Eight-year follow up result of the OTOASOR trial: The Optimal Treatment Of the Axilla - Surgery Or Radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: A randomized, single centre, phase III, non-inferiority trial

Axillary surgery in node-positive breast cancer

Long-term follow-up data from multicenter phase III non-inferiority trials confirmed the safety of omission of axillary dissection in selected patients with clinically node-negative, sentinel node-positive breast cancer. Several ongoing trials investigate extended eligibility of the Z0011 protocol in the adjuvant setting. De-escalation of axillary surgery in patients with clinically node-positive breast cancer is currently limited to the neoadjuvant setting, where the sentinel procedure is used to determine nodal pathological complete response. Targeted axillary dissection lowers the false-negative rate of the sentinel procedure, which, however, is consistently associated with a very low risk of axillary recurrence in several recent single-center series. Axillary dissection remains standard care in patients with residual disease after neoadjuvant chemotherapy while the results of Alliance A011202 are pending. The TAXIS trial investigates the role of tailored axillary surgery in patients with clinically node-positive breast cancer, a novel concept designed to selectively remove positive nodes in the adjuvant and neoadjuvant setting.

Macrometastasis at selective lymph node biopsy: A practical going-for-the-one clinical scoring system to personalize decision making

BACKGROUND

Axillary sentinel lymph node biopsy (SLNB) is standard treatment for patients with clinically and pathological negative lymph nodes. However, the role of completion axillary lymph node dissection (cALND) following positive sentinel lymph node biopsy (SLNB) is debated.

AIM

To identify a subgroup of women with high axillary tumor burden undergoing SLNB in whom cALND can be safely omitted in order to reduce the risk of long-term complications and create a Preoperative Clinical Risk Index (PCRI) that helps us in our clinical practice to optimize the selection of these patients.

METHODS

Patients with positive SLNB who underwent a cALND were included in this study. Univariate and multivariate analysis of prognostic and predictive factors were used to create a PCRI for safely omitting cALND.

RESULTS

From May 2007 to April 2014, we performed 1140 SLN biopsies, of which 125 were positive for tumor and justified to practice a posterior cALND. Pathologic findings at SLNB were micrometastases (mic) in 29 cases (23.4%) and macrometastasis (MAC) in 95 cases (76.6%). On univariate analysis of the 95 patients with MAC, statistically significant factors included: age, grade, phenotype, histology, lymphovascular invasion, lymph-node tumor size, and number of positive SLN. On multivariate analysis, only lymph-node tumor size (≤ 20 mm) and number of positive SLN (> 1) retained significance. A numerical tool was created giving each of the parameters a value to predict preoperatively which patients would not benefit from cALND. Patients with a PCRI ≤ 15 has low probability (< 10%) of having additional lymph node involvement, a PRCI between 15-17.6 has a probability of 43%, and the probability increases to 69% in patients with a PCRI > 17.6.

CONCLUSION

The PCRI seems to be a useful tool to prospectively estimate the risk of nodal involvement after positive SLN and to identify those patients who could omit cALND. Further prospective studies are necessary to validate PCRI clinical generalization.

Candidates of Genomic Tests in HR+/HER2- Breast Cancer Patients With 1-2 Positive Sentinel Lymph Node Without Axillary Lymph Node Dissection: Analysis From Multicentric Cohorts

Background

The genomic tests such as the MammaPrint and Oncotype DX test are being gradually applied for hormone receptor positive/HER-2 negative (HR+/HER2-) breast cancer patients with up to three positive axillary lymph nodes (ALNs). The first results from RxPONDER trial suggested that Oncotype DX could be applied to patients with 1-2 positive sentinel lymph nodes (SLNs) without axillary lymph node dissection (ALND), which constituted 37.4% of the intent-to-treat population. However, there was no distinctive research on how to apply genomic tests precisely to HR+/HER2- patients with 1-2 positive SLNs without ALND. The purpose was to construct a nomogram using the multi-center retrospective data to predict precisely which HR+/HER2- candidates with 1-2 positive SLNs could be subjected to genomic tests (≤ 3 positive lymph nodes).

Methods

We conducted a retrospective analysis of 18,600 patients with stage I-III breast cancer patients treated with sentinel lymph node biopsy (SLNB) in Shandong Cancer Hospital, Fudan University Shanghai Cancer Center, and West China Hospital. The univariate and multivariate logistic regression analysis was conducted to identify the independent predictive factors of having ≤ 3 positive nodes among patients with 1-2 positive SLNs. A nomogram was developed based on variables in the final model with p<0.05. Calibration of the nomogram was carried out by internal validation using the bootstrap resampling approach and was displayed using a calibration curve. The discrimination of the model was evaluated using the ROC curve.

Results

Based on the database of the three institutions, a total of 18,600 breast cancer patients were identified undergoing SLNB between May 2010 and 2020. Among the 1817 HR+/HER2- patients with 1-2 positive SLNs undergoing ALND, 84.2% harbored ≤ 3 totals metastatic ALNs. The multivariate logistic regression analysis identified imaging abnormal nodes (OR=0.197, 95%CI: 0.082-0.472), the number of positive SLNs (OR=0.351, 95%CI: 0.266-0.464), the number of negative SLNs (OR=1.639, 95%CI: 1.465-1.833), pathological tumor stage (OR=0.730, 95%CI: 0.552-0.964), and lympho-vascular invasion (OR=0.287, 95%CI: 0.222-0.398) as independent predictors for the proportion of patients with ≤ 3 total metastatic ALNs (all p<0.05). These five predictors were used to create a predictive nomogram. The AUC value was 0.804 (95%CI: 0.681-0.812, p<0.001). The calibration curve showed a satisfactory fit between the predictive and actual observation based on internal validation with a bootstrap resampling frequency of 1000.

Conclusion

The nomogram based on the multi-centric database showed a good accuracy and could assist the oncologist in determining precisely which HR+/HER2- candidates with 1-2 positive SLNs without ALND could perform genomic tests. In the era of SLNB and precision medicine, the combined application of genomic tests and SLNB could provide patients with a better strategy of dual de-escalation management, including the de-escalation of both surgery and systemic treatment.

Five-Year Breast Surgeon Experience in LYMPHA at Time of ALND for Treatment of Clinical T1-4N1-3M0 Breast Cancer

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a source of postoperative morbidity for breast cancer survivors. Lymphatic microsurgical preventive healing approach (LYMPHA) is a technique used to prevent BCRL at the time of axillary lymph node dissection (ALND). We report the 5-year experience of a breast surgeon trained in LYMPHA and investigate the outcomes of patients who underwent LYMPHA following ALND for treatment of cT1-4N1-3M0 breast cancer.

METHODS

A retrospective review of patients with cT1-4N1-3M0 breast cancer was performed in patients who underwent ALND with and without LYMPHA. Diagnosis of BCRL was made by certified lymphedema therapists. Descriptive statistics and lymphedema surveillance data were analyzed using results of Fisher's exact or Wilcoxon rank-sum tests. Logistic regression and propensity matching were performed to assess the reduction of BCRL occurrence following LYMPHA.

RESULTS

In a 5-year period, 132 patients met inclusion criteria with 76 patients undergoing LYMPHA at the time of ALND and 56 patients undergoing ALND alone. Patients who underwent LYMPHA at the time of ALND were significantly less likely to develop BCRL than those who underwent ALND alone (p = 0.045). Risk factors associated with BCRL development were increased patient age (p = 0.007), body mass index (BMI) (p = 0.003), and, in patients undergoing LYMPHA, number of positive nodes (p = 0.026).

CONCLUSIONS

LYMPHA may be successfully employed by breast surgeons trained in lymphatic-venous anastomosis at the time of ALND. While research efforts should continue to focus on prevention and surveillance of BCRL, LYMPHA remains an option to reduce BCRL and improve patient quality of life.

Stepwise Limited Axillary Lymph Node Dissection Based on Lymphatic Drainage from the Breast to Decrease Breast Cancer-Related Lymphedema: A Randomized Controlled Trial

BACKGROUND

Comprehensive axillary surgery is associated with an elevated rate of morbidity. This trial aimed to demonstrate the feasibility of axillary dissection of lymph nodes from the breast (bALND) for the purpose of limiting the extent of surgery.

METHODS

Patients enrolled from two tertiary referral centers from September 2018 to September 2019 were randomly allocated to two groups: bALND and standard axillary lymph node dissection (sALND). In the bALND group, the sentinel lymph node was filled with 0.1 ml methylene blue before resection. Then, bALND based on lymphatic drainage was subsequently performed. Lymph nodes at each breast lymphatic level and lymph nodes at Berg levels were sent for separate pathological examination. Arm lymphedema, locoregional recurrence, and distant metastasis were documented.

RESULTS

In the bALND group, lymphatic vessels and subsequent-echelon lymph nodes from the breast were stained blue after injection of methylene blue in 404 (89.0%, 404/454) cases, and 57.8% (228/394) of the patients harbored fewer than four metastatic nodes. With a median follow-up of 18 months, the incidence of arm lymphedema was 6.6% (26/394) in the bALND group versus 13.7% (60/438) in the sALND group (p = 0.008), while regional recurrence presented no difference between the two surgical procedures (0.76% vs 0.68%, p = 0.896).

CONCLUSION

For node-positive breast cancer patients, bALND based on lymphatic drainage is a less radical axillary surgery that can eliminate morbidity without impairing cancer control.

Management of the Axilla in Early-Stage Breast Cancer: Ontario Health (Cancer Care Ontario) and ASCO Guideline

PURPOSE

To provide recommendations on the best strategies for the management and on the best timing and treatment (surgical and radiotherapeutic) of the axilla for patients with early-stage breast cancer.

METHODS

Ontario Health (Cancer Care Ontario) and ASCO convened a Working Group and Expert Panel to develop evidence-based recommendations informed by a systematic review of the literature.

RESULTS

This guideline endorsed two recommendations of the ASCO 2017 guideline for the use of sentinel lymph node biopsy in patients with early-stage breast cancer and expanded on that guideline with recommendations for radiotherapy interventions, timing of staging after neoadjuvant chemotherapy (NAC), and mapping modalities. Overall, the ASCO 2017 guideline, seven high-quality systematic reviews, 54 unique studies, and 65 corollary trials formed the evidentiary basis of this guideline.

RECOMMENDATIONS

Recommendations are issued for each of the objectives of this guideline: (1) To determine which patients with early-stage breast cancer require axillary staging, (2) to determine whether any further axillary treatment is indicated for women with early-stage breast cancer who did not receive NAC and are sentinel lymph node-negative at diagnosis, (3) to determine which axillary strategy is indicated for women with early-stage breast cancer who did not receive NAC and are pathologically sentinel lymph node-positive at diagnosis (after a clinically node-negative presentation), (4) to determine what axillary treatment is indicated and what the best timing of axillary treatment for women with early-stage breast cancer is when NAC is used, and (5) to determine which are the best methods for identifying sentinel nodes.Additional information is available at www.asco.org/breast-cancer-guidelines.

A National Survey of Breast Surgeons and Radiation Oncologists on Contemporary Axillary Management in Mastectomy Patients

BACKGROUND

Management of axillary lymph nodes in breast cancer has undergone significant change over the past decade through landmark clinical trials. This study aimed to assess national practice patterns in axillary management in patients undergoing upfront mastectomy and examines what guides provider recommendations.

METHODS

A national case-based survey study was performed of surgeons and radiation oncologists from July to August 2020. Surgeons were identified through the American Society of Breast Surgeons (ASBrS) after review and approval by the ASBrS Research Committee, and radiation oncologists were identified through an institutional database. Both descriptive and comparative statistical analyses were performed.

RESULTS

Overall, 994 providers responded-680 surgeons and 314 radiation oncologists. Surgeons were older and in practice longer (p < 0.05) and treated a higher percentage of breast patients (81% vs. 40%, p < 0.001). Most surgeons were hospital-employed (43%), whereas most radiation oncologists were in private practice (40%; p < 0.001). Fifty-two percent of surgeons routinely send sentinel lymph nodes (SLNs) for frozen section (52%) during mastectomy, of which 78% proceed directly to axillary lymph node dissection (ALND) if positive. There was significant variability in treatment recommendations between the two groups among the hypothetical cases (p < 0.001). In the setting of low disease burden in the SLNs, > 30% of surgeons recommended ALND, while radiation oncologists recommend axillary radiotherapy over axillary clearance (p < 0.001).

CONCLUSION

There is significant heterogeneity in the management of the axilla in mastectomy patients with pathologically positive SLNs, both between and among surgeons and radiation oncologists. Efforts should be made to assist both groups in identifying de-escalation opportunities to ensure that mastectomy patients with positive SLNs are treated appropriately.

Sentinel lymph node assessment in breast cancer-an update on current recommendations

Sentinel lymph node biopsy (SLNB) has become the preferred method of surgical pathological nodal staging of early breast cancer by the end of the nineties. As the most likely sites of metastasis, the SLNs allow a more precise staging, and indeed gross sectioning, step sectioning, immunohistochemistry, and molecular staging methods have been used to disclose metastatic involvement of these lymph nodes. This review summarizes the backgrounds of SLNB, trends in related surgery and pathology. It also gives an insight into European National recommendations related to SLN and divergent daily practices in European pathology departments, on the basis of replies to questionnaires from 84 pathologists from 38 European countries. The questionnaires revealed the post-neoadjuvant setting as an area where a significant minority of pathologists report less confidence in classifying residual nodal involvement into TNM categories. The review also summarizes the neoadjuvant therapy-related aspects of SLNB.

A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema

BACKGROUND

Lymphoedema after cancer treatment is a chronic and disabling complication that presents a significant health care burden during survivorship with limited treatment options. Vascularised lymph node transfer (VLNT) can reconstruct lymphatic flow to reduce limb volumes, but limited higher-order evidence exists to support its effectiveness.

AIM

The aim of the study was to systematically review and meta-analyse the effectiveness of VLNT in reducing upper limb (UL) or lower limb (LL) volume and cellulitis episodes in patients with cancer treatment-related lymphoedema (CTRL).

METHODS

PubMed, Medline (Ovid) and Embase databases were searched between January 1974 and December 2019. Full-length articles where VLNT was the sole therapeutic procedure for CTRL, reporting volumetric limb, frequency of infection episodes and/or lymphoedema-specific quality-of-life data, were included in a random-effects meta-analysis of circumferential reduction rate (CRR). Methodological quality was assessed using STROBE/CONSORT, and a novel, lymphoedema-specific scoring tool was used to assess lymphoedema-specific methodological reporting. Sensitivity analyses on the site of VLNT harvest and recipient location were performed.

RESULTS

Thirty-one studies (581 patients) were eligible for inclusion. VLNT led to significant limb volume reductions in UL (above elbow pooled CRRs [CRR_P] = 42.7% [95% confidence interval (CI): 36.5-48.8]; below elbow CRR_P = 34.1% [95% CI: 33.0-35.1]) and LL (above knee CRR_P = 46.8% [95% CI: 43.2-50.4]; below knee CRR_P = 54.6% [95% CI: 39.0-70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRR_P = 49.5% [95% CI: 46.5-52.5]) than those from intra-abdominal donor sites (CRR_P = 39.6% [95% CI: 37.2-42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRR_P = 32.7% [95% CI: 11.1-54.4]) (p < 0.05). VLNT was also found to reduce the mean number of cellulitis episodes by 2.1 episodes per year (95% CI: -2.7- -1.4) and increased lymphoedema-specific quality-of-life scores (mean difference in Lymphoedema-Specific Quality of Life (LYMQOL) "overall domain" = +4.26).

CONCLUSIONS

VLNT is effective in reducing excess limb volume and cellulitis episodes in both UL and LL lymphoedema after cancer treatment. However, significant heterogeneity exists in outcome reporting, and standardisation of reporting processes is recommended.

Breast cancer

Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.

Lymph nodal radiotherapy in breast cancer: what are the unresolved issues?

Introduction: Sentinel lymph node biopsy (SLNB) is the gold standard in invasive breast cancer. Axillary dissection (ALND) is controversial in some presentations.Areas covered: Key questions were formulated and explored focused on four different scenarios in adjuvant axillary radiation management in early and locally advanced breast cancer. Answers to these questions were searched in MEDLINE, PubMed from June 1946 to August 2020. Clinical trials, retrospective studies, international guidelines, meta-analysis, and reviews were explored.Expert opinion: Analysis according to biological disease characteristics is necessary to establish the impact of ALND avoidance in unexpectedly positive SLNB (pN1) in cN0 patients. A low-risk probability of axillary recurrence was observed if axillary radiotherapy (ART) or ALND were offered without impact on outcomes. Adjuvant RNI in pT1-3 pN1 treated with mastectomy or BCS should be proposed in unfavorable disease and risk factors. In ycN0 after NACT, SLNB can be offered in selected cases or ALND should be performed. After SLNB post-NACT (ypN1), ALND and adjuvant radiotherapy are mandatory.

Axillary management in early breast cancer with onset surgical management and positive sentinel lymph node

Over the years, the management of early breast cancer has evolved by leaps and bounds, as has the concept of axillary staging and armpit surgical management. Five randomised studies exist that evaluate the possibility of omitting regional locus surgical axillary treatment in patients with early breast cancer and positive sentinel lymph nodes without it having an impact on the prognosis of the disease in selected cases. A review of the literature on the management of the axilla in early breast cancer is presented.

The Findings of SPECT/CT Concerning Bypass Lymph Circulation in Lymphedema Following Breast Cancer Surgery

This study aimed to determine whether bypass circulation was present in lymphedema and its effect. This was a retrospective, cross-sectional study. Patients who underwent unilateral breast cancer surgery with axillary lymph node dissection were recruited and underwent single-photon emission tomography/computed tomography (SPECT/CT). SPECT/CT was performed to detect the three-dimensional locations of radio-activated lymph nodes. Patients with radioactivity in anatomical locations other than axillary lymph nodes were classified into a positive group. All patients received complete decongestive therapy (CDT). Exclusion criteria were as follows: History of bilateral breast cancer surgery, cervical lymph node dissection history, and upper extremity amputation. The difference in the upper extremity circumference (cm) was measured at four points: Mid-point of the upper arm, elbow, and 10 and 15 cm below the elbow. Twenty-nine patients were included in this study. Fifteen patients (51.7%) had bypass lymphatic systems on the affected side, six (20.7%) had a bypass lymphatic system with axillary lymph nodes on the unaffected side, and 11 (37.9%) showed new lymphatic drainage. The positive group showed significantly less swelling than the negative group at the mid-arm, elbow, and 15 cm below the elbow. Bypass lymphatic circulation had two patterns: Infraclavicular lymph nodes and supraclavicular and/or cervical lymph nodes. Changes in lymph drainage caused by surgery triggered the activation of the superficial lymphatic drainage system to relieve lymphedema. Superficial lymphatic drainage has a connection through the deltopectoral groove.

Locoregional Management of the Axilla in Mastectomy Patients with One or Two Positive Sentinel Nodes: The Role of Intraoperative Pathology

INTRODUCTION

Controversy exists regarding optimal management of the axilla in clinically node-negative (cN0) mastectomy patients with one or two positive sentinel lymph nodes (+SLNs). We evaluated the influence of frozen-section pathology on axillary management and recurrence.

PATIENTS AND METHODS

We studied cN0 breast cancer patients treated from 2008 to 2018 with mastectomy and SLN surgery with one or two +SLNs. Patients with one or two +SLNs identified on frozen-section intraoperatively (FS+SLN) were compared to those with one or two +SLNs not detected by frozen section (FS-SLN). Recurrence rates were estimated using the Kaplan-Meier method.

RESULTS

Of 2295 cN0 mastectomy patients, 338 patients had one or two +SLNs: 108 (32%) FS-SLN and 230 (68%) FS+SLN. In the FS+SLN cases, completion axillary lymph node dissection (cALND) was more frequent (97% vs. 39%; P < .001), and median SLN metastasis size (5 vs. 1.3 mm; P < .001) and likelihood of positive non-SLNs (31% vs. 14%; P = .02) were greater compared with FS-SLN cases. Across all 338 patients, 40% had SLN surgery alone, and 47% of cALND patients received post-mastectomy radiation therapy (PMRT). At a median follow-up of 61 months, no axillary recurrences were observed among FS-SLN patients. Among FS+SLN patients, 97% proceeded to cALND but 49% avoided PMRT; three regional nodal recurrences were observed (all in patients treated with cALND, of whom two received PMRT).

CONCLUSION

Mastectomy patients with one or two FS+SLNs have a higher nodal disease burden than FS-SLN patients. The majority of FS+SLN patients underwent cALND, and 51% received PMRT with very low 5-year regional nodal recurrence rates. A substantial proportion of FS-SLN patients successfully avoided both cALND and PMRT. Frozen-section pathology analysis can guide de-escalation of axillary management.

A multidisciplinary view of mastectomy and breast reconstruction: Understanding the challenges

The current review paper was written in collaboration with breast cancer surgeons from the European Breast Cancer Research Association of Surgical Trialists (EUBREAST), a breast pathologist from the Danish Breast Cancer Group (DBCG), and representatives from the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer course. Herein we summarize the different mastectomies and reconstruction procedures and define high-risk anatomical areas for breast cancer recurrences, to further specify the challenges in the surgical procedure, histopathological evaluation, and target volumes in case of postmastectomy irradiation, as recommended by the ESTRO guidelines according to the surgical procedure. The paper has original figures and illustrations for all disciplines for in-depth understanding of the differences between the procedures.

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Mastectomy techniques and reconstruction evolved to improve cosmetic outcomes.

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Different techniques maybe associated with different amount of residual breast tissue.

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More data is needed to estimate who are the patients at risk for residual disease or recurrence.

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Multidisciplinary work needed to individualise treatment for optimal oncological outcomes while maintaining the significant improvements in achieving better cosmesis for these patients.

Identification of Risk Factors Associated with Axillary Lymph Node Metastasis for Sentinel Lymph Node-Positive Breast Cancer Patients

Objective

This study aimed to identify clinicopathological factors related to the extent of axillary lymph node (ALN) involvement in early-stage BC patients with positive sentinel lymph nodes (SLNs).

Methods

This was a retrospective analysis of 566 patients in cT1-2N0M0 with 1-2 positive SLNs that underwent axillary lymph node dissection (ALND) at Sun Yat-Sen Memorial Hospital. The clinical and pathologic data from these patients were analyzed.

Results

Of these 566 patients, 235 (41.5%) exhibited NSLN metastases. Multivariate analysis revealed that the number of positive SLNs (odds ratio (OR) = 1.511; P=0.038), the ratio of metastatic/dissected SLNs (SLN metastasis rate) (OR = 2.124; P < 0.001), and lymphovascular invasion (LVI) (OR = 1.503; P=0.022) were all independent predictors of NSLN metastasis. Patients with 0, 1, 2, or 3 of these risk factors exhibited NSLN metastases in 29.3%, 35.7%, 50.8%, and 68.3% of cases, respectively. We additionally found that the number of positive SLNs (OR = 3.582; P < 0.001), SLN metastasis rate (OR = 2.505; P=0.001), LVI (OR = 2.010; P=0.004), and HER2 overexpression (OR = 1.774; P=0.034) were all independent predictors of N2 disease. When individuals had 0, 1, 2, 3, or 4 of these risk factors, they had four or more involved ALNs in 5.2%, 10.8%, 21.1%, 37.5%, and 70.6% of cases, respectively.

Conclusion

These results suggest that the number of positive SLNs, the SLN metastasis rate, and LVI are all significant predictors of ALN status in BC patients that have 1-2 positive SLNs and that have undergone ALND. In addition, HER2 overexpression was a significant predictor of N2 disease.

Axillary lymph node dissection vs sentinel biopsy only among women with early-stage breast cancer and sentinel node metastasis: A systematic review and meta-analysis

Axillary lymph node dissection (ALND) in early-stage breast cancer with limited sentinel node metastasis may not be superior to sentinel lymph node dissection (SLND). We performed a meta-analysis comparing SLND/Radiotherapy (RT) with ALND. All data were analyzed using Review Manager Software 5.3. Five randomized controlled trials (RCTs) were included. Overall survival, death, and disease-free survival were estimated higher in the SLND group compared to the ALND group. Statistically significant differences in axillary recurrence were observed in favor of ALND. Omission of ALND in patients with <3 positive SLNs is indicated.

Updates on the treatment of invasive breast cancer: Quo Vadimus?

Breast cancer is a common malignancy among women. Despite an increase in incidence, breast cancer mortality has drastically dropped over the last 20 years. This change has been attributed to advances in screening, diagnosis, and treatment. This review summarises recent updates in the clinical approach to breast cancer. Advances in genetics have facilitated the stratification of the risk of recurrence in early-stage breast cancer. Advances in biology have led to the development of novel therapies (poly-ADP-ribose polymerase inhibitors, cyclin-dependent kinase 4/6 inhibitors, HER2 targeted agents). Their combination with endocrine (tamoxifen, aromatase inhibitors, GnRH-analogues, fulvestrant) and systematic therapy (anthracyclines, taxanes) in early and advanced disease have improved clinical outcomes. In the near future, neoadjuvant strategies in specific breast cancer subgroups (triple-negative breast cancers) and novel strategies (immune-modulatory agents) could further improve histopathological responses and survival. Radical mastectomies have been widely replaced by breast-conserving operations, while the traditional axillary dissection is being replaced with sentinel node techniques. Breast cancer therapeutics represents a great challenge due to patients' heterogeneous molecular and clinical characteristics, while the identification of reliable and easily reproducible predictive factors could further improve individualized treatment.

Axillary surgery for breast cancer: past, present, and future

In breast cancer surgery, there has been a major shift toward less invasive local treatment. Although axillary lymph node dissection (ALND) was an integral part of surgical treatment for breast cancer, sentinel lymph node (SLN) biopsy was developed as an accurate method for axillary staging. ALND can be avoided not only in patients with negative SLNs but also in those with one or two positive SLNs receiving breast and/or axillary radiation. On the other hand, ALND has remained the standard treatment for patients with clinically positive nodes. However, axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients receive postoperative chemotherapy and high-risk patients undergo axillary radiation. Standard ALND may not be necessary even for patients with clinically positive nodes who receive axillary radiation and systemic therapy. Thus, the extent of axillary surgery in breast cancer has been decreased with increased use of systemic and radiation therapy.

Axillary Clearance Following Positive Sentinel Lymph Node Biopsy in Symptomatic Breast Cancer

BACKGROUND/AIM

Symptomatic cancers display a different biological behaviour from screen-detected cancers, which may impact the management of axillary metastases. We aimed to determine the role of unselected axillary nodal clearance (ANC) in symptomatic patients with positive sentinel node biopsies (SNBs).

PATIENTS AND METHODS

A case-note review was performed on 95 symptomatic breast cancer patients who underwent ANC following positive SNB.

RESULTS

Thirty-eight (40%) patients were treated with a mastectomy and 57 (60%) with breast-conserving surgery. At ANC, 25 patients (26.3%) showed evidence of further lymph node metastases, with 15 (60%) having two or fewer macrometastases. The presence of more than 2 SNB macrometastases was associated with further ANC metastases (p<0.001). The presence of further metastases at ANC was not associated with either reduced overall survival or disease-free survival.

CONCLUSION

A number of symptomatic breast cancer patients with positive SNBs may be overtreated. Ongoing trials examining the management of low volume SNB macrometastases need to consider the symptomatic subgroup in their conclusions.

Axillary surgery in breast cancer: An updated historical perspective

This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing efforts of researchers toward new challenges, as documented by extensive studies and trials. Axillary surgery has evolved, aiming to offer the best oncologic treatment and improve the quality of life of women. Axillary lymph-node dissection (ALND) has been replaced by sentinel lymph-node biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with minimal morbidity, and becoming the standard of care in the management of breast cancer. However, this is only the beginning. Strategies in defining systemic and radiotherapeutic treatments have gradually been optimized, offering increasingly refined and targeted breast cancer treatment tools. In recent years, the paradigm of completion ALND after a positive SLNB has been questioned, and several studies have led to revolutionary changes in clinical practice. Moreover, the increasingly pivotal role played by neoadjuvant chemotherapy (NAC) has had a profound effect on the extent of axillary surgery, paving the way to a more finite "targeted" procedure in women with node-positive breast cancer who convert to negative nodes clinically after NAC. The utility of SLNB itself and its subsequent omission in women with negative nodes clinically and breast conservative surgery is also under scientific evaluation. The changes over time in the surgical approach to breast cancer have been numerous and significant. The novel emerging perspective characterized by recent advances in biology and genetics, in dedicated axillary ultrasound imaging and chemotherapy regimens, is the present reality that points to the future of axillary node treatment in breast cancer.

Omitting ALND Is Not Safe for a Cohort of Early-Stage Breast Cancer Patients with 1-2 SLNs Macro-Metastases and Breast-Conserving Therapy: A Single-Center Retrospective Study

Background:

Omitting axillary lymph node dissection (ALND) is recommended for early-stage breast cancer patients with 1–2 sentinel lymph nodes (SLNs) macro-metastases and breast-conserving therapy. However, it is not safe for part of patients, so it is significant to find risk factors and develop a predictive model of non-SLNs metastases in breast cancer patients with 1–2 SLNs macro-metastases and breast-conserving therapy.

Methods:

This retrospective study enrolled 228 breast cancer patients with 1–2 SLNs macro-metastases who underwent ALND and breast-conserving surgery between Jan 2012 and Dec 2017 at Cancer Hospital Chinese Academy of Medical Sciences. Chi-square test and backward stepwise binary logistic regression were used to find factors that influenced non-SLN metastases, then a predictive model was formulated and obtained its area under the curve.

Results:

Tumor pathologic invasion size, number of positive SLNs and ALN status on imaging was associated with non-SLNs metastases. The predictive model was also formulated based on these three factors to assess and the area under the curve of model was 0.708.

Conclusion:

We developed a predictive model to assess the high-risk cohort of patients of non-SLNs metastases which can be an auxiliary tool for doctors.

OPTimizing Irradiation through Molecular Assessment of Lymph node (OPTIMAL): a randomized open label trial

BACKGROUND

Conservative surgery followed by breast and nodal irradiation is the standard loco-regional early breast cancer (BC) treatment for patients with four or more involved lymph nodes. However, the treatment strategy when fewer nodes are involved remains unclear, especially when lymphadenectomy has not been performed. Sensitive nodal status assessment molecular techniques as the One-Step Nucleic Acid Amplification (OSNA) assay can contribute to the definition and standardization of the treatment strategy. Therefore, the OPTIMAL study aims to demonstrate the feasibility of incidental irradiation of axillary nodes in patients with early-stage BC and limited involvement of the SLN.

METHODS

BC patients who underwent conservative surgery and whose SLN total tumour load assessed with OSNA ranged between 250-15,000 copies/µL will be eligible. Patients will be randomized to receive irradiation on the breast, tumour bed, axillary and supraclavicular lymph node areas (intentional arm) or only on the breast and tumour bed (incidental arm). All areas, including the internal mammary chain, will be contoured. The mean, median, D5% and D95% doses received in all volumes will be calculated. The primary endpoint is the non-inferiority of the incidental irradiation of axillary nodes compared to the intentional irradiation in terms of 5-year disease free survival. Secondary endpoints comprise the comparison of acute and chronic toxicity and loco-regional and distant disease recurrence rates.

DISCUSSION

Standardizing the treatment and diagnosis of BC patients with few nodes affected is crucial due to the lack of consensus. Hence, the quantitative score for the metastatic burden of SLN provided by OSNA can contribute by improving the discrimination of which BC patients with limited nodal involvement can benefit from incidental radiation as an adjuvant treatment strategy.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT02335957; https://clinicaltrials.gov/ct2/show/NCT02335957.

Axillary Management After Neoadjuvant Endocrine Therapy for Hormone Receptor-Positive Breast Cancer

BACKGROUND

Data to guide axillary management after neoadjuvant endocrine therapy (NET) remain limited.

METHODS

We analyzed type of axillary surgery [sentinel lymph node biopsy (SLNB) vs. axillary lymph node dissection (ALND)] and residual nodal disease burden after NET in two cohorts of patients with cT1-4N0-1M0 hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) breast cancer: Dana-Farber/Brigham and Women's Cancer Center (DFBWCC) cohort (2015-2018) and the National Cancer Data Base (NCDB) cohort (2012-2016). Cox proportional hazard regression was used to determine adjusted 5-year overall survival (OS) by type of axillary surgery.

RESULTS

Ninety-four (4.3%) of 2191 HR+/HER2- DFBWCC patients and 4363 (1.5%) of 283,344 NCDB patients were selected for NET. Of those who underwent axillary surgery, 30 (43.5%) in the DFBWCC cohort and 1583 (40.6%) in the NCDB cohort had ALND. Over 90% of cN0 patients in both cohorts had fewer than three positive nodes on final pathology [44 (95.7%) DFBWCC and 2945 (91.3%) NCDB]. In contrast, only 7 (30.4%) DFBWCC patients and 342 (50.7%) NCDB cN1 patients had fewer than three positive nodes. In the DFBWCC patients, there were no locoregional recurrences and four distant recurrences. In the NCDB, 5-year OS did not differ by type of axillary surgery regardless of residual nodal disease burden: 96.6% SLNB versus 97.9% ALND for 0 positive nodes; 84.4% versus 84.4% for one to two positive nodes, and 75.9% versus 77.3% for three or more positive nodes (all p > 0.10).

CONCLUSIONS

In cN0 patients selected for NET, > 90% have fewer than three positive nodes at surgery. The lack of a survival difference between SLNB and ALND suggests an opportunity to de-escalate treatment of the axilla in patients with limited residual nodal disease.

Analyzing non-sentinel axillary metastases in patients with T3-T4 cN0 early breast cancer and tumor-involved sentinel lymph nodes undergoing breast-conserving therapy or mastectomy

Purpose

In the ACOSOG Z0011 trial, completing axillary lymph node dissection (cALND) did not benefit patients with T1–T2 cN0 early breast cancer and 1–2 positive sentinel lymph nodes (SLN) undergoing breast-conserving surgery (BCT). This paper reports cALND rates in the clinical routine for patients who had higher (T3–T4) tumor stages and/or underwent mastectomy but otherwise met the ACOSOG Z0011 eligibility criteria. Aim of this study is to determine cALND time trends and non-sentinel axillary metastases (NSAM) rates to estimate occult axillary tumor burden.

Methods

Data were included from patients treated in 179 German breast cancer centers between 2008 and 2015. Time-trend rates were analyzed for cALND of patients with T3–T4 tumors separated for BCT and mastectomy and regarding presence of axillary macrometastases or micrometastases.

Results

Data were available for 188,909 patients, of whom 19,009 were identified with 1–2 positive SLN. Those 19,009 patients were separated into 4 cohorts: (1) Patients with T1–T2 tumors receiving BCT (ACOSOG Z0011 eligible; n = 13,741), (2) T1–T2 with mastectomy (n = 4093), (3) T3–T4 with BCT (n = 269), (4) T3–T4 with mastectomy (n = 906). Among patients with T3–T4 tumors, cALND rates declined from 2008 to 2015: from 88.2 to 62.6% for patients receiving mastectomy and from 96.6 to 58.1% in patients receiving BCT. Overall rates for any NSAM after cALND for cohorts 1–4 were 33.4%, 42.3%, 46.9%, 58.8%, respectively.

Conclusions

The cALND rates have decreased substantially in routine care in patients with ‘extended’ ACOSOG Z0011 eligibility criteria. Axillary tumor burden is higher in these patients than in the ACOSOG Z0011 trial.

Development and external validation of a nomogram to predict four or more positive nodes in breast cancer patients with one to three positive sentinel lymph nodes

Objective

To develop a nomogram for predicting the possibility of four or more positive nodes in breast cancer patients with 1–3 positive sentinel lymph nodes (SLN).

Materials and methods

Retrospective analysis of data of patients from two institutions was conducted. The inclusion criteria were: invasive breast cancer; clinically node negative; received lumpectomy or mastectomy plus SLN biopsy followed by axillary lymph node dissection (ALND); and pathologically confirmed T1-2 tumor, with 1–3 positive SLNs. Patients from one institution formed the training group and patients from the other the validation group. Univariate and multivariate analyses were performed to identify the predictors of four or more positive nodes. These predictors were used to build the nomogram. The area under the receiver operating characteristic curve (AUC) was calculated to assess the accuracy of the model.

Results

Of the 1480 patients (966 patients in the training group, 514 in the validation group), 306 (20.7%) had four or more positive nodes. Multivariate stepwise logistic regression showed number of positive (p < .001) and negative SLN (p < .001), extracapsular extension (p < .001), pT stage (p = .016), and tumor location in outer upper quadrant (p = .031) to be independent predictors of four or more positive nodes. The nomogram was built using these five factors. The AUC was 0.845 in the training group and 0.804 in the validation group.

Conclusion

The proposed nomogram appears to accurately estimate the likelihood of four or more positive nodes and could help radiation oncologists to decide on use of regional nodal irradiation (RNI) for breast cancer patients with 1–3 positive nodes but no ALND.

•

Five predictors of four or more positive nodes in breast cancer patients were identified.

•

A nomogram was built using these five factors.

•

The nomogram was validated on an external cohort.

•

The proposed nomogram predicts four or more positive nodes with high accuracy.

•

The nomogram can help in decision making on use of regional nodal irradiation.

Modern surgical treatment of breast cancer

Breast cancer is the most frequent cancer in women all over the world. The prognosis is generally good, with a five-year overall survival rate above 90% for all stages. It is still the second leading cause of cancer-related death among women. Surgical treatment of breast cancer has changed dramatically over the years. Initially, treatment involved major surgery with long hospitalization, but it is now mostly accomplished as an outpatient procedure with a quick recovery. Thanks to well-designed retrospective and randomly controlled prospective studies, guidelines are continually changing. We are presently in an era where safely de-escalating surgery is increasingly emphasized. Breast cancer is a heterogenous disease, where a "one-size-fits-all" treatment approach is not appropriate. There is often more than one surgical solution carrying equal oncological safety for an individual patient. In these situations, it is important to include the patient in the treatment decision-making process through well informed consent. For this to be optimal, the physician must be fully updated on the surgical options. A consequence of an improved prognosis is more breast cancer survivors, and therefore physical appearance and quality of life is more in focus. Modern breast cancer treatment is increasingly personalized from a surgical point of view but is dependent on a multidisciplinary approach. Detailed algorithms for surgery of the breast and the axilla are required for optimal treatment and quality control. This review illustrates how breast cancer treatment has changed over the years and how the current standard is based on high quality scientific research.

Axillary nodal metastatic burden in patients with breast cancer with clinically positive axillary nodes

BACKGROUND

The aim of this study was to determine preoperative factors and tumour characteristics related to a high nodal tumour burden in patients with clinically node-positive breast cancer. These findings were used to construct a predictive tool to evaluate the patient-specific risk of having more than two axillary lymph node metastases.

METHODS

Altogether, 507 consecutive patients with breast cancer and axillary lymph node metastasis diagnosed by preoperative ultrasound-guided needle biopsy were reviewed. These patients underwent breast surgery and axillary lymph node dissection at Helsinki University Hospital between 2010 and 2014. Patients were grouped into those with one or two, and those with more than two lymph node metastases.

RESULTS

There were 153 patients (30·2 per cent) with one or two lymph node metastases and 354 (69·8 per cent) with more than two metastases. Five-year disease-free survival was poorer for the latter group (P = 0·032). Five-year overall survival estimates for patients with one or two and those with more than two lymph node metastases were 87·0 and 81·4 per cent respectively (P = 0·215). In multivariable analysis, factors significantly associated with more than two lymph node metastases were: age, tumour size, lymphovascular invasion in the primary tumour, extracapsular extension of metastasis in lymph nodes, and morphology of lymph nodes. These factors were included in a multivariable predictive model, which had an area under the curve of 0·828 (95 per cent c.i. 0·787 to 0·869).

CONCLUSION

The present study provides a patient-specific prediction model for evaluating nodal tumour burden in patients with clinically node-positive breast cancer.

Axillary nodal irradiation practice in the sentinel lymph node biopsy era: Comparison of the contemporary available 3D and IMRT techniques

OBJECTIVE

Our study aimed to compare regional node coverage and doses to the organ at risk (OAR) using conventional technique (CT) vs "AMAROS" (AT) vs intensity-modulated radiation therapy (IMRT) techniques in patients receiving regional nodal irradiation (RNI) for breast cancer (BC).

METHODS

We included 30 consecutive patients with BC who received RNI including axillary nodes. Two independent and blinded dosimetric RNI plans were generated for all patients. For target volume coverage, we analyzed the V95%, the D95%, the mean and the minimal dose within the nodal station. For hotspots within nodal target volume, we used the V105%, the V108% and the maximal doses. For OAR, lung V20, mean lung and heart doses, the maximal dose to the brachial plexus and the axillary-lateral thoracic vessel junction region were compared between the three techniques.

RESULTS

Target volume coverage and hotspots: Mean V95% in stations I, II, III and IV were 35.8% and 75% respectively with CV, 22.59 and 59.9% respectively with AT technique and 45.58 and 99.6% respectively with IMRT with statistically significant differences (p < 0.001). Mean V105% (cc) in axillary and supraclavicular stations were 21.3 and 6.4 respectively with CV, 1.2 and 0.02 respectively with AT technique and 0.5 and 0.4 respectively with IMRT with statistically significant differences (p < 0.001)..OARs: The mean ipsilateral lung V20 was 16.9%, 16.4 and 13.3% with CT, AT and IMRT respectively. The mean heart dose (Gy) was 0.3, 0.2 and 0.2 with CT, AT and IMRT respectively. The maximal dose to the plexus brachial (Gy) was 50.3, 46.3 and 47.3 with CT, AT and IMRT respectively. The maximal dose to the axillary-lateral thoracic vessel junction (Gy) was 52.3, 47.3 and 47.6 with CT, AT and IMRT respectively. The differences were statistically significant for all OAR (p < 0.001).

CONCLUSION

AT is a valuable technique for RNI including axilla in patients with limited sentinel lymph node biopsy involvement without additional axillary lymph node dissection since it decreases hotspots in the target volume and lowers the radiation exposure of the OAR. For more advanced tumors or patients who did not respond to primary systemic therapy, CT or IMRT should be considered because of their better coverage of the potentially residual nodal disease. IMRT combines several advantages of offering high conformal plans, limited hotspots and protection of main OAR. The clinical impact of these dosimetric differences need to be addressed.

ADVANCES IN KNOWLEDGE

This study is to our knowledge the first to compare conventional three-dimensional and IMRT techniques for regional nodal irradiation for each nodal station in breast cancer in a context of increasing utilization of axillary irradiation.

Validating the ACOSOG Z0011 Trial Result: A Population-Based Study Using the SEER Database

The Z0011 trial demonstrated that axillary lymph node dissection (ALND) could be omitted in spite of 1-2 metastatic sentinel lymph nodes. This study aimed to validate the results on a population-based database. The Surveillance, Epidemiology, and End Results (SEER) database was searched for patients comparable to the Z0011 participants. The type of axillary surgery was estimated using the total number of examined axillary lymph nodes (ALNs). Breast cancer-specific mortality (BCSM) was compared between patients with ≥10 ALNs (the sentinel lymph node dissection (SLND) and ALND group, or "SLND + ALND group") and patients with one or two ALNs (the "SLND group"). During 2010-2015, the SEER database included 7077 and 6620 patients categorized in the SLND group and the SLND + ALND group, respectively. Death was observed for 515 patients (7.3%) in the SLND group and 589 patients (8.9%) in the SLND + ALND group based on a median follow-up of 41 months. After propensity-score matching, the adjusted hazard ratio for BCSM in the SLND group (vs. the SLND + ALND group) was 1.038 (95% confidence interval: 0.798-1.350). Regardless of the SLND criteria, the outcomes were not significantly different between the two groups. This retrospective cohort study of Z0011-comparable patients revealed that ALND could be omitted based on the Z0011 strategy, even among patients with ≤2 dissected ALNs.

Recent advances in radiotherapy of breast cancer

Radiation therapy is an integral part of the multidisciplinary management of breast cancer. Regional lymph node irradiation in younger trials seems to provide superior target coverage as well as a reduction in long-term toxicity resulting in a small benefit in the overall survival rate. For partial breast irradiation there are now two large trials available which support the role of partial breast irradiation in low risk breast cancer patients. Multiple randomized trials have established that a sequentially applied dose to the tumor bed improves local control with the cost of worse cosmetic results.

Post-mastectomy Radiotherapy in T1-2 Breast Cancer Patients With One to Three Lymph Node Metastases: A Propensity Score Matching Analysis

Background and Objectives: Whether post-mastectomy radiotherapy (PMRT) could improve prognosis for T1-2 breast cancer patients with one to three lymph node metastases remains controversial. The present study aimed to determine the significance of PMRT in patients with T1-2N1M0 breast cancer. Methods: Data of 45,646 patients from the Surveillance, Epidemiology, and End Results (SEER) database were analyzed; 12,585 matched patients were divided into a PMRT group and non-radiotherapy group (no-PMRT), respectively, using the propensity score matching method. Univariate and multivariate analyses were performed to determine the prognostic factors of breast cancer, and subgroup analysis was performed according to the number of lymph node metastases. Results: With the median follow-up of 62 months, 5-year cancer-specific survival was 91.48% in the PMRT group and 91.88% in the no-PMRT group (P = 0.405). PMRT did not improve the breast cancer-specific survival (BCSS) in patients with stage T1-2N1M0 (HR = 0.99, 95% CI = 0.92-1.06, P = 0.715). In subgroup analysis, radiotherapy improved the BCSS in patients with three nodes positive, with the 5-year BCSS at 88.5% in the radiation group and 86.6% in the no-radiation group (HR = 0.78, 95% CI = 0.65-0.90, P < 0.001). In patients with two nodes positive, 5-year BCSS was 90.3% in the PMRT group and 89.5% in the no-PMRT group, with no significant difference between the two groups (HR = 0.96, 95% CI = 0.85-1.09, P = 0.552). In patients with one node positive, 5-year BCSS was higher in the no-PMRT group (92.1%) than that in the PMRT group (90.8%); radiotherapy increased the cancer-related death compared with those who did not receive it (HR = 1.21, 95% CI = 1.08-1.36, P = 0.002). Conclusion: The benefit of PMRT in T1-2N1M0 patients was obviously different, and the recommendation of PMRT for this population should be individualized. PMRT should be considered for patients with three nodes positive, should be suggested cautiously in those with two nodes positive, and could be omitted in those with one node positive.

Comparing Observation, Axillary Radiotherapy, and Completion Axillary Lymph Node Dissection for Management of Axilla in Breast Cancer in Patients with Positive Sentinel Nodes: A Systematic Review

PURPOSE

Several randomized controlled trials (RCTs) have investigated observation or axillary radiotherapy (ART) in place of completion axillary lymph node dissection (cALND) for management of positive sentinel nodes (SNs) in clinically node-negative women with breast cancer. The optimal treatment strategy for this population is not known.

METHODS

MEDLINE, Embase, and EBM Reviews-NHS Economic Evaluation Database were searched from inception until July 2019. A systematic review and narrative summary was performed of RCTs comparing observation or ART versus cALND in clinically node-negative female breast cancer patients with positive SNs. The Cochrane risk of bias tool for RCTs was used to assess risk of bias. Outcomes of interest included overall survival (OS), disease-free survival (DFS), axillary recurrence, and axillary surgery-related morbidity.

RESULTS

Three trials compared observation with cALND, and two trials compared ART with cALND. No studies blinded participants or personnel, and there was heterogeneity in inclusion criteria, study design, and follow-up. Neither observation nor ART resulted in statistically inferior 5- or 8-year OS or DFS compared with cALND. There was also no statistically significant increase in axillary recurrences associated with either approach. Four trials reported morbidity outcomes, and all showed cALND was associated with significantly more lymphedema, paresthesia, and shoulder dysfunction compared with observation or ART.

CONCLUSIONS

Women with clinically node-negative breast cancer and positive SNs can safely be managed without cALND.

The generalisability of randomised clinical trials: an interim external validity analysis of the ongoing SENOMAC trial in sentinel lymph node-positive breast cancer

Purpose

None of the key randomised trials on the omission of axillary lymph node dissection (ALND) in sentinel lymph-positive breast cancer have reported external validity, even though results indicate selection bias. Our aim was to assess the external validity of the ongoing randomised SENOMAC trial by comparing characteristics of Swedish SENOMAC trial participants with non-included eligible patients registered in the Swedish National Breast Cancer Register (NKBC).

Methods

In the ongoing non-inferiority European SENOMAC trial, clinically node-negative cT1–T3 breast cancer patients with up to two sentinel lymph node macrometastases are randomised to undergo completion ALND or not. Both breast-conserving surgery and mastectomy are eligible interventions. Data from NKBC were extracted for the years 2016 and 2017, and patient and tumour characteristics compared with Swedish trial participants from the same years.

Results

Overall, 306 NKBC cases from non-participating and 847 NKBC cases from participating sites (excluding SENOMAC participants) were compared with 463 SENOMAC trial participants. Patients belonging to the middle age groups (p = 0.015), with smaller tumours (p = 0.013) treated by breast-conserving therapy (50.3 versus 47.1 versus 65.2%, p < 0.001) and less nodal tumour burden (only 1 macrometastasis in 78.8 versus 79.9 versus 87.3%, p = 0.001) were over-represented in the trial population. Time trends indicated, however, that differences may be mitigated over time.

Conclusions

This interim external validity analysis specifically addresses selection mechanisms during an ongoing trial, potentially increasing generalisability by the time full accrual is reached. Similar validity checks should be an integral part of prospective clinical trials.

Trial registration: NCT 02240472, retrospective registration date September 14, 2015 after trial initiation on January 31, 2015

The Adventure of Axillary Treatment in Early Stage Breast Cancer

Axillary lymph node dissection (ALND) which was an essential part of breast cancer treatment and the gold standard in evaluation of the status of axillary lymph node had notorious with increased arm morbidity and reduction of quality of life. Sentinel lymph node biopsy (SLNB) accurately stages the axilla in early breast cancer and ALND is omitted in SLNB negative patients. In patients with positive SLNB the omission of ALND with or without replacement of axillary radiotherapy has also been recommended by guidelines. The neoadjuvant chemotherapy (NAC) which has been increasingly used for large breast cancers to downstage the tumours for allowing breast conserving surgery and decreasing mastectomy rate has also been used in axillary node positive patients to reduce the need for ALND. The issues surrounding the treatment of axilla in patients treated with NAC; application and false negative rate of SLNB, number of identified sentinel lymph nodes, and axillary radiotherapy instead of ALND are currently the discussed and practiced hot topics. The quests for decreasing arm morbidity without compromising outcome in breast cancer treatment which have begun with the invention of SLNB continue for axilla conserving surgery. This article reviews the adventure of axillary treatment in breast cancer patients treated with or without NAC.

Twenty-five years of change in the management of the axilla in breast cancer

Sentinel lymph node (SLN) biopsy is now used worldwide. It has led to many changes in how we manage the axilla in patients with breast cancer. This review covers four areas of management of the axilla in breast cancer: assessing the clinically node-negative axilla, managing the clinically negative axilla found to be involved at SLN biopsy, management of the clinically positive axilla in the context of neo-adjuvant chemotherapy, and treatment of the diseased axilla when radical therapy is required. We suggest that the evidence supports an optimum number of 3 nodes to be removed for accurate SLN biopsy. Breast cancer departments that have not adopted Z0011 patient management cannot continue to avoid change. The evidence is clear: Not all patients with limited axillary nodal disease on sentinel node biopsy need axillary lymph node dissection. For patients who do need axillary treatment, axillary radiotherapy continues to be under-used. Patients undergoing neo-adjuvant chemotherapy can be safely assessed by post-therapy SLN biopsy, with retrieval of any previously biopsied involved nodes by targeted axillary dissection. There is much to support the trend to doing less in the axilla. We are obliged to act based on the available robust clinical trial data in a way that limits morbidity while at the same time does not increase the risk of disease recurrence.

[Strategies in case of metastatic sentinel lymph node in breast cancer]

Management strategy of micro or macro metastatic sentinel lymph node(s) (SLNs) in breast cancer has dramatically changed over the past ten years and the publication of five randomized trials results: ACOSOG Z0011, IBCSG 23-01, and AATRM comparing axillary lymph node dissection (ALND) versus SLNs biopsy alone; and AMAROS and OTOASOR comparing ALND versus axillary radiotherapy. Despite methodological limitations of several of these trials, notably ACOSOG Z0011, the international recommendations (ASCO, NCCN) and the expert consensus of St Gallen do not recommend the performance of a complementary ALND in case of macro or micro metastatic SLN, if all ACOSOG Z0011 inclusion criteria are met. Moreover, in the context of a mastectomy, with one or two positive SLN and a wall irradiation indication, an axillary radiotherapy can be proposed as an alternative to ALND. Additionally, ALND is also indicated in extracapsular involvement or when three or more SLNs are metastatic. This change in strategy led to a significant decrease on the number of ALNDs performed and resulted on the abandon of SLNs extemporaneous examination. In France, there are no national recommendations on axillary management in the context of SLN involvement. Moreover, a multitude of different local guidelines, led to very heterogeneous practices in our country. The next evolution on axillary management strategy will be the implementation of a SLNs procedure after neoadjuvant chemotherapy (NAC) for patients with lymph node involvement proven before NAC and for whom NAC has allowed axillary downstaging.

Contemporary Issues in Breast Cancer Radiotherapy

A series of landmark studies have increasingly emphasized the role of adjuvant radiotherapy for the definitive management of breast cancer. Although regional nodal irradiation, including the internal mammary nodes, was typically reserved for high-risk patients, there is now evidence of benefit to this approach even for those with a limited nodal disease burden. Similarly, low-risk disease has historically been treated with whole-breast tangents, although contemporary studies now support accelerated partial breast irradiation or the omission of radiotherapy in select cases. This article presents recent data informing these contemporary developments in the radiotherapeutic management of breast cancer.

Major ambulatory surgery in breast diseases

INTRODUCTION

The use of ambulatory surgery (AS) for breast pathology (BP) has increased. The objective of this study is to analyse a group of patients treated surgically for breast pathology in order to evaluate its quality and security in a MAS setting in 2017.

METHODS

A retrospective review of all patients undergoing breast surgery was conducted within an AS programme from January to December 2017 in Consorcio Hospital General Universitario of Valencia (CHGUV). The study analysed the number of patients, exclusion reasons, type of surgical procedures, evolution of substitution rate (SR), rate and causes of conversion to admission, postoperative complications, motives for not being included in the ambulatory programme and the satisfaction rate of the patients treated with ambulatory surgery. This has been compared with a 2013 group.

RESULTS

In 2017, 396 procedures for BP were performed: 170 for benign and 226 for malignant disease. The SR for the global mammary pathology was 72.8%. The SR for benign pathology was 93.4% and the SR for malignant pathology was 57.2%, which has increased in recent years from 45.4% in 2013. The unexpected hospitalization rate (HR) of malignant pathologies was 14.1%, while the HR in benign pathologies was 0.6%. Patients hospitalized for malignant pathologies presented higher complications (17%) than ambulatory patients (8.5%) and benign pathologies (6.5%).

CONCLUSIONS

At the CHGUV, the SR has steadily increased in malignant pathologies. The unexpected hospitalization rate is determined by perioperative sentinel lymph node biopsy results. AS for the treatment of mammary pathology is efficient and safe.

Patterns of Axillary Management in Stages 2 and 3 Hormone Receptor-Positive Breast Cancer by Initial Treatment Approach

BACKGROUND

Data regarding axillary management after neoadjuvant endocrine therapy (NET) are lacking. This study examined axillary management of hormone receptor-positive (HR+) patients based on initial treatment with NET, neoadjuvant chemotherapy (NAC), or upfront surgery.

METHODS

Patients with stage 2 or 3 HR+/HER2- breast cancer treated between 2012 and 2015 were identified in the National Cancer Database. The study examined axillary surgery [sentinel lymph node biopsy (SLNB), SLNB followed by axillary lymph node dissection (ALND), or upfront ALND] by initial treatment stratified by cN0/N1 using pairwise comparisons and multivariable logistic regression.

RESULTS

Of 92,204 eligible patients, 2138 (2.3%) received NET, 11,014 (12%) received NAC, and 79,052 (85.7%) received surgery. Among 60,998 cN0 patients, attempted SLNB was more likely for surgery patients (86.2%, 47,159/54,684) and NET patients (85.8%, 1342/1564) than for NAC patients (79.9%, 3793/4750) (both p < 0.001). Among 31,206 cN1 patients, attempted SLNB was more likely for the surgery patients (46.0%, 11,201/24,368) than for the NET patients (41.8%, 240/574; p = 0.05) or the NAC patients (39.8%, 2491/6264; p < 0.0001). The differences between surgery and NET did not persist in the adjusted analyses. Among both the cN0 patients (n = 13,856) and the cN1 patients (n = 8688) with pN1 disease shown by SLNB, the NET patients were treated with ALND less frequently than those receiving NAC or surgery (p < 0.0001 for all comparisons). In the multivariate analysis, for the patients with pN1 disease shown by SLNB, NET use was associated with increased odds of undergoing SLNB alone [cN0 patients: odds ratio (OR), 1.31, 95% confidence interval (CI), 1.04-1.64; cN1 patients: OR 1.45; 95% CI 1.00-2.10].

CONCLUSIONS

For stages 2 and 3 HR+/HER2- patients, SLNB use after NET was similar to that for upfront surgery. Among those with pN1 disease, the NET patients were less likely to undergo ALND. Additional outcomes data are needed to guide axillary management after NET.

Postmastectomy radiotherapy in T1-2 patients with one to three positive lymph nodes - Past, present and future

PAST: The role of post-mastectomy radiotherapy (PMRT) in patients with tumor <5 cm and one to three positive lymph nodes after axillary dissection (ALND) is vigorously debated. Initial doubts over the efficacy and safety of PMRT in these patients were partially overcome by improvement in technology and systemic treatments. Several randomized controlled clinical trials confirmed benefit of PMRT in N1 patients, which were meta-analyzed by the Early Breast Cancer Trialists' Collaborative Group (EBCTCG). This meta-analysis provides the sole high-level evidence to guide clinical decision-making. PRESENT: Nevertheless, concerns have been evoked around these results, most notably concerning the patient selection bias and the era in which the patients were treated. More recent studies, albeit retrospective, are in contrast with this level I evidence, unequivocally reporting inferior recurrence rates in control arms than those of the EBCTCG meta-analysis. Taken together, these results suggest that one solution would not fit all N1 patients and that patient selection for PMRT shall be stratified upon risks factors. Most prominent of such factors identified are: patient age; number and ratio of positive lymph nodes; histological features such as lymphovascular invasion; and hormone receptor expression. FUTURE: A prospective randomized controlled trial SUPREMO will release its final results in 2023 and shed light onto the subject. Genomic tumor cell profiling will likely provide further guidelines in terms of risk stratification. SUPREMO translational sub-study will also offer material for genomic analyses. A cross-field tendency to forgo nodal dissection in favor of sentinel lymph node biopsy followed by nodal irradiation might eventually render the question of PMRT indication after ALND irrelevant.

Which target volume should be considered when irradiating the regional nodes in breast cancer? Results of a network-meta-analysis

Purpose/objective(s)

Radiation treatment to the regional nodes results in an improvement in survival in breast cancer according to a meta-analysis of randomized trials. However, different volumes were targeted in these studies: breast or chestwall only (WBI/CWI), inclusion of the medial supraclavicular region and axillary apex (MS + WBI/CWI) or additional inclusion of the internal mammary chain (IM + MS + WBI/CWI). The benefit of treating the medial supraclavicular region and axillary apex compared to tangential breast or chestwall irradiation only remains unclear.

Materials/methods

A literature search was conducted identifying trials for adjuvant radiation volumes in nodal irradiation after breast surgery and axillary treatment. Events and effect sizes were extracted from the publications for the endpoints of overall survival (OS), breast cancer-specific survival (BCSS), disease-free survival (DFS), distant metastasis-free survival (DMFS) and loco-regional control (LRC). A network meta-analysis was performed using MetaXL V5.3 with the inverse variance heterogeneity model.

Results

We found two randomized studies (n = 5836) comparing comprehensive nodal irradiation to sole breast treatment as well as one randomized (n = 1407) and one prospective cohort study (n = 3377) analysing the additional treatment of the internal mammary chain against sole local and supraclavicular and axillary apex radiation. Compared to WBI/CWI alone the treatment of IM + MS + WBI/CWI (HR = 0.88; CI:0.78-0.99; p = 0.036) results in improved OS unlike MS + WBI/CWI (HR = 0.99; CI:0.86-1.14; p = 0,89). These results are confirmed in BCSS: IM + MS + WBI/CWI (HR = 0.82; CI:0.72-0.92; p = 0.002) and MS + WBI/CWI (HR = 0.96; CI:0.79-1.18; p = 0.69). PFS is significantly improved with the treatment of MS + WBI/CWI (OR = 0.83; CI:0.71-0.97; p = 0.019). Both nodal treatment volumes improve LRC (MS + WBI/CWI OR = 0.74; CI:0.62-0.87; p = 0.004 and IM + MS + WBI/CWI OR = 0.60; CI:0.43-0.86; p < 0,001). Yet only the internal mammary nodes provide a benefit in DMFS (MS + WBI/CWI HR = 0.97; CI:0.81-1.16; p = 0.74 and IM + MS + WBI/CWI HR = 0.84; CI:0.75-0.94; p = 0.002).

Conclusion

Expanding the radiation field to the axillary apex and supraclavicular nodes after axillary node dissection reduced loco-regional recurrences without improvement in overall and cancer-specific survival. A prolongation in survival due to regional nodal irradiation is achieved when the internal mammary chain is included. This derives from a reduction in distant metastasis.