Meta-analysis of non-sentinel node metastases associated with micrometastatic sentinel nodes in breast cancer

Residual Axillary Metastases in Node-Positive Breast Cancer Patients After Neoadjuvant Treatment: A Register-Based Study

BACKGROUND

Lymph node (LN) metastasis after neoadjuvant chemotherapy (NACT) generally warrants axillary lymph node dissection, which opposes guidelines of upfront surgery in many cases. We investigated the risk of having additional metastases in the axilla when the LNs removed by targeted axillary dissection (TAD) harbored metastases after NACT. We aimed to identify subgroups suitable for de-escalated axillary treatment.

METHODS

This register-based study used data from the Danish Breast Cancer Cooperative Group database. Data were analyzed with logistic regression models. The primary outcome was the metastatic burden in non-TAD LNs in patients with positive TAD LNs after NACT.

RESULTS

Among 383 patients, < 66.6% positive TAD LNs (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.17-0.62), only isolated tumor cells (ITCs) [OR 0.11, 95% CI < 0.01-0.82], and breast pathological complete response (pCR) [OR 0.07, 95% CI < 0.01-0.56] were associated with a low risk of having more than three positive non-TAD LNs. In 315 patients with fewer than three positive non-TAD LNs, the proportion of positive TAD LNs (OR 0.45, 95% CI 0.27-0.76 for 33.3-66.6% vs. > 66.6%), size of the TAD LN metastasis (OR 0.14, 95% CI 0.04-0.54 for ITC vs. macrometastasis), tumor size at diagnosis (OR 0.30, 95% CI 0.15-0.64 for 20-49 mm vs. ≥ 50 mm) and breast pCR (OR 0.38, 95% CI 0.15-0.96) were associated with residual LN metastases in the axilla.

CONCLUSIONS

Breast pCR or ITC only in TAD LNs can, with reasonable certainty, preclude more than three positive non-TAD LNs. Additionally, patients with only ITCs in the TAD LN had a low risk of having any non-TAD LN metastases after NACT. De-escalated axillary treatment may be considered in both subgroups.

Associated Features with Non-Sentinel Lymph Node Involvement in Early Stage Breast Cancer Patients who Have Positive Macrometastatic Sentinel Lymph Node

Objective

The main goal of this study is to determine the clinico-pathological factors that correlate non-sentinel lymph nodes (LNs) involvement in clinically node negative breast cancer (BC) patients with positive macrometastatic sentinel lymph node (SLN) in order to derive future evidence to define a subgroup where completion axillary lymph node dissection (cALND) might not be recommended.

Materials and Methods

Total 289 SLN biopsies were performed in clinically node negative BC patients between March 2014 and April 2017. Seventy patients who performed cALND due to positive macrometastatic SLN were retrospectively selected and classified into two groups, according to non-SLN involvement (NSLNI). Clinico-pathological features of patients were examined computerized and documentary archives.

Results

Extracapsular extension (ECE) of SLN, number of harvested SLNs, metastatic rate of SLNs, absence of ductal carcinoma in situ (DCIS) and presence of multilocalization were significantly associated with the likelihood of non-SLN involvement after univariate analysis (p<0,05). Absence of DCIS and presence of multilocalization were found to be significant after multivariate analysis.

Conclusion

Careful examination of clinico-pathological features can help to decide avoiding cALND if enough LNs are removed and the rate of SLN metastases is low, particularly in case DCIS accompanying invasive cancer in patients without multi localized tumour.

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.

Is Low-Volume Disease in the Sentinel Node After Neoadjuvant Chemotherapy an Indication for Axillary Dissection?

BACKGROUND/OBJECTIVE

Intraoperative evaluation of sentinel lymph nodes (SLNs) after neoadjuvant chemotherapy (NAC) has a higher false-negative rate than in the primary surgical setting, particularly for small tumor deposits. Additional tumor burden seen with isolated tumor cells (ITCs) and micrometastases following primary surgery is low; however, it is unknown whether the same is true after NAC. We examined the false-negative rate of intraoperative frozen section (FS) after NAC, and the association between SLN metastasis size and residual disease at axillary lymph node dissection (ALND).

METHODS

Patients undergoing SLN biopsy after NAC were identified. The association between SLN metastasis size and residual axillary disease was examined.

RESULTS

From July 2008 to July 2017, 702 patients (711 cancers) had SLN biopsy after NAC. On FS, 181 had metastases, 530 were negative; 33 negative cases were positive on final pathology (false-negative rate 6.2%). Among patients with a positive FS, 3 (2%) had ITCs and no further disease on ALND; 41 (23%) had micrometastases and 125 (69%) had macrometastases. Fifty-nine percent of patients with micrometastases and 63% with macrometastases had one or more additional positive nodes at ALND. Among those with a false-negative result, 10 (30%) had ITCs, 15 (46%) had micrometastases, and 8 (24%) had macrometastases; 17 had ALND and 59% had one or more additional positive lymph nodes. Overall, 1/6 (17%) patients with ITCs and 28/44 (64%) patients with micrometastases had additional nodal metastases at ALND.

CONCLUSION

Low-volume SLN disease after NAC is not an indicator of a low risk of additional positive axillary nodes and remains an indication for ALND, even when not detected on intraoperative FS.

Is OSNA better than imprint cytology for intraoperative diagnosis of cancer involvement of axillary sentinel node in breast cancer?

OBJECTIVE

The study aim was to establish Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value (NPV), and Accuracy Values of both imprint cytology (IC) and the OSNA assay for intraoperative assessment of axillary sentinel node (SN) cancer involvement in breast cancer. Specifically, we wished to find out if true positive and false negative results of IC were associated to axillary lymphadenectomy (ALND). Also, we addressed a comparative cost analysis between techniques.

METHODS

244 patients treated for breast cancer in the Breast Unit of Hospital Germans Trias i Pujol from 2011 to 2015 were prospectively included. A transversal, consecutive design was applied to assess IC compared to the reference test (OSNA). Inclusion criteria were: T1 and T2 tumors with negative nodes, both clinically and on ultrasound.

RESULTS

Sensitivity of IC for macrometastases was 70%. The NPV of IC for macrometastases was 95,75%. Accuracy of IC was 96,12%. In the comparative cost analysis, the release time of results for OSNA doubled that of IC and was associated with an increased cost of € 370.

CONCLUSIONS

IC has been stated as a good technique for intraoperative cancer involvement SN with high sensitivity and NPV compared to the OSNA assay. It allows keeping the whole node tissue and thus the possibility of improved histopathological evaluation, which can be useful for adjuvant, and offers the advantage of being less time consuming. Cost analysis shows a higher cost for OSNA, which may exceed the benefit of sorting out false negatives from IC.

Sentinel Lymph Node Biopsy in Breast Cancer: A Clinical Review and Update

Sentinel lymph node biopsy has become a standard staging tool in the surgical management of breast cancer. The positive impact of sentinel lymph node biopsy on postoperative negative outcomes in breast cancer patients, without compromising the oncological outcomes, is its major advantage. It has evolved over the last few decades and has proven its utility beyond early breast cancer. Its applicability and efficacy in patients with clinically positive axilla who have had a complete clinical response after neoadjuvant chemotherapy is being aggressively evaluated at present. This article discusses how sentinel lymph node biopsy has evolved and is becoming a useful tool in new clinical scenarios of breast cancer management.

Axillary Micrometastases and Isolated Tumor Cells Are Not an Indication for Post-mastectomy Radiotherapy in Stage 1 and 2 Breast Cancer

BACKGROUND

Randomized trials demonstrate equivalent locoregional control with sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for T1-2 micrometastatic breast cancer, but include few mastectomy patients. Consensus is lacking on indications for post-mastectomy radiotherapy (PMRT) in this population. Herein, we evaluate locoregional recurrence (LRR) in an unselected, modern cohort of T1-2 breast cancer patients with micrometastases or isolated tumor cells (ITCs; N0i+/N1mi) having a mastectomy.

METHODS

We identified patients with T1-2N0i+/N1mi breast cancer treated with mastectomy from January 2006 to December 2011. Recurrent, bilateral, and neoadjuvant cases were excluded. The primary outcome of interest was LRR.

RESULTS

Overall, 352 patients [211 (60%) with ITCs and 141 (40%) with micrometastases] were identified. 162 (46%) patients had SLNB alone and one node was positive in 295 (84%) cases; 31 (9%) patients had PMRT and 95% had systemic therapy. At a median 6 years of follow-up, the overall crude LRR rate was 2.8% (n = 9), with no axillary recurrences, and the crude LRR rate was 3.9% among those who had SNB alone. Those with LRR had a median age of 55 years, median tumor size of 1.7 cm, and ductal histology; the majority were high-grade (89%) and estrogen receptor positive (78%), with one positive node (89%). There was no association between LRR and receipt of PMRT (p = 0.4), SLNB versus ALND (p = 0.2), or number of positive nodes (p = 0.7) using the log-rank test.

CONCLUSIONS

LRR was infrequent among T1-2N0i+/N1mi patients treated with mastectomy without PMRT, with no axillary failures, suggesting that PMRT or nodal radiotherapy are not routinely indicated in this population.

De-escalation of axillary surgery in early breast cancer

With the advent of sentinel lymph node biopsy, surgical methods for accurately staging the axilla in patients with early-stage breast cancer have become progressively less extensive, with formal axillary lymph node dissection confined to a dwindling group of patients. Although details of methods for sentinel lymph node biopsy have yet to be standardised, this technique is now widely practised and accepted as standard of care worldwide. In the past 5 years, attention has focused on minimisation of surgical morbidity by restricting further axillary surgery or considering radiotherapy in patients with a small tumour burden in their sentinel nodes. This change in approach to patients with positive sentinel lymph node biopsies has increased the complexity of axillary management, and any policy of de-escalation and avoidance of morbidity must not compromise patient outcomes. This trend for de-escalation has accompanied a shift in understanding of how any residual tumour burden can be adequately managed without surgical extirpation and reliance on effective adjuvant therapies. Indications for omission of completion axillary lymph node dissection in patients with two or fewer nodes containing macrometastases demand further clarification, together with the roles of preoperative imaging in defining axillary nodal burden, deselection of patients for sentinel lymph node biopsy, and provision of radiotherapy. Downstaging of biopsy-proven node-positive patients with neoadjuvant chemotherapy could safely permit sentinel lymph node biopsy alone when the index node has been successfully retrieved at surgery, while nodal deposits of any size continue to mandate completion axillary lymph node dissection. Developments in molecular imaging technologies and percutaneous biopsy techniques could potentially render sentinel lymph node biopsy redundant in the future.

Medico-economic impact of MSKCC non-sentinel node prediction nomogram for ER-positive HER2-negative breast cancers

Background

Avoiding axillary lymph node dissection (ALND) for invasive breast cancers with isolated tumor cells or micrometastatic sentinel node biopsy (SNB) could decrease morbidity with minimal clinical significance.

Purpose

The aim of this study is to simulate the medico-economic impact of the routine use of the MSKCC non-sentinel node (NSN) prediction nomogram for ER+ HER2- breast cancer patients.

Methods

We studied 1036 ER+ HER2- breast cancer patients with a metastatic SNB. All had a complementary ALND. For each patient, we calculated the probability of the NSN positivity using the MSKCC nomogram. After validation of this nomogram in the population, we described how the patients’ characteristics spread as the threshold value changed. Then, we performed an economic simulation study to estimate the total cost of caring for patients treated according to the MSKCC predictive nomogram results.

Results

A 0.3 threshold discriminate the type of sentinel node (SN) metastases: 98.8% of patients with pN0(i+) and 91.6% of patients with pN1(mic) had a MSKCC score under 0.3 (false negative rate = 6.4%). If we use the 0.3 threshold for economic simulation, 43% of ALND could be avoided, reducing the costs of caring by 1 051 980 EUROS among the 1036 patients.

Conclusion

We demonstrated the cost-effectiveness of using the MSKCC NSN prediction nomogram by avoiding ALND for the pN0(i+) or pN1(mic) ER+ HER2- breast cancer patients with a MSKCC score of less than or equal to 0.3.

Impact of completion axillary lymph node dissection in patients with breast cancer and isolated tumour cells or micrometastases in sentinel nodes

BACKGROUND

Omission of completion axillary lymph node dissection (ALND) is a standard practice in patients with breast cancer (BC) and negative sentinel nodes (SNs) but has shown insufficient evidence to be recommended in those with SN invasion.

METHODS

A retrospective analysis of a cohort of patients with BC and micrometastases (Mic) or isolated tumour cells (ITCs) in SN. Factors associated with ALND were identified, and patients with ALND were matched to patients without ALND. Overall survival (OS) and recurrence-free survival (RFS) were estimated in the overall population, in Mic and in ITC cohorts.

FINDINGS

Among 2009 patients analysed, 1390 and 619 had Mic and ITC in SN, respectively. Factors significantly associated with ALND were SN status, histological type, age, number of SN harvested and absence of adjuvant chemotherapy. After a median follow-up of 60.4 months, ALND omission was independently associated with reduced OS (hazard ratio [HR] 2.41, 90 confidence interval [CI] 1.36-4.27, p = 0.0102), but not with increased RFS (HR 1.21, 90 CI 0.74-2.0, p = 0.52) in the overall population. In matched patients, the increased risk of death in case of ALND omission was found only in the Mic cohort (HR 2.88, 90 CI 1.46-5.69), not in the ITC cohort. The risk of recurrence was also significantly increased in the subgroup of matched Mic patients (HR 1.56, 90 CI 0.90-2.73).

INTERPRETATION

A separate analysis of Mic and ITC groups, matched for the determinants of ALND, suggested that patients with Mic had increased recurrence rates and shorter OS when ALND was not performed. Our results are consistent with those of previous studies for patients with ITC but not for those with Mic. Randomised controlled clinical trials are still warranted to show with a high level of evidence if ALND can be safely omitted in patients with micrometastatic disease in SN.

Sentinel Lymph Node in Breast Cancer: Review Article from a Pathologist's Point of View

Breast cancer staging, in particular N-stage changed most significantly due to the advanced technique of sentinel lymph node biopsy two decades ago. Pathologists have more thoroughly examined and scrutinized sentinel lymph node and found increased number of small volume metastases. While pathologists use the strict criteria from the Tumor Lymph Node Metastasis (TNM) Classification, studies have shown poor reproducibility in the application of American Joint Committee on Cancer and International Union Against Cancer/TNM guidelines for sentinel lymph node classification in breast cancer. In this review article, a brief history of TNM with a focus on N-stage is described, followed by innate problems with the guidelines, and why pathologists may have difficulties in assessing lymph node metastases uniformly. Finally, clinical significance of isolated tumor cells, micrometastasis, and macrometastasis is described by reviewing historical retrospective data and significant prospective clinical trials.

Elaboration of a nomogram to predict non sentinel node status in breast cancer patients with positive sentinel node, intra-operatively assessed with one step nucleic acid amplification method

BACKGROUNDS

Tumor-positive sentinel node(SLN) biopsy results in a risk of nonsentinel node metastases in case of micro and macro metastases ranging from 20 to 50 %, respectively. Therefore, most patients underwent unnecessary axillary lymph node dissections. Thus, the development of a mathematical model for predicting patient-specific risk of non sentinel node(NSLN) metastases is strongly warranted.

METHODS

The following parameters were recorded:

CLINICAL

hospital, age, medical record number Bio-pathological: tumor (T) size, grading (G), multifocality, histological type, LVI, ER-PR status, HER-2, ki67, molecular classification (luminal A, luminal B, HER2 like, triple negative) Sentinel and nonsentinel lymph node related: number of removed SLNs, number of positive and negative SLNs, copy number of positive sentinel nodes, ratio: number of positive SLNs to number of removed SLNs, number of removed and number of positive nodes after ALND. A total of 2460 patients have been included in the database. All the patients have been provided by the authors of this paper.

RESULTS

Multivariate logistic regression analysis demonstrated that only the number of a CK19 mRNA copies (p < 0.0001), T size (p < 0.0001) and LVI (p < 0.0001) were associated with NSN metastases. The discrimination of the model, quantified with the area under the receiver operating characteristics curve, was 0.71 (95 %, C.I. 0.69-0.73), thus confirming a good level of reliability.

CONCLUSIONS

The nomogram may be employed by the surgeon as a decision making tool on whether to perform an intraoperative axillary lymph node dissection on breast cancer patients with SLN positive. The large population employed and the standardized method of measuring the value of CK19 mRNA copies are appropiate prerequisites for a reliable nomogram.

Partial mastectomy using manual blunt dissection (MBD) in early breast cancer

BACKGROUND

Breast-preserving surgery (Bp) and sentinel lymph node biopsy (SNB) are established as standard treatment for axillary lymph node-negative early breast cancer.

METHODS

A surgical technique using manual blunt dissection (MBD), in which use of electrocautery, an ultrasonically activated scalpel, and ligation is minimized, is described. This involves an approach from small incisions in the axilla or areola to avoid injury to skin flaps, and with adequate mobilization of the breast, so that regardless of the tumor site, surgical wounds are not noticeable. The usefulness and tolerability of this surgical technique were examined.

RESULTS

This surgical technique was evaluated in 233 patients. Surgery could be performed rapidly, with a mean operative time of 67 ± 21 min and a low mean blood loss of only 35 ± 28 ml. There was little need for postoperative analgesia, and surgery was well tolerated without postoperative bleeding or wound infection.

CONCLUSION

Our proposed technique for partial mastectomy using MBD provides good curative and cosmetic results.

Prognostic significance of axillary dissection in breast cancer patients with micrometastases or isolated tumor cells in sentinel nodes: a nationwide study

We estimated the impact of axillary lymph node dissection (ALND) on the risk of axillary recurrence (AR) and overall survival (OS) in breast cancer patients with micrometastases or isolated tumor cells (ITC) in sentinel nodes. We used the Danish Breast Cancer Cooperative Group (DBCG) database to identify patients with micrometastases or ITC in sentinel nodes following surgery for primary breast cancer between 2002 and 2008. A Cox proportional hazard regression model was developed to assess the hazard ratios (HR) for AR and OS between patients with and without ALND. We identified 2074 patients, of which 240 did not undergo further axillary surgery. The 5-year cumulated incidence for AR was 1.58 %. No significant difference in AR was seen between patients with and without ALND. The age adjusted HR for AR if ALND was omitted was 1.79 (95 % CI 0.41-7.80, P = 0.44) in patients with micrometastases and 2.21 (95 % CI 0.54-8.95, P = 0.27), in patients with ITC after a median follow-up of 6 years and 3 months. There was no significant difference in overall survival between patients with and without ALND, when adjusting for age, co-morbidity, tumor size, histology type, malignancy grade, lymphovascular invasion, hormone receptor status, adjuvant systemic treatment and radiotherapy, with a HR for death if ALND was omitted of 1.21 (95 % CI 0.86-1.69, P = 0.27) in patients with micrometastases and 0.96 (95 % CI 0.57-1.62, P = 0.89) in patients with ITC after a medium follow-up on 8 and 5 years. In this nationwide study, we found a low risk of AR on 1.58 % and we did not find a significantly increased risk of AR if ALND was omitted in patients with micrometastases or ITC in sentinel nodes. Furthermore, no significant difference in overall survival was seen between patients with and without ALND when adjusting for adjuvant treatment.

[Prophylactic axillary radiotherapy for breast cancer]

Adjuvant radiotherapy, after breast conserving surgery or mastectomy for breast cancer, improves overall survival while decreasing the risk of recurrence. However, prophylactic postoperative radiotherapy of locoregional lymph nodes for breast cancer, particularly of the axillary region, is still controversial since the benefits and the risks due to axillary irradiation have not been well defined. To begin with, when performing conformal radiotherapy, volume definition is crucial for the analysis of the risk-benefit balance of any radiation treatment. Definition and contouring of the axillary lymph node region is discussed in this work, as per the recommendations of the European Society for Radiotherapy and Oncology (ESTRO). Axillary recurrences are rare, and the recent trend leads toward less aggressive surgery with regard to the axilla. In this literature review we present the data that lead us to avoid adjuvant axillary radiotherapy in pN0, pN0i+ and pN1mi patients even without axillary clearance and to perform it in some other situations. Finally, we propose an update about the potential toxicity of adjuvant axillary irradiation, which is essential for therapeutic decision-making based on current evidence, and to guide us in the evolution of our techniques and indications of axillary radiotherapy.

Standardized processing of native tissue in breast pathology

In breast surgery, replacement of intraoperative frozen section by core needle and vacuum biopsies hampers collections of unfixed breast specimens. We practice immediate intraoperative macroscopic analysis of resection margins and vacuum-cooling of breast specimens to enable native tissue asservation for assessment of biological markers and tissue banking of tumor tissue. In addition, slicing of native tissue before formalin fixation guarantees a standardized and uniform fixation. Starting in 2013, more than 350 breast specimens were processed as native specimens in the Institute of Pathology of Hannover Medical School. Breast specimens with an invasive carcinoma and request of an intraoperative resection margin assessment were processed with an immediate intraoperative pathological analysis. All other breast specimens without assessment of an intraoperative resection margin were vacuum-fixed processed. In all cases, native tissue for biomarker analyses and tumor banking could be preserved.

[Is there a rationale for regional node irradiation in pN1mi and pN0(i+) breast tumours?]

The advent of sentinel lymph node technique has led to a shift in lymph node staging, due to the emergence of new entities, namely micrometastases and isolated tumour cells. In addition, the therapeutic role of axillary lymph node dissection is more and more questioned and radiotherapy has been shown to be equivalent to complementary axillary lymph node dissection in patients without clinical node involvement. This article looks at the literature in favour of performing axillary irradiation in patients with pN1mi stage breast cancer who have undergone a mastectomy without a complementary axillary lymph node dissection, and in favour of abstention of any further treatment of the axilla in patients with pN0(i+) or pN1mi tumours who have undergone breast conserving surgery and a sentinel lymph node procedure followed by systemic treatment. The impact of regional lymph nodes irradiation in case of axillary involvement 2mm or less is also discussed.

[Regional treatment for axillary lymph node micrometastases of breast cancer]

In patients with breast cancer, axillary lymph node micrometastasis detection has been more frequent with a better definition since the introduction of the sentinel node procedure. In this review, we focus on pN1mi micrometastasis and review the literature in order to determine factors involved in making the decision of a regional treatment.

Axillary lymph node management in breast cancer with positive sentinel lymph node biopsy

The surgical treatment of localized breast cancer has become progressively less aggressive over the years. The management of the axillary lymph nodes has been modified by the introduction of sentinel lymph node biopsy. Axillary dissection can be avoided in patients with sentinel lymph node negative biopsies. Based on randomized trials data, it has been proposed that no lymph node dissection should be carried out even in certain patients with sentinel lymph node positive biopsies. This commentary discusses the basis of such recommendations and cautions against a general omission of lymph node dissection in breast cancer patients with positive sentinel lymph node biopsies. Instead, an individualized approach based on axillary tumor burden and biology of the cancer should be considered.

Histological examination of sentinel lymph nodes: significance of macrometastasis, micrometastasis, and isolated tumor cells

Sentinel lymph node biopsy has been started in 1990s and has become one of the standard diagnostic procedures used to treat patients with early breast cancer in this century. In Japan, for the microscopic diagnosis of metastasis to sentinel lymph nodes, intraoperative frozen section diagnosis is widely used in combination with subsequent permanent section diagnosis of the residual specimens. Metastatic foci to sentinel lymph nodes have been classified into macrometastasis, micrometastasis, and isolated tumor cells in 2002, and the definition of isolated tumor cells was modified in 2010. Clinical significance of occult sentinel lymph node metastases, being mostly composed of micrometastasis and isolated tumor cells, has been clarified in terms of predictive factors for non-sentinel lymph node metastasis and patient prognosis by large-scale retrospective studies and prospective randomized clinical trials. In the present review, clinical implications of micrometastases and isolated tumor cells in sentinel lymph nodes and the methods for pathological examination of SLN metastases employed in these studies were overviewed.

New concepts in axillary management of breast cancer

In the last decades, surgical treatment of breast cancer has evolved from more extensive procedures like radical mastectomy to less invasive breast conserving surgery. Similarly, surgical management of axilla has enormously changed from routine axillary dissection to sentinel lymph node biopsy. Traditional surgical approach to the axilla in case of sentinel lymph node negativity is to avoid completion axillary dissection. However, surgeons even avoid performing axillary dissection in selected patients with positive sentinel lymph node in clinical practice depending on the recent randomized controlled studies supporting this concept. All of the recent changes in the management of positive axilla necessitate surgeons to refresh their knowledge on this challenging topic.

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

SUMMARY 

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

Is regional nodes radiotherapy an alternative to surgery?

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

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

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

Axillary ultrasound and sentinel lymph node biopsy: an evolving paradigm for management of the axilla

SUMMARY 

Axillary lymph node dissection was used to treat and to provide staging information for women with invasive breast cancer. With the adoption of sentinel lymph node biopsy over the past two decades, evaluation and management of the axilla has become less invasive for many patients. However, as treatment decisions are more frequently based on tumor biology rather than anatomic staging information, the information obtained from even more minimal axillary surgery may be less clinically relevant, and any surgery may cause morbidity. Imaging technologies, such as axillary ultrasound, offer the capability of providing some staging information without the risks associated with surgery. In addition, the therapeutic need for axillary surgery is in question, and less invasive means of managing the axilla are under investigation.

Cross-validation of three predictive tools for non-sentinel node metastases in breast cancer patients with micrometastases or isolated tumor cells in the sentinel node

BACKGROUND

We cross-validated three existing models for the prediction of non-sentinel node metastases in patients with micrometastases or isolated tumor cells (ITC) in the sentinel node, developed in Danish and Finnish cohorts of breast cancer patients, to find the best model to identify patients who might benefit from further axillary treatment.

MATERIAL AND METHOD

Based on 484 Finnish breast cancer patients with micrometastases or ITC in sentinel node a model has been developed for the prediction of non-sentinel node metastases. Likewise, two separate models have been developed in 1577 Danish patients with micrometastases and 304 Danish patients with ITC, respectively. The models were cross-validated in the opposite cohort.

RESULTS

The Danish model for micrometatases was accurate when tested in the Finnish cohort, with a slight change in AUC from 0.64 to 0.63. The AUC of the Finnish model decreased from 0.68 to 0.58 when tested in the Danish cohort, and the AUC of the Danish model for ITC decreased from 0.73 to 0.52, when tested in the Finnish cohort. The Danish micrometastatic model identified 14-22% of the patients as high-risk patients with over 30% risk of non-sentinel node metastases while less than 1% was identified by the Finish model. In contrast, the Finish model predicted a much larger proportion of patients being in the low-risk group with less than 10% risk of non-sentinel node metastases.

CONCLUSION

The Danish model for micrometastases worked well in predicting high risk of non-sentinel node metastases and was accurate under external validation.

Sentinel lymph node status and axillary lymph node dissection in the surgical treatment of breast cancer

Axillary lymph node dissection has been traditionally perceived as a therapeutic and a staging procedure and unselectively removes all axillary lymph nodes. There still remains some controversy as concerns the survival benefit associated with axillary clearance. Sentinel lymph node biopsy removes the most likely sites of regional metastases, the lymph nodes directly connected with the primary tumour. It allows a more accurate staging and a selective indication for clearing the axilla, restricting this to patients who may benefit of it. Axillary dissection was performed in all patients during the learning phase of sentinel lymphadenectomy, but later only patients with metastasis to a sentinel node underwent this operation. Currently, even some patients with minimal sentinel node involvement, including some with macrometastasis may skip axillary clearance. This review summarizes the changes that have occurred in the surgical management of the axilla, the evidences and controversies behind these changes, along with current recommendations. Orv. Hetil., 2014, 155(6), 203–215.

Axillary Lymph Node Status in Early-Stage Breast Cancer Patients with Sentinel Node Micrometastases (0.2-2 mm)

BACKGROUND

Omission of axillary lymph node dissection (ALND) is increasingly becoming the new standard of care for patients with sentinel lymph node micrometastases (SNMMs). However, a formidable proportion of patients is afflicted with non-sentinel node (NSN) macrometastatic tumor burden.

METHODS

Over 1 decade 5,000 patients underwent sentinel node biopsies (SNB) at 2 certified breast cancer centers in Austria. All available cases of SNMM during this time period were reviewed. Clinical, tumor and lymph node parameters were analyzed using univariate and multivariate analysis to retrieve predictors for further NSN involvement.

RESULTS

We identified 216 patients with SNMMs, of whom 181 subsequently underwent ALND. Of the latter patients, 16% (n = 29/181) presented with NSN axillary metastases. ALND revealed NSN macrometastases in 10.5% (n = 19/181) of all the investigated patients, and 66% of the NSN-positive patients (n = 19/29). In 28% (n = 8/29) of the NSN-positive patients, more than 1 macrometastasis was detected. The number of removed sentinel nodes was found to be a significant predictor (p = 0.007) for NSN involvement.

CONCLUSION

In this retrospective investigation of breast cancer patients with SNMMs, a substantial proportion exhibited involvement of NSNs. Macrometastases accounted for the largest fraction of NSN tumor burden. Refraining from ALND in the face of SNMMs may entail substantial micro- and macrometastatic tumor burden in the remaining axillary lymph node basin.

Treatment of sentinel node-positive breast cancer

Sentinel node biopsy has become well accepted as a minimally invasive means of accurately staging the axilla in breast cancer patients. Patients with metastases in the sentinel node(s) have traditionally proceeded to completion of axillary node dissection, whereas patients who are node negative can be spared the morbidity of this procedure. Recently, there has been some debate as to what constitutes node-positive disease and whether patients with metastasis in the sentinel node(s) require completion axillary dissection. This review addresses the controversies regarding the management of sentinel node-positive breast cancer patients.

Meta-analysis of the efficacy of pancreatoduodenectomy with extended lymphadenectomy in the treatment of pancreatic cancer

Background

The purpose of this meta-analysis is to compare the efficacy of pancreatoduodenectomy (PD) with extended lymphadenectomy (PD/ELND) versus standard PD in the treatment of pancreatic cancer, with the hope of providing evidence for clinical practice.

Methods

The retrieval of relevant literature published before September 2012 was carried out on PubMed, Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) by computer. Information was extracted according to Cochrane systematic review methods, and analyzed using software Stata 11.0.

Results

Five prospective randomized controlled trials (RCTs) were included in this meta-analysis of 555 cases (278 in the PD/ELND group and 277 in the standard PD group). The PD/ELND group showed a significantly lower 3-year survival rate (relative risk (RR) = 1.46, 95% confidence interval (CI) 1.03 to approximately 2.06, P = 0.034), prolonged operative time (weighted mean difference WMD = −1.03, 95% CI −1.96 to approximately −0.10, P = 0.029) and higher incidence of postoperative complications (RR = 0.56, 95% CI 0.42 to approximately 0.77, P = 0.000) by comparing with standard PD group. Besides, no significant difference was observed in the 1-year survival rate (RR = 0.87, 95% CI 0.60 to approximately 1.25, P = 0.69), 5-year survival rate (RR = 1.04, 95% CI 0.68 to approximately 1.58, P = 0.854), postoperative mortality (RR = 1.14, 95% CI 0.43 to approximately 3.00, P = 0.789), length of stay (WMD = −0.32, 95% CI −2.57 to approximately 1.94 , P = 0.784) and the amount of blood transfusions (WMD = −0.14, 95% CI −0.36 to approximately 0.08, P = 0.213).

Conclusions

PD/ELND does not have an advantage over standard PD in the survival rate for patients with pancreatic cancer, but does increase operative time and incidences of postoperative complications.

Advantages of one step nucleic acid amplification (OSNA) whole node assay in sentinel lymph node (SLN) analysis in breast cancer

BACKGROUND

The purpose of this study is to present our first results of sentinel node analysis (SLN) by one step nucleic acid amplification (OSNA) in routine clinical practice in our centre and compare them with the results of classic histopathological analysis in a historical cohort from our same institution.

METHODS

407 patients (total study population) with early breast cancer and no clinical nodal involvement underwent SLN biopsy in our institution. The SLN was analysed by OSNA in 164 biopsies. OSNA results were compared with the conventional histopathology study of 244 patients who had undergone SLN biopsy previously. The characteristics of the patients in both groups were evaluated and a comparison was made of the rate of metastases detected by both methods and of the surgical procedures needed in each group. We also investigated the state of non-sentinel lymph nodes if micrometastases where found in SLN.

RESULTS

SLN biopsy result was considered as positive in 45 patients (28%) in the OSNA group and in 58 in the historical group (24%). There was no difference in the rate of macrometastases (16,5% for OSNA, 20% for HE) but we found differences in the rate of micrometastases (11% for OSNA and 3,6% for HE p = 0.0007). Axillary lymphadenectomy (ALND) was performed in 43/45 cases in the OSNA group and in 51/58 of the historical group. In all patients diagnosed by OSNA, ALND was performed during the initial surgical procedure. In the historical cohort ALND was performed during the initial surgical procedure in 41 patients and in a second surgical procedure in 10 patients. Patients from both groups with micrometastases in the SLN had no metastases in other nodes when the ALND was performed.

CONCLUSIONS

OSNA analysis allows the detection of SLN metastases as precisely as conventional pathology with an increased detection of micrometastases. The OSNA method can reduce the need of a deferred lymphadenectomy.

Does the result of completion axillary lymph node dissection influence the recommendation for adjuvant treatment in sentinel lymph node-positive patients?

OBJECTIVE

The Hungarian National Institute of Oncology has just closed a single-center randomized clinical study. The Optimal Treatment of the Axilla-Surgery or Radiotherapy (OTOASOR) trial compares completion axillary lymph node dissection (cALND) with regional nodal irradiation (RNI) in patients with sentinel lymph node-positive (SLN+) primary invasive breast cancer. In the investigational treatment arm, patients received 50 Gy RNI instead of cALND. In these patients we had information only about the sentinel lymph node (SLN) status, but the further axillary nodal involvement remained unknown. The aim of this study was to investigate whether the result of cALND influenced the recommendation for adjuvant treatment in patients with SLN+ breast cancer.

PATIENTS AND METHODS

Patients with SLN+ primary breast cancer were randomized for cALND (arm A, standard treatment) or RNI (arm B, investigational treatment). Adjuvant systemic treatments were given according to the standard institutional protocol, and patients were followed according to the actual institutional guidelines.

RESULTS

Between August 2002 and June 2009, 474 SLN+ patients were randomized to cALND (arm A, standard treatment = 244 patients) or RNI (arm B, investigational treatment = 230 patients). The 2 arms were well balanced according to the majority of main prognostic factors. However, more patients were premenopausal (34% vs. 27%; P = .095) and had pT2-3 tumors (57% vs. 40%; P = .003) in the completion axillary lymph node dissection (ALND) arm. On the other hand, there were more patients with known human epidermal growth factor receptor type 2 positive tumor (12% vs. 17%, P = .066) in the RNI arm. In the ALND and RNI arms, 78% (190/244) and 69% (159/230), respectively, received chemotherapy (P = .020). Endocrine therapy was administered in 87% (213/244) of the patients in the ALND arm and 89% (204/230) of the patients in the RNI arm (P = .372). Six patients (2.5%) on arm A and 13 patients (5.7%) on arm B received adjuvant trastuzumab treatment (P = not significant). Subgroup analyses explored that more frequent administration of adjuvant chemotherapy in arm A was associated with the higher percentage of premenopausal patients and patients with larger (pT2-3) tumors.

CONCLUSIONS

The result of cALND after positive SLN biopsy seems to have no major impact on the administration of adjuvant systemic therapy.