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van Amstel FJG, de Mooij CM, Simons JM, Mitea C, van Diest PJ, Nelemans PJ, van der Pol CC, Luiten EJT, Koppert LB, Smidt ML, van Nijnatten TJA. Disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and molecular subtype: prediction of axillary treatment response after neoadjuvant systemic therapy for breast cancer. Br J Surg 2024; 111:znae203. [PMID: 39302345 DOI: 10.1093/bjs/znae203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/19/2024] [Accepted: 07/23/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT combined with pathological axillary treatment response has been proposed to guide de-escalation of axillary treatment for clinically node-positive breast cancer patients treated with neoadjuvant systemic therapy. The aim of this study was to assess whether axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and breast cancer molecular subtype are predictors of axillary pCR. METHODS This study included clinically node-positive patients treated with neoadjuvant systemic therapy in the prospective Radioactive Iodine Seed placement in the Axilla with Sentinel lymph node biopsy ('RISAS') trial (NCT02800317) with baseline [18F]fluorodeoxyglucose PET/CT imaging available. The predictive value of axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and breast cancer molecular subtype to estimate axillary pCR was evaluated using logistic regression analysis. Discriminative ability is expressed using ORs with 95% confidence intervals. RESULTS Overall, 185 patients were included, with an axillary pCR rate of 29.7%. The axillary pCR rate for patients with limited versus advanced baseline axillary disease according to [18F]fluorodeoxyglucose PET/CT was 31.9% versus 26.1% respectively. Axillary disease extent was not a significant predictor of axillary pCR (OR 0.75 (95% c.i. 0.38 to 1.46) (P = 0.404)). There were significant differences in axillary pCR rates between breast cancer molecular subtypes. The lowest probability (7%) was found for hormone receptor+/human epidermal growth factor receptor 2- tumours. Using this category as a reference group, significantly increased ORs of 14.82 for hormone receptor+/human epidermal growth factor receptor 2+ tumours, 40 for hormone receptor-/human epidermal growth factor receptor 2+ tumours, and 6.91 for triple-negative tumours were found (P < 0.001). CONCLUSION Molecular subtype is a significant predictor of axillary pCR after neoadjuvant systemic therapy, whereas axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT is not.
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Affiliation(s)
- Florien J G van Amstel
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Cornelis M de Mooij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Janine M Simons
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
- Department of Radiotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Cristina Mitea
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patty J Nelemans
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | | | - Ernest J T Luiten
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
- Tawam Breast Care Center, Tawam Hospital, Al Ain, United Arab Emirates
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Thiemo J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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van Nijnatten TJA, Morscheid S, Baltzer PAT, Clauser P, Alcantara R, Kuhl CK, Wildberger JE. Contrast-enhanced breast imaging: Current status and future challenges. Eur J Radiol 2024; 171:111312. [PMID: 38237520 DOI: 10.1016/j.ejrad.2024.111312] [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: 12/21/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Contrast-enhanced breast MRI and recently also contrast-enhanced mammography (CEM) are available for breast imaging. The aim of the current overview is to explore existing evidence and ongoing challenges of contrast-enhanced breast imaging. METHODS This narrative provides an introduction to the contrast-enhanced breast imaging modalities breast MRI and CEM. Underlying principle, techniques and BI-RADS reporting of both techniques are described and compared, and the following indications and ongoing challenges are discussed: problem-solving, high-risk screening, supplemental screening in women with extremely dense breast tissue, breast implants, neoadjuvant systemic therapy (NST) response monitoring, MRI-guided and CEM- guided biopsy. RESULTS Technique and reporting for breast MRI are standardised, for the newer CEM standardisation is in progress. Similarly, compared to other modalities, breast MRI is well established as superior for problem-solving, screening women at high risk, screening women with extremely dense breast tissue or with implants; and for monitoring response to NST. Furthermore, MRI-guided biopsy is a reliable technique with low long-term false negative rates. For CEM, data is as yet either absent or limited, but existing results in these settings are promising. CONCLUSION Contrast-enhanced breast imaging achieves highest diagnostic performance and should be considered essential. Of the two contrast-enhanced modalities, evidence of breast MRI superiority is ample, and preliminary results on CEM are promising, yet CEM warrants further study.
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Affiliation(s)
- T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - S Morscheid
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
| | - P A T Baltzer
- Department of Biomedical Imaging and Image-Guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Vienna, Austria
| | - P Clauser
- Department of Biomedical Imaging and Image-Guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Vienna, Austria
| | - R Alcantara
- Radiology and Nuclear Medicine Department, Hospital del Mar, Barcelona, Spain
| | - C K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
| | - J E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
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Guo X, Zhang J, Gong X, Wang J, Dai H, Jiao D, Ling R, Zhao Y, Yang H, Liu Y, Liu K, Zhang J, Mao D, He J, Yu Z, Liu Y, Fu P, Wang J, Jiang H, Zhao Z, Tian X, Cao Z, Wu K, Song A, Jin F, Fan Z, Liu Z. Axillary lymph node dissection in triple-negative or HER2-positive breast cancer patients with clinical N2 achieving pathological complete response after neoadjuvant therapy: Is it necessary? Breast 2024; 73:103671. [PMID: 38277714 PMCID: PMC10832498 DOI: 10.1016/j.breast.2024.103671] [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: 11/09/2023] [Revised: 12/26/2023] [Accepted: 01/05/2024] [Indexed: 01/28/2024] Open
Abstract
AIM This study aims to identify suitable candidates for axillary sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) among clinical N2 (cN2) triple-negative (TN) or HER2 positive (HER2+)breast cancer patients following neoadjuvant therapy(NAT). BACKGROUND Despite the substantial axillary burden in cN2 breast cancer patients, high pathological response rates can be achieved with NAT in TN or HER2+ subtypes, thus enabling potential downstaging of axillary surgery. METHODS A retrospective analysis was conducted on data from the CSBrS-012 study, screening 709 patients with initial cN2, either HER2+ or TN subtype, from January 1, 2010 to December 31, 2020. The correlation between axillary pathologic complete response (pCR) (yPN0) and breast pCR was examined. RESULTS Among the 177 cN2 patients who achieved breast pCR through NAT, 138 (78.0 %) also achieved axillary pCR. However, in the 532 initial clinical N2 patients who did not achieve breast pCR, residual axillary lymph node metastasis persisted in 77.4 % (412/532) of cases. The relative risk of residual axillary lymph node metastasis in patients who did not achieve breast pCR was 12.4 (8.1-19.1), compared to those who did achieve breast pCR, P < 0.001. CONCLUSION For cN2 TN or HER2+ breast cancer patients who achieve breast pCR following NAT, consideration could be given to downstaging and performing an axillary SLNB or TAD.
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Affiliation(s)
- Xuhui Guo
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Jiao Zhang
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Xilong Gong
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Jia Wang
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Hao Dai
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Dechuang Jiao
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Rui Ling
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Yi Zhao
- Surgical Oncology Department, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110022, China
| | - Hongjian Yang
- Department of Breast Surgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang Province, 310022, China
| | - Yunjiang Liu
- Department of Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 052360, China
| | - Ke Liu
- Fourth Department of Breast Surgery, Jilin Cancer Hospital. Changchun, Jilin Province, 130012, China
| | - Jianguo Zhang
- Department of Breast Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150086, China
| | - Dahua Mao
- Department of Breast Surgery, Affiliated Wudang Hospital of Guizhou Medical University, Guiyang, Guizhou Province, 550009, China
| | - Jianjun He
- Department of Breast Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China
| | - Zhigang Yu
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, 250033, China
| | - Yinhua Liu
- Breast Disease Center, Peking University First Hospital, Beijing, 100034, China
| | - Peifen Fu
- Department of Breast Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, 310003, China
| | - Jiandong Wang
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, 100852, China
| | - Hongchuan Jiang
- Department of Breast Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Zuowei Zhao
- Department of Breast Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, 116023, China
| | - Xingsong Tian
- Department of Breast and Thyroid Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, 250021, China
| | - Zhongwei Cao
- Department of Thyroid, Breast, Hernia Surgery, The Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia Autonomous Region, 010017, China
| | - Kejin Wu
- Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200433, China
| | - Ailin Song
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu Province, 730000, China
| | - Feng Jin
- Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, 110002, China
| | - Zhimin Fan
- Department of Breast Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, 130021, China
| | - Zhenzhen Liu
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China.
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Siso C, Esgueva A, Rivero J, Morales C, Miranda I, Peg V, Gil-Moreno A, Espinosa-Bravo M, Rubio IT. Feasibility and safety of targeted axillary dissection guided by intraoperative ultrasound after neoadjuvant treatment. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106938. [PMID: 37244843 DOI: 10.1016/j.ejso.2023.05.013] [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: 02/08/2023] [Revised: 04/07/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Axillary management in cN + axillary nodes after neoadjuvant systemic therapy (NST) in breast cancer (BC) remains under research with the aim of de-escalation of axillary node dissection (ALND). Several axillary guided localization techniques have been reported. This study evaluates the safety of intraoperative ultrasound (IOUS) guided targeted axillary dissection (TAD) in a large sample after the results of ILINA trial. MATERIALS Prospective data have been collected from October 2015 to June 2022 in patients with cT0-T4 and positive axillary lymph nodes (cN1) treated with NST. Before NST, an ultrasound visible marker was placed into the positive node. After NST, IOUS guided TAD was performed including sentinel node biopsy (SLN). Until December 2019, all patients underwent an ALND after TAD procedure. From January 2020, ALND was spared in those patients with an axillary pathological complete response (pCR). RESULTS 235 patients were included. pCR (ypT0/is ypN0) was achieved in 29% patients. Identification rate (IR) of the clipped node by IOUS was 96% (95% IC, 92.5-98.1%) and IR of SLN was 95% (95% IC, 90.8-97.2%). False negative rate (FNR) for TAD procedure (SLN + clipped node) was 7.0% (95% IC, 2.3-15.7%), which decreased to 4.9% when a total of 3 or more nodes were removed. Axillary ultrasound before surgery assessed residual disease with an AUC of 0.5241. Residual axillary disease tend to be the most significant factor for axillary recurrences. CONCLUSIONS This study confirms the feasibility, safety and accuracy of IOUS guided surgery for axillary staging after NST in node positive BC patients.
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Affiliation(s)
- Christian Siso
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Antonio Esgueva
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Joaquin Rivero
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Clara Morales
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Ignacio Miranda
- Departament of Radiology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Vicente Peg
- Departament of Pathology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Antonio Gil-Moreno
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Martin Espinosa-Bravo
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Isabel T Rubio
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain.
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García-Calvo L, Martí Álvarez C, Gutiérrez AH, García AB, Muñoz RA, Sánchez-Méndez JI. Sentinel Node Biopsy in Patients With Breast Carcinoma Without Axillary Involvement at Diagnosis Receiving Primary Systemic Therapy. Clin Breast Cancer 2023:S1526-8209(23)00140-4. [PMID: 37331894 DOI: 10.1016/j.clbc.2023.05.018] [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: 04/24/2023] [Revised: 05/27/2023] [Accepted: 05/27/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Primary systemic therapy (PST) has acquired great importance in breast cancer (BC) in the last few years. In this scenario, even if it is accepted to perform SLNB before PST, most of the guidelines remark the advantages of this practice after it, such as avoiding another surgery to the patient, a rapid start of the treatment and no need of axillary dissection in cases of pathologic complete response (pCR). Nevertheless, the lack of knowledge of the initial axillary state and the need to practice axillary dissection with any axillary disease are claimed to be some other disadvantages. There are no randomized studies yet that can conclude the optimal timing of SLNB in PST, so for the moment we may settle for our common practice. PATIENTS AND METHODS We studied all the cases attended in the Breast Unit that joined the inclusion criteria between 2011 and 2019 in our hospital and we compared the group with SLNB before PST with the group with SLNB after PST in terms of unnecessary axillary dissection and description features. RESULTS We included 223 female patients diagnosed with BC and without clinical nor radiological axillary disease (cN0), who had received NAC and SLNB performed before or after it. We observed a higher proportion of high-grade histological tumors (G3), tumors with aggressive phenotypes (Basal like and Her 2 enriched), and younger women in the group of SLNB before NAC compared with the SLNB after NAC group (P < .01). Despite this, we did not find any difference in the number of positive SLNBs or in the number of ALND performed between the 2 groups. We found a higher proportion of ALND with all the lymph node (LN) negatives in the SLNB before NAC group. CONCLUSION Taking into account that in the observation period we did not use ACOSOG Z0011 criteria with all the SLNBs, we figure out what would have been the real results nowadays following these criteria. In this scenario we conclude that patients with luminal phenotype seemed to benefit from practicing SLNB before NAC in terms of avoiding axillary dissections. We could not make any conclusion in the rest of the phenotypes. However, prospective studies are needed to confirm if this affirmation could be proved.
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Affiliation(s)
- Laura García-Calvo
- Department of Gynecology and Obstetrics, Breast Pathology Unit, Campo Grande Hospital, Valladolid, Spain.
| | - Covadonga Martí Álvarez
- Department of Gynecology and Obstetrics, Breast Pathology Unit, La Paz University Hospital, Madrid, Spain
| | - Alicia Hernández Gutiérrez
- Universidad Autónoma Department, Madrid, Spain; Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain; Gynecology and Obstetrics Department, Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | | | - Rocío Arnedo Muñoz
- Gynecology and Obstetrics Department, Rey Juan Carlos University Hospital, Madrid, Spain
| | - José I Sánchez-Méndez
- Department of Gynecology and Obstetrics, Breast Pathology Unit, La Paz University Hospital, Madrid, Spain; Universidad Autónoma Department, Madrid, Spain; Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain
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Ma L, Chen H, He J, Xie P, Gao P, Li Y, Zhang H, Fan Z. The nodal positivity rate in breast pCR patients with initially, clinically node-negative breast cancer after neoadjuvant systemic therapy: A systematic review and meta-analysis. Front Oncol 2023; 13:1167912. [PMID: 37064127 PMCID: PMC10090490 DOI: 10.3389/fonc.2023.1167912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
BackgroundThe axillary lymph node positive (ypN+) rate in patients with clinically node-negative (cN0) breast cancer who have achieved breast pathologic complete response (bpCR) after neoadjuvant systemic therapy (NST) is extremely low, and this population has the potential to be exempt from sentinel lymph node biopsy (SLNB). However, an overview of the ypN+ rate in this population for different breast cancer subtypes is lacking.ObjectiveTo provide the pooled ypN+ rate in cN0 patients who achieved bpCR after NST in different breast cancer subtypes defined by hormone receptor (HR) status and human epidermal growth factor receptor 2 (HER2) status.MethodsA systematic literature search was conducted in Embase and PubMed on July 20, 2022. Two authors independently selected studies that met the inclusion criteria and extracted all data. The pooled ypN+ rates for each subtype were calculated by a random-effects model using the Stata 16.0 metaprop command.ResultsThe pooled analysis of 9609 cN0 patients who achieved bpCR showed that the ypN+ rate was lowest for the HR+/HER2+ (0%) subtype, followed by HR+/HER2- (5.1%), HR-/HER2+ (0.6%), and HR-/HER2- (0.3%). Additionally, 6571 cT1-T2N0 patients who achieved bpCR had a pooled ypN+ rate of 0.6%, and the ypN+ rates for different subtypes were as follows: HR+/HER2+ (1.7%), HR+/HER2- (2.7%), HR-/HER2+ (0.1%), and HR-/HER2- (0.8%).ConclusionOur results suggested that cN0 patients who achieve bpCR may be exempt from axillary surgery in the HR+/HER2-, HR+/HER2+, and HR-/HER2- subtypes because of the extremely low probability of residual axillary lymph node disease. However, the safety of omitting axillary surgery needs to be further confirmed by prospective studies.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD42022351739.
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Affiliation(s)
- Le Ma
- Department of Breast Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun, Jilin, China
| | - Heyan Chen
- Department of Breast Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Jianjun He
- Department of Breast Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Peiling Xie
- Department of Breast Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Pin Gao
- Department of Breast Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun, Jilin, China
| | - Yijun Li
- Department of Breast Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Huimin Zhang
- Department of Breast Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
- *Correspondence: Zhimin Fan, ; Huimin Zhang,
| | - Zhimin Fan
- Department of Breast Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun, Jilin, China
- *Correspondence: Zhimin Fan, ; Huimin Zhang,
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De-Escalating the Management of In Situ and Invasive Breast Cancer. Cancers (Basel) 2022; 14:cancers14194545. [PMID: 36230468 PMCID: PMC9559495 DOI: 10.3390/cancers14194545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022] Open
Abstract
Simple Summary De-escalation of breast cancer treatment reduces morbidity and toxicity for patients. De-escalation is safe if cancer outcomes, such as recurrence and survival, remain unaffected compared to more radical regimens. This review provides an overview on treatment de-escalation for ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments have facilitated de-escalation of treatment over time. Abstract It is necessary to identify appropriate areas of de-escalation in breast cancer treatment to minimize morbidity and maximize patients’ quality of life. Less radical treatment modalities, or even no treatment, have been reconsidered if they offer the same oncologic outcomes as standard therapies. Identifying which patients benefit from de-escalation requires particular care, as standard therapies will continue to offer adequate cancer outcomes. We provide an overview of the literature on the de-escalation of treatment of ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. De-escalation of breast cancer treatment is a key area of investigation that will continue to remain a priority. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments will expand this even further. Future efforts will continue to challenge us to consider the true role of various treatment modalities.
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Rubio IT, Sobrido C. Neoadjuvant approach in patients with early breast cancer: patient assessment, staging, and planning. Breast 2022; 62 Suppl 1:S17-S24. [PMID: 34996668 PMCID: PMC9097809 DOI: 10.1016/j.breast.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022] Open
Abstract
Neoadjuvant treatment (NAT) has become an option in early stage (stage I-II) breast cancer (EBC). New advances in systemic and targeted therapies have increased rates of pathologic complete response increasing the number of patients undergoing NAT. Clear benefits of NAT are downstaging the tumor and the axillary nodes to de-escalate surgery and to evaluate response to treatment. Selection of patients for NAT in EBC rely in several factors that are related to patient characteristics (i.e, age and comorbidities), to tumor histology, to stage at diagnosis and to the potential changes in surgical or adjuvant treatments when NAT is administered. Imaging and histologic confirmation is performed to assess extent of disease y to confirm diagnosis. Besides mammogram and ultrasound, functional breast imaging MRI has been incorporated to better predict treatment response and residual disease. Contrast enhanced mammogram (CEM), shear wave elastography (SWE), or Dynamic Optical Breast Imaging (DOBI) are emerging techniques under investigation for assessment of response to neoadjuvant therapy as well as for predicting response. Surgical plan should be delineated after NAT taking into account baseline characteristics, tumor response and patient desire. In the COVID era, we have witnessed also the increasing use of NAT in patients who may be directed to surgery, unable to have it performed as surgery has been reserved for emergency cases only.
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Liu H, Lv L, Gao H, Cheng M. Pathologic Complete Response and Its Impact on Breast Cancer Recurrence and Patient's Survival after Neoadjuvant Therapy: A Comprehensive Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:7545091. [PMID: 35003324 PMCID: PMC8741368 DOI: 10.1155/2021/7545091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Earlier research has illustrated prognostic significance of pathologic complete response (pCR) in neoadjuvant therapy (NAT) for breast cancer, whereas correlation between treatment after achieving pCR and survival improvement remains underexplored. We attempted to measure the relation between pCR achieved after NAT and breast cancer recurrence or patient's survival. METHODS We searched PubMed, EMBASE, Web of Science, and The Cochrane Library databases to find relevant articles from their inception to November 2020. According to eligibility criteria, studies were selected and basic data were extracted. The primary endpoint was the correlation between pCR achieved after NAT and event-free survival (EFS) or overall survival (OS). The results were obtained by directly extracting specific information from the literature or estimating individual data by survival curves on DigitizeIt software, presented with HR and 95% CI. All data were processed on Stata 14.0 software. RESULTS Among 4338 articles, there were 25 eligible articles involving 8767 patients. The EFS of patients achieved pCR after NAT improved obviously (HR = 0.27; 95% CI, 0.24-0.31), especially in triple negative (HR = 0.17; 95% CI, 0.12-0.24) and HER2 positive (HR = 0.24; 95% CI, 0.20-0.30) breast cancer patients. As such, pCR after NAT was implicated in significantly increased OS (HR = 0.32; 95% CI, 0.27-0.37). CONCLUSION Achieving pCR after NAT was notably related to the improvement of EFS and OS, especially for patients with triple-negative and HER2-positive breast cancer. pCR can be a surrogate indicator for outcome of breast cancer patients after NAT, as well as a predictor of treatment efficacy after NAT. Besides, well-designed studies are still warranted for confirmation.
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Affiliation(s)
- Hui Liu
- Department of Breast Surgery, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, Guangxi Province, China
| | - Liqiong Lv
- Department of Breast Surgery, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, Guangxi Province, China
| | - Hui Gao
- Department of Breast Surgery, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, Guangxi Province, China
| | - Ming Cheng
- Department of Breast Surgery, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, Guangxi Province, China
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Martínez-Jaimez P, Armora Verdú M, Forero CG, Álvarez Salazar S, Fuster Linares P, Monforte-Royo C, Masia J. Breast cancer-related lymphoedema: Risk factors and prediction model. J Adv Nurs 2021; 78:765-775. [PMID: 34363640 DOI: 10.1111/jan.15005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/08/2021] [Accepted: 07/24/2021] [Indexed: 12/30/2022]
Abstract
AIMS To identify the risk factors for lymphoedema following axillary lymph node dissection (ALND) in a European sample and to propose a lymphoedema prediction model for this population. DESIGN Predictive retrospective cohort study comparing women who developed lymphoedema in 2 years of undergoing ALND with those who did not developed lymphoedema. METHODS We reviewed the clinical records of 504 women who, between January 2008 and May 2018, underwent surgery for breast cancer that involved ALND. Logistic regression was used to identify significant risk factors for lymphoedema. The prediction accuracy of the model was assessed by calculating the area under the receiver operating characteristic curve. RESULTS Of the 504 women whose records were analysed, 156 developed lymphoedema. Significant predictors identified in the regression model were level of lymph node dissection, lymph node status, post-operative complications, body mass index (BMI) and number of lymph nodes extracted. The prediction model showed good sensitivity (80%) in the study population. CONCLUSIONS The factor contributing most to the risk of lymphoedema was the level of lymph node dissection, and the only patient-related factor in the prediction model was BMI. The model offers good predictive capacity in this population and it is a simple tool that breast care units could use to assess the risk of lymphoedema following ALND. Nurses with specialist knowledge of lymphoedema have a key role to play in ensuring that women receive holistic and individualized care. IMPACT What problem did the study address? Secondary lymphoedema is one of the main complications in the treatment of breast cancer. What were the main findings? The prediction model included five factors associated with the risk of lymphoedema following ALND. The strongest predictor was the level of lymph node dissection, and the only patient-related factor was BMI. Where and on whom will the research have an impact? The prediction model offers breast care units a tool for assessing the risk of lymphoedema in women undergoing surgery involving ALND. The results highlight the importance of weight reduction as a preventive measure and support a more conservative surgical approach.
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Affiliation(s)
- Patricia Martínez-Jaimez
- Breast Reconstruction and Lymphoedema Surgery Unit, Clínica Planas, Barcelona, Spain.,Nursing Department. Faculty of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Miriam Armora Verdú
- Nursing Department, Hospital de la Santa Creu i Sant Pau, Universitat Autonòma de Barcelona, Barcelona, Spain
| | - Carlos G Forero
- Department of Medicine. Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Samantha Álvarez Salazar
- Department of Medicine. Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Pilar Fuster Linares
- Nursing Department. Faculty of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Cristina Monforte-Royo
- Nursing Department. Faculty of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Jaume Masia
- Breast Reconstruction and Lymphoedema Surgery Unit, Clínica Planas, Barcelona, Spain.,Nursing Department, Hospital de la Santa Creu i Sant Pau, Universitat Autonòma de Barcelona, Barcelona, Spain.,Department of Plastic Surgery, Hospital del Mar, Barcelona, Spain
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11
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Banys-Paluchowski M, Gasparri ML, de Boniface J, Gentilini O, Stickeler E, Hartmann S, Thill M, Rubio IT, Di Micco R, Bonci EA, Niinikoski L, Kontos M, Karadeniz Cakmak G, Hauptmann M, Peintinger F, Pinto D, Matrai Z, Murawa D, Kadayaprath G, Dostalek L, Nina H, Krivorotko P, Classe JM, Schlichting E, Appelgren M, Paluchowski P, Solbach C, Blohmer JU, Kühn T. Surgical Management of the Axilla in Clinically Node-Positive Breast Cancer Patients Converting to Clinical Node Negativity through Neoadjuvant Chemotherapy: Current Status, Knowledge Gaps, and Rationale for the EUBREAST-03 AXSANA Study. Cancers (Basel) 2021; 13:1565. [PMID: 33805367 PMCID: PMC8037995 DOI: 10.3390/cancers13071565] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022] Open
Abstract
In the last two decades, surgical methods for axillary staging in breast cancer patients have become less extensive, and full axillary lymph node dissection (ALND) is confined to selected patients. In initially node-positive patients undergoing neoadjuvant chemotherapy, however, the optimal management remains unclear. Current guidelines vary widely, endorsing different strategies. We performed a literature review on axillary staging strategies and their place in international recommendations. This overview defines knowledge gaps associated with specific procedures, summarizes currently ongoing clinical trials that address these unsolved issues, and provides the rationale for further research. While some guidelines have already implemented surgical de-escalation, replacing ALND with, e.g., sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) in cN+ patients converting to clinical node negativity, others recommend ALND. Numerous techniques are in use for tagging lymph node metastasis, but many questions regarding the marking technique, i.e., the optimal time for marker placement and the number of marked nodes, remain unanswered. The optimal number of SLNs to be excised also remains a matter of debate. Data on oncological safety and quality of life following different staging procedures are lacking. These results provide the rationale for the multinational prospective cohort study AXSANA initiated by EUBREAST, which started enrollment in June 2020 and aims at recruiting 3000 patients in 20 countries (NCT04373655; Funded by AGO-B, Claudia von Schilling Foundation for Breast Cancer Research, AWOgyn, EndoMag, Mammotome, and MeritMedical).
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, Campus Lübeck, University Hospital of Schleswig Holstein, 23538 Lübeck, Germany
- Medical Faculty, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, 6900 Lugano, Switzerland;
- Faculty of Biomedicine, University of the Italian Switzerland (USI), 6900 Lugano, Switzerland
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden; (J.d.B.); (M.A.)
- Department of Surgery, Capio St. Göran’s Hospital, 112 19 Stockholm, Sweden
| | - Oreste Gentilini
- Breast Surgery Unit, San Raffaele Hospital Milan, 20132 Milano MI, Italy; (O.G.); (R.D.M.)
| | - Elmar Stickeler
- Department of Gynecology and Obstetrics, University Hospital Aachen, 52074 Aachen, Germany;
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, 18059 Rostock, Germany;
| | - Marc Thill
- Department of Gynecology and Gynecological Oncology, AGAPLESION Markus Krankenhaus, 60431 Frankfurt am Main, Germany;
| | - Isabel T. Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, 28027 Madrid, Spain;
| | - Rosa Di Micco
- Breast Surgery Unit, San Raffaele Hospital Milan, 20132 Milano MI, Italy; (O.G.); (R.D.M.)
| | - Eduard-Alexandru Bonci
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania;
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Laura Niinikoski
- Breast Surgery Unit, Comprehensive Cancer Center, Helsinki University Hospital, University of Helsinki, 00280 Helsinki, Finland;
| | - Michalis Kontos
- 1st Department of Surgery, Laiko Hospital, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Guldeniz Karadeniz Cakmak
- Breast and Endocrine Unit, General Surgery Department, Zonguldak BEUN The School of Medicine, Kozlu/Zonguldak 67600, Turkey;
| | - Michael Hauptmann
- Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany;
| | | | - David Pinto
- Champalimaud Clinical Center, Breast Unit, Champalimaud Foundation, 1400-038 Lisboa, Portugal;
| | - Zoltan Matrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, 1122 Budapest, Hungary;
| | - Dawid Murawa
- Collegium Medicum, University of Zielona Góra, 65-046 Zielona Góra, Poland;
| | - Geeta Kadayaprath
- Breast Surgical Oncology and Oncoplastic Surgery, Max Institute of Cancer Care, Max Healthcare Delhi, Delhi 110092, India;
| | - Lukas Dostalek
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, 128 00 Prague, Czech Republic;
| | - Helidon Nina
- Oncology Hospital, University Hospital Center “Nene Tereza”, 1000 Tirana, Albania;
| | - Petr Krivorotko
- Petrov Research Institute of Oncology, 197758 Saint-Petersburg, Russia;
| | - Jean-Marc Classe
- Department of surgical oncology, Institut de cancerologie de l’Ouest Nantes, 44800 Saint Herblain, France;
| | - Ellen Schlichting
- Department for Breast and Endocrine Surgery, Oslo University Hospital, 0188 Oslo, Norway;
| | - Matilda Appelgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden; (J.d.B.); (M.A.)
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics, Regio Klinikum Pinneberg, 25421 Pinneberg, Germany;
| | - Christine Solbach
- Breast Center, Department of Gynecology and Obstetrics, University of Frankfurt, 60590 Frankfurt am Main, Germany;
| | - Jens-Uwe Blohmer
- Department of Gynecology and Breast Cancer Center, Charite Berlin, 10117 Berlin, Germany;
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Klinikum Esslingen, 73730 Esslingen, Germany;
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