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van der Voort A, Louis FM, van Ramshorst MS, Kessels R, Mandjes IA, Kemper I, Agterof MJ, van der Steeg WA, Heijns JB, van Bekkum ML, Siemerink EJ, Kuijer PM, Scholten A, Wesseling J, Vrancken Peeters MJTFD, Mann RM, Sonke GS. MRI-guided optimisation of neoadjuvant chemotherapy duration in stage II-III HER2-positive breast cancer (TRAIN-3): a multicentre, single-arm, phase 2 study. Lancet Oncol 2024; 25:603-613. [PMID: 38588682 DOI: 10.1016/s1470-2045(24)00104-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Patients with stage II-III HER2-positive breast cancer have good outcomes with the combination of neoadjuvant chemotherapy and HER2-targeted agents. Although increasing the number of chemotherapy cycles improves pathological complete response rates, early complete responses are common. We investigated whether the duration of chemotherapy could be tailored on the basis of radiological response. METHODS TRAIN-3 is a single-arm, phase 2 study in 43 hospitals in the Netherlands. Patients with stage II-III HER2-positive breast cancer aged 18 years or older and a WHO performance status of 0 or 1 were enrolled. Patients received neoadjuvant chemotherapy consisting of paclitaxel (80 mg/m2 of body surface area on day 1 and 8 of each 21 day cycle), trastuzumab (loading dose on day 1 of cycle 1 of 8 mg/kg bodyweight, and then 6 mg/kg on day 1 on all subsequent cycles), and carboplatin (area under the concentration time curve 6 mg/mL per min on day 1 of each 3 week cycle) and pertuzumab (loading dose on day 1 of cycle 1 of 840 mg, and then 420 mg on day 1 of each subsequent cycle), all given intravenously. The response was monitored by breast MRI every three cycles and lymph node biopsy. Patients underwent surgery when a complete radiological response was observed or after a maximum of nine cycles of treatment. The primary endpoint was event-free survival at 3 years; however, follow-up for the primary endpoint is ongoing. Here, we present the radiological and pathological response rates (secondary endpoints) of all patients who underwent surgery and the toxicity data for all patients who received at least one cycle of treatment. Analyses were done in hormone receptor-positive and hormone receptor-negative patients separately. This trial is registered with ClinicalTrials.gov, number NCT03820063, recruitment is closed, and the follow-up for the primary endpoint is ongoing. FINDINGS Between April 1, 2019, and May 12, 2021, 235 patients with hormone receptor-negative cancer and 232 with hormone receptor-positive cancer were enrolled. Median follow-up was 26·4 months (IQR 22·9-32·9) for patients who were hormone receptor-negative and 31·6 months (25·6-35·7) for patients who were hormone receptor-positive. Overall, the median age was 51 years (IQR 43-59). In 233 patients with hormone receptor-negative tumours, radiological complete response was seen in 84 (36%; 95% CI 30-43) patients after one to three cycles, 140 (60%; 53-66) patients after one to six cycles, and 169 (73%; 66-78) patients after one to nine cycles. In 232 patients with hormone receptor-positive tumours, radiological complete response was seen in 68 (29%; 24-36) patients after one to three cycles, 118 (51%; 44-57) patients after one to six cycles, and 138 (59%; 53-66) patients after one to nine cycles. Among patients with a radiological complete response after one to nine cycles, a pathological complete response was seen in 147 (87%; 95% CI 81-92) of 169 patients with hormone receptor-negative tumours and was seen in 73 (53%; 44-61) of 138 patients with hormone receptor-positive tumours. The most common grade 3-4 adverse events were neutropenia (175 [37%] of 467), anaemia (75 [16%]), and diarrhoea (57 [12%]). No treatment-related deaths were reported. INTERPRETATION In our study, a third of patients with stage II-III hormone receptor-negative and HER2-positive breast cancer had a complete pathological response after only three cycles of neoadjuvant systemic therapy. A complete response on breast MRI could help identify early complete responders in patients who had hormone receptor negative tumours. An imaging-based strategy might limit the duration of chemotherapy in these patients, reduce side-effects, and maintain quality of life if confirmed by the analysis of the 3-year event-free survival primary endpoint. Better monitoring tools are needed for patients with hormone receptor-positive and HER2-positive breast cancer. FUNDING Roche Netherlands.
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Affiliation(s)
- Anna van der Voort
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Fleur M Louis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mette S van Ramshorst
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Rob Kessels
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Ingrid A Mandjes
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Inge Kemper
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mariette J Agterof
- Department of Medical Oncology, St Antonius Hospital, Nieuwegein, Netherlands
| | | | - Joan B Heijns
- Department of Medical Oncology, Amphia, Breda, Netherlands
| | | | - Ester J Siemerink
- Department of Medical Oncology, Ziekenhuisgroep Twente, Hengelo, Netherlands
| | | | - Astrid Scholten
- Department of Radiation, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology and Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Pathology, University Medical Centre, Leiden, Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Surgery, Amsterdam University Medical Centre, Amsterdam, Netherlands
| | - Ritse M Mann
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Medical Imaging, Radboud University Medical Center, Amsterdam, Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Medical Oncology, Amsterdam University Medical Centre, Amsterdam, Netherlands.
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Pislar N, Gasljevic G, Music MM, Borstnar S, Zgajnar J, Perhavec A. Axillary ultrasound for predicting response to neoadjuvant treatment in breast cancer patients-a single institution experience. World J Surg Oncol 2023; 21:292. [PMID: 37715188 PMCID: PMC10504742 DOI: 10.1186/s12957-023-03174-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/09/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND In node-positive breast cancer patients at diagnosis (cN +) that render node-negative after neoadjuvant systemic treatment (NAST), axillary lymph node dissection (ALND) can be avoided in selected cases. Axillary ultrasound (AUS) is most often used for re-staging after NAST. We aimed to determine sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AUS after NAST for predicting nodal response at the Institute of Oncology, Ljubljana. METHODS Biopsy-confirmed cN + patients consecutively diagnosed at our institution between 2008 and 2021, who received NAST, followed by surgery were identified retrospectively. Only patients that underwent AUS after NAST were included. AUS results were compared to definite nodal histopathology results. We calculated sensitivity, specificity, PPV and NPV of AUS. We also calculated the proportion of patients with false-positive AUS that results in surgical overtreatment (unnecessary ALND). RESULTS We identified 437 cN + patients. In 244 (55.8%) AUS after NAST was performed. Among those, 42/244 (17.2%) were triple negative (TN), 78/244 (32.0%) Her-2 positive (Her-2 +), and 124/244 (50,8%) luminal Her-2 negative cancers. AUS was negative in 179/244 (73.4%), suspicious/positive in 65/244 (26.6%) (11/42 (26.2%) TN, 19/78 (24.4%) Her-2 + , and 35/124 (28.2%) luminal Her-2 negative cancers). On definite histopathology, nodal complete response (pCR) was observed in 89/244 (36.5%) (19/42 (45.2%) TN, 55/78 (70.5%) Her-2 + , and 15/124 (12.1%) luminal Her-2 negative cancers). Among patients with suspicious/positive AUS, pCR was observed in 20/65 (30.8%) (6/11 (54.5%) TN, 13/19 (68.4%) Her-2 + and 1/35 (2.9%) luminal Her-2 negative cancers). Sensitivity was 29.0%, specificity 77,5%, PPV 69.2%, NPV 38.5%. Specificity and PPV in TN was 68.4% and 45.4%, in Her-2 + 76.4% and 31.6%, in luminal Her-2 negative 93,3% and 97,1%, respectively. CONCLUSION In approximately half of the patients, AUS falsely predicts nodal response after NAST and may lead to overtreatment in 30% of the cases (ALND). However, AUS has to be interpreted in context with tumor subtype. In luminal Her-2 negative cancers, it has a high PPV and is therefore useful.
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Affiliation(s)
- Nina Pislar
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Zaloska cesta 2, 1000, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Gorana Gasljevic
- Department of Pathology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Maja Marolt Music
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Department of Radiology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Simona Borstnar
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Janez Zgajnar
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Zaloska cesta 2, 1000, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Andraz Perhavec
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Zaloska cesta 2, 1000, Ljubljana, Slovenia.
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
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Wu SY, Li JW, Zhang Y, Wu HL, Mo M, Hu N, Shao ZM, Liu GY. Repeated core needle biopsy and targeted fine-needle aspiration to optimize axillary surgery after neoadjuvant chemotherapy in node-positive breast cancer: prospective clinical study. Br J Surg 2023; 110:1264-1266. [PMID: 37252942 DOI: 10.1093/bjs/znad106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/10/2023] [Accepted: 04/02/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Si-Yu Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian-Wei Li
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ying Zhang
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huai-Liang Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Miao Mo
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Cancer Prevention, Fudan University Shanghai Cancer Centre, Shanghai, China
| | - Na Hu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Ultrasound, Fudan University Shanghai Cancer Centre, Shanghai, China
| | - Zhi-Ming Shao
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Guang-Yu Liu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Banys-Paluchowski M, de Boniface J. Axillary staging in node-positive breast cancer converting to node negativity through neoadjuvant chemotherapy: Current evidence and perspectives. Scand J Surg 2023; 112:117-125. [PMID: 36642957 DOI: 10.1177/14574969221145892] [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] [Indexed: 01/17/2023]
Abstract
PURPOSE Over the recent years, axillary staging of initially node-positive breast cancer patients converting to clinical node negativity after neoadjuvant chemotherapy has seen rapid changes. This narrative review aims to give a contemporary overview over published evidence and clinical practice, and thus provide some guidance to the surgical community in the process of re-evaluating and re-shaping surgical practice. METHODS The search strategy aimed at finding relevant studies. Only articles in English were considered. RESULTS The introduction of modern techniques offer more precise staging surgery and thus hopefully reduced arm morbidity. Clinical practice has however diverged both within countries and internationally. While some countries have adapted de-escalated axillary staging techniques such as targeted axillary dissection, targeted lymph node biopsy or sentinel lymph node biopsy, others continue to recommend a full axillary lymph node dissection. With the implementation of new techniques, many questions arise, regarding aspects of oncological safety, technical performance, budget and practicality, patient selection and indications for different levels of axillary staging procedures. CONCLUSIONS There is a growing body of evidence on de-escalation of axillary surgery in the setting of cN+ → ycN0 breast cancer treated with neoadjuvant chemotherapy. However, standards differ between countries and future studies are necessary to fully assess the optimal strategy for these patients.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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Huang C, Zhu XD, Shen YH, Xu B, Wu D, Ji Y, Chen LL, Song TQ, Zhang W, Zeng ZM, Huang HS, Wang K, Huang LQ, Chen YJ, Yang YC, Zhou LD, Long G, Zhao HT, Wang YC, Ge NL, Chen Y, Tan CJ, Zhou J, Fan J, Sun HC. Radiographic and α-fetoprotein response predict pathologic complete response to immunotherapy plus a TKI in hepatocellular carcinoma: a multicenter study. BMC Cancer 2023; 23:416. [PMID: 37158833 PMCID: PMC10169382 DOI: 10.1186/s12885-023-10898-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Pathologic complete response (pCR) following preoperative systemic therapy is associated with improved outcomes after subsequent liver transplant/resection in hepatocellular carcinoma (HCC). However, the relationship between radiographic and histopathological response remains unclear. METHODS We retrospectively examined patients with initially unresectable HCC who received tyrosine kinase inhibitor (TKI) plus anti-programmed death 1 (PD-1) therapy before undergoing liver resection between March 2019 and September 2021 across 7 hospitals in China. Radiographic response was evaluated using mRECIST. A pCR was defined as no viable tumor cells in resected samples. RESULTS We included 35 eligible patients, of whom 15 (42.9%) achieved pCR after systemic therapy. After a median follow-up of 13.2 months, tumors recurred in 8 non-pCR and 1 pCR patient. Before resection, there were 6 complete responses, 24 partial responses, 4 stable disease cases, and 1 progressive disease case, per mRECIST. Predicting pCR by radiographic response yielded an area under the receiver operating characteristic curve (AUC) of 0.727 (95% CI: 0.558-0.902), with an optimal cutoff value of 80% reduction in the enhanced area in MRI (called major radiographic response), which had a 66.7% sensitivity, 85.0% specificity, and a 77.1% diagnostic accuracy. When radiographic response was combined with α-fetoprotein response, the AUC was 0.926 (95% CI: 0.785-0.999); the optimal cutoff value was 0.446, which had a 91.7% sensitivity, 84.6%, specificity, and an 88.0% diagnostic accuracy. CONCLUSIONS In patients with unresectable HCC receiving combined TKI/anti-PD 1 therapy, major radiographic response alone or combined with α-fetoprotein response may predict pCR.
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Affiliation(s)
- Cheng Huang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xiao-Dong Zhu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Ying-Hao Shen
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Bin Xu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Dong Wu
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Ji
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ling-Li Chen
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tian-Qiang Song
- Department of Hepatobiliary, Oncology Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Wei Zhang
- Department of Hepatobiliary, Oncology Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Zhi-Ming Zeng
- Department of Medical Oncology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Hua-Sheng Huang
- Department of Medical Oncology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Kui Wang
- Department of Hepatic Surgery II, Eastern Hepatobiliary Surgery Hospital, Navy Medical University, Shanghai, China
| | - Lan-Qing Huang
- Department of Hepatic Surgery II, Eastern Hepatobiliary Surgery Hospital, Navy Medical University, Shanghai, China
| | - Yong-Jun Chen
- Department of Hepatobiliary Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Chen Yang
- Department of Hepatobiliary Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Le-Du Zhou
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Guo Long
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Hai-Tao Zhao
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yun-Chao Wang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ling Ge
- Department of Hepatic Oncology, Liver Cancer Institute and Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Chen
- Department of Hepatic Oncology, Liver Cancer Institute and Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chang-Jun Tan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Jian Zhou
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Jia Fan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Hui-Chuan Sun
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Wu SY, Li JW, Wu HL, Shao ZM, Liu GY, Hu N. Accuracy of ultrasound-guided targeted fine-needle aspiration in assessing nodal response in node-positive breast cancer after neoadjuvant chemotherapy: prospective feasibility study. Br J Surg 2022; 109:1194-1197. [PMID: 36018290 DOI: 10.1093/bjs/znac277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/19/2022] [Accepted: 07/16/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Si-Yu Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian-Wei Li
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huai-Liang Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhi-Ming Shao
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Guang-Yu Liu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Na Hu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Ultrasound, Fudan University Shanghai Cancer Centre, Shanghai, China
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Comprehensive Review of Metastatic Breast Carcinoma in Cytology Specimens. JOURNAL OF MOLECULAR PATHOLOGY 2022. [DOI: 10.3390/jmp3040025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Breast carcinomas are known to metastasize to various organs of the human body. Fine needle aspiration cytology or exfoliative cytology often are the standard method for diagnosis at these metastatic sites due to ease of procurement of diagnostic material, accessibility, less complications, high sensitivity, and specificity of diagnosis and evaluation of biomarker status needed to guide future management. This comprehensive review article discusses in detail metastatic patterns, cytomorphology of metastatic breast cancer at different body sites, immunohistochemistry needed for diagnosis of breast carcinoma, sensitivity and specificity of diagnosis and breast biomarker assays in the cytology material.
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8
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Līcīte B, Irmejs A, Maksimenko J, Loža P, Trofimovičs G, Miklaševičs E, Nazarovs J, Romanovska M, Deičmane J, Irmejs R, Purkalne G, Gardovskis J. Ultrasound guided needle biopsy of axilla to evaluate nodal metastasis after preoperative systemic therapy in cohort of 106 breast cancers enriched with BRCA1/2 pathogenic variant carriers. Hered Cancer Clin Pract 2021; 19:30. [PMID: 34233740 PMCID: PMC8262039 DOI: 10.1186/s13053-021-00187-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/18/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Aim of the study is to evaluate the role of ultrasound guided fine needle aspiration cytology (FNAC) in the restaging of node positive breast cancer after preoperative systemic therapy (PST). METHODS From January 2016 - October 2020 106 node positive stage IIA-IIIC breast cancer cases undergoing PST were included in the study. 18 (17 %) were carriers of pathogenic variant in BRCA1/2. After PST restaging of axilla was performed with ultrasound and FNAC of the marked and/or the most suspicious axillary node. In 72/106 cases axilla conserving surgery and in 34/106 cases axillary lymph node dissection (ALND) was performed. RESULTS False Positive Rate (FPR) of FNAC after PST in whole cohort and BRCA1/2 positive subgroup is 8 and 0 % and False Negative Rate (FNR) - 43 and 18 % respectively. Overall Sensitivity - 55 %, specificity- 93 %, accuracy 70 %. CONCLUSION FNAC after PST has low FPR and is useful to predict residual axillary disease and to streamline surgical decision making regarding ALND both in BRCA1/2 positive and negative subgroups. FNR is high in overall cohort and FNAC alone are not able to predict ypCR and omission of further axillary surgery. However, FNAC performance in BRCA1/2 positive subgroup is more promising and further research with larger number of cases is necessary to confirm the results.
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Affiliation(s)
- Baiba Līcīte
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia.
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia.
| | - Arvīds Irmejs
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jeļena Maksimenko
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Pēteris Loža
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Genādijs Trofimovičs
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Edvīns Miklaševičs
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jurijs Nazarovs
- Department of Pathology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Māra Romanovska
- Department of Pathology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Justīne Deičmane
- Department of Radiology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Reinis Irmejs
- St John's College, University of Cambridge, Cambridge, England
| | - Gunta Purkalne
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Oncology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jānis Gardovskis
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
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9
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Xia C, Zhou Q, Zhang Q, Hu S, Meacci E, Matsuura Y, Durand M, Hu Q, Cai H, Wang Y. Comparative study on the diagnostic value of intravenous/peritumoral injection of indocyanine green for metastatic lymph node location in patients with head and neck squamous cell carcinoma (HNSCC). ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:507. [PMID: 33850904 PMCID: PMC8039712 DOI: 10.21037/atm-21-392] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Accurate assessment of regional lymph node (LN) status is essential for the treatment of head and neck squamous cell carcinoma (HNSCC) patients. In this study, we aimed to compare the difference between intravenous injection of indocyanine green (ICG) and peritumoral injection of ICG in the location of metastatic LNs. Methods Twenty-nine patients were enrolled in this study with 13 patients receiving intravenous injection of ICG and 16 patients receiving peritumoral injection of ICG. During the surgery, the fluorescence-positive LNs in vivo were sent to undergo frozen section after fluorescence intensity was recorded. After the cervical LN dissection, all LNs were sorted by region, and the fluorescence intensity was recorded before the LNs were sent for paraffin section. Results During the surgery, both intravenous or peritumoral injections with near-infrared (NIR) fluorescence imaging of ICG had their respective pros and cons in vivo, with the sensitivity and specificity being 62.5%/75% and 98.1%/89.1% respectively. After the surgery, both methods could reduce the pathological workload by preselecting the LNs at-risk in the premise of accurate assessing the cervical LN stage. However, intravenous ICG administration was more valuable in determining all types of LN status according to the fluorescence intensity [area under the curve (AUC): 0.91 vs. 0.78, P<0.001]. Conclusions With the assistance of NIR fluorescence imaging using ICG, both administration methods could reduce the postoperative complication and the pathological workload, whereas the intravenous mode of ICG administration is superior in application value.
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Affiliation(s)
- Chengwan Xia
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qunzhi Zhou
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qian Zhang
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Shiqi Hu
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Elisa Meacci
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yosuke Matsuura
- Department of Thoracic Surgical Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Marion Durand
- Ramsay Santé, Thoracic Unit, Hôpital Privé d'Antony, Antony, France
| | - Qingang Hu
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Huiming Cai
- Department of Biomedical Engineering, College of Engineering and Applied Sciences, Nanjing University, Nanjing, China
| | - Yuxin Wang
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
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10
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Postlewait LM, Teshome M, DeSnyder SM, Lim B, Kuerer HM, Bedrosian I, Woodward WA, Ueno NT, Lucci A. Factors Associated with Pathological Node Negativity in Inflammatory Breast Cancer: Are There Patients Who May be Candidates for a De-Escalation of Axillary Surgery? Ann Surg Oncol 2020; 27:4603-4612. [PMID: 32710271 DOI: 10.1245/s10434-020-08891-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/09/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Modified radical mastectomy (MRM), which includes axillary dissection, is the standard of care for inflammatory breast cancer (IBC). While more limited axillary staging after neoadjuvant chemotherapy (NAC) in clinically node-positive non-IBC has been increasingly adopted, the impact of these techniques in IBC is not clear. To inform patient selection for further study of limited axillary surgery, we aimed to describe the frequency and factors associated with pathological node-negativity (ypN0) in IBC. METHODS Patients with IBC who received NAC and MRM were identified from a prospective institutional database (2004-2019). Binary logistic regression analyses were conducted to identify factors associated with ypN0. RESULTS Of 453 patients, 189 (41.7%) had a post-NAC clinical nodal stage (ycN stage) of N0 (ycN1: 150, 33.1%; ycN2: 4, 0.9%; ycN3: 47, 10.4%; unknown: 63, 13.9%); 156 (34%) were ypN0. On multivariable analysis, higher tumor grade was not associated with ypN0 (odds ratio [OR] 1.59, 95% confidence interval [CI] 0.90-2.81, p =0.11). Compared with hormone receptor (HR)-negative/human epidermal growth factor receptor 2 (HER2)-negative tumors (n =113, 24.9%), HR-positive/HER2-negative tumors (n =169, 37.3%) had a trend toward less ypN0 (OR 0.55, 95% CI 0.29-1.02, p =0.06); HR-positive/HER2-positive tumors (n =79, 17.4%) were similar to HR-negative/HER2-negative tumors (OR 0.72, 95% CI 0.35-1.48, p =0.37); and HR-negative/HER2-positive tumors (n =92, 20.3%) were associated with increased ypN0 (OR 4.82, 95% CI 2.41-9.63, p <0.001). As ycN stage increased, the likelihood of ypN0 decreased compared with ycN0 patients (ycN1/2: OR 0.54, 95% CI 0.32-0.89, p =0.02; ycN3: OR 0.29, 95% CI 0.13-0.67, p =0.004). CONCLUSIONS One-third of patients with IBC who received NAC and MRM had pathologically negative nodes. Factors associated with ypN0 included ycN0 status and HR-negative/HER2-positive subtype. Large, prospective studies are needed to investigate the feasibility of alternative nodal evaluation strategies in IBC, with consideration to these subgroups.
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Affiliation(s)
- Lauren M Postlewait
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah M DeSnyder
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bora Lim
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy A Woodward
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Division of Radiation Oncology, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naoto T Ueno
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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11
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Kuhl CK, Lehman C, Bedrosian I. Imaging in Locoregional Management of Breast Cancer. J Clin Oncol 2020; 38:2351-2361. [PMID: 32442068 PMCID: PMC7343437 DOI: 10.1200/jco.19.03257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Constance Lehman
- Breast Imaging Section, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, Division of Surgery, University of Texas MD Anderson Cancer, Center, Houston, TX
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12
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Banys-Paluchowski M, Gruber IV, Hartkopf A, Paluchowski P, Krawczyk N, Marx M, Brucker S, Hahn M. Axillary ultrasound for prediction of response to neoadjuvant therapy in the context of surgical strategies to axillary dissection in primary breast cancer: a systematic review of the current literature. Arch Gynecol Obstet 2020; 301:341-353. [PMID: 31897672 DOI: 10.1007/s00404-019-05428-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Data on the optimal treatment strategy for patients undergoing neoadjuvant therapy (NAT) who initially presented with metastatic nodes and convert to node-negative disease (cN+ → ycN0) are limited. Since NAT leads to axillary downstaging in 20-60% of patients, the question arises whether these patients might be offered less-invasive procedures than axillary dissection, such as sentinel node biopsy or targeted removal of lymph nodes marked before therapy. METHODS We performed a systematic review of clinical studies on the use of axillary ultrasound for prediction of response to NAT and ultrasound-guided marking of metastatic nodes for targeted axillary dissection. RESULTS The sensitivity of ultrasound for prediction of residual node metastasis was higher than that of clinical examination and MRI/PET in most studies; specificity ranged in large trials from 37 to 92%. The diagnostic performance of ultrasound after NAT seems to be associated with tumor subtype: the positive predictive value was highest in luminal, the negative in triple-negative tumors. Several trials evaluated the usefulness of ultrasound for targeted axillary dissection. Before NAT, nodes were most commonly marked using ultrasound-guided clip placement, followed by ultrasound-guided placement of a radioactive seed. After chemotherapy, the clip was detected on ultrasound in 72-83% of patients; a comparison of sonographic visibility of different clips is lacking. Detection rate after radioactive seed placement was ca. 97%. CONCLUSION In conclusion, ultrasound improves prediction of axillary response to treatment in comparison to physical examination and serves as a reliable guiding tool for marking of target lymph nodes before the start of treatment. High quality and standardization of the examination is crucial for selection of patients for less-invasive surgery.
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Affiliation(s)
| | - Ines Verena Gruber
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Andreas Hartkopf
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics, Regio Klinikum Pinneberg, Pinneberg, Germany
| | - Natalia Krawczyk
- Department of Obstetrics and Gynecology, University of Düsseldorf, Düsseldorf, Germany
| | - Mario Marx
- Department for Women's Health, University of Tübingen, Tübingen, Germany.,Department of Plastic, Reconstructive and Breast Surgery, Elblandklinikum Radebeul, Radebeul, Germany
| | - Sara Brucker
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Markus Hahn
- Department for Women's Health, University of Tübingen, Tübingen, Germany
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13
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Wu S, Wang Y, Li J, Zhang N, Mo M, Klimberg S, Kaklamani V, Cochet A, Shao Z, Cheng J, Liu G. Subtype-Guided 18 F-FDG PET/CT in Tailoring Axillary Surgery Among Patients with Node-Positive Breast Cancer Treated with Neoadjuvant Chemotherapy: A Feasibility Study. Oncologist 2019; 25:e626-e633. [PMID: 32297448 DOI: 10.1634/theoncologist.2019-0583] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/25/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the value of 18 [F]-fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) in tailoring axillary surgery by predicting nodal response among patients with node-positive breast cancer after neoadjuvant chemotherapy (NAC). METHODS One hundred thirty-three patients with breast cancer with biopsy-confirmed nodal metastasis were prospectively enrolled. 18 F-FDG PET/CT scan was performed before NAC (a second one after two cycles with baseline maximum standardized uptake value [SUVmax ] ≥2.5), and a subset of patients underwent targeted axillary dissection (TAD). All the patients underwent axillary lymph node dissection (ALND). The accuracy was calculated by a comparison with the final pathologic results. RESULTS With the cutoff value of 2.5 for baseline SUVmax and 78.4% for change in SUVmax , sequential 18 F-FDG PET/CT scans demonstrated a sensitivity of 79.0% and specificity of 71.4% in predicting axillary pathologic complete response with an area under curve (AUC) of 0.75 (95% confidence interval, 0.65-0.84). Explorative subgroup analyses indicated little value for estrogen receptor (ER)-negative, human epidermal growth factor receptor 2 (HER2)-positive patients (AUC, 0.55; sensitivity, 56.5%; specificity, 50.0%). Application of 18 F-FDG PET/CT could spare 19 patients from supplementary ALNDs and reduce one of three false-negative cases in TAD among the remaining patients without ER-negative/HER2-positive subtype. CONCLUSION Application of the subtype-guided 18 F-FDG PET/CT could accurately predict nodal response and aid in tailoring axillary surgery among patients with node-positive breast cancer after NAC, which includes identifying candidates appropriate for TAD or directly proceeding to ALND. This approach might help to avoid false-negative events in TAD. IMPLICATIONS FOR PRACTICE This feasibility study showed that 18 [F]-fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) could accurately predict nodal response after neoadjuvant chemotherapy (NAC) among patients with breast cancer with initial nodal metastasis except in estrogen receptor-negative, human epidermal growth factor receptor 2-positive subtype. Furthermore, the incorporation of 18 F-FDG PET/CT can tailor subsequent axillary surgery by identifying patients with residual nodal disease, thus sparing those patients supplementary axillary lymph node dissection. Finally, we have proposed a possibly feasible flowchart involving 18 F-FDG PET/CT that might be applied in post-NAC axillary evaluation.
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Affiliation(s)
- Siyu Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Yujie Wang
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jianwei Li
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Na Zhang
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Miao Mo
- Clinical Statistics Center, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Suzanne Klimberg
- Division of Breast Surgical Oncology, Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Virginia Kaklamani
- Division of Hematology and Oncology, Northwestern University, Chicago, Illinois, USA
| | - Alexandre Cochet
- Department of Nuclear Medicine, Centre Georges-François Leclerc, University Hospital of Dijon, Dijon, France
| | - Zhiming Shao
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Jingyi Cheng
- Department of Nuclear Medicine, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Guangyu Liu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
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14
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Sun S, van la Parra RFD, Rauch GM, Checka C, Tadros AB, Lucci A, Teshome M, Black D, Hwang RF, Smith BD, Krishnamurthy S, Valero V, Yang WT, Kuerer HM. Patient Selection for Clinical Trials Eliminating Surgery for HER2-Positive Breast Cancer Treated with Neoadjuvant Systemic Therapy. Ann Surg Oncol 2019; 26:3071-3079. [PMID: 31342361 DOI: 10.1245/s10434-019-07533-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with epidermal growth factor receptor 2-positive (HER2+) breast cancer and pathologic complete response (pCR) after neoadjuvant systemic therapy (NST) may be candidates for nonoperative clinical trials if residual invasive and in situ disease are eradicated. METHODS This study analyzed 280 patients with clinical T1-2N0-1 HER2+ breast cancer who underwent NST followed by surgical resection to determine key characteristics of patients with pCR in the breast and lymph nodes compared with those with residual disease. RESULTS Of the 280 patients, 102 (36.4%) had pCR in the breast and lymph nodes after NST, and 50 patients (17.9%) had residual ductal carcinoma in situ (DCIS) in the breast only. For 129 patients (46.1%), DCIS was present on the pretreatment biopsy, and NST failed to eradicate the DCIS component in 64.3%. Patients with residual disease were more likely to have hormone receptor-positive (HR+) tumors than those with negative tumors (73.4% vs. 50.8%; p < 0.0001). Radiologic response (odds ratio [OR], 5.62; p = 0.002) and HR+ status (OR, 2.56; p < 0.0001) were predictive of residual disease. Combined imaging methods after NST had a sensitivity of 97.1% and a negative predictive value of 70.6% for detection of residual disease. Patients with invasive disease and DCIS shown on the pretreatment core biopsy were less likely than those without DCIS to achieve pCR in the breast (31% vs. 43%; p = 0.038). CONCLUSION The study results delineate and identify unique characteristics associated with HER2+ breast cancers that are important in selecting patients for inclusion in clinical trials assessing nonoperative management after NST, and the low negative predictive value of imaging mandates image-guided biopsy for selection.
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MESH Headings
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Carcinoma, Intraductal, Noninfiltrating/metabolism
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Female
- Follow-Up Studies
- Humans
- Image-Guided Biopsy/methods
- Lymph Nodes/pathology
- Mastectomy/statistics & numerical data
- Middle Aged
- Neoadjuvant Therapy/methods
- Neoplasm, Residual/drug therapy
- Neoplasm, Residual/metabolism
- Neoplasm, Residual/pathology
- Patient Selection
- Prognosis
- Prospective Studies
- Receptor, ErbB-2/metabolism
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Affiliation(s)
- Susie Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raquel F D van la Parra
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gaiane M Rauch
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina Checka
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Audree B Tadros
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dalliah Black
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rosa F Hwang
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Savitri Krishnamurthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vicente Valero
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei T Yang
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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15
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Racz JM, Caudle AS. Sentinel Node Lymph Node Surgery After Neoadjuvant Therapy: Principles and Techniques. Ann Surg Oncol 2019; 26:3040-3045. [PMID: 31342394 DOI: 10.1245/s10434-019-07591-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Indexed: 02/05/2023]
Abstract
Surgical management of the axilla in breast cancer has been a topic of great interest. While sentinel lymph node biopsy (SLNB) is an established approach for patients undergoing surgical treatment as the first element of their care, there is continued debate regarding surgical management of the axilla in patients receiving neoadjuvant chemotherapy (NAC). In clinically node-negative patients, it has been debated whether or not SLNB should be performed before chemotherapy to accurately determine the clinical stage, or after chemotherapy, thus prioritizing the response to therapy and potentially minimizing axillary surgery. Node-positive patients have undergone axillary lymph node dissection in the past, however this paradigm has been challenged in recent years. Thus, surgeons must understand the importance of accurate axillary information both before and after NAC, and its role in multidisciplinary planning. We present a summary of the data surrounding axillary management in patients receiving NAC, and recommendations for surgical technique.
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Affiliation(s)
| | - Abigail S Caudle
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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