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Wintraecken VM, Boersma LJ, van Roozendaal LM, de Vries J, van Kuijk SMJ, Vane MLG, van Dalen T, van der Hage JA, Strobbe LJA, Linn SC, Lobbes MBI, Poortmans PMP, Tjan-Heijnen VCG, van de Vijver KKBT, Westenberg AH, de Wilt JHW, Smidt ML, Simons JM. Quality assurance of radiation therapy after breast-conserving surgery among patients in the BOOG 2013-08 trial. Radiother Oncol 2024; 191:110069. [PMID: 38141879 DOI: 10.1016/j.radonc.2023.110069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND AND PURPOSE In the BOOG 2013-08 trial (NCT02271828), cT1-2N0 breast cancer patients were randomized between breast conserving surgery with or without sentinel lymph node biopsy (SLNB) followed by whole breast radiotherapy (WBRT). While awaiting primary endpoint results (axillary recurrence rate), this study aims to perform a quality assurance analysis on protocol adherence and (incidental) axillary radiation therapy (RT) dose. MATERIALS AND METHODS Patients were enrolled between 2015 and 2022. Data on prescribed RT and (in 25% of included patients) planning target volumes (PTV) parameters were recorded for axillary levels I-IV and compared between treatment arms. Multivariable linear regression analysis was performed to determine prognostic variables for incidental axillary RT dose. RESULTS 1,439/1,461 included patients (98.5%) were treated according to protocol and 87 patients (5.9%) received regional RT (SLNB 10.9%, no-SLNB 1.5 %). In 326 patients included in the subgroup analysis, the mean incidental PTV dose at axilla level I was 59.5% of the prescribed breast RT dose. In 5 patients (1.5%) the mean PTV dose at level I was ≥95% of the prescribed breast dose. No statistically or clinically significant differences regarding incidental axillary RT dose were found between treatment arms. Tumour bed boost (yes/no) was associated with a higher incidental mean dose in level I (R2 = 0.035, F(6, 263) = 1.532, p 0.168). CONCLUSION The results indicate that RT-protocol adherence was high, and that incidental axillary RT dose was low in the BOOG 2013-08 trial. Potential differences between treatmentarms regarding the primary endpoint can thus not be attributed to different axillary radiation doses.
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Affiliation(s)
- V M Wintraecken
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - L J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - L M van Roozendaal
- Department of Surgical Oncology, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - J de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands; Board member Adrz, Goes, the Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - M L G Vane
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - T van Dalen
- Division of Surgical Oncology, Diakonessenhuis Hospital, Utrecht, the Netherlands; Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - J A van der Hage
- Division of Surgical Oncology, Leids University Medical Center, Leiden, the Netherlands
| | - L J A Strobbe
- Division of Surgical Oncology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - S C Linn
- Division of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - M B I Lobbes
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - P M P Poortmans
- Department of Radiation Oncology, Iridium Network, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - V C G Tjan-Heijnen
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Division of Medical Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - K K B T van de Vijver
- Department of Pathology, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium; Center for Gynecological Oncology Amsterdam (CGOA), Department of Gynecology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - A H Westenberg
- Radiation Oncology, Radiotherapiegroep location Arnhem, Arnhem, the Netherlands
| | - J H W de Wilt
- Division of Surgical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M L Smidt
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - J M Simons
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
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Vakaet V, Deseyne P, Schoepen M, Stouthandel M, Post G, Speleers B, Van Greveling A, Monten C, Mareel M, Van Hulle H, Paelinck L, De Gersem W, De Neve W, Vandecasteele K, Veldeman L. Prone Breast and Lymph Node Irradiation in 5 or 15 Fractions: A Randomized 2 × 2 Design Comparing Dosimetry, Acute Toxicity, and Set-Up Errors. Pract Radiat Oncol 2022; 12:324-334. [PMID: 35717049 DOI: 10.1016/j.prro.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/20/2021] [Accepted: 01/18/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Prone whole breast irradiation results in lower dose to organs at risk compared with supine position, especially lung dose. However, the adoption of prone position for whole breast irradiation + lymph node irradiation remains limited and data on lymph node irradiation in 5 fractions are lacking. Although the study was ended prematurely for the primary endpoint (breast retraction at 2 years), we decided to report acute toxicity for prone and supine positions and 5 and 15 fractions. Additionally, dosimetry and set-up accuracy between prone and supine positions were evaluated. METHODS AND MATERIALS A randomized open-label factorial 2 × 2 design was used for an acute toxicity comparison between prone and supine positions and 5 and 15 fractions. The primary endpoint of the trial was breast retraction 2 years after treatment. In total, 57 patients were evaluated. Dosimetry and set-up errors were compared between prone and supine positions. All patients were positioned on either our in -house developed prone crawl breast couch or a Posirest-2 (Civco). RESULTS No difference in acute toxicity between prone and supine positions was found, but 5 fractions did result in a lower risk of desquamation (15% vs 41%; P = .04). Prone positioning resulted in lower mean ipsilateral lung dose (2.89 vs 4.89 Gy; P < .001), mean thyroid dose (3.42 vs 6.61 Gy; P = .004), and mean contralateral breast dose (0.41 vs 0.54 Gy; P = .007). No significant difference in mean heart dose (0.90 vs 1.07 Gy; P = .22) was found. Set-up accuracy was similar between both positions. CONCLUSIONS Unfortunately, the primary endpoint of the trial was not met due to premature closure of the trial. Acceleration in 5 fractions resulted in a lower risk of desquamation. Prone positioning did not influence acute toxicity or set-up accuracy, but did result in lower ipsilateral mean lung dose, thyroid dose, and contralateral breast dose.
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Affiliation(s)
- Vincent Vakaet
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium.
| | - Pieter Deseyne
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Max Schoepen
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Industrial Systems Engineering and Product Design, Kortrijk, Belgium
| | - Michael Stouthandel
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Giselle Post
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Bruno Speleers
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | | | - Christel Monten
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Marcus Mareel
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Hans Van Hulle
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Leen Paelinck
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Werner De Gersem
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Wilfried De Neve
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Katrien Vandecasteele
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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The Impact of an Incidental Dose on Axillary Tumor Control and Toxicity in Localized Breast Cancer: A Retrospective Analysis. Cancers (Basel) 2022; 14:cancers14030807. [PMID: 35159074 PMCID: PMC8834453 DOI: 10.3390/cancers14030807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary The incidental axillary dose varies according to the whole breast irradiation technique. However, this dose has not been shown to be a prognostic factor for locoregional recurrence. The objectives of our retrospective study are to dosimetrically evaluate the incidental axillary dose according to the different irradiation techniques and the risk factors of axillary recurrence. We confirmed that the irradiation technique has an influence on the incidental dose delivered to the axillary area, but has no influence on the risk of axillary recurrence. The risk of lymphoedema could be related to the use of high tangential beams and the mean dose delivered at level II. Abstract Purpose: The dosimetric analysis of the incidental axillary dose delivered to axillary lymph node levels I–III by different techniques of whole breast irradiation and the analysis of prognostic factors of axillary recurrence of breast cancer. Methods: We perform a retrospective analysis that includes 171 patients with localized breast carcinoma irradiated at Centre Paul Strauss. To be included in the study, patients had to have a histological confirmation of breast cancer diagnosis, surgical treatment without axillary lymph node dissection (ALND), whole breast irradiation without axillary irradiation by a specific field, and a treatment plan available. Results: Three patients had lymph node recurrence. There was no significant correlation between the maximal or mean dose delivered at the three axillary levels and the risk of axillary lymph node recurrence. There was no significant correlation between the irradiation technique and the risk of axillary lymph node recurrence. Two patients, both in the HT group, had lymphoedema. There was significantly more lymphoedema in the HT group than in the ST and IMRT groups (p < 0.048). The mean dose in level II was significantly higher in the group of patients with lymphoedema (3.45 Gy (1.08; 9.62) vs. 23.4 Gy (23.1; 23.6)) (p < 0.02). Conclusion: The irradiation technique has an influence on the incidental dose delivered to the axillary area, but has no influence on the risk of axillary recurrence. The risk of lymphoedema could be related to the use of HT and the mean dose delivered at level II.
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Moorman AM, Rutgers EJT, Kouwenhoven EA. Omitting SLNB in Breast Cancer: Is a Nomogram the Answer? Ann Surg Oncol 2021; 29:2210-2218. [PMID: 34739639 DOI: 10.1245/s10434-021-11007-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUNDS Sentinel lymph node biopsy (SLNB) is standard care as a staging procedure in patients with invasive breast cancer. The axillary recurrence rate, even after positive SLNB, is low. This raises serious doubts regarding the clinical value of SLNB in early breast cancer. The purpose of this study is to select patients with low suspected axillary burden in whom SLNB might be omitted. PATIENTS AND METHODS We retrospectively analyzed 2015 primary breast cancer patients between 2007 and 2015, with 982 patients allocated to the training and 961 to the validation cohort. Variables associated with nodal disease were analyzed and used to build a nomogram for predicting nodal disease. RESULTS A total of 32.8% of patients had macrometastatic disease. A predictive model was constructed based on age, cN0, morphology, grade, multifocality, and tumor size with an area under the receiver operating characteristic curve (AUC) of 0.83. Considering a false-negative rate of 5%, 32.8% of patients could be spared axillary surgery. In a subanalysis of patients with relatively favorable characteristics, 26.8% had less than 5% chance of macrometastases. CONCLUSIONS We present a model with excellent predictive value that can select one-third of patients in whom SLNB is deemed not necessary because of less than 5% chance of nodal involvement. Whether missing 1 in 20 patients with macrometastatic disease is worthwhile balanced against preventing side-effects of the SLN procedure remains to be established. A number of ongoing large prospective trials evaluating the outcome of omitting SLNB are awaited. Meanwhile, this nomogram may be used for individual decision-making.
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Affiliation(s)
- A M Moorman
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands.
| | - E J Th Rutgers
- Department of Surgery, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - E A Kouwenhoven
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands
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Incidental axillary dose delivery to axillary lymph node levels I-III by different techniques of whole-breast irradiation: a systematic literature review. Strahlenther Onkol 2021; 197:820-828. [PMID: 34292348 DOI: 10.1007/s00066-021-01808-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/13/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE In breast cancer treatment, radiotherapy is an essential component for locoregional management. Axillary recurrence in patients with invasive breast carcinoma remains an issue. The question of whether breast irradiation may unintentionally include levels I, II, and III, and may decrease the risk of axillary recurrence, remains a topic of discussion. PATIENTS AND METHODS A literature search was performed in PubMed and the Cochrane Library to identify articles that have published data regarding dose-volume analysis of axillary levels in breast irradiation. The following MESH terms were used: "breast cancer/lymph nodes" AND "radiotherapy dosage." RESULTS Thirteen articles were identified. The irradiation technique, initial dose prescribed to the breast, delineated volumes, and dose received at axillary levels were heterogeneous. The average dose delivered to axilla levels I, II, and III with three-dimensional conformal radiotherapy using standard fields (ST) ranged between 22 and 43.5 Gy, 3 and 35.6 Gy, and 1.0 and 20.5 Gy, respectively. The average doses delivered to axilla levels I, II, and III with three-dimensional conformal radiotherapy using "high tangential" fields (HT) ranged between 38 and 49.7 Gy, 11 and 47.1 Gy, and 5 and 44.7 Gy, respectively. Finally, the average doses delivered to axilla levels I, II, and III using intensity-modulated radiation therapy (IMRT) were between 14.5 and 42.6 Gy, 3.4 and 35 Gy, and 1.2 and 25.5 Gy, respectively. CONCLUSION Our literature review suggests that the incidental dose delivered to the axilla during whole-breast irradiation is heterogenous and dependent on the irradiation technique used. However, whether this observation can be translated into a therapeutic effect is still a matter of debate.
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[Diffusion prophylactic axillary irradiation in breast cancer - Literature review]. Cancer Radiother 2021; 25:191-199. [PMID: 33402287 DOI: 10.1016/j.canrad.2020.06.035] [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: 07/09/2019] [Revised: 12/24/2019] [Accepted: 06/16/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE In breast cancer, radiotherapy is an essential component of the treatment. However, indications of irradiation of the internal mammary chain and axillary area are debatables. Axillary recurrence in patients with invasive breast carcinoma remains an issue. Currently, the substitution of axillary lymph node dissection by sentinel node biopsy leads to revisit the role of axillary irradiation. Breast irradiation including level I, II and III might decrease the risk of axillary recurrence. MATERIAL AND METHODS A literature search was performed in PubMed and the Cochrane library to identify articles publishing data regarding dose-volume analysis of axillary levels in breast irradiation aiming to determine the potential therapeutic implications. RESULTS Eleven articles were retained. A total of 375 treatment plans were analyzed. The results concerning the irradiation technique, initial dose prescribed to breast, delineated volumes and dose received at axillary levels were heterogeneous. The average dose delivered to axilla levels I-III with 3D-conformal radiotherapy using standard fields were between 24Gy and 43.5Gy, 3Gy and 32.5Gy and between 1.0Gy and 20.5Gy respectively. The average doses delivered to axilla levels I-III with 3D-conformal radiotherapy using high tangential fields were between 38Gy and 49.7Gy, 11Gy and 47.1Gy and 5Gy 38.7Gy, 32.1Gy and 5Gy (result available for only one study) respectively. Finally, the average doses delivered to axilla levels I-III with intensity modulated radiation therapy were between 14.5Gy and 42.6Gy, 3.4Gy and 35Gy and between 1.2Gy and 25.5Gy respectively. CONCLUSIONS Incidental axillary dose seems insufficient to be therapeutic regardless of the irradiation technique. There are meaningful differences between intensity modulated radiation therapy and 3D-conformal radiotherapy.
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Algara López M, Rodríguez García E, Beato Tortajada I, Martínez Arcelus FJ, Salinas Ramos J, Rodríguez garrido JR, Sanz Latiesas X, Soler Rodríguez A, Juan Rijo G, Flaquer García A. OPTimizing Irradiation through Molecular Assessment of Lymph node (OPTIMAL): a randomized open label trial. Radiat Oncol 2020; 15:229. [PMID: 33008422 PMCID: PMC7531133 DOI: 10.1186/s13014-020-01672-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conservative surgery followed by breast and nodal irradiation is the standard loco-regional early breast cancer (BC) treatment for patients with four or more involved lymph nodes. However, the treatment strategy when fewer nodes are involved remains unclear, especially when lymphadenectomy has not been performed. Sensitive nodal status assessment molecular techniques as the One-Step Nucleic Acid Amplification (OSNA) assay can contribute to the definition and standardization of the treatment strategy. Therefore, the OPTIMAL study aims to demonstrate the feasibility of incidental irradiation of axillary nodes in patients with early-stage BC and limited involvement of the SLN. METHODS BC patients who underwent conservative surgery and whose SLN total tumour load assessed with OSNA ranged between 250-15,000 copies/µL will be eligible. Patients will be randomized to receive irradiation on the breast, tumour bed, axillary and supraclavicular lymph node areas (intentional arm) or only on the breast and tumour bed (incidental arm). All areas, including the internal mammary chain, will be contoured. The mean, median, D5% and D95% doses received in all volumes will be calculated. The primary endpoint is the non-inferiority of the incidental irradiation of axillary nodes compared to the intentional irradiation in terms of 5-year disease free survival. Secondary endpoints comprise the comparison of acute and chronic toxicity and loco-regional and distant disease recurrence rates. DISCUSSION Standardizing the treatment and diagnosis of BC patients with few nodes affected is crucial due to the lack of consensus. Hence, the quantitative score for the metastatic burden of SLN provided by OSNA can contribute by improving the discrimination of which BC patients with limited nodal involvement can benefit from incidental radiation as an adjuvant treatment strategy. TRIAL REGISTRATION ClinicalTrial.gov, NCT02335957; https://clinicaltrials.gov/ct2/show/NCT02335957.
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Affiliation(s)
- Manuel Algara López
- Radiation Oncology Department, Del Mar Hospital, Autonomous University of Barcelona, Hospital del Mar Medical Research Institute, Passeig Maritim, 25, 08003 Barcelona, Spain
| | | | | | | | - Juan Salinas Ramos
- Radiation Oncology Department, Santa Lucia General University Hospital, Cartagena, Spain
| | | | - Xavier Sanz Latiesas
- Radiation Oncology Department, Del Mar Hospital, Pompeu Fabra University, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Germán Juan Rijo
- Radiation Oncology Department, Cabueñes University Hospital, Gijón, Spain
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Central Review of Radiation Therapy Planning Among Patients with Breast-Conserving Surgery: Results from a Quality Assurance Process Integrated into the INSEMA Trial. Int J Radiat Oncol Biol Phys 2020; 107:683-693. [PMID: 32437921 DOI: 10.1016/j.ijrobp.2020.04.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE After publication of the radiation field design in the American College of Surgeons Oncology Group Z0011 trial, a radiation therapy quality assurance review was integrated into the Intergroup-Sentinel-Mamma (INSEMA) trial. We aimed to investigate the role of patient characteristics, extent of axillary surgery, and radiation techniques for dose distribution in ipsilateral axillary levels. METHODS AND MATERIALS INSEMA (NCT02466737) has randomized 5542 patients who underwent breast-conserving surgery. Of these, 276 patients from 108 radiation therapy facilities were included in the central review, using the planning records of the first 3 patients treated at each site. RESULTS Of the 276 patients, 41 had major deviations (ie, no axillary contouring or submission of insufficient records) leading to exclusion. A total of 235 (85.1%) radiation therapy planning records were delineated according to the INSEMA protocol, including 9 (3.8%) cases with minor deviations. At least 25% of INSEMA patients were unintentionally treated with ≥95% of the prescribed breast radiation dose in axillary level I. Approximately 50% of patients were irradiated with a median radiation dose of more than 85% of prescription dose in level I. Irradiated volumes and applied doses were significantly lower in levels II and III compared with level I. However, 25% of patients still received a median radiation dose of ≥75% of prescription dose to level II. Subgroup analysis revealed a significant association between incidental radiation dose in the axilla and obesity. Younger age, boost application, and fractionation schedule showed no impact on axillary dose distribution. CONCLUSIONS Assuming ≥80% of prescribed breast dose as the optimal dose for curative radiation of low-volume disease in axillary lymph nodes, at least 50% of reviewed INSEMA patients received an adequate dose in level I, even with contemporary 3-dimensional techniques. Dose coverage was much less in axillary levels II and III, and far below therapeutically relevant doses.
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van Steenhoven JEC, Kuijer A, van Maaren MC, Roos M, Elias SG, van Diest PJ, Siesling S, Smidt ML, Boersma LJ, van Dalen T. Quantifying the Mitigating Effects of Whole-Breast Radiotherapy and Systemic Treatments on Regional Recurrence Incidence Among Breast Cancer Patients. Ann Surg Oncol 2020; 27:3402-3411. [PMID: 32198570 PMCID: PMC7410865 DOI: 10.1245/s10434-020-08356-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Indexed: 12/25/2022]
Abstract
Background Despite the potential for residual lymph node metastases after a negative or positive sentinel lymph node biopsy (SLNB), breast cancer patients rarely experience regional recurrences (RRs). This study aimed to quantify the effects of nonsurgical treatments on RR incidence among SLNB-negative (SLNB N0) breast cancer patients. Methods All primary SLNB N0-staged breast cancer patients with a diagnosis between 2005 and 2008 and 5-year follow-up data on recurrences were selected from the Netherlands Cancer Registry. The cumulative incidence function (CIF) for RR was calculated as the first event at 5 years, taking into account any other first-event (local or distant recurrence, contralateral breast cancer, or death) as competing risk. Cox regression analysis was used to model the cause-specific hazard of RR developing as the first event to quantify the effect of adjuvant systemic therapy and whole-breast radiotherapy (RT) on RR incidence at 5 years. Results The study included 13,512 patients. Of these patients, 162 experienced an RR. The CIF of RR at 5 years was 1.3% (95% confidence interval [CI], 1.1–1.5%), whereas the CIFs for death and other events were 4.4% and 9.5%, respectively. Cox regression analysis showed hazard ratios (HRs) of 0.46 (95% CI 0.33–0.64), 0.31 (95% CI 0.18–0.55), and 0.40 (95% CI 0.24–0.67) respectively for patients treated by RT as a routine part of breast-conserving therapy (BCT), chemotherapy, and hormonal therapy. Conclusion RT as routine part of BCT, chemotherapy, and hormonal therapy independently exerted a mitigating effect on the risk for the development of RR. The three methods at least halved the risk. Electronic supplementary material The online version of this article (10.1245/s10434-020-08356-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julia E C van Steenhoven
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands. .,Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Anne Kuijer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marissa C van Maaren
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Marleen Roos
- Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Sjoerd G Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Marjolein L Smidt
- Department of Surgery, University Medical Center Maastricht, Maastrischt, The Netherlands
| | - Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Thijs van Dalen
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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Ojala K, Meretoja TJ, Mattson J, Leidenius MHK. Surgical treatment and prognosis of breast cancer in elderly - A population-based study. Eur J Surg Oncol 2019; 45:956-962. [PMID: 30691722 DOI: 10.1016/j.ejso.2019.01.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate outcome of treatment in patients over 80 years of age with early breast cancer at the time of the diagnosis with special interest in surgical treatment. MATERIALS AND METHODS Breast cancer patients older than 80 years of age, treated at the Breast Surgery Unit of Helsinki University Hospital in 2005-2010 were identified from electronic patient records. Patients were followed-up until the end of 2014. Patient and tumour characteristics, recurrences, co-morbidities and reasons for omission of surgery were collected from electronic patient records. Survival data was obtained from Finnish Cancer Registry. RESULTS 446 patients were eligible for the study: 401 (90%) received surgery. The median follow-up time was 52 months. In the entire study population, local and regional recurrences/disease progression were diagnosed in 16 (3.6%) and 6 (1.3%) patients, respectively. The five-year overall survival was 50.6% in the surgical treatment and only 15.2% in non-surgical treatment group, p < 0.001. Also, the five-year breast cancer specific survival was significantly better in the patients with surgery, 82.0%, but 56.0% in the patients without surgery, p < 0.001. There was no mortality related to the surgery, but 122 (30%) patients died within three years from surgery. CONCLUSION Surgical treatment rate was high. OS and BCSS were better in surgically treated elderly patients. Local and regional disease control was excellent, probably due to high rate of surgical treatment. Surgical treatment also seemed safe in this elderly patient population. However, surgical overtreatment was obvious in some patients.
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Affiliation(s)
- Kaisu Ojala
- Breast Surgery Unit, Comprehensive Cancer Centre, Helsinki University Hospital and Helsinki University, Finland.
| | - Tuomo J Meretoja
- Breast Surgery Unit, Comprehensive Cancer Centre, Helsinki University Hospital and Helsinki University, Finland
| | - Johanna Mattson
- Department of Oncology, Comprehensive Cancer Centre, Helsinki University Hospital and Helsinki University, Finland
| | - Marjut H K Leidenius
- Breast Surgery Unit, Comprehensive Cancer Centre, Helsinki University Hospital and Helsinki University, Finland
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11
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Roos MM, van Steenhoven JEC, Aalders KC, Schreuder K, Burgmans JPJ, Siesling S, Elias S, van Dalen T. Regional Recurrence Risk Following a Negative Sentinel Node Procedure Does Not Approximate the False-Negative Rate of the Sentinel Node Procedure in Breast Cancer Patients Not Receiving Radiotherapy or Systemic Treatment. Ann Surg Oncol 2018; 26:372-378. [PMID: 30387028 DOI: 10.1245/s10434-018-6940-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Although the false-negative rate of the sentinel lymph node biopsy (SLNB) in breast cancer patients is 5-7%, reported regional recurrence (RR) rates after negative SLNB are much lower. Adjuvant treatment modalities probably contribute to this discrepancy. This study assessed the 5-year RR risk after a negative SLNB in the subset of patients who underwent breast amputation without radiotherapy or any adjuvant treatment. METHODS All patients operated for primary unilateral invasive breast cancer between 2005 and 2008 were identified in the Netherlands Cancer Registry. Patients with a negative SLNB who underwent breast amputation and who were not treated with axillary lymph node dissection, radiotherapy, or any adjuvant systemic treatment were selected. The cumulative 5-year RR rate was estimated by Kaplan-Meier analysis. RESULTS A total of 13,452 patients were surgically treated for primary breast cancer and had a negative SLNB, and 2012 patients fulfilled the selection criteria. Thirty-eight RRs occurred during follow-up. Multifocal disease was associated with a higher risk of developing RR (P = 0.04). The median time to RR was 27 months and was significantly shorter in patients with estrogen receptor-negative (ER-) breast cancer (9.5 months; P = 0.003). The 5-year RR rate was 2.4% in the study population compared with 1.1% in the remainder of 11,440 SLNB-negative patients (P = 0.0002). CONCLUSIONS Excluding the effect of radiotherapy and systemic treatment resulted in a twofold 5-year RR risk in breast cancer patients with a tumor-free SLNB. This 5-year RR rate was still much lower than the reported false-negative rate of the SLNB procedure.
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Affiliation(s)
- Marleen M Roos
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands.
| | | | - Kim C Aalders
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Kay Schreuder
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | | | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Sjoerd Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thijs van Dalen
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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12
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de Boniface J, Schmidt M, Engel J, Smidt ML, Offersen BV, Reimer T. What Is the Best Management of cN0pN1(sn) Breast Cancer Patients? Breast Care (Basel) 2018; 13:331-336. [PMID: 30498417 DOI: 10.1159/000491704] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Although the majority of breast cancer patients are clinically node-negative (cN0) at diagnosis, 15-20% will have a metastatic sentinel lymph node (SLN, pN1(sn)). While a less radical approach regarding axillary surgery in cN0 patients with a positive SLN biopsy is advocated, the limitations of 5 published trials on axillary management in pN1(sn) are discussed intensely in the literature and support the performance of ongoing validation and extension trials, especially considering the lack of data in the setting of mastectomy. As locoregional radiotherapy has a significant effect on both recurrence and survival, a standardization of locoregional radiotherapy in the situation of SLN biopsy alone in pN1(sn) patients has to be defined in the future, and de-escalation trials should embrace a truly multidisciplinary approach. This is also of utmost importance considering the fact that high-volume nodal disease requires an intensified adjuvant chemotherapy strategy to which patients omitting axillary dissection cannot be stratified. Finally, there is mounting evidence that the therapeutic role of extensive axillary surgery in low-volume nodal disease is negligible, and multidisciplinary and translational efforts must be undertaken to individualize treatment in order to gain a reasonable balance between necessary staging information and unnecessary treatment-related morbidity.
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Affiliation(s)
- Jana de Boniface
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Marcus Schmidt
- Division of Molecular Medicine, Department of Obstetrics and Gynecology, Comprehensive Cancer Center, University Medical Center Mainz, Mainz, Germany
| | - Jutta Engel
- Munich Cancer Registry (MCR), Institute for Medical Information Processing, Biometry and Epidemiology (IBE) at the University Hospital of Munich, Ludwig Maximilians-University (LMU), Munich, Germany
| | - Marjolein L Smidt
- Division of Surgical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
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13
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Stüber TN, Stangl S, Jackisch C, Janni W, Brucker SY, Hartkopf A, Gerber B, Budach W, Lux MP, Wöckel A. Implementation of a Systematic Literature Search Strategy in a National Breast Cancer Guideline: The Relevance of Systemic Therapy in Lymph Node Recurrent Disease. Oncol Res Treat 2018; 41:554-559. [PMID: 30114683 DOI: 10.1159/000490501] [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: 04/16/2018] [Accepted: 05/30/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Our aim was to implement a structured literature search using PICO (patient/intervention/comparison/outcome) questions and a standardized consensus method for the German Guideline 'Detection, diagnostics, therapy and follow-up of Breast Cancer' using, as an example, the significance of systemic therapy in lymph node recurrent disease (LNRD). METHODS We defined specified PICO questions according to the clinical significance of a recommendation for systemic therapies in locoregional LNRD. A methodologist performed a systematic literature search including randomized controlled trials, systematic reviews and observational studies (2007-2016). In a consensus conference, the level of evidence and consensus was determined and the clinical recommendation was adopted. RESULTS In total 143 publications were identified according to the search strategy including 14 duplicates, which were excluded. 4 publications were included based on experts' choice. The team excluded 119 publications, leaving 14 that were then screened by a full text search. Finally, 1 publication was found to be of methodologically and clinically reliable content. The conclusion of this publication in favor of systemic therapy for LNRD received strong consent from the consensus conference. CONCLUSIONS The literature search strategy using PICO questions helped to achieve a fast and standardized selection of publications. The recommendation concerning systemic treatment of LNRD was first implemented in the update of the German Breast Cancer guideline.
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14
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Castaneda CA, Rebaza P, Castillo M, Gomez HL, De La Cruz M, Calderon G, Dunstan J, Cotrina JM, Abugattas J, Vidaurre T. Critical review of axillary recurrence in early breast cancer. Crit Rev Oncol Hematol 2018; 129:146-152. [PMID: 30097233 DOI: 10.1016/j.critrevonc.2018.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 05/20/2018] [Accepted: 06/18/2018] [Indexed: 01/07/2023] Open
Abstract
Around 2% of early breast cancer cases treated with axillary lymph node dissection (ALND) underwent axillary recurrence (AR) and it has a deleterious effect in prognosis. Different scenarios have incorporated Sentinel Lymph Node (SLN) Biopsy (SLNB) instead of ALND as part of the standard treatment and more effective systemic treatment has also been incorporated in routine management after first curative surgery and after regional recurrence. However, there is concern about the effect of SLNB alone over AR risk and how to predict and treat AR. SLN biopsy (SLNB) has been largely accepted as a valid option for SLN-negative cases, and recent prospective studies have demonstrated that it is also safe for some SLN-positive cases and both scenarios carry low AR rates. Different studies have identified clinicopathological factors related to aggressiveness as well as high-risk molecular signatures can predict the development of locoregional recurrence. Other publications have evaluated factors affecting prognosis after AR and find that time between initial treatment and AR as well as tumor aggressive behavior influence patient survival. Retrospective and prospective studies indicate that treatment of AR should include local and systemic treatment for a limited time.
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Affiliation(s)
- Carlos A Castaneda
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru.
| | - Pamela Rebaza
- Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Miluska Castillo
- Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Henry L Gomez
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Miguel De La Cruz
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Gabriela Calderon
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jorge Dunstan
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jose Manuel Cotrina
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Julio Abugattas
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Tatiana Vidaurre
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
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15
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de Boniface J, Frisell J, Bergkvist L, Andersson Y. Breast-conserving surgery followed by whole-breast irradiation offers survival benefits over mastectomy without irradiation. Br J Surg 2018; 105:1607-1614. [PMID: 29926900 PMCID: PMC6220856 DOI: 10.1002/bjs.10889] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 01/22/2018] [Accepted: 04/08/2018] [Indexed: 01/18/2023]
Abstract
Background The prognostic equivalence between mastectomy and breast‐conserving surgery (BCS) followed by radiotherapy was shown in pivotal trials conducted decades ago. Since then, detection and treatment of breast cancer have improved substantially and recent retrospective analyses point towards a survival benefit for less extensive breast surgery. Evidence for the association of such survival data with locoregional recurrence rates is largely lacking. Methods The Swedish Multicentre Cohort Study prospectively included clinically node‐negative patients with breast cancer who had planned sentinel node biopsy between 2000 and 2004. Axillary lymph node dissection was undertaken only in patients with sentinel node metastases. For the present investigation, adjusted survival analyses were used to compare patients who underwent BCS and postoperative radiotherapy with those who received mastectomy without radiotherapy. Results Of 3518 patients in the Swedish Multicentre Cohort Study, 2767 were included in the present analysis; 2338 had BCS with postoperative radiotherapy and 429 had mastectomy without radiotherapy. Median follow‐up was 156 months. BCS followed by whole‐breast irradiation was superior to mastectomy without irradiation in terms of both overall survival (79·5 versus 64·3 per cent respectively at 13 years; P < 0·001) and breast cancer‐specific survival (90·5 versus 84·0 per cent at 13 years; P < 0·001). The local recurrence rate did not differ between the two groups. The axillary recurrence‐free survival rate at 13 years was significantly lower after mastectomy without irradiation (98·3 versus 96·2 per cent; P < 0·001). Conclusion The present data support the superiority of BCS with postoperative radiotherapy over mastectomy without radiotherapy. The axillary recurrence rate differed significantly, and could be one contributing factor in a complex explanatory model. Radiotherapy to lower axilla key?
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Affiliation(s)
- J de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden
| | - J Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - L Bergkvist
- Centre for Clinical Research Uppsala University, Västmanland County Hospital, Västerås, Sweden.,Department of Surgery, Västmanland County Hospital, Västerås, Sweden
| | - Y Andersson
- Centre for Clinical Research Uppsala University, Västmanland County Hospital, Västerås, Sweden.,Department of Surgery, Västmanland County Hospital, Västerås, Sweden
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16
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de Meric de Bellefon M, Lemanski C, Ducteil A, Fenoglietto P, Azria D, Bourgier C. Management of the Axilla in the Era of Breast Cancer Heterogeneity. Front Oncol 2018; 8:84. [PMID: 29670853 PMCID: PMC5893721 DOI: 10.3389/fonc.2018.00084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/12/2018] [Indexed: 01/07/2023] Open
Abstract
Systemic cancer therapies take into account breast cancer (BC) heterogeneity by targeting pathways specifically involved in some BC subtypes. On the other hand, BC intrinsic radiosensitivity is poorly understood and studied. Hence, radiotherapy personalization in BC is still “work in progress”. In this review, we will summarize the existing data on the management of axillary lymph nodes in BC, the impact of BC radiotherapy on axillary management, the indications for axillary radiotherapy, and biomarkers to predict patients’ outcome (tumor control and late toxicities) after axillary irradiation.
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Affiliation(s)
| | - Claire Lemanski
- Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Angélique Ducteil
- Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | | | - David Azria
- Institut Régional du Cancer de Montpellier (ICM), Montpellier, France.,Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France.,Université de Montpellier, Montpellier, France
| | - Celine Bourgier
- Institut Régional du Cancer de Montpellier (ICM), Montpellier, France.,Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France.,Université de Montpellier, Montpellier, France
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17
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99mTc-rituximab as a tracer for sentinel lymph node biopsy in breast cancer patients: a single-center analysis. Breast Cancer Res Treat 2017; 168:365-370. [DOI: 10.1007/s10549-017-4591-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/22/2017] [Indexed: 01/06/2023]
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18
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van Roozendaal LM, Vane MLG, van Dalen T, van der Hage JA, Strobbe LJA, Boersma LJ, Linn SC, Lobbes MBI, Poortmans PMP, Tjan-Heijnen VCG, Van de Vijver KKBT, de Vries J, Westenberg AH, Kessels AGH, de Wilt JHW, Smidt ML. Clinically node negative breast cancer patients undergoing breast conserving therapy, sentinel lymph node procedure versus follow-up: a Dutch randomized controlled multicentre trial (BOOG 2013-08). BMC Cancer 2017; 17:459. [PMID: 28668073 PMCID: PMC5494134 DOI: 10.1186/s12885-017-3443-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 06/22/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Studies showed that axillary lymph node dissection can be safely omitted in presence of positive sentinel lymph node(s) in breast cancer patients treated with breast conserving therapy. Since the outcome of the sentinel lymph node biopsy has no clinical consequence, the value of the procedure itself is being questioned. The aim of the BOOG 2013-08 trial is to investigate whether the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients treated with breast conserving therapy. METHODS The BOOG 2013-08 is a Dutch prospective non-inferiority randomized multicentre trial. Women with pathologically confirmed clinically node negative T1-2 invasive breast cancer undergoing breast conserving therapy will be randomized for sentinel lymph node biopsy versus no sentinel lymph node biopsy. Endpoints include regional recurrence after 5 (primary endpoint) and 10 years of follow-up, distant-disease free and overall survival, quality of life, morbidity and cost-effectiveness. Previous data indicate a 5-year regional recurrence free survival rate of 99% for the control arm and 96% for the study arm. In combination with a non-inferiority limit of 5% and probability of 0.8, this result in a sample size of 1.644 patients including a lost to follow-up rate of 10%. Primary and secondary endpoints will be reported after 5 and 10 years of follow-up. DISCUSSION If the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients undergoing breast conserving therapy, this study will cost-effectively lead to a decreased axillary morbidity rate and thereby improved quality of life with non-inferior regional control, distant-disease free survival and overall survival. TRIAL REGISTRATION The BOOG 2013-08 study is registered in ClinicalTrials.gov since October 20, 2014, Identifier: NCT02271828. https://clinicaltrials.gov/ct2/show/NCT02271828.
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Affiliation(s)
- L M van Roozendaal
- Division of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M L G Vane
- Division of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands. .,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - T van Dalen
- Division of Surgical Oncology, Diakonessenhuis Hospital, Utrecht, the Netherlands
| | - J A van der Hage
- Division of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - L J A Strobbe
- Division of Surgical Oncology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - L J Boersma
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Radiation Oncology, Maastricht University Medical Centre (MAASTRO clinic), Maastricht, the Netherlands
| | - S C Linn
- Division of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - M B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - P M P Poortmans
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - V C G Tjan-Heijnen
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands.,Division of Medical Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - K K B T Van de Vijver
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - J de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands
| | - A H Westenberg
- Radiation Oncology, Radiotherapy group, Arnhem, the Netherlands
| | - A G H Kessels
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J H W de Wilt
- Division of Surgical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M L Smidt
- Division of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
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19
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Marrazzo A, Damiano G, Taormina P, Buscemi S, Lo Monte AI, Marrazzo E. Does Conservative Surgery for Breast Carcinoma Still Require Axillary Lymph Node Evaluation? A Retrospective Analysis of 1156 Consecutive Women With Early Breast Cancer. Clin Breast Cancer 2017; 17:e53-e57. [DOI: 10.1016/j.clbc.2016.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/06/2016] [Accepted: 10/12/2016] [Indexed: 02/05/2023]
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20
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Reimer T, Stachs A, Nekljudova V, Loibl S, Hartmann S, Wolter K, Hildebrandt G, Gerber B. Restricted Axillary Staging in Clinically and Sonographically Node-Negative Early Invasive Breast Cancer (c/iT1-2) in the Context of Breast Conserving Therapy: First Results Following Commencement of the Intergroup-Sentinel-Mamma (INSEMA) Trial. Geburtshilfe Frauenheilkd 2017; 77:149-157. [PMID: 28331237 DOI: 10.1055/s-0042-122853] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Axillary lymph node status remains an important prognostic factor in early breast cancer. It is regarded as an indicator for (neo)adjuvant systemic treatment and postoperative radiotherapy of the regional lymphatics. Commenced in September 2015, the INSEMA trial is investigating whether operative determination of nodal status as part of breast conserving therapy (BCT) for early stage breast cancer (c/iT1-2 c/iN0) can be avoided without reducing oncological safety. After inclusion of 1001 patients there was general acceptance of the complex study design by patients and study doctors so that recruitment for the first randomisation (axillary sentinel lymph node biopsy [SLNB]: yes or no) achieved predicted case numbers. The second randomisation however (SLNB alone versus complete axillary dissection when one or two macrometastases are present at SLNB) recruited fewer cases than expected for the following three reasons: a) the 13 % rate of one or two macrometastases after SLNB in the INSEMA trial collective was lower than expected; b) around 20 % of patients refused the second randomisation; c) there was delayed inclusion of the Austrian study centres, which only recruited for the second randomisation. Lack of knowledge of nodal status when SLNB is avoided represents a new challenge for the postoperative tumour board. In particular decisions on chemotherapy for luminal-like tumours and irradiation of the lymphatics (excluding axilla) must be guided by tumour biological parameters. The INSEMA trial does not provide answers to some important questions, e.g. it remains unclear whether patients without SLNB can be offered partial breast irradiation alone in low-risk situations and whether SLNB can also be avoided in patients with stage T1-2 tumours who have a mastectomy indication.
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Affiliation(s)
- T Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - A Stachs
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | | | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
| | - S Hartmann
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - K Wolter
- Department of Radiotherapy, University of Rostock, Rostock, Germany
| | - G Hildebrandt
- Department of Radiotherapy, University of Rostock, Rostock, Germany
| | - B Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
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21
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Gentilini O, Botteri E, Leonardi MC, Rotmensz N, Vila J, Peradze N, Thomazini MV, Jereczek BA, Galimberti V, Luini A, Veronesi P, Orecchia R. Ipsilateral axillary recurrence after breast conservative surgery: The protective effect of whole breast radiotherapy. Radiother Oncol 2017; 122:37-44. [PMID: 28063695 DOI: 10.1016/j.radonc.2016.12.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/07/2016] [Accepted: 12/19/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Whole breast radiotherapy (WBRT) is one of the possible reasons for the low rate of axillary recurrence after breast-conserving surgery (BCS). PATIENTS AND METHODS We retrospectively collected data from 4,129 consecutive patients with breast cancer ⩽2cm and negative sentinel lymph node who underwent BCS between 1997 and 2007. We compared the risk of axillary lymph node recurrence between patients treated by WBRT (n=2939) and patients who received partial breast irradiation (PBI; n=1,190) performed by a single dose of electron intraoperative radiotherapy. RESULTS Median tumour diameter was 1.1cm in both WBRT and PBI. Women who received WBRT were significantly younger and expressed significantly more multifocality, extensive in situ component, negative oestrogen receptor status and HER2 over-expression than women who received PBI. After a median follow-up of 8.3years, 37 and 28 axillary recurrences were observed in the WBRT and PBI arm, respectively, corresponding to a 10-year cumulative incidence of 1.3% and 4.0% (P<0.001). Multivariate analysis resulted in a hazard ratio of 0.30 (95% CI 0.17-0.51) in favour of WBRT. CONCLUSIONS In this large series of women with T1 breast cancer and negative sentinel lymph node treated by BCS, WBRT lowered the risk of axillary recurrence by two thirds as compared to PBI.
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Affiliation(s)
- Oreste Gentilini
- Breast Surgery Division, European Institute of Oncology, Milano, Italy.
| | - Edoardo Botteri
- Epidemiology and Biostatistics Division, European Institute of Oncology, Milano, Italy
| | | | - Nicole Rotmensz
- Epidemiology and Biostatistics Division, European Institute of Oncology, Milano, Italy
| | - Jose Vila
- Breast Surgery Division, European Institute of Oncology, Milano, Italy
| | - Nickolas Peradze
- Breast Surgery Division, European Institute of Oncology, Milano, Italy
| | | | - Barbara Alicja Jereczek
- Radiotherapy Division, European Institute of Oncology, Milano, Italy; University of Milan, European Institute of Oncology, Italy
| | | | - Alberto Luini
- Breast Surgery Division, European Institute of Oncology, Milano, Italy
| | - Paolo Veronesi
- Breast Surgery Division, European Institute of Oncology, Milano, Italy; Epidemiology and Biostatistics Division, European Institute of Oncology, Milano, Italy; Radiotherapy Division, European Institute of Oncology, Milano, Italy; University of Milan, European Institute of Oncology, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology, Milano, Italy; University of Milan, European Institute of Oncology, Italy
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22
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Navarro-Rodríguez E, Díaz-Jiménez N, Ruiz-Rabelo J, Gómez-Luque I, Bascuñana-Estudillo G, Rioja-Torres P, Torres-Lorite M, Ciria-Bru R, Álvarez-Benito M, Briceño-Delgado J. Factors Associated With Disease Recurrence in Breast Cancer Patients With Negative Sentinel Lymph Node Biopsy. Clin Breast Cancer 2016; 16:e181-e186. [PMID: 27498119 DOI: 10.1016/j.clbc.2016.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 05/21/2016] [Accepted: 06/17/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The objective of our study was to assess recurrence after negative sentinel lymph node biopsy (SLNB) and to determine the risk factors related to local and distant recurrence in this group of patients. MATERIALS AND METHODS We conducted a prospective observational study from 2006 to 2011. It included 607 patients with early-stage breast cancer and negative SLNB with a 5-year follow-up period. RESULTS The disease-free survival rate was 98.5% and 96.5% at 2 and 5 years, respectively. Multivariate analysis identified the following prognostic factors for disease recurrence: tumor necrosis (hazard ratio [HR], 4.89; 95% confidence interval [CI], 1.61-14.89; P = .005), lymphovascular invasion (HR, 3.46; 95% CI, 1.14-10.55; P = .029), T2 tumor size (HR, 4.35; 95% CI, 1.40-13.52; P = .011), and moderate to severe lymphoplasmacytic stromal infiltration (HR, 3.06; 95% CI, 1.18-7.96; P = .022). CONCLUSION Recurrence in patients with negative SLNB was satisfactorily low. Nevertheless, determining the prognostic factors related to a greater recurrence rate could help identify high-risk patients and influence systemic adjuvant therapy.
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Affiliation(s)
| | | | - Juan Ruiz-Rabelo
- Department of Surgery, University Hospital Reina Sofía, Córdoba, Spain
| | - Irene Gómez-Luque
- Department of Surgery, University Hospital Reina Sofía, Córdoba, Spain
| | | | | | | | - Rubén Ciria-Bru
- Department of Surgery, University Hospital Reina Sofía, Córdoba, Spain
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Predicting Non-sentinel Lymph Node Metastasis in a Chinese Breast Cancer Population with 1-2 Positive Sentinel Nodes: Development and Assessment of a New Predictive Nomogram. World J Surg 2016; 39:2919-27. [PMID: 26324157 DOI: 10.1007/s00268-015-3189-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND We have developed a new nomogram to predict the probability of a patient with 1-2 metastatic sentinel lymph nodes (SLNs) to present further axillary disease. METHODS Data were collected from 480 patients who were diagnosed with 1-2 positive lymph nodes and thus underwent axillary lymph node dissection between March 2005 and June 2011. Clinical and pathological features of the patients were assessed with multivariable logistic regression. The Shanghai Cancer Center Non-SLN nomogram (SCC-NSLN) was created from the logistic regression model. This new model was subsequently applied to 481 patients from July 2011 to December 2013. The predictive accuracy of the SCC-NSLN nomogram was measured by calculating the area under the receiver operating characteristic curve (AUC). RESULTS Based on the results of the univariate analysis, the variables that were significantly associated with the incidence of non-SLN metastasis in an SLN-positive patient included lymphovascular invasion, neural invasion, the number of positive SLNs, the number of negative SLNs, and the size of SLN metastasis (P < 0.05). Using multivariate analysis, lymphovascular invasion, the number of positive SLNs, the number of negative SLNs, and the size of SLN metastasis were identified as independent predictors of non-SLN metastasis. The SCC-NSLN nomogram was then developed using these four variables. The new model was accurate and discriminating on both the modeling and validation groups (AUC: 0.7788 vs 0.7953). The false-negative rates of the SCC-NSLN nomogram were 3.54 and 9.29 % for the predicted probability cut-off points of 10 and 15 % when applied to patients who have 1-2 positive SLNs. CONCLUSION The SCC-NSLN nomogram could serve as an acceptable clinical tool in clinical discussions with patients. The omission of ALND might be possible if the probability of non-SLN involvement is <10 and <15 % in accordance with the acceptable risk determined by medical staff and patients.
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van la Parra RFD, de Wilt JHW, Mol SJJ, Mulder AH, de Roos WK, Bosscha K. Is SLN Biopsy Alone Safe in SLN Positive Breast Cancer Patients? Breast J 2015; 21:621-6. [PMID: 26391102 DOI: 10.1111/tbj.12496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Z0011 trial demonstrated no difference in overall survival (OS) and locoregional recurrence in breast cancer patients with a positive sentinel lymph node (SLN) randomized to axillary lymph node dissection (ALND) or no further surgery. The aim of this study was to evaluate locoregional recurrence in a nonrandomized group of SLN positive patients, in whom cALND was not performed, that were retrospectively categorized by the Z0011 eligibility criteria. From two hospital breast cancer databases consisting of 656 consecutive SLN positive breast cancer patients, 88 patients, who did not undergo cALND, were identified. This population was categorized by the Z0011 inclusion criteria (e.g., eligible versus ineligible) and the groups were compared. Thirty-four patients (38.6%) were retrospectively eligible for omitting cALND according to the Z0011 criteria and 54 (61.4%) were not. The median number of SLNs removed in both groups was 1 (range 1-5). The number of positive SLNs did not differ between the groups. Tumor size was slightly larger in the ineligible group (21 mm versus 19 mm) and 76% of patients in the ineligible group underwent a mastectomy. At a median follow-up of 26 months (range 1-84 months), one axillary recurrence was observed in the ineligible group versus 0 in the eligible group. Axillary recurrence was low, even in patients who did not meet the Z0011 inclusion criteria. Future trials that randomize Z0011 ineligible patients are needed to investigate long-term results.
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Affiliation(s)
- Raquel F D van la Parra
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suzanne J J Mol
- Department of Pathology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Andries H Mulder
- Department of Pathology, Rijnstate Hospital/Gelderse Vallei Hospital, Arnhem/Ede, The Netherlands
| | - Wilfred K de Roos
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
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van Roozendaal LM, de Wilt JHW, van Dalen T, van der Hage JA, Strobbe LJA, Boersma LJ, Linn SC, Lobbes MBI, Poortmans PMP, Tjan-Heijnen VCG, Van de Vijver KKBT, de Vries J, Westenberg AH, Kessels AGH, Smidt ML. The value of completion axillary treatment in sentinel node positive breast cancer patients undergoing a mastectomy: a Dutch randomized controlled multicentre trial (BOOG 2013-07). BMC Cancer 2015; 15:610. [PMID: 26335105 PMCID: PMC4559064 DOI: 10.1186/s12885-015-1613-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 08/19/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Trials failed to demonstrate additional value of completion axillary lymph node dissection in case of limited sentinel lymph node metastases in breast cancer patients undergoing breast conserving therapy. It has been suggested that the low regional recurrence rates in these trials might partially be ascribed to accidental irradiation of part of the axilla by whole breast radiation therapy, which precludes extrapolation of results to mastectomy patients. The aim of the randomized controlled BOOG 2013-07 trial is therefore to investigate whether completion axillary treatment can be safely omitted in sentinel lymph node positive breast cancer patients treated with mastectomy. DESIGN This study is designed as a non-inferiority randomized controlled multicentre trial. Women aged 18 years or older diagnosed with unilateral invasive clinically T1-2 N0 breast cancer who are treated with mastectomy, and who have a maximum of three axillary sentinel lymph nodes containing micro- and/or macrometastases, will be randomized for completion axillary treatment versus no completion axillary treatment. Completion axillary treatment can consist of completion axillary lymph node dissection or axillary radiation therapy. Primary endpoint is regional recurrence rate at 5 years. Based on a 5-year regional recurrence free survival rate of 98 % among controls and 96 % for study subjects, the sample size amounts 439 per arm (including 10 % lost to follow-up), to be able to reject the null hypothesis that the rate for study and control subjects is inferior by at least 5 % with a probability of 0.8. Results will be reported after 5 and 10 years of follow-up. DISCUSSION We hypothesize that completion axillary treatment can be safely omitted in sentinel node positive breast cancer patients undergoing mastectomy. If confirmed, this study will significantly decrease the number of breast cancer patients receiving extensive treatment of the axilla, thereby diminishing the risk of morbidity and improving quality of life, while maintaining excellent regional control and without affecting survival. TRIAL REGISTRATION The BOOG 2013-07 study is registered in the register of ClinicalTrials.gov since April 10, 2014, Identifier: NCT02112682 .
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Affiliation(s)
- L M van Roozendaal
- Division of Surgical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Department of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800 6202 AZ, Maastricht, The Netherlands.
| | - J H W de Wilt
- Division of Surgical Oncology, Radboud university medical centre, Nijmegen, The Netherlands.
| | - T van Dalen
- Division of Surgical Oncology, Diakonessenhuis Hospital, Utrecht, The Netherlands.
| | - J A van der Hage
- Division of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
| | - L J A Strobbe
- Division of Surgical Oncology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.
| | - L J Boersma
- Department of Radiation Oncology, Maastricht University Medical Centre (MAASTRO clinic), Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - S C Linn
- Division of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
| | - M B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - P M P Poortmans
- Department of Radiation Oncology, Radboud university medical centre, Nijmegen, The Netherlands.
| | - V C G Tjan-Heijnen
- Division of Medical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - K K B T Van de Vijver
- Department of Pathology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
| | - J de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.
| | - A H Westenberg
- Radiation Oncology, Arnhem Institute for Radiation Oncology, Arnhem, The Netherlands.
| | - A G H Kessels
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - M L Smidt
- Division of Surgical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Rivera S, Louvel G, Rivin Del Campo E, Boros A, Oueslati H, Deutsch É. [Prophylactic axillary radiotherapy for breast cancer]. Cancer Radiother 2015; 19:253-60. [PMID: 26044178 DOI: 10.1016/j.canrad.2015.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 05/02/2015] [Accepted: 05/07/2015] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- S Rivera
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France.
| | - G Louvel
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - E Rivin Del Campo
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - A Boros
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - H Oueslati
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - É Deutsch
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
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van Roozendaal LM, Schipper RJ, Smit LHM, Brans BT, Beets-Tan RGH, Lobbes MBI, Boersma LJ, Smidt ML. Three-Dimensional Breast Radiotherapy and the Elective Radiation Dose at the Sentinel Lymph Node Site in Breast Cancer. Ann Surg Oncol 2015; 22:3824-30. [PMID: 25707492 PMCID: PMC4595528 DOI: 10.1245/s10434-015-4413-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Indexed: 11/19/2022]
Abstract
Background Several trials are presently randomizing clinically node-negative breast cancer patients treated with breast-conserving therapy (BCT) to sentinel lymph node biopsy (SLNB) or watchful waiting. We aimed to investigate the elective radiation dose at the sentinel lymph node (SLN) site while evaluating two techniques for SLN localization, in breast cancer patients treated with lumpectomy and three-dimensional (3D) whole-breast radiotherapy. Methods The SLN site of consecutive Tis-2N0 breast cancer patients undergoing lumpectomy and forward intensity-modulated whole-breast radiotherapy was determined by the location of the hotspot on preoperative single-photon emission computed tomography (SPECT)/computed tomography (CT) and by a surgical clip placed at the removed SLN(s) during SLNB. The radiation dose at the SLN site was subsequently determined on the postoperative radiotherapy planning CT. An elective radiation dose to the SLN site was defined as at least 95 % of the breast dose. Results Of the 42 included patients, the mean percentage of the breast dose on the SLN site was 90 % (standard deviation 26, range 7–132, median 99), with a non-significant difference between the two techniques (surgical clip or SPECT/CT) (p = 0.608). In 32/42 patients (76 %) the SLN site received an elective radiation dose. Conclusions A surgical clip placed at the removed SLN(s) during SLNB proved to be an adequate method of determining the radiation dose at the SLN site when compared with using SPECT/CT. With the use of 3D radiotherapy, the site of the SLN is treated with an elective radiation dose in the majority of patients who are treated with BCT.
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Affiliation(s)
- Lori M van Roozendaal
- Department of Surgical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands. .,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands. .,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Robert-Jan Schipper
- Department of Surgical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leonie H M Smit
- Department of Surgical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Boudewijn T Brans
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Liesbeth J Boersma
- Department of Radiation Oncology, Maastricht University Medical Center (MAASTRO Clinic), Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marjolein L Smidt
- Department of Surgical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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Tangential vs. defined radiotherapy in early breast cancer treatment without axillary lymph node dissection: a comparative study. Strahlenther Onkol 2014; 190:715-21. [PMID: 24838410 DOI: 10.1007/s00066-014-0681-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/15/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE Recent studies have demonstrated low regional recurrence rates in early-stage breast cancer omitting axillary lymph node dissection (ALND) in patients who have positive nodes in sentinel lymph node dissection (SLND). This finding has triggered an active discussion about the effect of radiotherapy within this approach. The purpose of this study was to analyze the dose distribution in the axilla in standard tangential radiotherapy (SRT) for breast cancer and the effects on normal tissue exposure when anatomic level I-III axillary lymph node areas are included in the tangential radiotherapy field configuration. PATIENTS AND METHODS We prospectively analyzed the dosimetric treatment plans from 51 consecutive women with early-stage breast cancer undergoing radiotherapy. We compared and analyzed the SRT and the defined radiotherapy (DRT) methods for each patient. The clinical target volume (CTV) of SRT included the breast tissue without specific contouring of lymph node areas, whereas the CTV of DRT included the level I-III lymph node areas. RESULTS We evaluated the dose given in SRT covering the axillary lymph node areas of level I-III as contoured in DRT. The mean VD95% of the entire level I-III lymph node area in SRT was 50.28% (range, 37.31-63.24%), VD45 Gy was 70.1% (54.8-85.4%), and VD40 Gy was 83.5% (72.3-94.8%). A significant difference was observed between lung dose and heart toxicity in SRT vs. DRT. The V20 Gy and V30 Gy of the right and the left lung in DRT were significantly higher in DRT than in SRT (p<0.001). The mean heart dose in SRT was significantly lower (3.93 vs. 4.72 Gy, p=0.005). CONCLUSION We demonstrated a relevant dose exposure of the axilla in SRT that should substantially reduce local recurrences. Furthermore, we demonstrated a significant increase in lung and heart exposure when including the axillary lymph nodes regions in the tangential radiotherapy field set-up.
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Reimer T, Hartmann S, Stachs A, Gerber B. Local treatment of the axilla in early breast cancer: concepts from the national surgical adjuvant breast and bowel project B-04 to the planned intergroup sentinel mamma trial. Breast Care (Basel) 2014; 9:87-95. [PMID: 24944550 PMCID: PMC4038316 DOI: 10.1159/000360411] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Local treatment of the axilla in clinically node-negative, early-stage breast cancer patients has been hotly debated after the release of the American College of Surgeons Oncology Group (ACOSOG) Z0011 findings. However, this review does not focus on the 'Z0011-eligible' patients alone, because this subgroup represents a minority of our patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB). The following topics are discussed: axillary diagnostics, timing of axillary procedures in the neoadjuvant setting, long-term follow-up of SLNB trials, omission of axillary surgery in randomized trials, management of the involved axilla with low tumor volume, positive sentinel lymph nodes and BCS, involved sentinel lymph nodes and mastectomy, and axillary radiotherapy. Finally, the current innovative study concepts (i.e. Sentinel Node versus Observation after Axillary Ultrasound (SOUND) and Intergroup Sentinel Mamma (INSEMA)) including patients with axillary observation alone in clinically node-negative women are presented.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Germany
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García Fernández A, Chabrera C, García Font M, Fraile M, Lain J, Barco I, González C, Gónzalez S, Reñe A, Veloso E, Cassadó J, Pessarrodona A, Giménez N. Positive versus negative sentinel nodes in early breast cancer patients: Axillary or loco-regional relapse and survival. A study spanning 2000–2012. Breast 2013; 22:902-7. [DOI: 10.1016/j.breast.2013.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/09/2013] [Accepted: 04/17/2013] [Indexed: 11/15/2022] Open
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Galimberti V, Cole BF. Axillary versus sentinel-lymph-node dissection for micrometastatic breast cancer--authors' reply. Lancet Oncol 2013; 14:e251-2. [PMID: 23725705 DOI: 10.1016/s1470-2045(13)70241-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-term follow-up of axillary recurrences after negative sentinel lymph node biopsy: effect on prognosis and survival. Breast Cancer Res Treat 2013; 140:143-9. [DOI: 10.1007/s10549-013-2608-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 06/09/2013] [Indexed: 10/26/2022]
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Boyages J, Winch C. Axillary versus sentinel-lymph-node dissection for micrometastatic breast cancer. Lancet Oncol 2013; 14:e250-1. [DOI: 10.1016/s1470-2045(13)70218-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bayo E, Herruzo I, Arenas M, Algara M. Consensus on the regional lymph nodes irradiation in breast cancer. Clin Transl Oncol 2013; 15:766-73. [PMID: 23519538 DOI: 10.1007/s12094-013-1027-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 03/04/2013] [Indexed: 01/25/2023]
Abstract
Standard locoregional treatment of early-stage breast cancer currently consists of the conservative surgery and sentinel lymph node biopsy. In the event of positive sentinel node biopsy, an axillary level I-II lymphadenectomy should be carried out. However, recent publications have increasingly supported a tendency not to apply the surgical lymphadenectomy, but simultaneously, it has been developed a new role of regional radiotherapy, even if there is only 1-3 axillary lymph nodes involved. Given these new trends, radiation oncologists are facing the dilemma with regard to deciding about regional irradiation of breast cancer. For such purpose, The Spanish Group of Breast Cancer Radiation Oncology (GEORM as per its Spanish acronym) decided to reach a consensus to issue the respective guidelines for such types of cases. GEORM Managing Commission, gathering 13 members of different Spanish regional communities, issued a questionnaire including different clinical situations. These questions were set as key questions seeking responses, which were answered by 66 % out of the 75 members of the group. Following the response, the guidelines were drafted based on the replies to the mentioned questionnaire. All the respective issues were discussed by means of a virtual platform. In this article, we show the levels of consensus for different clinical situations, depending on the number of nodes involved and the type of surgical procedure performed on the axillary lymph nodes. The ongoing evolution of the oncological treatments obliges the radiation oncologists to take decisions without any existing clarifying evidence, and therefore, the consensus is necessary, which can assist in the decision-making process by the practitioners in such kinds of clinical situations.
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Affiliation(s)
- E Bayo
- Hospital Juan Ramón Jiménez, Huelva, Spain,
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Meretoja TJ, Leidenius MHK, Heikkilä PS, Boross G, Sejben I, Regitnig P, Luschin-Ebengreuth G, Žgajnar J, Perhavec A, Gazic B, Lázár G, Takács T, Vörös A, Saidan ZA, Nadeem RM, Castellano I, Sapino A, Bianchi S, Vezzosi V, Barranger E, Lousquy R, Arisio R, Foschini MP, Imoto S, Kamma H, Tvedskov TF, Kroman N, Jensen MB, Audisio RA, Cserni G. International multicenter tool to predict the risk of nonsentinel node metastases in breast cancer. J Natl Cancer Inst 2012; 104:1888-96. [PMID: 23117131 DOI: 10.1093/jnci/djs455] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Axillary treatment of breast cancer patients is undergoing a paradigm shift, as completion axillary lymph node dissections (ALNDs) are being questioned in the treatment of patients with tumor-positive sentinel nodes. This study aims to develop a novel multi-institutional predictive tool to calculate patient-specific risk of residual axillary disease after tumor-positive sentinel node biopsy. METHODS Breast cancer patients with a tumor-positive sentinel node and a completion ALND from five European centers formed the original patient series (N = 1000). Statistically significant variables predicting nonsentinel node involvement were identified in logistic regression analysis. A multivariable predictive model was developed and validated by area under the receiver operating characteristics curve (AUC), first internally in 500 additional patients and then externally in 1068 patients from other centers. All statistical tests were two-sided. RESULTS Nine tumor- and sentinel node-specific variables were identified as statistically significant factors predicting nonsentinel node involvement in logistic regression analysis. A resulting predictive model applied to the internal validation series resulted in an AUC of 0.714 (95% confidence interval [CI] = 0.665 to 0.763). For the external validation series, the AUC was 0.719 (95% CI = 0.689 to 0.750). The model was well calibrated in the external validation series. CONCLUSIONS We present a novel, international, multicenter, predictive tool to assess the risk of additional axillary metastases after tumor-positive sentinel node biopsy in breast cancer. The predictive model performed well in internal and external validation but needs to be further studied in each center before application to clinical use.
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Affiliation(s)
- Tuomo J Meretoja
- Helsinki University Central Hospital, Breast Surgery Unit, PO Box 140, FI-00029 HUS, Finland.
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Sentinel lymph node dissection only versus complete axillary lymph node dissection in early invasive breast cancer: a systematic review and meta-analysis. Eur J Cancer 2012; 49:812-25. [PMID: 23084155 DOI: 10.1016/j.ejca.2012.09.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 09/04/2012] [Accepted: 09/10/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The Z0011-study, a landmark randomised controlled trial (RCT) challenged the benefits of complete axillary lymph node dissection (ALND) compared with sentinel lymph node dissection only (SLND) in breast cancer patients with positive sentinel nodes. The study, however, has been criticised for lack of power and low applicability. The aim of this review was to systematically assess the evidence on the comparative benefits and harms of ALND versus SLND for sentinel node positive breast cancer patients. METHODS We systematically searched PubMed, Embase, the Cochrane Library, and reference lists of pertinent review articles from January 2006 to August 2011. We dually reviewed the literature and rated the risk of bias of each study. For effectiveness, we included RCTs and observational studies of at least 1 year follow-up. In addition, we considered studies conducted in sentinel node-negative women to assess the risk of harms. If data were sufficient, we conducted random effects meta-analysis of outcomes of interest. RESULTS Meta-analysis of three studies with 50,120 patients indicated similar 5-year survival and regional recurrence rates between patients treated with ALND or SLND, although prognostic tumour characteristics varied among the 3 study-populations. Results from 6 studies on more than 11,500 patients reported a higher risk for harms for ALND than SLND. Long-term evidence on pertinent health outcomes is missing. CONCLUSION The available evidence indicates that for some women with early invasive breast cancer SLND appears to be a justifiable alternative to ALND. Surgeons need to discuss advantages and disadvantages of both approaches with their patients.
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Abstract
Our understanding of the role of lymph nodes (LN) in the metastasization process (MET) is marginal. Positive LNs (pLN) are the most important prognostic factor and lymph node dissection (LND) is still standard practice in primary treatment. However, up to now, there is almost no evidence that elective LND has a survival benefit. Based on many clinical and experimental findings, we propose that tumor foci in regional LN are incapable of metastasization and can therefore not infiltrate further LN and organs. Available data demonstrate a very early infiltration of MET capable tumor cells from the primary tumor into regional LN, and thereafter an increased probability of subsequent LN infiltrations. Disparate growth rates of the first versus subsequent infiltrating tumors as well as the asymptotic growth and prognosis of large tumor foci in LN explain many clinical observations for solid tumors. The consequence of the hypothesis "pLN do not metastasize" would impact clinical treatment and research and contribute to understanding the mounting evidence against LND.
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Affiliation(s)
- Jutta Engel
- Ludwig-Maximilians-University, Clinic Großhadern, Munich, Germany
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Francissen CMTP, Dings PJM, van Dalen T, Strobbe LJA, van Laarhoven HWM, de Wilt JHW. Axillary recurrence after a tumor-positive sentinel lymph node biopsy without axillary treatment: a review of the literature. Ann Surg Oncol 2012; 19:4140-9. [PMID: 22890590 PMCID: PMC3505491 DOI: 10.1245/s10434-012-2490-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Indexed: 12/22/2022]
Abstract
Background Sentinel lymph node biopsy (SLNB) has become standard of care as a staging procedure in patients with invasive breast cancer. A positive SLNB allows completion axillary lymph node dissection (cALND) to be performed. The axillary recurrence rate (ARR) after cALND in patients with positive SLNB is low. Recently, several studies have reported a similar low ARR when cALND is not performed. This review aims to determine the ARR when cALND is omitted in SLNB-positive patients. Methods A literature search was performed in the PubMed database with the search terms “breast cancer,” “sentinel lymph node biopsy,” “axillary” and “recurrence.” Articles with data regarding follow-up of patients with SLNB-positive breast cancer were identified. To be eligible, patients should not have received cALND and ARR should be reported. Results Thirty articles were analyzed. This resulted in 7,151 patients with SLNB-positive breast cancer in whom a cALND was omitted (median follow-up of 45 months, range 1–142 months). Overall, 41 patients developed an axillary recurrence. 27 studies described 3,468 patients with micrometastases in the SLNB, of whom 10 (0.3 %) developed an axillary recurrence. ARR varied between 0 and 3.7 %. Sixteen studies described 3,268 patients with macrometastases, 24 (0.7 %) axillary recurrences were seen. ARR varied between 0 and 7.1 %. Details regarding type of surgery and adjuvant treatment were lacking in the majority of studies. Conclusions ARR appears to be low in SLNB-positive patients even when a cALND is not performed. Withholding cALND may be safe in breast cancer selected patients such as those with isolated tumor cells or micrometastatic disease.
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Affiliation(s)
- Claire M T P Francissen
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Nitsche M, Hermann R. Axillary Irradiation as an Imperative Alternative to Axillary Dissection in Clinically Lymph Node-Negative but Sentinel Node-Positive Breast Cancer Patients? ACTA ACUST UNITED AC 2011; 6:353-358. [PMID: 22619644 DOI: 10.1159/000333835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
At the moment, positive sentinel lymph node dissection (SLND) of the axilla is followed by axillary lymph node dissection (ALND) as standard of care. Recent data proves that omitting ALND after positive SLND in clinically lymph node-negative early stage breast cancer patients is feasible with low recurrence rates. The well known effect of radiotherapy to destroy occult tumor cells highly contributes to these results as a large extent of level I and II lymph nodes are unavoidably included in standard tangential radiation treatment fields. Reviewing the up to date published data on axillary lymph node treatment with radiotherapy, we hypothesize that full dosage coverage of level I and II of the axilla in early stage breast cancer will improve outcome and should be further evaluated.
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Affiliation(s)
- Mirko Nitsche
- Zentrum für Strahlentherapie und Radioonkologie, Ärztehaus am DIAKO, Bremen, Germany
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Meretoja TJ, Strien L, Heikkilä PS, Leidenius MHK. A simple nomogram to evaluate the risk of nonsentinel node metastases in breast cancer patients with minimal sentinel node involvement. Ann Surg Oncol 2011; 19:567-76. [PMID: 21792511 DOI: 10.1245/s10434-011-1882-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tumor-positive sentinel node biopsy (SNB) suggests a risk of nonsentinel node metastases in breast cancer. This risk is lower after micrometastasis or isolated tumor cells (ITC) in the sentinel node (SN), and recent studies suggest that completion axillary lymph node dissection (ALND) might not improve outcome in these patients. We aim to validate existing predictive models and to develop a new model for micrometastatic and ITC patients. METHODS A series of 484 patients with micrometastases or ITC in SN followed by ALND was used to evaluate factors affecting nonsentinel node involvement. Logistic regression analysis was performed to construct a predictive model, which was validated by a separate series of 51 patients. RESULTS Only 7.2% of patients had additional metastases on completion ALND. Tumor diameter and multifocality associated with nonsentinel status on multivariate analysis. A predictive model was constructed showing good [area under the curve (AUC) 0.791] discrimination in the validation series. Previously published models performed poorly in our patient population. CONCLUSIONS Nonsentinel node metastases are rare with micrometastasis or ITC in SN. Most published predictive models for nonsentinel node involvement perform poorly in the present patient population. We developed a new predictive model which seems to perform well in discriminating patients with more than 10% risk of additional metastases. However, the presented nomogram needs to be validated with an independent patient series to evaluate its accuracy, especially for high-risk patients.
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Affiliation(s)
- T J Meretoja
- Breast Surgery Unit, Department of Gastrointestinal and General Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Dekhne N, Shah C, Wilkinson JB, Mitchell C, Chen P, Margolis J, Vicini F. Axillary lymph node failure in patients treated with accelerated partial breast irradiation. Cancer 2011; 118:38-43. [DOI: 10.1002/cncr.26305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 04/27/2011] [Accepted: 05/09/2011] [Indexed: 11/06/2022]
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Aburabia M, Roses RE, Kuerer HM, Fine R, Beitsch PD, Goyal S, Haffty B, Lyden M, Vicini FA. Axillary Failure in Patients Treated with MammoSite Accelerated Partial Breast Irradiation. Ann Surg Oncol 2011; 18:3415-21. [DOI: 10.1245/s10434-011-1734-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Indexed: 11/18/2022]
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