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Teng L, Du J, Yan S, Xu P, Liu J, Zhao X, Tao W. A novel nomogram and survival analysis for different lymph node status in breast cancer based on the SEER database. Breast Cancer 2024; 31:769-786. [PMID: 38802681 PMCID: PMC11341746 DOI: 10.1007/s12282-024-01591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/04/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION The axillary lymph node status (ALNS) and internal mammary lymph nodes (IMLN) expression associated with breast cancer are closely linked to prognosis. This study aimed to establish a nomogram to predict survival at 3, 5, and 10 years in patients with various lymph node statuses. METHODS We obtained data from patients with breast cancer between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER database). Chi-square analysis was performed to test for differences in the pathological characteristics of the groups, and Kaplan-Meier analysis and the log-rank test were used to plot and compare the correlation between overall survival (OS) and breast cancer specific survival (BCSS). The log-rank test was used for the univariate analysis, and statistically significant characteristics were included in the multivariate and Cox regression analyses. Finally, Independent factor identification was included in constructing the nomogram using R studio 4.2.0; area under curve (AUC) values were calculated, and receiver operating characteristic (ROC) curve, calibration, and decision curve analysis (DCA) curves were plotted for evaluation. RESULTS A total of 279,078 patients were enrolled and analysed, demonstrating that the isolated tumour cells (ITC) group had clinicopathological characteristics similar to those of micrometastases (Mic). Multivariate analysis was performed to identify each subgroup's independent risk factors and construct a nomogram. The AUC values were 74.7 (95% CI 73.6-75.8), 72.8 (95% CI 71.9-73.8), and 71.2 (95% CI 70.2-72.2) for 3-, 5-, and 10-year OS, respectively, and 82.2 (95% CI 80.9-83.6), 80.1 (95% CI 79.0-81.2), and 75.5 (95% CI 74.3-76.8) for BCSS in overall breast cancer cases, respectively. AUC values for 3-, 5-, and 10-year OS in the ITC group were 64.8 (95% CI 56.5-73.2), 67.7 (95% CI 62.0-73.4), and 65.4 (95% CI 60.0-70.7), respectively. For those in the Mic group, AUC values for 3-, 5-, and 10-year OS were 72.9 (95% CI 70.7-75.1), 72.4 (95% CI 70.6-74.1), and 71.3 (95% CI 69.6-73.1), respectively, and AUC values for BCSS were 77.8 (95% CI 74.9-80.7), 75.7 (95% CI 73.5-77.9), and 70.3 (95% CI 68.0-72.6), respectively. In the IMLN group, AUC values for 3-, 5-, and 10-year OS were 75.2 (95% CI 71.7-78.7), 73.4 (95% CI 70.0-76.8), and 74.0 (95% CI 69.6-78.5), respectively, and AUC values for BCSS were 76.6 (95% CI 73.0-80.3), 74.1 (95% CI 70.5-77.7), and 74.7 (95% CI 69.8-79.5), respectively. The ROC, calibration, and DCA curves verified that the nomogram had better predictability and benefits. CONCLUSION This study is the first to investigate the predictive value of different axillary lymph node statuses and internal mammary lymph node metastases in breast cancer, providing clinicians with additional aid in treatment decisions.
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Affiliation(s)
- Lizhi Teng
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Juntong Du
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Shuai Yan
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Peng Xu
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Jiangnan Liu
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Xinyang Zhao
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Weiyang Tao
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China.
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China.
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China.
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China.
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Houvenaeghel G, Heinemann M, Classe JM, Bouteille C, Gimbergues P, Azuar AS, Martino M, Tallet A, Cohen M, de Nonneville A. Omission of Completion Axillary Lymph Node Dissection for Patients with Breast Cancer Treated by Upfront Mastectomy and Sentinel Node Isolated Tumor Cells or Micrometastases. Cancers (Basel) 2024; 16:2666. [PMID: 39123393 PMCID: PMC11312260 DOI: 10.3390/cancers16152666] [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: 07/02/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Omission of completion axillary lymph node dissection (cALND) in patients undergoing mastectomy with sentinel node (SN) isolated tumor cells (ITC) or micrometastases is debated due to potential under-treatment, with non-sentinel node (NSN) involvement detected in 7% to 18% of patients. This study evaluated the survival impact of cALND omission in a cohort of breast cancer (BC) patients treated by mastectomy with SN ITC or micrometastases. Among 554 early BC patients (391 pN1mi, 163 ITC), the NSN involvement rate was 13.2% (49/371). With a median follow-up of 66.46 months, multivariate analysis revealed significant associations between cALND omission and overall survival (OS, HR: 2.583, p = 0.043), disease-free survival (DFS, HR: 2.538, p = 0.008), and metastasis-free survival (MFS, HR: 2.756, p = 0.014). For Her2-positive or triple-negative patients, DFS was significantly affected by cALND omission (HR: 38.451, p = 0.030). In ER-positive Her2-negative BC, DFS, OS, recurrence-free survival (RFS), and MFS were significantly associated with cALND omission (DFS HR: 2.358, p = 0.043; OS HR: 3.317; RFS HR: 2.538; MFS HR: 2.756). For 161 patients aged ≤50 years with ER-positive/Her2-negative cancer, OS and breast cancer-specific survival (BCSS) were notably impacted by cALND omission (OS HR: 103.47, p = 0.004; BCSS HR: 50.874, p = 0.035). These findings suggest a potential negative prognostic impact of cALND omission in patients with SN micrometastases or ITC. Further randomized trials are needed.
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Affiliation(s)
- Gilles Houvenaeghel
- Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, Department of Surgical Oncology, CRCM, 13009 Marseille, France
| | | | - Jean-Marc Classe
- Institut René Gauducheau, Site Hospitalier Nord, 44800 St Herblain, France;
| | - Catherine Bouteille
- Institut Paoli-Calmettes, Department of Surgical Oncology, CRCM, 13009 Marseille, France; (C.B.); (M.C.)
| | - Pierre Gimbergues
- Centre Jean Perrin, 58 rue Montalembert, 63003 Clermont Ferrand, France;
| | | | - Marc Martino
- Hôpital Saint Joseph, 26 Bd de Louvain, 13008 Marseille, France;
| | - Agnès Tallet
- Institut Paoli-Calmettes, Department of Radiotherapy, CRCM, 13009 Marseille, France;
| | - Monique Cohen
- Institut Paoli-Calmettes, Department of Surgical Oncology, CRCM, 13009 Marseille, France; (C.B.); (M.C.)
| | - Alexandre de Nonneville
- Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, Department of Medical Oncology, CRCM, 13009 Marseille, France;
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Li C, Zhang P, Lv J, Dong W, Hu B, Zhang J, Zhu H. Axillary management in patients with clinical node-negative early breast cancer and positive sentinel lymph node: a systematic review and meta-analysis. Front Oncol 2024; 13:1320867. [PMID: 38260843 PMCID: PMC10800700 DOI: 10.3389/fonc.2023.1320867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/13/2023] [Indexed: 01/24/2024] Open
Abstract
Background The omission of axillary lymph node dissection (ALND) or axillary radiation (AxRT) remains controversial in patients with clinical node-negative early breast cancer and a positive sentinel lymph node. Methods We conducted a comprehensive review by searching PubMed, Embase, Web of Science, and Cochrane databases (up to November 2023). Our primary outcomes were overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and axillary recurrence (AR). Results We included 26 studies encompassing 145,548 women with clinical node-negative early breast cancer and positive sentinel lymph node. Pooled data revealed no significant differences between ALND and sentinel lymph node biopsy (SLNB) alone in terms of OS (hazard ratio [HR]0.99, 95% confidence interval [CI] 0.91-1.08, p=0.84), DFS (HR 1.04, 95% CI 0.90-1.19, p=0.61), LRR (HR 0.76, 95% CI 0.45-1.20, p=0.31), and AR (HR 1.01, 95% CI 0.99-1.03, p=0.35). Similarly, no significant differences were observed between AxRT and SLNB alone for OS (HR 0.57, 95% CI 0.32-1.02, p=0.06) and DFS (HR 0.52, 95% CI 0.26-1.05, p=0.07). When comparing AxRT and ALND, a trend towards higher OS was observed the AxRT group (HR 0.08, 95% CI 0.67-1.15), but the difference did not reach statistical significance (p=0.35, I2 = 0%). Additionally, no significant differences significance observed for DFS or AR (p=0.13 and p=0.73, respectively) between the AxRT and ALND groups. Conclusion Our findings suggest that survival and recurrence rates are not inferior in patients with clinical node-negative early breast cancer and a positive sentinel lymph node who receive SLNB alone compared to those undergoing ALND or AxRT.
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Affiliation(s)
- Changzai Li
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Pan Zhang
- College of Nursing and Rehabilitation, North China University of Science and Technology, Tangshan, Hebei, China
| | - Jie Lv
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Wei Dong
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Baoshan Hu
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Jinji Zhang
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Hongcheng Zhu
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
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Sousa N, Peleteiro B, Fougo JL. Omission of axillary lymph node dissection in breast cancer patients with micrometastasis or isolated tumor cells in sentinel lymph nodes: a 12-year experience in a tertiary breast unit. J Cancer Res Clin Oncol 2023; 150:1. [PMID: 38153534 DOI: 10.1007/s00432-023-05513-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION After the IBCSG 23-01 trial, our breast center no longer performed axillary lymph node dissection (ALND) after detection of isolated tumor cells (ITC) or micrometastasis in the sentinel lymph nodes (SLN). A recent study suggested that up to half of the patients with micrometastasis in the SLN could benefit from ALND in terms of disease-free survival (DFS) and overall survival (OS). METHODS This retrospective, unicentric, study analyzed 261 consecutive cT1-3 cN0 breast cancer patients with ITC or micrometastasis in their SLN. Primary objective was comparison of ALND vs. SLN biopsy (SLNB) with regard to DFS and OS. Secondary objectives included analysis of factors associated with an increased rate of locoregional recurrence (LRR), distant metastasis (DM) and metachronous contralateral breast cancer (MCBC). RESULTS DFS events occurred in 19 patients (7.3%) and 14 patients died (5.4%). Median follow-up time was 78 months. 251 patients (96.2%) had micrometastasis in their SLN. There was no difference in the OS or DFS of ALND vs. SLNB patients. History of previous contralateral breast cancer and WBI were associated with an increased and decreased rate of LRR, respectively. Larger tumor size was associated with an increased rate of DM. Non-ductal histological types were associated with an increased rate of MCBC. DISCUSSION Avoiding ALND may be safe in pN1mi/pN0(i+) patients. Besides, we strongly encourage clinicians to develop their own follow-up protocols based on the best available evidence, to rapidly identify and treat breast cancer recurrence.
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Affiliation(s)
- Nuno Sousa
- Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Bárbara Peleteiro
- Faculty of Medicine, University of Porto, Porto, Portugal
- Breast Center, Centro Hospitalar Universitário São João, Porto, Portugal
- Institute of Public Health, EPI Unit, University of Porto, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health, University of Porto, Porto, Portugal
| | - José Luis Fougo
- Breast Center, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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Fan YJ, Li JC, Zhu DM, Zhu HL, Zhao Y, Zhu XB, Wu G, Bai TT. Efficacy and safety comparison between axillary lymph node dissection with no axillary surgery in patients with sentinel node-positive breast cancer: a systematic review and meta-analysis. BMC Surg 2023; 23:209. [PMID: 37495945 PMCID: PMC10369839 DOI: 10.1186/s12893-023-02101-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 07/07/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND This systematic review and meta-analysis aimed to study the evidence on the efficacy and safety of omitting axillary lymph node dissection (ALND) for patients with clinically node-negative but sentinel lymph node (SLN)-positive breast cancer using all the available evidence. METHODS The Embase, Medline, and Cochrane Library databases were searched through February 25, 2023. Original trials that compared only the sentinel lymph node biopsy (SLNB) with ALND as the control group for patients with clinically node-negative but SLN-positive breast cancer were included. The primary outcomes were axillary recurrence rate, total recurrence rate, disease-free survival (DFS), and overall survival (OS). Meta-analyses were performed to compare the odds ratio (OR) in rates and the hazard ratios (HR) in time-to-event outcomes between both interventions. Based on different study designs, tools in the revised Cochrane risk of bias tool were used for randomized trials and the risk of bias in nonrandomized studies of interventions to assess the risk of bias for each included article. Funnel plots and Egger's test were used for the publication's bias assessment. RESULTS In total, 30 reports from 26 studies were included in the systematic review (9 reports of RCTs, 21 reports of retrospective cohort studies). According to our analysis, omitting ALND in patients with clinically node-negative but SLN-positive breast cancer had a similar axillary recurrence rate (OR = 0.95, 95% confidence interval (CI): 0.76-1.20), DFS (HR = 1.02, 95% CI: 0.89-1.16), and OS (HR = 0.97, 95% CI: 0.92-1.03), but caused a significantly lower incidence of adverse events and benefited in locoregional recurrence rate (OR = 0.76, 95% CI: 0.59-0.97) compared with ALND. CONCLUSION For patients with clinically node-negative but SLN-positive breast cancer (no matter the number of the positive SLN), this review showed that SLNB alone had a similar axillary recurrence rate, DFS, and OS, but caused a significantly lower incidence of adverse events and showed a benefit for the locoregional recurrence compared with ALND. An OS benefit was found in the Macro subset that used SLNB alone versus complete ALND. Therefore, omitting ALND is feasible in this setting. TRIAL REGISTRATION CRD 42023397963.
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Affiliation(s)
- Yu-Jia Fan
- Thyroid & Breast Surgery Department,, Liaocheng People's Hospital, Liaocheng, 252000, Shandong Province, P. R. China
| | - Jin-Cheng Li
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China.
| | - De-Miao Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Hai-Long Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Yi Zhao
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Xin-Bing Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Gang Wu
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
| | - Ting-Ting Bai
- Department of Breast Surgery, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, P. R. China
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Huang Z, Wu Z, Zou QQ, Xie YJ, Li LH, Huang YP, Wu FM, Huang D, Pan YH, Yang JR. Risk factors of non-sentinel lymph node metastasis in breast cancer with 1-2 sentinel lymph node macrometastases underwent total mastectomy: a case-control study. World J Surg Oncol 2023; 21:125. [PMID: 37024930 PMCID: PMC10077622 DOI: 10.1186/s12957-023-02888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/09/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND The randomized trials which include ACOSOG Z0011 and IBCSG 23-01 had found that the survival rates were not different in patients with cT1/2N0 and 1-2 sentinel lymph node (SLN)-positive, macro/micrometastases who underwent breast-conserving therapy, and micrometastases who underwent total mastectomy (TM), when axillary lymph node dissection (ALND) was omitted. However, for patients with cT1/2N0 and 1-2 SLN macrometastases who underwent TM; there was still insufficient evidence from clinical studies to support whether ALND can be exempted. This study aimed to investigate the risk factors of non-sentinel lymph node (nSLN) metastasis in breast cancer patients with 1-2 SLN macrometastases undergoing TM. METHODS The clinicopathological data of 1491 breast cancer patients who underwent TM and SLNB from January 2017 to February 2022 were retrospectively analyzed. Univariate and multivariate analyses were performed to analyze the risk factors for nSLN metastasis. RESULTS A total of 273 patients with 1-2 SLN macrometastases who underwent TM were enrolled. Postoperative pathological data showed that 35.2% patients had nSLN metastasis. The results of multivariate analysis indicated that tumor size (TS) (P = 0.002; OR: 1.051; 95% CI: 1.019-1.084) and ratio of SLN macrometastases (P = 0.0001; OR: 12.597: 95% CI: 4.302-36.890) were the independent risk factors for nSLN metastasis in breast cancer patients with 1-2 SLN macrometastases that underwent TM. The ROC curve analysis suggested that when TS ≤22 mm and ratio of SLN macrometastases ≤0.33, the incidence of nSLN metastasis could be reduced to 17.1%. CONCLUSIONS The breast cancer patients with cT1/2N0 stage, undergoing TM and 1-2 SLN macrometastases, when the TS ≤22 mm and macrometastatic SLN does not exceed 1/3 of the total number of detected SLN, the incidence of nSLN metastasis is significantly reduced, but whether ALND can be exempted needs further exploration.
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Affiliation(s)
- Zhen Huang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Zhe Wu
- Department of Gynaecology, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, Nanning, China
| | - Quan-Qing Zou
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yu-Jie Xie
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Li-Hui Li
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yan-Ping Huang
- Department of Breast Surgery, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Feng-Ming Wu
- Department of Breast Surgery, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Dong Huang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Yin-Hua Pan
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China
| | - Jian-Rong Yang
- Department of Breast Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, No. 6 Taoyuan Road, Nanning, 53002, China.
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