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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Costarelli L, Arienzo F, Broglia L, La Pinta M, Scavina P, Meli EZ, Colavito MH, Ascarelli A, Campagna D, Mastropietro T, Manna E, Amato M, Andrulli AD, Schiavone A, Minelli M, Fortunato L. Clipping a Positive Lymph Node Improves Accuracy of Nodal Staging After Neoadjuvant Chemotherapy for Breast Cancer Patients, but Does It Drive Management Changes? Ann Surg Oncol 2024; 31:3186-3193. [PMID: 38427160 DOI: 10.1245/s10434-024-15052-y] [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: 09/01/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy for cN+ breast cancer patients after neoadjuvant chemotherapy (NAC) is controversial because the false-negative rate (FNR) is high. Identification of three or more SLNs with a dual tracer improves these results, and inclusion of a clipped lymph node (CLN) (targeted axillary dissection [TAD]) may be even more effective. METHODS A retrospective, single-institution analysis of consecutive cN+ patients undergoing NAC from 2019 to 2021 was performed. Patients routinely underwent placement of a clip in the positive lymph node before NAC, and TAD was performed after completion of therapy. RESULTS The study analyzed 73 patients, and the identification rate for CLN was 98.6% (72/73). A complete response in the lymph nodes was achieved for 43 (59%) of the 73 patients. Overall, the CLN was not a SLN in 18 (25%) of 73 cases, and for women who had one or two and those who had three or more SLNs identified, this occurred in 11 (32%) and 7 (21%) of 34 cases, respectively. Failure of SLN or TAD to identify a positive residual lymph node status after NAC occurred in 10 (15%) of 69 and 2 (3%) of 73 cases, respectively (p = 0.01). In four cases, a SLN was not retrieved (5.5%), and two of these cases had a positive CLN. In three cases, the CLN was the only positive node and did not match with a SLN, directing lymphadenectomy and oncologic management change in two cases. Therefore, 7 (10%) of 73 cases had a change in surgical or oncologic management with TAD. CONCLUSIONS For a conservative axillary treatment in this setting, TAD is an effective method. It is more accurate than SLN alone and allows management changes. Further studies are warranted.
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Affiliation(s)
- Leopoldo Costarelli
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy.
- Pathology Unit, San Giovanni-Addolorata Hospital, Rome, Italy.
| | - Francesca Arienzo
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Pathology Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Laura Broglia
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Radiology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Massimo La Pinta
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Paola Scavina
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Medical Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Emanuele Zarba Meli
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Maria Helena Colavito
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Radiology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Alessandra Ascarelli
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Radiology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Domenico Campagna
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Pathology Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Tiziana Mastropietro
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Elena Manna
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Michela Amato
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Pathology Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Angela Damiana Andrulli
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Radiotherapy Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Alfonso Schiavone
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Mauro Minelli
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Medical Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Lucio Fortunato
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Breast Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
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de Wild SR, Koppert LB, van Nijnatten TJA, Kooreman LFS, Vrancken Peeters MJTFD, Smidt ML, Simons JM. Systematic review of targeted axillary dissection in node-positive breast cancer treated with neoadjuvant systemic therapy: variation in type of marker and timing of placement. Br J Surg 2024; 111:znae071. [PMID: 38531689 PMCID: PMC10965400 DOI: 10.1093/bjs/znae071] [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: 10/22/2023] [Revised: 01/15/2024] [Accepted: 03/02/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND In node-positive (cN+) breast cancer treated with neoadjuvant systemic therapy, combining sentinel lymph node biopsy and targeted lymph node excision, that is targeted axillary dissection, increases accuracy. Targeted axillary dissection procedures differ in terms of the targeted lymph node excision technique. This systematic review aimed to provide an overview of targeted axillary dissection procedures regarding definitive marker type and timing of placement: before neoadjuvant systemic therapy (1-step procedure) or after neoadjuvant systemic therapy adjacent to a clip placed before the neoadjuvant therapy (2-step procedure). METHODS PubMed and Embase were searched, to 4 July 2023, for RCTs, cohort studies, and case-control studies with at least 25 patients. Studies of targeted lymph node excision only (without sentinel lymph node biopsy), or where intraoperative localization of the targeted lymph node was not attempted, were excluded. For qualitative synthesis, studies were grouped by definitive marker and timing of placement. The targeted lymph node identification rate was reported. Study quality was assessed using a National Institutes of Health quality assessment tool. RESULTS Of 277 unique records, 51 studies with a total of 4512 patients were included. Six definitive markers were identified: wire, 125I-labelled seed, 99mTc, (electro)magnetic/radiofrequency markers, black ink, and a clip. Fifteen studies evaluated one-step procedures, with the identification rate of the targeted lymph node at surgery varying from 8 of 13 to 47 of 47. Forty-one studies evaluated two-step procedures, with the identification rate of the clipped targeted lymph node on imaging after neoadjuvant systemic therapy varying from 49 to 100%, and the identification rate of the targeted lymph node at surgery from 17 of 24 to 100%. Most studies (40 of 51) were rated as being of fair quality. CONCLUSION Various targeted axillary dissection procedures are used in clinical practice. Owing to study heterogeneity, the optimal targeted lymph node excision technique in terms of identification rate and feasibility could not be determined. Two-step procedures are at risk of not identifying the clipped targeted lymph node on imaging after neoadjuvant systemic therapy.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Thiemo J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Loes F S Kooreman
- Department of Pathology, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Janine M Simons
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
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Loonis AST, Chesebro AL, Bay CP, Portnow LH, Weiss A, Chikarmane SA, Giess CS. Positive predictive value of axillary lymph node cortical thickness and nodal, clinical, and tumor characteristics in newly diagnosed breast cancer patients. Breast Cancer Res Treat 2024; 203:511-521. [PMID: 37950089 DOI: 10.1007/s10549-023-07155-z] [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: 08/14/2023] [Accepted: 09/30/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Axillary lymph nodes (LNs) with cortical thickness > 3 mm have a higher likelihood of malignancy. To examine the positive predictive value (PPV) of axillary LN cortical thickness in newly diagnosed breast cancer patients, and nodal, clinical, and tumor characteristics associated with axillary LN metastasis. METHODS Retrospective review of axillary LN fine needle aspirations (FNAs) performed 1/1/2018-12/31/2019 included 135 axillary FNAs in 134 patients who underwent axillary surgery. Patient demographics, clinical characteristics, histopathology, and imaging features were obtained from medical records. Hypothesis testing was performed to identify predictors of axillary LN metastasis. RESULTS Cytology was positive in 72/135 (53.3%), negative in 61/135 (45.2%), and non-diagnostic in 2/135 (1.5%). At surgery, histopathology was positive in 84 (62.2%) and negative in 51 (37.8%). LN cortices were thicker in metastatic compared to negative nodes (p < 0.0001). PPV of axillary LNs with cortical thickness ≥ 3 mm, ≥ 3.5 mm, ≥ 4 mm and, ≥ 4.25 mm was 0.62 [95% CI 0.53, 0.70], 0.63 [0.54, 0.72], 0.67 [0.57, 0.76] , and 0.74 [0.64, 0.83], respectively. At multivariable analysis, abnormal hilum (OR = 3.44, p = 0.016) and diffuse cortical thickening (OR = 2.86, p = 0.038) were associated with nodal metastasis. CONCLUSION In newly diagnosed breast cancer patients, increasing axillary LN cortical thickness, abnormal fatty hilum, and diffuse cortical thickening are associated with nodal metastasis. PPV of axillary LN cortical thickness ≥ 3 mm and ≥ 3.5 mm is similar but increases for cortical thickness ≥ 4 mm. FNA of axillary LNs with cortex < 4 mm may be unnecessary for some patients undergoing sentinel LN biopsy.
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Affiliation(s)
- Anne-Sophie T Loonis
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Allyson L Chesebro
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
| | - Camden P Bay
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Takeda Pharmaceuticals, Cambridge, MA, USA
| | - Leah H Portnow
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Anna Weiss
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Division of Surgical Oncology, Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Sona A Chikarmane
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Catherine S Giess
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
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Munck F, Andersen IS, Vejborg I, Gerlach MK, Lanng C, Kroman NT, Tvedskov THF. Targeted Axillary Dissection with 125I Seed Placement Before Neoadjuvant Chemotherapy in a Danish Multicenter Cohort. Ann Surg Oncol 2023; 30:4135-4142. [PMID: 37062781 PMCID: PMC10250439 DOI: 10.1245/s10434-023-13432-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/13/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Targeted axillary dissection (TAD), with marking of the metastatic lymph node before neoadjuvant chemotherapy (NACT), is increasingly used for breast cancer axillary staging. In the case of axillary pathological complete response (ax-pCR), axillary lymph node clearance can be omitted. Several marking methods exist, most using re-marking before surgery. Feasibility, learning curve, and identification rate (IR) vary. Marking with 125I seed before NACT makes re-marking at surgery redundant, possibly increasing feasibility and IR. Here, TAD with 125I seed placed before NACT is evaluated in a Danish multicenter cohort. METHODS Patients staged with 125I TAD in Denmark between 1 January 2016 and 31 August 2021 were included. Patients were identified in radioactivity-emitting implant registries at the radiology departments and from the Danish Breast Cancer Group database. Data were extracted from patients' medical records. Information on patient/tumor characteristics, 125I seed activity, marking period, TAD success, number of sentinel nodes (SNs), the histopathological status of excised nodes, and whether the marked lymph node (MLN) was an SN were registered. RESULTS 142 patients were included. The IR of the MLN was 99.3%, and the IR of the SLNB was 91.5%. TAD success was 91.5%. Minor challenges in marking or removal of the MLN were noted in three patients. In 72.3% of the patients, the MLN was a sentinel node. Overall, 40.8% had axillary pCR. CONCLUSION TAD with 125I seed marking before NACT is feasible without re-marking at surgery and with only minor surgical challenges. The IR is high. Staging with TAD spares 41% of breast cancer patients an axillary dissection.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark.
| | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
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Fuertes Manuel J, Kohan S, Jordà Solé M, Mateu Hidalgo I, Miralles Curto M, Aguiló Sagristà O, Aguilar Alomá E, Peña González K, Lafuerza Torres A, Melé Olivé M, Repkova J, Montero Jaime M, Gumà Padró J. Pacientes con afectación ganglionar inicial por cáncer de mama que han recibido quimioterapia neoadyuvante: técnica combinada ganglio centinela-cirugía radioguiada del ganglio patológico. Rev Esp Med Nucl Imagen Mol 2022. [DOI: 10.1016/j.remn.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Acea-Figueira E, García-Novoa A, Díaz Carballada C, Bouzón Alejandro A, Conde C, Santiago Freijanes P, Mosquera Oses J, Acea-Nebril B. Lymph node staging after primary systemic therapy in women with breast cancer and lymph node involvement at diagnosis. Cir Esp 2022:S2173-5077(22)00158-2. [PMID: 35660095 DOI: 10.1016/j.cireng.2022.06.007] [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: 03/01/2022] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The main objective of this study is to analyze the efficacy of combined axillary marking (lymph node clipping and sentinel lymph node biopsy (SLNB)) for axillary staging in patients with primary systemic treatment (PST) and pathologically confirmed node-positive breast cancer at diagnosis. The secondary objective is to determine the impact of lymph node marking in the suppression of axillary lymph node dissection (ALND) in the study group. METHODS We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and a SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an ALND. The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS Eighty one patients met the inclusion criteria. We identified and extirpated the clip/ wire-marked node in 80 of 81 patients (98.8%), with SLNB performed successfully in 88,9% of patients. The SLN and wire-marked node matched in 78.9% of patients; 76.2% of patients did not undergo ALND. CONCLUSIONS The combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and PST offers a high identification rate (98.8%) and a high correlation between the wire-marked lymph node and the SLN (78.9%). This procedure has enabled the suppression of ALND in 76.2% of patients.
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Affiliation(s)
- Eva Acea-Figueira
- Servicio de Cirugía General, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Alejandra García-Novoa
- Servicio de Cirugía General, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain.
| | - Carlota Díaz Carballada
- Servicio de Ginecología, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Alberto Bouzón Alejandro
- Servicio de Cirugía General, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Carmen Conde
- Servicio de Ginecología, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Paz Santiago Freijanes
- Servicio de Anatomía Patológica, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Joaquín Mosquera Oses
- Servicio de Radiología, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Benigno Acea-Nebril
- Servicio de Cirugía General, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
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Acea-Figueira E, García-Novoa A, Díaz Carballada C, Bouzón Alejandro A, Conde C, Santiago Freijanes P, Mosquera Oses J, Acea-Nebril B. Estadificación ganglionar tras terapia sistémica primaria en mujeres con cáncer de mama y afectación ganglionar al diagnóstico. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Management of the axilla in T1-2N1 breast cancer. NPJ Breast Cancer 2022; 8:69. [PMID: 35637226 PMCID: PMC9151923 DOI: 10.1038/s41523-022-00432-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/22/2022] [Indexed: 11/08/2022] Open
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Fuertes Manuel J, Kohan S, Jordà Solé M, Mateu Hidalgo I, Miralles Curto M, Aguiló Sagristà O, Aguilar Alomá E, Peña González K, Lafuerza Torres A, Melé Olivé M, Repkova J, Montero Jaime MJ, Gumà Padró J. Patients with initial nodal involvement due to breast cancer who have received neoadjuvant chemotherapy: Combined sentinel node-radioguided surgery of the pathological node. Rev Esp Med Nucl Imagen Mol 2022; 41:284-291. [PMID: 35597764 DOI: 10.1016/j.remnie.2022.05.002] [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: 08/16/2021] [Revised: 12/21/2021] [Accepted: 12/26/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To study the feasibility and usefulness of ultrasound-guided pre-chemotherapy marking of pathologic lymph node followed by sentinel lymph node biopsy (SLNB)-pathologic node radioguided biopsy (ROLL) combined technique, in axillary involvement breast cancer patients undergoing neoadjuvant chemotherapy (NACT). MATERIAL AND METHODS Prospective diagnostic study of 30 patients with breast cancer and cN1 axillary staging with NACT indication. Before NACT, the biopsied node was marked with a clip (MBN). After NACT an ultrasound was performed and in case of good response a SLNB (99mTc-nanocolloids) plus targeted axillary dissection MBN ROLL biopsy (99mTc-albumin macroaggregates) was performed. Axillary lymph node dissection (ALND) was performed if SLNB and/or MBN were positive for tumor cells. The localization-removal rate of the sentinel lymph node (SLN) and MBN were evaluated. False-negative rate (FNR) and positive predictive value (PPV) of SLNB alone were also evaluated. RESULTS Thirty patients were included in the study. SLN could be detected in all patients while MBN was successfully removed in 27 (90%). The SLN coincided with MBN in 15 patients (50%). In 12 patients SLNB was negative while MBN positive, leading to a FNR of 44.4% for SLNB alone. We found a PPV of 37% for the SLNB. In 5 patients (18.5%) both SLNB and MBN were negative, avoiding ALND. CONCLUSIONS SLNB-MBN radioguided biopsy ROLL combined technique is a useful and accessible procedure for accurate axillary restaging after NACT, avoiding the high rate of FNR of SLNB alone in this group of patients and avoiding a great number of ALND.
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Affiliation(s)
- J Fuertes Manuel
- Medicina Nuclear-Diagnóstico por Imagen, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain; Universitat Rovira i Virgili (URV), Tarragona, Spain.
| | - S Kohan
- Radiodiagnóstico-Diagnóstico por Imagen, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain
| | - M Jordà Solé
- Ginecología y Obstetricia, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain; Universitat Rovira i Virgili (URV), Tarragona, Spain
| | - I Mateu Hidalgo
- Ginecología y Obstetricia, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain; Universitat Rovira i Virgili (URV), Tarragona, Spain
| | - M Miralles Curto
- Ginecología y Obstetricia, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain
| | - O Aguiló Sagristà
- Ginecología y Obstetricia, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain
| | - E Aguilar Alomá
- Ginecología y Obstetricia, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain
| | - K Peña González
- Anatomía Patológica, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain; Universitat Rovira i Virgili (URV), Tarragona, Spain
| | - A Lafuerza Torres
- Oncología Radioterápica, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain; Universitat Rovira i Virgili (URV), Tarragona, Spain
| | - M Melé Olivé
- Oncología Médica, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain
| | - J Repkova
- Oncología Médica, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain; Universitat Rovira i Virgili (URV), Tarragona, Spain; Institut d'Investigació Sanitària Pere Virgili (IISPV), Tarragona, Spain
| | - M J Montero Jaime
- Radiodiagnóstico-Diagnóstico por Imagen, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain; Universitat Rovira i Virgili (URV), Tarragona, Spain
| | - J Gumà Padró
- Oncología Médica, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, Spain; Universitat Rovira i Virgili (URV), Tarragona, Spain; Institut d'Investigació Sanitària Pere Virgili (IISPV), Tarragona, Spain; Institut d'Oncologia de la Catalunya Sud (IOCS), Reus, Tarragona, Spain
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11
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Song YX, Xu Z, Liang MX, Liu Z, Hou JC, Chen X, Xu D, Fei YJ, Tang JH. Diagnostic accuracy of de-escalated surgical procedure in axilla for node-positive breast cancer patients treated with neoadjuvant systemic therapy: A systematic review and meta-analysis. Cancer Med 2022; 11:4085-4103. [PMID: 35502768 DOI: 10.1002/cam4.4769] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/19/2022] [Accepted: 04/10/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND More initial clinical node-positive breast cancer patients achieve axillary pathological complete response (ax-pCR) after neoadjuvant systemic therapy (NST). Restaging axillary status and performing de-escalated surgical procedures to replace routine axillary lymph nodes dissection (ALND) is urgently needed. Targeted axillary lymph node biopsy (TLNB) is a novel de-escalated surgical strategy marking metastatic axillary nodes before NST and targeted dissection and biopsy intraoperatively to tailor individual axillary management. METHODS This study provided a systematic review and meta-analysis to evaluate the feasibility and diagnosis accuracy of TLNB. Prospective and retrospective clinical trials on TLNB were searched from Pubmed, Embase, and Cochrane. Identification rate (IFR), false-negative rate (FNR), negative predictive value (NPV), and rate of ax-pCR were the outcomes of this meta-analysis. RESULTS One thousand nine hundred and twenty patients attempted TLNB, with an overall IFR of 93.5% (95% confidence interval [CI] 90.1%-96.2%). IFR of three nodal marking methods, namely iodine seeds, clips, and carbon dye, was 95.6% (95% CI 91.2%-98.7%), 91.7% (95% CI 87.3%-95.4%), and 97.1% (95% CI 89.1%-100.0%), respectively. Of them, 847 patients received ALND, with an overall FNR of 5.5% (95% CI 3.3%-8.0%), and NPV ranged from 90.1% to 96.1%. Regression analysis showed that the overlap of targeted and sentinel biopsied nodes might associate with IFRs and FNRs. CONCLUSION TLNB is a novel, less invasive surgical approach to distinguish initial node-positive breast cancer that achieves negative axillary conversion after NST. It yields an excellent IFR with a low FNR and a high NPV. A combination of preoperative imaging, intraoperative TLNB with SLNB, and postoperative nodal radiotherapy might affect the future treatment paradigm of primary breast cancer with nodal metastases.
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Affiliation(s)
- Yu-Xin Song
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Xu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming-Xing Liang
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Liu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun-Chen Hou
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiu Chen
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Di Xu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yin-Jiao Fei
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jin-Hai Tang
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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12
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Pinto CS, Peleteiro B, Pinto CA, Osório F, Costa S, Magalhães A, Mora H, Amaral J, Gonçalves D, Fougo JL. Initial experience with targeted axillary dissection after neoadjuvant therapy in breast cancer patients. Breast Cancer 2022; 29:709-719. [PMID: 35304711 PMCID: PMC8933233 DOI: 10.1007/s12282-022-01349-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/09/2022] [Indexed: 02/06/2023]
Abstract
Background Targeted axillary dissection (TAD) combines sentinel node biopsy (SNB) with the removal of the previously marked metastatic node. TAD is a promising concept for axillary restaging in node-positive breast cancer patients with pathological complete response (pCR) to neoadjuvant therapy (NAT). We aimed to evaluate TAD feasibility in this context. Methods A prospective observational study was conducted in biopsy-confirmed cN1 patients. The removal of the clipped node (CN) was guided by intraoperative ultrasound. SNB used indocyanine green and patent blue V dye. If the CN or sentinel lymph nodes (SLN) had any metastatic foci, or the TAD procedure was unsuccessful, the patient underwent axillary lymph node dissection (ALND). Results Thirty-seven patients were included. TAD and SNB identification rates were 97.3%. Every retrieved CN was also a SLN. At the individual level, SNB identification rate was 89.2% with indocyanine green and 85.5% with patent blue V dye. The CN identification rate was 81.1%, being higher when the CN was localized on the intraoperative ultrasound (84.4% vs 60.0%). Nodal pCR was achieved by 54.1% of our patients and was more frequent in HER2-positive and triple-negative tumors (p = 0.039). Nineteen patients were spared from ALND. Conclusion TAD with intraoperative ultrasound-guided excision of the CN and SNB with indocyanine green and patent blue V dye is a feasible concept to identify patients without axillary residual disease after NAT, that can be spared from ALND, although the need for marking the biopsied node should be further investigated.
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Affiliation(s)
- C S Pinto
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - B Peleteiro
- EPIUnit-Institute of Public Health, University of Porto, Rua das Taipas, 135, 4050-598, Porto, Portugal
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health (ITR), Rua das Taipas, 135, 4050-598, Porto, Portugal
| | - C A Pinto
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - F Osório
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Centro de Mama, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - S Costa
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Centro de Mama, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - A Magalhães
- Centro de Mama, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - H Mora
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Centro de Mama, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - J Amaral
- Centro de Mama, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - D Gonçalves
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Centro de Mama, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - J L Fougo
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Centro de Mama, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
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13
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Rebollo Aguirre A, Fernández Fernández J, Sánchez Sánchez R, Mendoza Arnau I, Rivas Navas D, Martínez Meca S. Radioguided surgery with iodine-125 seeds in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2022; 41:71-77. [DOI: 10.1016/j.remnie.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/20/2021] [Indexed: 11/29/2022]
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14
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Friedrich M, Kühn T, Janni W, Müller V, Banys-Pachulowski M, Kolberg-Liedtke C, Jackisch C, Krug D, Albert US, Bauerfeind I, Blohmer J, Budach W, Dall P, Fallenberg EM, Fasching PA, Fehm T, Gerber B, Gluz O, Hanf V, Harbeck N, Heil J, Huober J, Kreipe HH, Kümmel S, Loibl S, Lüftner D, Lux MP, Maass N, Möbus V, Mundhenke C, Nitz U, Park-Simon TW, Reimer T, Rhiem K, Rody A, Schmidt M, Schneeweiss A, Schütz F, Sinn HP, Solbach C, Solomayer EF, Stickeler E, Thomssen C, Untch M, Witzel I, Wöckel A, Thill M, Ditsch N. AGO Recommendations for the Surgical Therapy of the Axilla After Neoadjuvant Chemotherapy: 2021 Update. Geburtshilfe Frauenheilkd 2021; 81:1112-1120. [PMID: 34629490 PMCID: PMC8494519 DOI: 10.1055/a-1499-8431] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022] Open
Abstract
For many decades, the standard procedure to treat breast cancer included complete dissection of the axillary lymph nodes. The aim was to determine histological node status, which was then used as the basis for adjuvant therapy, and to ensure locoregional tumour control. In addition to the debate on how to optimise the therapeutic strategies of systemic treatment and radiotherapy, the current discussion focuses on improving surgical procedures to treat breast cancer. As neoadjuvant chemotherapy is becoming increasingly important, the surgical procedures used to treat breast cancer, whether they are breast surgery or axillary dissection, are changing. Based on the currently available data, carrying out SLNE prior to neoadjuvant chemotherapy is not recommended. In contrast, surgical axillary management after neoadjuvant chemotherapy is considered the procedure of choice for axillary staging and can range from SLNE to TAD and ALND. To reduce the rate of false negatives
during surgical staging of the axilla in pN+
CNB
stage before NACT and ycN0 after NACT, targeted axillary dissection (TAD), the removal of > 2 SLNs (SLNE, no untargeted axillary sampling), immunohistochemistry to detect isolated tumour cells and micro-metastases, and marking positive lymph nodes before NACT should be the standard approach. This most recent update on surgical axillary management describes the significance of isolated tumour cells and micro-metastasis after neoadjuvant chemotherapy and the clinical consequences of low volume residual disease diagnosed using SLNE and TAD and provides an overview of this yearʼs AGO recommendations for surgical management of the axilla during primary surgery and in relation to neoadjuvant chemotherapy.
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Affiliation(s)
- Michael Friedrich
- Klinik für Frauenheilkunde und Geburtshilfe, HELIOS Klinikum Krefeld, Krefeld, Germany
| | | | - Wolfgang Janni
- Frauenklinik, Klinikum der Universität Ulm, Ulm, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Maggie Banys-Pachulowski
- Klinik für Frauenheilkunde und Geburtshilfe, UK-SH, Lübeck, Germany.,Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach, Offenbach, Germany
| | - David Krug
- Universitätsklinikum Schleswig-Holstein, Klinik für Strahlentherapie, Campus Kiel, Kiel, Germany
| | - Ute-Susann Albert
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Ingo Bauerfeind
- Frauenklinik, Klinikum Landshut gemeinnützige GmbH, Landshut, Germany
| | - Jens Blohmer
- Klinik für Gynäkologie mit Brustzentrum des Universitätsklinikums der Charité, Berlin, Germany
| | - Wilfried Budach
- Strahlentherapie, Radiologie Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Peter Dall
- Frauenklinik, Städtisches Klinikum Lüneburg, Lüneburg, Germany
| | - Eva M Fallenberg
- Klinikum der Universität München, Campus Großhadern, Institut für Klinische Radiologie, München, Germany
| | | | - Tanja Fehm
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt, Klinikum Südstadt Rostock, Rostock, Germany
| | - Oleg Gluz
- Evangelisches Krankenhaus Bethesda, Brustzentrum, Mönchengladbach, Germany
| | - Volker Hanf
- Frauenklinik, Nathanstift Klinikum Fürth, Fürth, Germany
| | - Nadia Harbeck
- Brustzentrum, Klinik für Gynäkologie und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, München, Germany
| | - Jörg Heil
- Universitäts-Klinikum Heidelberg, Brustzentrum, Heidelberg, Germany
| | - Jens Huober
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Germany
| | | | | | - Sibylle Loibl
- German Breast Group Forschungs GmbH, Neu-Isenburg, Germany
| | - Diana Lüftner
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité, Berlin, Germany
| | - Michael Patrick Lux
- Kooperatives Brustzentrum Paderborn, Klinik für Gynäkologie und Geburtshilfe, Frauenklinik, St. Louise, Paderborn, St. Josefs-Krankenhaus, Salzkotten, St. Vincenz Krankenhaus GmbH, Germany
| | - Nicolai Maass
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Volker Möbus
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Frankfurt Höchst GmbH, Frankfurt am Main, Germany
| | - Christoph Mundhenke
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ulrike Nitz
- Evangelisches Krankenhaus Bethesda, Brustzentrum, Mönchengladbach, Germany
| | - Tjoung-Won Park-Simon
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Hannover, Hannover, Germany
| | - Toralf Reimer
- Universitätsfrauenklinik am Klinikum Südstadt, Klinikum Südstadt Rostock, Rostock, Germany
| | - Kerstin Rhiem
- Zentrum Familiärer Brust- und Eierstockkrebs, Universitätsklinikum Köln, Köln, Germany
| | - Achim Rody
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marcus Schmidt
- Klinik und Poliklinik für Geburtshilfe und Frauengesundheit der Johannes-Gutenberg-Universität Mainz, Mainz, Germany
| | | | - Florian Schütz
- Klinik für Gynäkologie und Geburtshilfe, Diakonissen Krankenhaus Speyer, Speyer, Germany
| | - Hans-Peter Sinn
- Sektion Gynäkopathologie, Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Christine Solbach
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Erich-Franz Solomayer
- Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Universitätsklinikum Aachen, Aachen, Germany
| | - Christoph Thomssen
- Universitätsfrauenklinik, Martin-Luther-Universität Halle-Wittenberg, Halle-Wittenberg, Germany
| | - Michael Untch
- Klinik für Gynäkologie und Geburtshilfe, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Isabell Witzel
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Achim Wöckel
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marc Thill
- Klinik für Gynäkologie und Gynäkologische Onkologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Nina Ditsch
- Frauenklinik, Universitätsklinikum Augsburg, Augsburg, Germany
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Gurleyik G, Aksu SA, Aker F, Tekyol KK, Tanrikulu E, Gurleyik E. Targeted axillary biopsy and sentinel lymph node biopsy for axillary restaging after neoadjuvant chemotherapy. Ann Surg Treat Res 2021; 100:305-312. [PMID: 34136426 PMCID: PMC8176200 DOI: 10.4174/astr.2021.100.6.305] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/26/2021] [Accepted: 03/23/2021] [Indexed: 01/09/2023] Open
Abstract
Purpose Accurate restaging of the axilla after neoadjuvant chemotherapy (NAC) is an important issue to ensure deescalating axillary surgery in patients with initial metastatic nodes. We aimed to present our results of targeted axillary biopsy (TAB) combined with sentinel lymph node biopsy (SLNB) for axillary restaging after NAC. Methods In 64 breast cancer patients who underwent NAC, biopsy-proven positive nodes were marked with clips before NAC, and ultrasound-guided wire localization of clip-marked nodes was performed after NAC. Patients underwent TAB and SLNB for post-NAC axilla restaging. Results Identification rates of post-NAC TAB and SLNB were 98.4% and 87.5%, respectively (P = 0.033). Histopathology revealed a nodal pathologic complete response (pCR) rate of 47% in which axillary lymph node dissection (ALND) was avoided. TAB alone and SLNB alone detected residual disease in 29 (85.3%) and 20 (58.8%) patients (P = 0.029), respectively. Whereas rates of up to 97% had been achieved with a combination of TAB and SLNB. The pCR rates after NAC were 64.3% for human epidermal growth factor receptor 2 positive and triple-negative tumors and 13.6% in luminal tumors (P = 0.0002). Conclusion Pathologic analysis following TAB combined with SLNB revealed the pCR rates to NAC in a considerable number of patients that provided de-escalation of axillary surgery. A combination of SLNB and TAB was found to be an accurate procedure in establishing residual nodal disease. This combined procedure in patients with initially positive nodes was a reliable method for post-NAC axillary restaging.
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Affiliation(s)
- Gunay Gurleyik
- Department of Surgery, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Sibel Aydin Aksu
- Department of Radiology, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Fügen Aker
- Department of Pathology, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Kubra Kaytaz Tekyol
- Department of Surgery, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Eda Tanrikulu
- Department of Surgery, Health Science University, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey
| | - Emin Gurleyik
- Department of Surgery, Duzce University Medical Faculty, Duzce, Turkey
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16
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Beniey M, Boulva K, Rodriguez-Qizilbash S, Kaviani A, Younan R, Patocskai E. Targeted Axillary Dissection in Node-Positive Breast Cancer: A Retrospective Study and Cost Analysis. Cureus 2021; 13:e14610. [PMID: 34040910 PMCID: PMC8139537 DOI: 10.7759/cureus.14610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Targeted axillary dissection (TAD) is a novel technique in the field of surgical oncology. During TAD, patients with node-positive breast cancer who clinically responded to neoadjuvant chemotherapy undergo resection of a previously proven metastatic node together with sentinel lymph node dissection (SLND). We aimed to assess the success rates of seed insertion and seed retrieval in the Canadian setting, as well as hospital costs of the procedure. Methods Patients converted to clinically node-negative status post-neoadjuvant chemotherapy underwent TAD. Before surgery, an iodine-125 radioactive seed was inserted in the previously proven metastatic node. The seed node was resected together with an SLND. Axillary lymph node dissection (ALND) was performed in all patients with residual metastases. Results Radioactive seeds were successfully inserted in 34/35 patients. In 34 patients, the targeted node was successfully resected with the radioactive probe during TAD. In one patient, the seed was retrieved inferiorly in the axilla during surgery. There was no adverse event. In total, 50% (17/34) of patients had no residual metastases and were able to avoid ALND. Eight out of 17 patients who underwent ALND did not have any residual disease in their specimen. The mean cost of TAD was 25% superior to the mean cost of ALND (p = 0.02). However, the mean total cost of the hospital stay for TAD was 20% superior to the mean cost of ALND (p = 0.11). The mean cost of TAD was 4,322 Can$ (Canadian dollars), similar to the mean cost of both ALND and SLND performed during the same procedure (4,479 Can$). Conclusions TAD was successful in 97% of patients. Despite increased procedural costs, with a lesser impact on total hospital stay costs, TAD was beneficial in 50% of patients. These patients avoided the unnecessary morbidity associated with ALND.
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Affiliation(s)
- Michèle Beniey
- Department of General Surgery, Université de Montréal, Montreal, CAN
| | - Kerianne Boulva
- Department of Surgical Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | | | - Ahmad Kaviani
- Department of Surgical Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Rami Younan
- Department of Surgical Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
| | - Erica Patocskai
- Department of Surgical Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, CAN
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Rebollo Aguirre AC, Fernández Fernández J, Sánchez Sánchez R, Mendoza Arnau I, Rivas Navas DJ, Martínez Meca S. Radioguided surgery with iodine-125 seeds in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2021; 41:S2253-654X(21)00067-6. [PMID: 33863696 DOI: 10.1016/j.remn.2021.02.017] [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: 01/29/2021] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the use of radioactive iodine-125 seed (RIS) in breast and/or axillary surgery, in patients with breast cancer treated with neoadjuvant chemotherapy (NAC). MATERIAL AND METHODS Prospective study between January 2016 and June 2020. 80 women T1-3,N0-2,M0: 30 RIS marking the breast tumor, 36 both the tumor and the biopsied positive axillary node, and 14 only the axilla. Age: 54.7±11.4 years. Tumor size: 34.1±14.6mm. Histological type: invasive ductal carcinoma 90.0%. Molecular subtypes: luminal-A 23.8%, luminal-B/HER2- 33.7%, luminal-B/HER2+ 18.8%, HER2+ 7.5%, basal-like 16,2%. RESULTS Of the 66 patients with RIS marking of the tumor (51 pre-NAC, 15 post-NAC), 92.1% had tumor-free surgical margins, with a specimen volume of 126.7±111.2 cm3. Of the 5 second local excisions, in 3 the resection margin was involved (1 mastectomy). Of the 50 patients N1 with RIS marking (MLN), 44 pre-NAC and 6 post-NAC, MLN was identified in 97.2%: negative 23, positive 26. In 45/50 patients, sentinel node biopsy (SNB) was performed and it was identified in 93.3%: negative 26, positive 16. In 1 case RIS was not placed correctly and SNB was not identified due to non-migration. In 61.9% of the patients, MLN was among the SNB identified in the surgery. In 5 patients with mismatched SNB and MLN, the pathological result of the SNB was negative and the MLN was positive. Axillary lymph node dissection was performed in 53.8% of the patients. CONCLUSION RIS allow to perform breast-conserving surgery and improve detection of residual axillary disease in patients treated with NAC.
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Affiliation(s)
- A C Rebollo Aguirre
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España.
| | - J Fernández Fernández
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - R Sánchez Sánchez
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - I Mendoza Arnau
- Servicio de Radiodiagnóstico. Hospital Universitario Virgen de las Nieves, Granada, España
| | - D J Rivas Navas
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - S Martínez Meca
- Servicio de Radiodiagnóstico. Hospital Universitario Virgen de las Nieves, Granada, España
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Malter W, Eichler C, Hanstein B, Mallmann P, Holtschmidt J. First Reported Use of Radiofrequency Identification (RFID) Technique for Targeted Excision of Suspicious Axillary Lymph Nodes in Early Stage Breast Cancer - Evaluation of Feasibility and Review of Current Recommendations. In Vivo 2021; 34:1207-1213. [PMID: 32354911 DOI: 10.21873/invivo.11894] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/15/2020] [Accepted: 03/16/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIM The purpose of this study was to evaluate, whether radio frequency identification (RFID) labeling of axillary lymph nodes (LNs) for the use of targeted resection is feasible in primary breast cancer patients with suspicious LNs. PATIENTS AND METHODS We analyzed 10 consecutive patients where RFID technique was used for intraoperative detection of suspicious LNs without preceding neoadjuvant chemotherapy (NACT). We compared the specifics of these procedures to 10 consecutive sentinel lymph node biopsies (SLNB) in the cN0 situation. RESULTS Intraoperative detection rate (DR) for the RFID-labeled target lymph node (TLN) was 100%. Perioperative complications were infrequent and comparable to SLNB. Average time for location of the RFID labeled TLN was quicker than for the SLN. In 71.4% the chip bearing TLN equaled a SLN. CONCLUSION The use of the RFID technique for intraoperative localization of axillary LNs for targeted excision seems feasible. RFID technique for targeted axillary dissection (TAD) following NACT should be investigated in a prospective manner.
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Affiliation(s)
- Wolfram Malter
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Christian Eichler
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Bettina Hanstein
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Peter Mallmann
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Johannes Holtschmidt
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
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Targeted Axillary Dissection for Patients Who Convert to Clinically Node Negative After Neoadjuvant Chemotherapy for Node-Positive Breast Cancer. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00375-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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García-Novoa A, Acea-Nebril B, Díaz Carballada C, Bouzón Alejandro A, Conde C, Cereijo Garea C, Varela JR, Santiago Freijanes P, Antolín Novoa S, Calvo Martínez L, Díaz I, Rodríguez Martínez S, Mosquera Oses J. Combining Wire Localization of Clipped Nodes with Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: Preliminary Results from a Prospective Study. Ann Surg Oncol 2020; 28:958-967. [PMID: 32725521 DOI: 10.1245/s10434-020-08925-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The ideal technique for lymph node staging for patients with pathologically confirmed node-positive breast cancer at diagnosis and neoadjuvant chemotherapy (NAC) is unclear. OBJECTIVE The aim of this study was to analyze the feasibility of wire/clip localization and sentinel lymph node biopsy (SLNB) for the axillary staging of these patients. METHODS We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and an SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an axillary lymph node dissection (ALND). The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS Forty-two patients met the inclusion criteria. We identified and extirpated the clip/wire-marked node in all patients (100%), with SLNB performed successfully in 95.3% of patients. The SLN and wire-marked node matched in 80% of patients; 73.8% of patients did not undergo ALND. DISCUSSION AND CONCLUSIONS Several studies have evaluated the efficacy of various procedures for lymph node marking for women with prechemotherapy lymph node involvement. Most of the studies reported high identification rates (> 94.8%), with false negative rates of < 7%. Similarly, our study allows us to conclude that combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and NAC offers a high identification rate (100%) and a high correlation between the wire-marked lymph node and the SLN (80%). This procedure has enabled the suppression of ALND for a significant number of patients (73%).
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Affiliation(s)
- Alejandra García-Novoa
- Breast Unit, Department of General Surgery, University Hospital Complex of A Coruña, A Coruña, Spain.
| | - Benigno Acea-Nebril
- Breast Unit, Department of General Surgery, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carlota Díaz Carballada
- Breast Unit, Department of Gynecology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Alberto Bouzón Alejandro
- Breast Unit, Department of General Surgery, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carmen Conde
- Breast Unit, Department of Gynecology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carmen Cereijo Garea
- Breast Unit, Case Manager Nurse, University Hospital Complex of A Coruña, A Coruña, Spain
| | - José Ramón Varela
- Breast Unit, Department of Radiology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Paz Santiago Freijanes
- Breast Unit, Department of Pathology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Silvia Antolín Novoa
- Breast Unit, Department of Oncology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Lourdes Calvo Martínez
- Breast Unit, Department of Oncology, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Inma Díaz
- Breast Unit, Department of Radiation Therapy, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Sofia Rodríguez Martínez
- Breast Unit, Department of Nuclear Medicine, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Joaquin Mosquera Oses
- Breast Unit, Department of Radiology, University Hospital Complex of A Coruña, A Coruña, Spain
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Vrancken Peeters MTFD. Management of the axilla after neoadjuvant chemotherapy for breast cancer. Br J Surg 2019; 106:1571-1573. [DOI: 10.1002/bjs.11397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 11/07/2022]
Abstract
Minor international differences
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Affiliation(s)
- M T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
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