLN enhancement pattern could predict the lymph node metastasis burden (P<0.001). In patients presenting with a type I (homogeneous enhancement) or type II (heterogeneous enhancement) SLN, 91.5% (65/71) had ≤2 positive SLNs, whereas in patients with a type III (no enhancement) SLN, 70.6% (12/17) had >2 metastatic nodes. Conclusions The contrast-enhanced pattern of the SLN is an independent risk factor for SLN status. Patients presenting with a type I or type II SLN enhanced pattern are unlikely to have high-burden metastases detected at their final surgical treatment and omission of ALND may be appropriate.
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Affiliation(s)
- Yangyang Zhu
- Ultrasound Medicine Center, Lanzhou University Second Hospital, Lanzhou, China
| | - Yingying Jia
- Ultrasound Medicine Center, Lanzhou University Second Hospital, Lanzhou, China
| | - Wenjing Pang
- Ultrasound Medicine Center, Lanzhou University Second Hospital, Lanzhou, China
| | - Ying Duan
- Ultrasound Medicine Center, Lanzhou University Second Hospital, Lanzhou, China
| | - Kundi Chen
- Ultrasound Medicine Center, Lanzhou University Second Hospital, Lanzhou, China
| | - Fang Nie
- Ultrasound Medicine Center, Lanzhou University Second Hospital, Lanzhou, China;,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
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90
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Dihge L, Bendahl PO, Skarping I, Hjärtström M, Ohlsson M, Rydén L. The implementation of NILS: A web-based artificial neural network decision support tool for noninvasive lymph node staging in breast cancer. Front Oncol 2023; 13:1102254. [PMID: 36937408 PMCID: PMC10014909 DOI: 10.3389/fonc.2023.1102254] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Objective To implement artificial neural network (ANN) algorithms for noninvasive lymph node staging (NILS) to a decision support tool and facilitate the option to omit surgical axillary staging in breast cancer patients with low-risk of nodal metastasis. Methods The NILS tool is a further development of an ANN prototype for the prediction of nodal status. Training and internal validation of the original algorithm included 15 clinical and tumor-related variables from a consecutive cohort of 800 breast cancer cases. The updated NILS tool included 10 top-ranked input variables from the original prototype. A workflow with four ANN pathways was additionally developed to allow different combinations of missing preoperative input values. Predictive performances were assessed by area under the receiver operating characteristics curves (AUC) and sensitivity/specificity values at defined cut-points. Clinical utility was presented by estimating possible sentinel lymph node biopsy (SLNB) reduction rates. The principles of user-centered design were applied to develop an interactive web-interface to predict the patient's probability of healthy lymph nodes. A technical validation of the interface was performed using data from 100 test patients selected to cover all combinations of missing histopathological input values. Results ANN algorithms for the prediction of nodal status have been implemented into the web-based NILS tool for personalized, noninvasive nodal staging in breast cancer. The estimated probability of healthy lymph nodes using the interface showed a complete concordance with estimations from the reference algorithm except in two cases that had been wrongly included (ineligible for the technical validation). NILS predictive performance to distinguish node-negative from node-positive disease, also with missing values, displayed AUC ranged from 0.718 (95% CI, 0.687-0.748) to 0.735 (95% CI, 0.704-0.764), with good calibration. Sensitivity 90% and specificity 34% were demonstrated. The potential to abstain from axillary surgery was observed in 26% of patients using the NILS tool, acknowledging a false negative rate of 10%, which is clinically accepted for the standard SLNB technique. Conclusions The implementation of NILS into a web-interface are expected to provide the health care with decision support and facilitate preoperative identification of patients who could be good candidates to avoid unnecessary surgical axillary staging.
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Affiliation(s)
- Looket Dihge
- Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
- *Correspondence: Looket Dihge, ; Lisa Rydén,
| | - Pär-Ola Bendahl
- Department of Clinical Sciences Lund, Division of Oncology, Lund University, Lund, Sweden
| | - Ida Skarping
- Department of Clinical Sciences Lund, Division of Oncology, Lund University, Lund, Sweden
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund, Sweden
| | - Malin Hjärtström
- Department of Clinical Sciences Lund, Division of Oncology, Lund University, Lund, Sweden
| | - Mattias Ohlsson
- Department of Astronomy and Theoretical Physics, Division of Computational Biology and Biological Physics, Lund University, Lund, Sweden
| | - Lisa Rydén
- Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
- *Correspondence: Looket Dihge, ; Lisa Rydén,
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91
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Abbas Y, Hamdy O. Axillary reverse mapping in breast cancer: An overview. Breast Dis 2023; 42:137-146. [PMID: 37154174 DOI: 10.3233/bd-220040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Standard operative management for breast carcinoma has significantly shifted from extensive procedures to minor interventions.Although axillary dissection was a fundamental component of operative management, sentinel biopsy is an actual process for axillary staging. Axillary dissection may be postponed for cases that have negative SLNs or 1 or 2 infiltrated lymph nodes undergoing breast or axillary radiation. Contrarily, axillary dissection is still the conventional management for patients with clinically positive nodes.Arm lymphedema is a frequent and overwhelming complication of axillary dissection, with a worse impact on the patient's life.Axillary reverse mapping was recently introduced to map and conserve the lymph drain of the upper limb throughout axillary dissection or sentinel biopsy. A technique based on the theory that the breast's lymphatic drainage differs from those that drain the arm, so preserving lymphatic drainage of the upper limb can prevent lymphedema, thereby not raising the risk of axillary recurrence.Therefore, this technique is the reverse of sentinel biopsy, which remove the lymph nodes that drain the breast.
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Affiliation(s)
- Yara Abbas
- Mansoura Manchester Medical Program, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Omar Hamdy
- Surgical Oncology Unit, Oncology Center, Mansoura University, Mansoura, Egypt
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92
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Special Techniques of Adjuvant Breast Carcinoma Radiotherapy. Cancers (Basel) 2022; 15:cancers15010298. [PMID: 36612294 PMCID: PMC9818986 DOI: 10.3390/cancers15010298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Modern radiotherapy techniques are designed to permit reduced irradiation of healthy tissue, resulting in a diminished risk of adverse effects and shortened recovery times. Several randomized studies have demonstrated the benefits of increased dosage to the tumor bed area in combination with whole breast irradiation (WBI). Conventional WBI treatment following breast-conserving procedures, which required 5-7 weeks of daily treatments, has been reduced to 3-4 weeks when using hyperfractionated regimens. The dosage administration improves local control, albeit with poorer cosmesis. The method of accelerated partial breast irradiation (APBI) shortens the treatment period whilst reducing the irradiated volume. APBI can be delivered using intraoperative radiation, brachytherapy, or external beam radiotherapy. Currently available data support the use of external beam partial breast irradiation in selected patients. Modern radiotherapy techniques make it possible to achieve favorable cosmesis in most patients undergoing immediate breast reconstruction surgery, and studies confirm that current methods of external beam radiation allow an acceptable coverage of target volumes both in the reconstructed breast and in the regional lymphatic nodes.
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93
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Aktaş A, Gürleyik MG, Aydın Aksu S, Aker F, Güngör S. Diagnostic Value of Axillary Ultrasound, MRI, and 18F-FDG-PET/ CT in Determining Axillary Lymph Node Status in Breast Cancer Patients. Eur J Breast Health 2022; 18:37-47. [DOI: 10.4274/ejbh.galenos.2021.2021-3-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/04/2021] [Indexed: 12/01/2022]
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94
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Wienerroither V, Hammer R, Kornprat P, Schrem H, Wagner D, Mischinger HJ, El-Shabrawi A. Use of LigaSure vessel sealing system versus conventional axillary dissection in breast cancer patients: a retrospective comparative study. BMC Surg 2022; 22:436. [PMID: 36544128 PMCID: PMC9773442 DOI: 10.1186/s12893-022-01888-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In locally advanced breast cancer, axillary lymph node dissection remains a pivotal component of surgical therapy. Apart from this, it has been mostly replaced by sentinel node biopsy. Complications after axillary dissection include wound infection, neuropathy, lymphedema and-most frequently-seroma. In this retrospective multi-centre study, we compared the use of LigaSureTM with monopolar electrocautery regarding perioperative outcome. METHODS A retrospective data analysis from female breast cancer patients who underwent axillary dissection at two breast centres in Austria that are using two different surgical techniques was performed for this study. We compared the rate of complications and re-operations, length of hospital stay, time to drain removal, total drain fluid, seroma formation after drain removal, number of seroma aspirations and total seroma fluid. RESULTS Seventy one female patients with a median age of 63 (30-83) were included in this study. In 35 patients LigaSureTM and in 36 monopolar cautery was used for axillary dissection. There was no significant difference regarding intraoperative complications and rate of re-operations between the two groups (2.9 vs. 5.6%; p = 1 and 2.9 vs. 13.9%; p = 0.199). The time to drain removal and the length of hospital stay was similar in both groups. A significant difference in the occurence of postoperative wound infection could also not be shown. However, we found a significantly smaller total drain fluid in the LigaSureTM-group compared to the cautery-group (364.6 ml vs. 643.4 ml; p = 0.004). Seroma formation after drain removal was more frequent in the LigaSureTM-group (68.6 vs. 41.7%; p = 0.032) with a higher number of outpatient seroma aspirations (2.0 vs. 0.9; p = 0.005). CONCLUSION LigaSureTM and monopolar cautery provide equivalent techniques in axillary lymph node dissection with comparable postoperative outcomes.
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Affiliation(s)
- V. Wienerroither
- grid.11598.340000 0000 8988 2476Department of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - R. Hammer
- Department of Surgery, LKH Graz II, Graz, Austria
| | - P. Kornprat
- grid.11598.340000 0000 8988 2476Department of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - H. Schrem
- grid.11598.340000 0000 8988 2476Department of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - D. Wagner
- grid.11598.340000 0000 8988 2476Department of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - H. J. Mischinger
- grid.11598.340000 0000 8988 2476Department of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - A. El-Shabrawi
- grid.11598.340000 0000 8988 2476Department of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
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95
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Zhang JY, Xu BH. Factors Predicting Positive Sentinel Lymph Node Biopsy in Clinically Node-Negative Breast Cancer [Letter]. BREAST CANCER (DOVE MEDICAL PRESS) 2022; 14:489-490. [PMID: 36575688 PMCID: PMC9790141 DOI: 10.2147/bctt.s400958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022]
Affiliation(s)
- Jia-Yu Zhang
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Bao-Hua Xu
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China,China-Japan Friendship Hospital Stomatology Center, Beijing, People’s Republic of China,Correspondence: Bao-Hua Xu, China-Japan Friendship Hospital, 2 Cherry Blossom Garden East Street, Chaoyang District, Beijing, 100029, People’s Republic of China, Email
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96
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Effect of Telerehabilitation Versus In-Clinic Rehabilitation Delivery on Self-Efficacy in Breast Cancer–Related Lymphedema. REHABILITATION ONCOLOGY 2022. [DOI: 10.1097/01.reo.0000000000000326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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97
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Geng SK, Fu SM, Zhang HW, Fu YP. Predictive nomogram based on serum tumor markers and clinicopathological features for stratifying lymph node metastasis in breast cancer. BMC Cancer 2022; 22:1328. [PMID: 36536344 PMCID: PMC9764558 DOI: 10.1186/s12885-022-10436-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study was aimed to establish the nomogram to predict patients' axillary node status by using patients' clinicopathological and tumor characteristic factors. METHODS A total of 705 patients with breast cancer were enrolled in this study. All patients were randomly divided into a training group and a validation group. Univariate and multivariate ordered logistic regression were used to determine the predictive ability of each variable. A nomogram was performed based on the factors selected from logistic regression results. Receiver operating characteristic curve (ROC) analysis, calibration plots and decision curve analysis (DCA) were used to evaluate the discriminative ability and accuracy of the models. RESULTS Logistic regression analysis demonstrated that CEA, CA125, CA153, tumor size, vascular-invasion, calcification, and tumor grade were independent prognostic factors for positive ALNs. Integrating all the predictive factors, a nomogram was successfully developed and validated. The C-indexes of the nomogram for prediction of no ALN metastasis, positive ALN, and four and more ALN metastasis were 0.826, 0.706, and 0.855 in training group and 0.836, 0.731, and 0.897 in validation group. Furthermore, calibration plots and DCA demonstrated a satisfactory performance of our nomogram. CONCLUSION We successfully construct and validate the nomogram to predict patients' axillary node status by using patients' clinicopathological and tumor characteristic factors.
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Affiliation(s)
- Sheng-Kai Geng
- Department of Breast Surgery, The Obstetrics and Gynecology Hospital of Fudan University, 200011, Shanghai, People's Republic of China
- Department of General Surgery, Zhongshan Hospital, Fudan University, 200032, Shanghai, People's Republic of China
| | - Shao-Mei Fu
- Department of Breast Surgery, The Obstetrics and Gynecology Hospital of Fudan University, 200011, Shanghai, People's Republic of China
| | - Hong-Wei Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, 200032, Shanghai, People's Republic of China.
| | - Yi-Peng Fu
- Department of Breast Surgery, The Obstetrics and Gynecology Hospital of Fudan University, 200011, Shanghai, People's Republic of China.
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98
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Sousa N, Peleteiro B, Fougo JL. Total Tumor Load to assist in the decision for additional axillary surgery in the positive sentinel node breast cancer patients. Surg Oncol 2022; 45:101882. [PMID: 36395579 DOI: 10.1016/j.suronc.2022.101882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022]
Abstract
The Total Tumor Load (TTL) concept has been demonstrated to accurately predict the status of the non-sentinel lymph nodes (NSLN) in breast cancer patients. In 2019, our center implemented the TTL cut-off of 30,000 CK19 mRNA copies/μL as sole criterion for deciding on performing ALND. This retrospective, unicentric, study analyzed 87 cT1-3N0 breast cancer patients treated consecutively in a period of two years and aimed to evaluate the performance of this criterion. Secondary objectives included the comparison of the criterion versus our previous Clinical Decision Rule (CDR) versus ACOSOG Z0011 criteria for avoiding an ALND in proportion of patients spared an ALND and in proportion of patients left with a surgically untreated metastasized axilla. An interim analysis revealed new TTL cut-offs for deciding on performing an ALND. The 30,000 CK19 mRNA copies/μL criterion yielded an area under the ROC Curve (AUC) of 0.849, a false positive (FP) rate of 30.1% and a positive predictive value (PPV) of 38.9%. The 30,000 CK19 mRNA copies/μL criterion spared 58.6% of the patients an ALND versus 41.4% with CDR versus 73.6% with Z0011 and left 0.0% patients with a surgically untreated metastasized axilla versus 21.4% with CDR versus 42.9% with Z0011. The new TTL cut-off of 260,000 CK19 mRNA copies/μL for deciding on an ALND yielded an AUC of 0.753, a FP rate of 13.7% and a PPV of 47.4%. This new criterion spared 78.2% of the study sample an ALND and left 35.7% of metastasized axillae surgically untreated. This study emphasizes the need to find a new balance between locoregional control and the morbidity associated with Berg levels I + II axillary lymph node dissection.
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Affiliation(s)
- Nuno Sousa
- Faculty of Medicine, University of Porto, Portugal.
| | - Bárbara Peleteiro
- Faculty of Medicine, University of Porto, Portugal; Breast Center, Centro Hospitalar Universitário São João, Porto, Portugal; EPI Unit, Institute of Public Health, University of Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health, University of Porto, Portugal.
| | - José Luis Fougo
- Breast Center, Centro Hospitalar Universitário São João, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Portugal.
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99
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Chiu CW, Chang LC, Su CM, Shih SL, Tam KW. Precise application of sentinel lymph node biopsy in patients with ductal carcinoma in situ: A systematic review and meta-analysis of real-world data. Surg Oncol 2022; 45:101880. [DOI: 10.1016/j.suronc.2022.101880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/26/2022] [Accepted: 10/16/2022] [Indexed: 11/21/2022]
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100
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Cocco D, Shah C, Wei W, Wilkerson A, Grobmyer SR, Al-Hilli Z. Axillary lymph node dissection can be omitted in patients with limited clinically node-positive breast cancer: a National Cancer Database analysis. Br J Surg 2022; 109:1293-1299. [PMID: 36066266 DOI: 10.1093/bjs/znac305] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/20/2022] [Accepted: 08/08/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND De-escalation of axillary surgery in breast cancer has progressively taken place when appropriate. Data supporting surgical de-escalation in patients with clinically node-positive (cN+) disease remains scarce. Here, survival among patients with cN+ T1-2 tumours undergoing sentinel lymph node biopsy (SLNB) and regional nodal irradiation (RNI) was investigated and compared with that among patients undergoing axillary lymph node dissection (ALND) with or without RNI. METHODS The National Cancer Data Base was used to identify three groups of patients with cN+ tumours according to axillary management among those treated between 2010 and 2016: patients who underwent SLNB and RNI (cN+ SLNB/RNI group); those who had ALND and RNI (cN+ ALND/RNI group); and those who had ALND alone (cN+ ALND/no RNI group). Patients who underwent neoadjuvant chemotherapy, and those who had stage IV breast cancer or pN2-3 disease were excluded. RESULTS A total of 12 560 patients met the inclusion criteria: 3030 in the cN+ SLNB/RNI, 5446 in the cN+ ALND/RNI, and 4084 in the cN+ ALND/no RNI group. The sizes of cN + SLNB/RNI and cN+ ALND/RNI groups increased over the study interval, whereas the cN+ ALND/no RNI group decreased in size (P < 0.001). There was a median of one positive node in the cN+ SLNB/RNI group and two nodes in the cN+ ALND/RNI and cN+ ALND/no RNI groups. The median number of nodes examined was three, 14, and 14, respectively (P < 0.001). Median follow-up was 57.9 (range 0.8-114) months. The overall survival rate was 97, 97, and 92 per cent respectively at two years, and 88, 86, and 78 per cent at five years (P < 0.001). CONCLUSION Patients with limited cN+ T1-2 breast cancer undergoing upfront SLNB and RNI have favourable survival outcomes that are not inferior to those of patients undergoing ALND with or without RNI. Prospective studies are warranted to assess locoregional control and long-term outcomes.
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Affiliation(s)
- Daniela Cocco
- Division of Breast Surgery, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wei Wei
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Avia Wilkerson
- Division of Breast Surgery, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stephen R Grobmyer
- Cancer Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Zahraa Al-Hilli
- Division of Breast Surgery, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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