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Recent Advances and Concepts in SLNB (Sentinel Lymph Node Biopsy) and Management of SLNB Positive Axilla in Carcinoma Breast. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03100-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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van Loevezijn AA, van der Noordaa MEM, Stokkel MPM, van Werkhoven ED, Groen EJ, Loo CE, Elkhuizen PHM, Sonke GS, Russell NS, van Duijnhoven FH, Vrancken Peeters MJTFD. Three-year follow-up of de-escalated axillary treatment after neoadjuvant systemic therapy in clinically node-positive breast cancer: the MARI-protocol. Breast Cancer Res Treat 2022; 193:37-48. [PMID: 35239072 PMCID: PMC8993719 DOI: 10.1007/s10549-022-06545-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/13/2022] [Indexed: 12/29/2022]
Abstract
Purpose In clinically node-positive (cN+) breast cancer patients, evidence supporting response-guided treatment after neoadjuvant systemic therapy (NST) instead of axillary lymph node dissection (ALND) is increasing, but follow-up results are lacking. We assessed three-year axillary recurrence-free interval (aRFI) in cN+ patients with response-adjusted axillary treatment according to the ‘Marking Axillary lymph nodes with Radioactive Iodine seeds’ (MARI)-protocol. Methods We retrospectively assessed all stage II–III cytologically proven cN+ breast cancer patients who underwent the MARI-protocol between July 2014 and November 2018. Pre-NST axillary staging with FDG-PET/CT (less- or more than four suspicious axillary nodes; cALN < 4 or cALN ≥ 4) and post-NST pathological axillary response measured in the pre-NST largest tumor-positive axillary lymph node marked with an iodine seed (MARI-node; ypMARI-neg or ypMARI-pos) determined axillary treatment: no further treatment (cALN < 4, ypMARI-neg), axillary radiotherapy (ART) (cALN < 4, ypMARI-pos and cALN ≥ 4, ypMARI-neg) or ALND plus ART (cALN ≥ 4, ypMARI-pos). Results Of 272 women included, the MARI-node was tumor-negative in 56 (32%) of 174 cALN < 4 patients and 43 (44%) of 98 cALN ≥ 4 patients. According to protocol, 56 (21%) patients received no further axillary treatment, 161 (59%) received ART and 55 (20%) received ALND plus ART. Median follow-up was 3.0 years (IQR 1.9–4.1). Five patients (one no further treatment, four ART) had axillary metastases. Three-year aRFI was 98% (95% CI 96–100). The overall recurrence risk remained highest for patients with ALND (HR 4.36; 95% CI 0.95–20.04, p = 0.059). Conclusions De-escalation of axillary treatment according to the MARI-protocol prevented ALND in 80% of cN+ patients with an excellent three-year aRFI of 98%.
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Affiliation(s)
- Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marieke E M van der Noordaa
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marcel P M Stokkel
- Department of Nuclear Medicine, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Erik D van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Emma J Groen
- Department of Pathology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Claudette E Loo
- Department of Radiology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Nicola S Russell
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Lin SQ, Vo NP, Yen YC, Tam KW. Outcomes of Sentinel Node Biopsy for Women with Breast Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis of Real-World Data. Ann Surg Oncol 2022; 29:3038-3049. [PMID: 35018590 DOI: 10.1245/s10434-021-11297-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Evidence on the accuracy of sentinel lymph node biopsy (SLNB) after neoadjuvant therapy (NAT) for patients with breast cancer is inconclusive. This study reviewed the real-world data to determine the acceptability of SLNB after NAT. METHODS The study searched for articles in the PubMed, EMBASE, and Cochrane Library databases. The primary outcomes were the identification rate for sentinel lymph nodes (SLNs) and the false-negative rate (FNR) for SLNB. The study also evaluated the FNR in subgroups defined by tumor stage, nodal stage, hormone receptor status, human epidermal growth factor receptor-2 status, tumor response, mapping technique, and number of SLNs removed. RESULTS The study retrieved 61 prospective and 18 retrospective studies with 10,680 initially cN± patients. The pooled estimate of the identification rate was 0.906 (95 % confidence interval [CI], 0.891-0.922), and the pooled FNR was 0.118 (95 % CI, 0.103-0.133). In subgroup analysis, the FNR was significantly higher for the patients with estrogen receptor (ER)-negative status and fewer than three SLNs removed. The FNR did not differ significantly between the patients with and those without complete tumor response. Among the patients with initial clinical negative axillary lymph nodes, the incidence of node metastasis was 26.8 % (275/1041) after NAT. CONCLUSION Real-world evidence indicates that the FNR of SLNB after NAT in breast cancer is 11.8 %, exceeding only slightly the commonly adopted threshold of 10 %. The FNR is significantly higher for patients with ER-negative status and removal of fewer than three SLNs. Using a dual tracer and removing at least three SLNs may increase the accuracy of SLNB after NAT.
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Affiliation(s)
- Shi-Qian Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Nguyen-Phong Vo
- International PhD Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chun Yen
- Biostatistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Center for Evidence-based Health Care, Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291 Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan. .,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
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Iles K, Strassle PD, Agala CB, Button J, Downs-Canner S. Surgical Axillary Staging Before Neoadjuvant Chemotherapy: Who Gets It and Why We Should Avoid It. Ann Surg Oncol 2021; 28:5788-5797. [PMID: 34379251 DOI: 10.1245/s10434-021-10628-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical axillary staging demonstrating positive nodal disease before neoadjuvant chemotherapy (NAC) necessitates axillary lymph node dissection (ALND) post-NAC. Despite evidence supporting post-NAC surgical staging, we hypothesized that there is persistent use of pre-NAC staging and that it is associated with aggressive clinicopathologic features and a higher rate of subsequent ALND. PATIENTS AND METHODS Stage I-III breast cancer patients who underwent lymph node staging surgery and received NAC between 2013 and 2017 in the National Cancer Database were included. Sequence of staging surgery and chemotherapy administration was determined. Multivariable regression was used to assess characteristics associated with pre-NAC staging. Rate of ALND was compared between those who had pre- and post-NAC surgical axillary staging. RESULTS In total, 120,538 met inclusion; 68% received NAC first and 32% had pre-NAC staging. Pre-NAC staging surgery was associated with younger age (age < 30 versus 40-49 years, HR 1.1) and decreased with older age (ages 70-79/80+ versus 40-49 years, HR 0.86 and 0.73). Advancing clinical T stage, lobular subtype, higher grade, and HR+/HER2- subtype were also associated with pre-NAC surgical staging. Women who underwent pre-NAC surgical staging were more likely to undergo ALND. CONCLUSIONS Over 30% of women underwent surgical axillary staging prior to NAC, resulting in higher rates of ALND in this cohort. While certain features suggestive of aggressive behavior (grade and T stage) were associated with pre-NAC surgical axillary staging, women with more aggressive tumor subtypes (triple negative/HER2+) were less likely to undergo pre-NAC surgical axillary staging. Pre-NAC surgical axillary staging should be performed only in rare circumstances to avoid unnecessary ALND.
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Affiliation(s)
- Kathleen Iles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula D Strassle
- Division of Intramural Research, National Institute on Minority Health and Health Disparities (NIMHD), National Institutes of Health, Bethesda, MD, USA
| | - Chris B Agala
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Julia Button
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie Downs-Canner
- Department of Surgical Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Li J, Jia S, Wang Y, Zhang Y, Kong L, Cao Y, Liu Y, Zhang Y, Chen B. Long-term tracing and staining of carbon nanoparticles for axillary lymph node in patients with local advanced breast cancer treated with neoadjuvant chemotherapy. Asian J Surg 2021; 45:89-96. [PMID: 33926797 DOI: 10.1016/j.asjsur.2021.03.020] [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: 09/15/2020] [Revised: 12/10/2020] [Accepted: 03/26/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The regression of positive nodes in breast cancer after neoadjuvant chemotherapy (NAC) remains unknown. This study aimed to investigate this regression by injecting and tracing carbon nanoparticles (CNs) into the fusion node prior to NAC in patients with breast cancer. METHODS Guided by ultrasound, 0.3 mL of CNs suspension was injected in the fusion node prior to NAC in 110 patients with local advanced breast cancer. Then the patients underwent breast surgery and total axillary lymph node dissection following 2-6 cycles of NAC. The distribution by intercostobrachial nerves (ICBN) of positive nodes and black-stained nodes was researched, and the relationship between the distribution and lymphovascular invasion were investigated by response to NAC. RESULTS When patients were ranked by response to NAC (from sensitive to resistance), the number of positive nodes increased, as did the proportion of lymphovascular invasion, the number of black-stained nodes decreased. A significantly negative relationship was found between the number of positive nodes and the number of black-stained nodes (p < 0.001). The positive nodes in patients with sensitive consequence followed the rule from under the ICBN to above the ICBN. However, there was counter-example (skip metastasis) in the patients with resistance result. CONCLUSION The regression of positive nodes follows the rule from upper to under, inner to outer in the patients with sensitive consequence to NAC. Long-term staining and tracing by CNs might provide an acceptable and feasible technique to investigate the regression of positive nodes, and would be a potential method for NAC-treated patients by using of ICBN. TRIAL REGISTRATION NCT03355261. Retrospectively registered on November 28, 2017.
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Affiliation(s)
- Jianyi Li
- Department of Breast Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, 110042, Liaoning Province, China.
| | - Shi Jia
- Department of Breast Surgery, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China.
| | - Yitong Wang
- Department of Breast Surgery, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China.
| | - Yang Zhang
- Department of Breast Surgery, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China.
| | - Linna Kong
- Department of Breast and Thyroid Surgery, Jinan Central Hospital of Shandong University, Jinan 250013, Shandong Province, China.
| | - Yanan Cao
- Department of Breast Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, 110042, Liaoning Province, China.
| | - Yushi Liu
- Department of Breast Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, 110042, Liaoning Province, China.
| | - Yan Zhang
- Department of Breast Surgery, The Second Hospital of Jilin University, Changchun 130041, Jilin Province, China.
| | - Bo Chen
- The First Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China.
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Di Micco R, Zuber V, Fiacco E, Carriero F, Gattuso MI, Nazzaro L, Panizza P, Gianolli L, Canevari C, Di Muzio N, Pasetti M, Sassi I, Zambetti M, Gentilini OD. Sentinel node biopsy after primary systemic therapy in node positive breast cancer patients: Time trend, imaging staging power and nodal downstaging according to molecular subtype. Eur J Surg Oncol 2019; 45:969-975. [PMID: 30744944 DOI: 10.1016/j.ejso.2019.01.219] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/20/2019] [Accepted: 01/29/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The management of axilla after Primary Systemic Therapy (PST) for breast cancer is a highly debated field. Despite the proven axillary downstaging occurring after PST, there is still some degree of reluctance in applying sentinel node biopsy (SNB) in the neoadjuvant setting. PATIENTS AND METHODS We performed a retrospective analysis on 181 PST patients with axillary positive nodes at presentation treated between 2005 and 2017 at San Raffaele Hospital in Milan. The aim was to observe the application time trend of SNB, to determine the imaging staging power and the axillary downstaging according to molecular subtypes. RESULTS Median follow-up after surgery was 32.5(IQR: 12-59) months. After PST, 119 (65.7%) patients had no clinically palpable nodes, 72 (39.7%) converted to N0 on final imaging and 34 (18.8%) underwent SNB with an increasing application trend. Axillary-US showed the highest accuracy (69.3%) in re-staging axilla after PST. Staging power of preoperative testing varied with tumour biology: Positive Predictive Value was higher in Luminal A (80% for clinical examination and 100% for axillary-US) and Luminal B (72% and 70.5%) tumours, whilst Negative Predictive Value was higher in HER2 positive (100% and 93.3%), and triple negative (71.4% and 93.3%) tumours. Ninety five (52.5%) patients experienced axillary downstaging after PST, by molecular subtype 15% (3/20) in Luminal A, 46.4% (45/97) in Luminal B, 90.9% (20/22) in HER2+ and 70.3% (26/37) in triple negative breast tumours. CONCLUSION SNB application after PST for breast cancer in node positive patients at presentation is increasing. Pre-operative axillary imaging and tumour biology help identify patients who might be candidates for SNB as a single staging procedure.
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Affiliation(s)
- Rosa Di Micco
- Breast Surgery Unit, San Raffaele Hospital, Milan, Italy; Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Veronica Zuber
- Breast Surgery Unit, San Raffaele Hospital, Milan, Italy
| | - Enrico Fiacco
- Breast Surgery Unit, San Raffaele Hospital, Milan, Italy
| | | | | | | | - Pietro Panizza
- Breast Radiology Unit, San Raffaele Hospital, Milan, Italy
| | - Luigi Gianolli
- Nuclear Medicine Unit, San Raffaele Hospital, Milan, Italy
| | - Carla Canevari
- Nuclear Medicine Unit, San Raffaele Hospital, Milan, Italy
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Koolen BB, Donker M, Straver ME, van der Noordaa MEM, Rutgers EJT, Valdés Olmos RA, Vrancken Peeters MJTFD. Combined PET-CT and axillary lymph node marking with radioactive iodine seeds (MARI procedure) for tailored axillary treatment in node-positive breast cancer after neoadjuvant therapy. Br J Surg 2017; 104:1188-1196. [PMID: 28524246 DOI: 10.1002/bjs.10555] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/04/2016] [Accepted: 03/06/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND The treatment of axillary lymph node metastases after neoadjuvant systemic therapy (NST) remains debatable and axillary lymph node dissection (ALND) is still the standard of care. Marking axillary lymph nodes with radioactive iodine seeds (MARI procedure) is accurate in restaging the axilla after NST (false-negative rate 7 per cent). Here, the potential of tailored axillary treatment, determined by combining the results of PET-CT before NST with those of the MARI procedure after NST, was analysed. METHODS A cohort of axillary node-positive patients was used to construct a hypothetical treatment algorithm based on a combination of PET-CT and the MARI procedure. In the algorithm, the number of fluorodeoxyglucose (FDG)-avid axillary lymph nodes (1-3 versus 4 or more) before NST and the tumour status of the MARI node (positive versus negative) after NST were used to tailor axillary treatment. All patients in the cohort underwent ALND, allowing estimation of potential overtreatment and undertreatment. RESULTS A total of 93 patients were included in the study. Between one and three FDG-avid axillary lymph nodes were observed in 59 patients, and four or more in 34 patients. The MARI node was tumour-negative in 32 patients and showed residual disease in 61. Treatment according to the constructed algorithm would have resulted in 74 per cent of patients avoiding an ALND, with potential undertreatment in three patients (3 per cent) and overtreatment in 16 (17 per cent). CONCLUSION Tailored axillary treatment after NST in node-positive patients, by combining PET-CT before NST and the MARI procedure after NST, has the potential for ALND to be avoided in 74 per cent of patients.
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Affiliation(s)
- B B Koolen
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M Donker
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M E Straver
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M E M van der Noordaa
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E J T Rutgers
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - R A Valdés Olmos
- Department of Nuclear Medicine, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M J T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Masood S. Neoadjuvant chemotherapy in breast cancers. WOMEN'S HEALTH (LONDON, ENGLAND) 2016; 12:480-491. [PMID: 27885165 PMCID: PMC5373271 DOI: 10.1177/1745505716677139] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/22/2016] [Accepted: 10/03/2016] [Indexed: 12/20/2022]
Abstract
With advances in science and technology, there are more innovations in the approach to management of patients with breast cancer. Neoadjuvant chemotherapy that is designed to be used prior to surgical removal of a tumor has received significant attention. Currently, neoadjuvant chemotherapy is offered to patients with locally advanced breast cancer and also those breast cancer patients who may benefit from size reduction before conservation therapy. There is now sufficient evidence that if neoadjuvant chemotherapy leads to complete pathologic response, the patient will enjoy a better outcome. Therefore, assessment of the degree of response to neoadjuvant chemotherapy has a major impact on patient selection and the follow-up management of each patient and defines patient outcome.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/therapy
- Carcinoma, Lobular/metabolism
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/therapy
- Female
- Humans
- Mastectomy
- Mastectomy, Segmental
- Neoadjuvant Therapy/methods
- Neoplasm Staging
- Prognosis
- Receptor, ErbB-2/metabolism
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
- Treatment Outcome
- Tumor Burden
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Affiliation(s)
- Shahla Masood
- Department of Pathology and Laboratory Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
- UF Health Breast Center, University of Florida Health-Jacksonville, Jacksonville, FL, USA
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Mamtani A, Barrio AV, King TA, Van Zee KJ, Plitas G, Pilewskie M, El-Tamer M, Gemignani ML, Heerdt AS, Sclafani LM, Sacchini V, Cody HS, Patil S, Morrow M. How Often Does Neoadjuvant Chemotherapy Avoid Axillary Dissection in Patients With Histologically Confirmed Nodal Metastases? Results of a Prospective Study. Ann Surg Oncol 2016; 23:3467-3474. [PMID: 27160528 DOI: 10.1245/s10434-016-5246-8] [Citation(s) in RCA: 216] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND In breast cancer patients with nodal metastases at presentation, false-negative rates lower than 10 % have been demonstrated for sentinel node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) when three or more negative sentinel nodes (SLNs) are retrieved. However, the frequency with which axillary dissection (ALND) can be avoided is uncertain. METHODS Among 534 prospectively identified consecutive patients with clinical stages 2 and 3 cancer receiving NAC from November 2013 to November 2015, all biopsy-proven node-positive (N+) cases were identified. Patients clinically node-negative after NAC were eligible for SLNB. The indications for ALND were failed mapping, fewer than three SLNs retrieved, and positive SLNs. RESULTS Of 288 N+ patients, 195 completed surgery, with 132 (68 %) of these patients eligible for SLNB. The median age was 50 years. Of these patients, 73 (55 %) were estrogen receptor-positive (ER+), 21 (16 %) were ER- and human epidermal growth factor receptor-2-positive (HER2+), and 38 (29 %) were triple-negative. In four cases, SLNB was deferred intraoperatively. Among 128 SLNB attempts, three or more SLNs were retrieved in 110 cases (86 %), one or two SLNs were retrieved in 15 cases (12 %), and failed mapping occurred in three cases (2 %). In 66 cases, ALND was indicated: 54 (82 %) for positive SLNs, 9 (14 %) for fewer than three negative SLNs, and 3 (4 %) for failed mapping. Persistent disease was found in 17 % of the patients with fewer than three negative SLNs retrieved. Of the 128 SLNB cases, 62 (48 %) had SLNB alone with three or more SLNs retrieved. Among 195 N+ patients who completed surgery, nodal pathologic complete response (pCR) was achieved for 49 %, with rates ranging from 21 % for ER+/HER2- to 97 % for ER-/HER2+ cases, and was significantly more common than breast pCR in ER+/HER2- and triple-negative cases. CONCLUSIONS Nearly 70 % of the N+ patients were eligible for SLNB after NAC. For 48 %, ALND was avoided, supporting the role of NAC in reducing the need for ALND among patients presenting with nodal metastases.
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Tari A King
- Department of Breast Surgery, Dana Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Alexandra S Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Lisa M Sclafani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
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Vugts G, Maaskant-Braat AJG, Nieuwenhuijzen GAP, Roumen RMH, Luiten EJT, Voogd AC. Patterns of Care in the Administration of Neo-adjuvant Chemotherapy for Breast Cancer. A Population-Based Study. Breast J 2016; 22:316-21. [PMID: 26945566 DOI: 10.1111/tbj.12568] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Neo-adjuvant chemotherapy (NAC) is used to facilitate radical surgery for initially irresectable or locally advanced breast cancer. The indication for NAC has been extended to clinically node negative (cN0) patients in whom adjuvant systemic therapy is foreseen. A population-based study was conducted to evaluate the increasing use of NAC, breast conserving surgery (BCS) after NAC and timing of the sentinel node biopsy (SNB). All female breast cancer patients, treated in 10 hospitals in the Eindhoven Cancer Registry area in the Netherlands between January 2003 and June 2012 were included (N = 18,427). In total, 1,402 patients (7.6%) received NAC. The administration increased from 2.5% in 2003 to 13.0% in 2011 (p < 0.001). Use of NAC increased from 0.5% to 2.3% for cT1 tumors, from 2.8% to 27.0% for cT2, from 30.6% to 70.9% for cT3, and from 40.5% to 58.1% for cT4 tumors (p < 0.001). In cN0 patients, use of NAC increased from 1.0% to 4.4% and in clinically node positive patients from 12.0% to 57.5% (p < 0.001). Downsizing of the tumor and BCS are achieved increasingly. In 2011, in three hospitals NAC was administered in <10% of patients, in five hospitals in 10-15% and in two hospitals the proportion of patients receiving NAC was >20% (p < 0.001). Of the 1,402 patients with NAC, 495 patients underwent SNB, 91.5% of whom prior to NAC. In the Netherlands up to one in eight patients receive NAC. The administration of NAC and the percentage of BCS increased over the past decade, especially in cT2 tumors. Considerable hospital variation in the administration of NAC exists.
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Affiliation(s)
- Guusje Vugts
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Eindhoven Cancer Registry, Comprehensive Cancer Centre The Netherlands (IKNL), Eindhoven, The Netherlands
| | | | | | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Adri C Voogd
- Eindhoven Cancer Registry, Comprehensive Cancer Centre The Netherlands (IKNL), Eindhoven, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
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11
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Ge WK, Yang B, Zuo WS, Zheng G, Dai YQ, Han C, Yang L, Zheng MZ. Sentinel lymph node biopsy does not apply to all axillary lymph node-positive breast cancer patients after neoadjuvant chemotherapy. Thorac Cancer 2014; 5:550-5. [PMID: 26767051 DOI: 10.1111/1759-7714.12131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 04/27/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the feasibility of sentinel lymph node biopsy (SLNB) after neoadjuant chemotherapy (NAC) in breast cancer patients with confirmed axillary nodal metastases. METHODS We enrolled 51 patients with breast cancer who received NAC. All patients were proven to have axillary nodal metastases by histopathology biopsy prior to NAC. They all underwent SLNB before breast surgery, and complete axillary lymph node dissection immediately followed. RESULTS The identification rate for SLNB was 87.5% (84/96); the false negative rate was 24.5% (12/49). The clinicopathological factors were not significantly correlated with the identification and false negative rate of the SLNB. Lymphatic mapping, blue dye or radionuclide methods tended to decrease the identification rate of SLNB (P = 0.073). Clinical nodal status before NAC has a trend to increase the false-negative rates of the SLNB (P = 0.059). For patients with N1 clinical axillary lymph nodal status, the identification rate was 93.9%, and the false negative rate was 5.9%, compared with N2-3 patients with 73.9% and 38.9%, respectively. CONCLUSIONS SLNB is feasible for the patients whose axillary lymph nodal status before NAC is N1. However, for N2-3 patients, SLNB cannot be used as an infallible indicator of non-SLN status.
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Affiliation(s)
- Wen-Kai Ge
- School of Medicine and Life Sciences, University of Jinan, Shandong Academy of Medical Sciences, Shandong Cancer Hospital Jinan, China; Department of Surgery II, Shandong Breast Center of Prevention and Treatment, Shandong Cancer Hospital Jinan, China
| | - Ben Yang
- Department of Surgery II, Shandong Breast Center of Prevention and Treatment, Shandong Cancer Hospital Jinan, China
| | - Wen-Shu Zuo
- Department of Surgery II, Shandong Breast Center of Prevention and Treatment, Shandong Cancer Hospital Jinan, China
| | - Gang Zheng
- Department of Surgery II, Shandong Breast Center of Prevention and Treatment, Shandong Cancer Hospital Jinan, China
| | - Ying-Qi Dai
- School of Medicine and Life Sciences, University of Jinan, Shandong Academy of Medical Sciences, Shandong Cancer Hospital Jinan, China
| | - Chao Han
- School of Medicine and Life Sciences, University of Jinan, Shandong Academy of Medical Sciences, Shandong Cancer Hospital Jinan, China
| | - Li Yang
- Department of Surgery II, Shandong Breast Center of Prevention and Treatment, Shandong Cancer Hospital Jinan, China
| | - Mei-Zhu Zheng
- Department of Surgery II, Shandong Breast Center of Prevention and Treatment, Shandong Cancer Hospital Jinan, China
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12
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Han A, Moon HG, Kim J, Ahn SK, Park IA, Han W, Noh DY. Reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patients. J Breast Cancer 2013; 16:378-85. [PMID: 24454459 PMCID: PMC3893339 DOI: 10.4048/jbc.2013.16.4.378] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/24/2013] [Indexed: 11/30/2022] Open
Abstract
Purpose Sentinel lymph node biopsy (SLNB) is an accurate and effective means of axillary nodal staging in early breast cancer. However its indication after neoadjuvant chemotherapy (NAC) is under constant debate. The present study evaluates the reliability of SLNB in assessing axillary nodal status after NAC. Methods Data from 281 patients who had received NAC and subsequent SLNB were reviewed. The identification and false negative rates of SLNB were determined and the clinicopathologic factors associated with false negative results were investigated using univariate analysis. Results The identification rate of SLNB after NAC was 93.6% and the false negative rate was 10.4%. Hormone receptor status, especially progesterone receptor positivity, was significantly associated with false negative results. The accuracy of intraoperative frozen section examination of sentinel lymph nodes was 91.2%. Conclusion The identification rate of SLNB and the accuracy of intraoperative frozen section examination after NAC are comparable to the results without NAC in patients with early breast cancer. However considering the high false negative rates, general application of SLNB after NAC should be avoided. Patients with progesterone-positive tumors and non-triple-negative breast cancers may be a select group of patients in whom SLNB can be employed safely after NAC, but further studies are necessary.
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Affiliation(s)
- Ahram Han
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyeong-Gon Moon
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Jisun Kim
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Soo Kyung Ahn
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - In Ae Park
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University Hospital, Seoul, Korea. ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Young Noh
- Department of Surgery, Seoul National University Hospital, Seoul, Korea. ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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13
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Park S, Park JM, Cho JH, Park HS, Kim SI, Park BW. Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with cytologically proven node-positive breast cancer at diagnosis. Ann Surg Oncol 2013; 20:2858-65. [PMID: 23645483 DOI: 10.1245/s10434-013-2992-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND The performance of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NCT) was investigated in patients with locally advanced breast cancer (LABC). METHODS After NCT of 178 patients with cytology-proven axillary/supraclavicular nodes metastasis at the time of diagnosis, SLNB using radioisotope was performed including completion node dissection between 2008 and 2011. The detection rate, sensitivity, false negative rate (FNR), negative predictive value (NPV) and accuracy of SLNB were analyzed. RESULTS SLNB was successfully performed in 169 (94.9%) patients. Tumor nonresponse and extensive residual nodal disease were found to be significantly associated with detection failure of sentinel nodes. Sensitivity, FNR, NPV, and accuracy of SLNB were 78.0, 22.0, 75.8, and 87.0%, respectively, and a greater number of retrieved SLNs increased all four of these performance measures. Conversion to node-negative disease was achieved in 69 (40.8%) patients: 24% of patients with the luminal A subtype, 51.6% of patients with the luminal B, 51.7% of patients with the HER2-enriched, and 58.5% of patients with the triple-negative breast cancer (TNBC) subtype. Luminal B, HER2-enriched, and TNBC subtypes showed comparable responses to NCT; however, the TNBC subtype had a significantly better FNR and accuracy. CONCLUSIONS SLNB was found to be technically feasible, but its routine use was not recommended for LABCs after NCT. However, acceptable performance was noted for locally advanced TNBCs, and thus SLNB might be safely considered in these selected patients.
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Affiliation(s)
- Seho Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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14
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Luo C, Guo W, Yang J, Sun Q, Wei W, Wu S, Fang S, Zeng Q, Zhao Z, Meng F, Huang X, Zhang X, Li R, Ma X, Luo C, Yang Y. Comparison of mastoscopic and conventional axillary lymph node dissection in breast cancer: long-term results from a randomized, multicenter trial. Mayo Clin Proc 2012; 87:1153-61. [PMID: 23146657 PMCID: PMC3541933 DOI: 10.1016/j.mayocp.2012.07.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 07/02/2012] [Accepted: 07/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare the long-term results of mastoscopic axillary lymph node dissection (MALND) and conventional axillary lymph node dissection (CALND). PATIENTS AND METHODS From January 1, 2003, through December 31, 2005, a group of 1027 consecutive patients with operable breast cancer were randomly assigned to 1 of 2 study groups: MALND and CALND. The median follow-up was 63 months. The primary end points of the study were operative outcomes, complication reduction, function conservation, and cosmetics. The secondary end points were disease-free and overall survival. RESULTS The mean operative blood loss in the MALND group was less than in the CALND group (P<.001). The patients who underwent MALND had less axillary pain, numbness or paresthesias, and arm swelling (P<.001). The aesthetic appearance of the axilla in the MALND group was much better than that in the CALND group (P=.001 at 6 months and P=.002 at 24 months). A significant difference was found between the 2 groups in distant metastasis (P=.04). The disease-free survival rate was 64.5% in the MALND group and 60.8% in the CALND group (P=.88). The overall survival rate was 81.7% in the MALND group and 78.6% in the CALND group (P=.95). CONCLUSION Compared with CALND, MALND has advantages in operative outcomes, complication reduction, function conservation, and cosmetics.
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Affiliation(s)
- Chengyu Luo
- Fuxing Hospital, Capital Medical University, Beijing, China.
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15
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Alvarado R, Yi M, Le-Petross H, Gilcrease M, Mittendorf EA, Bedrosian I, Hwang RF, Caudle AS, Babiera GV, Akins JS, Kuerer HM, Hunt KK. The role for sentinel lymph node dissection after neoadjuvant chemotherapy in patients who present with node-positive breast cancer. Ann Surg Oncol 2012; 19:3177-84. [PMID: 22772869 DOI: 10.1245/s10434-012-2484-2] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Sentinel lymph node (SLN) dissection has been investigated after neoadjuvant chemotherapy and has shown mixed results. Our objective was to evaluate SLN dissection in node-positive patients and to determine whether postchemotherapy ultrasound could select patients for this technique. METHODS Between 1994 and 2010, 150 patients with biopsy proven axillary metastasis underwent SLN dissection after chemotherapy and 121 underwent axillary lymph node dissection (ALND). Clinicopathologic characteristics were analyzed before and after chemotherapy. Statistical analyses included Fisher's exact test for nodal response and multivariate logistic regression for factors associated with false-negative events. RESULTS Median age was 52 years. Median tumor size at presentation was 2 cm. The SLN was identified in 93 % (139/150). In 111 patients in whom a SLN was identified and ALND performed, 15 patients had a false-negative SLN (20.8 %). In the 52 patients with normalized nodes on ultrasound, the false-negative rate decreased to 16.1 %. Multivariate analysis revealed smaller initial tumor size and fewer SLNs removed (<2) were associated with a false-negative SLN. There were 63 (42 %) patients with a pathologic complete response (pCR) in the nodes. Of those with normalized nodes on ultrasound, 38 (51 %) of 75 had a pCR. Only 25 (33 %) of 75 with persistent suspicious/malignant-appearing nodes had a pCR (p = 0.047). CONCLUSIONS Approximately 42 % of patients have a pCR in the nodes after chemotherapy. Normalized morphology on ultrasound correlates with a higher pCR rate. SLN dissection in these patients is associated with a false-negative rate of 20.8 %. Removing fewer than two SLNs is associated with a higher false-negative rate.
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Affiliation(s)
- Rosalinda Alvarado
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lee MC, Joh JE, Chau A. Axillary Staging Prior to Neoadjuvant Chemotherapy: The Roles of Sentinel Lymph Node Biopsy and Axillary Ultrasonography. Cancer Control 2012; 19:277-285. [DOI: 10.1177/107327481201900404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Marie Catherine Lee
- Comprehensive Breast Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Division of Oncologic Sciences at the University of South Florida, Tampa, Florida
| | - Jennifer E. Joh
- Comprehensive Breast Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Hoffberger Breast Center at Mercy, Mercy Medical Center, Baltimore, Maryland
| | - Alec Chau
- Diagnostic Imaging Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Division of Oncologic Sciences at the University of South Florida, Tampa, Florida
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Shigekawa T, Sugitani I, Takeuchi H, Misumi M, Nakamiya N, Sugiyama M, Sano H, Matsuura K, Takahashi T, Fujiuchi N, Osaki A, Saeki T. Axillary ultrasound examination is useful for selecting patients optimally suited for sentinel lymph node biopsy after primary systemic chemotherapy. Am J Surg 2012; 204:487-93. [DOI: 10.1016/j.amjsurg.2011.09.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 09/26/2011] [Accepted: 09/26/2011] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW Breast cancer is the most common malignancy in women in the United States and the second most common cause of cancer death in women. This review will focus on the current and clinically relevant recommendations for breast cancer diagnosis, staging, and treatment. RECENT FINDINGS Screening for breast cancer is based on patient history, exam, mammography, and ultrasound. In select patient populations, MRI adds additional detection benefit. Once pathology is found, nipple-sparing mastectomy is felt to be an oncologically well tolerated procedure for both ductal carcinoma in situ and invasive tumors in properly selected patients. Prophylactic mastectomy rates are increasing despite no clear survival benefit. Sentinel lymph node biopsy continues to be the staging procedure of choice, but data are available that completion axillary dissection for a positive sentinel node may not affect outcomes. SUMMARY Strategies for caring for breast cancer patients continue to evolve. Multiple variables including genetic predisposition, disease burden, tumor markers, receptor status, and patient preference are integral to the decision making for each individual patient.
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Kaufmann M, Karn T, Ruckhäberle E. Controversies Concerning the Use of Neoadjuvant Systemic Therapy for Primary Breast Cancer. World J Surg 2012; 36:1480-5. [DOI: 10.1007/s00268-012-1424-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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The usefulness of Tc-99m-tetrofosmin SPECT/CT in the detection of residual tumors and axillary lymph node metastases in breast cancer patients following neoadjuvant therapy. Clin Nucl Med 2012; 36:997-1002. [PMID: 21975387 DOI: 10.1097/rlu.0b013e3182291b59] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Single photon emission computed tomography (SPECT)/CT is emerging as a useful diagnostic tool in several oncological fields. In this prospective study, we assessed the usefulness of Tc-99m-tetrofosmin SPECT/CT in the detection of both residual breast tumors and axillary lymph node metastases following neoadjuvant therapy. Thirty-seven consecutive breast cancer patients scheduled to surgery following neoadjuvant therapy preoperatively underwent a Tc-99m-tetrofosmin SPECT/CT study, using a dual head gamma camera integrated with a x-ray tube for low-dose CT, including both breasts and axillary regions in the field of view. Within 1 week of SPECT/CT, all 37 patients had breast surgery with associated axillary lymph node dissection in 33/37 cases. At surgery, 31/37 patients had breast residues (microscopic in 4/31 cases and macroscopic in 27/31 cases). Axillary lymph node metastases were ascertained in 19/33 cases (N1mi: 2 cases, N1a: 8 cases, N2a: 6 cases, N2b: 3 cases). SPECT/CT sensitivity, specificity, and accuracy in detecting residual tumors were 87%, 100%, and 89.2%, respectively; the corresponding values in detecting axillary lymph node metastases were 36.8%, 92.8%, and 60.6%. SPECT/CT missed breast cancer residues in 4/31 patients, including 2 cases with microscopic residual disease. Moreover, lymph node metastases were missed in 12/19 patients (10/12 with pN1mi or pN1a metastases), all with lymph nodes with post-therapy fibrotic changes and small deposits of metastases. Tc-99m-tetrofosmin SPECT/CT proved a useful diagnostic tool in the detection and in the localization of residual breast tumors following neoadjuvant therapy. The procedure lacked in sensitivity in identifying axillary lymph node metastases, especially in patients with a limited lymph node involvement. According to our data, SPECT/CT may guide the surgeon to the most appropriate breast surgical treatment and to eventually select the most suitable axillary lymph node sampling (axillary lymph node dissection or sentinel node biopsy).
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Kaufmann M, von Minckwitz G, Mamounas EP, Cameron D, Carey LA, Cristofanilli M, Denkert C, Eiermann W, Gnant M, Harris JR, Karn T, Liedtke C, Mauri D, Rouzier R, Ruckhaeberle E, Semiglazov V, Symmans WF, Tutt A, Pusztai L. Recommendations from an international consensus conference on the current status and future of neoadjuvant systemic therapy in primary breast cancer. Ann Surg Oncol 2011; 19:1508-16. [PMID: 22193884 DOI: 10.1245/s10434-011-2108-2] [Citation(s) in RCA: 342] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Indexed: 01/01/2023]
Abstract
The use of neoadjuvant systemic therapy (NST) for the treatment of primary breast cancer has constantly increased, especially in trials of new therapeutic regimens. In the 1980 s, NST was shown to substantially improve breast-conserving surgery rates and was first typically used for patients with inoperable locally advanced or inflammatory breast cancer. Investigators have since also used NST as an in vivo test for chemosensitivity by assessing pathologic complete response. Today, by using pathologic response and other biomarkers as intermediate end points, results from trials of new regimens and therapies that use NST are aimed to precede and anticipate the results from larger adjuvant trials. In 2003, a panel of representatives from various breast cancer clinical research groups was first convened in Biedenkopf to formulate recommendations on the use of NST. The obtained consensus was updated in two subsequent meetings in 2004 and 2006. The most recent conference on recommendations on the use of NST took place in 2010 and forms the basis of this report.
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Affiliation(s)
- Manfred Kaufmann
- Department of Gynecology and Obstetrics and Breast Unit, Goethe University, Frankfurt, Germany.
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Kim J, Lee J, Chang E, Suh K, Lee C, Jee J, Shin H. Prognostic Factors in Patients with Stage II/III Breast Cancer Treated with Adjuvant Extension of Neoadjuvant Chemotherapy: A Retrospective Cohort Study with Ten-Years of Follow-Up Data. J Breast Cancer 2011; 14:39-45. [PMID: 21847393 PMCID: PMC3148511 DOI: 10.4048/jbc.2011.14.1.39] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 02/07/2011] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The aim of this retrospective study was to identify the reliable long term prognostic factors in patients with stage II/III breast cancer who were treated with an adjuvant extension of neoadjuvant chemotherapy (NC). METHODS Women under the age of 70-years, with previously untreated clinical stage II and III breast cancer, were treated with NC, which was comprised of three cycles of FEC (5-FU, epirubicin, and cyclophosphamide every 3 weeks) or MMM (methotrexate, mitoxantrone, and mitomycin-C every 3 weeks) with an adjuvant extension of three cycles of the same regimen. RESULTS Cumulative 10-years disease-free survival (DFS) was 87.3% for patients with a good response and 55.5% for patients with no response (p=0.032); 92.9% for node negative patients, 75.0% for 1-3 positive nodes, 50.0% for 4-9 positive nodes and no survival for 10 or more positive nodes (p<0.001). Cumulative 10-years overall survival (OS) was 89.1% for patients with good response and 55.5% for patients with no response (p=0.024); 95.2% for node negative patients, 80.0% for 1-3 positive nodes, 50.0% for 4-9 positive nodes and no survival for 10 or more positive nodes (p<0.001). No significant difference was observed in DFS and OS between the FEC and MMM treated groups. CONCLUSION Based on a review of data with a long follow-up, only the clinical response to NC and the absolute number of metastatic axillary lymph node identified at surgical staging were independent predictors of both DFS and OS in patients with stage II/III breast cancer patients treated with adjuvant extension of NC.
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Affiliation(s)
- Jeryong Kim
- Department of Surgery, Research Institute for Medical Science, Chungnam National University College of Medicine, Daejeon, Korea
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Pechlivanides G, Vassilaros D, Tsimpanis A, Apostolopoulou A, Vasilaros S. Sentinel node biopsy for breast cancer patients: issues for discussion and our practice. PATHOLOGY RESEARCH INTERNATIONAL 2010; 2011:109712. [PMID: 21234361 PMCID: PMC3018621 DOI: 10.4061/2011/109712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 12/09/2010] [Indexed: 11/20/2022]
Abstract
Sentinel node biopsy has been established for several years now as a standard procedure of breast cancer surgery, but there are several variations of the indications and the technique used. This paper provides information regarding several issues of debate for its application as are the selection criteria, the application to patients with multifocal/multicentric breast cancer or DCIS, postneoadjuvant chemotherapy, the necessary number of nodes to be biopsied, the need for lymphoscintigraphy, the technique for frozen section, the factors that may predict nonsentinel nodes (NSNs) involvement, the value of micrometastasis and isolated tumour cells, the internal mammary chain sentinel nodes, and finally the axillary recurrence after SLNB. Our view for these issues is included together with our experience of 430 SLNBs.
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Affiliation(s)
- Georgios Pechlivanides
- "Prolipsis" Diagnostic Center, Breast Unit, 88A Mihalacopoulou Street, 11528 Athens, Greece
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Croshaw RL, Erb KM, Shapiro-Wright HM, Julian TB. The Need for Axillary Dissection in Patients with Positive Axillary Sentinel Lymph Nodes. Curr Oncol Rep 2010; 13:5-10. [DOI: 10.1007/s11912-010-0133-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ansari B, Boughey JC. Sentinel Lymph Node Surgery in Uncommon Clinical Circumstances. Surg Oncol Clin N Am 2010; 19:539-53. [DOI: 10.1016/j.soc.2010.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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26
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Sabel MS. Sentinel lymph node biopsy before or after neoadjuvant chemotherapy: pros and cons. Surg Oncol Clin N Am 2010; 19:519-38. [PMID: 20620925 DOI: 10.1016/j.soc.2010.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This article summarizes the relative pros and cons surrounding the timing of sentinel lymph node (SLN) biopsy in patients undergoing neoadjuvant chemotherapy. Several institutions initiated prospective trials of SLN biopsy performed after neoadjuvant chemotherapy in conjunction with a completion axillary lymph node dissection, with the goal of ultimately showing that SLN biopsy could be safely and accurately performed after the patient completed systemic therapy. Other institutions adopted a policy of performing SLN biopsy before initiation of chemotherapy. This avoided the issue surrounding the accuracy of SLN biopsy after chemotherapy and potentially provided information that might influence adjuvant therapy decisions. This article addresses the clinical questions regarding the 2 approaches including the accuracy of the procedure and the prognostic information gleaned.
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Affiliation(s)
- Michael S Sabel
- Department of Surgery, University of Michigan Comprehensive Cancer Center, 3304 Cancer Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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