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Teng L, Du J, Yan S, Xu P, Liu J, Zhao X, Tao W. A novel nomogram and survival analysis for different lymph node status in breast cancer based on the SEER database. Breast Cancer 2024; 31:769-786. [PMID: 38802681 PMCID: PMC11341746 DOI: 10.1007/s12282-024-01591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/04/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION The axillary lymph node status (ALNS) and internal mammary lymph nodes (IMLN) expression associated with breast cancer are closely linked to prognosis. This study aimed to establish a nomogram to predict survival at 3, 5, and 10 years in patients with various lymph node statuses. METHODS We obtained data from patients with breast cancer between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER database). Chi-square analysis was performed to test for differences in the pathological characteristics of the groups, and Kaplan-Meier analysis and the log-rank test were used to plot and compare the correlation between overall survival (OS) and breast cancer specific survival (BCSS). The log-rank test was used for the univariate analysis, and statistically significant characteristics were included in the multivariate and Cox regression analyses. Finally, Independent factor identification was included in constructing the nomogram using R studio 4.2.0; area under curve (AUC) values were calculated, and receiver operating characteristic (ROC) curve, calibration, and decision curve analysis (DCA) curves were plotted for evaluation. RESULTS A total of 279,078 patients were enrolled and analysed, demonstrating that the isolated tumour cells (ITC) group had clinicopathological characteristics similar to those of micrometastases (Mic). Multivariate analysis was performed to identify each subgroup's independent risk factors and construct a nomogram. The AUC values were 74.7 (95% CI 73.6-75.8), 72.8 (95% CI 71.9-73.8), and 71.2 (95% CI 70.2-72.2) for 3-, 5-, and 10-year OS, respectively, and 82.2 (95% CI 80.9-83.6), 80.1 (95% CI 79.0-81.2), and 75.5 (95% CI 74.3-76.8) for BCSS in overall breast cancer cases, respectively. AUC values for 3-, 5-, and 10-year OS in the ITC group were 64.8 (95% CI 56.5-73.2), 67.7 (95% CI 62.0-73.4), and 65.4 (95% CI 60.0-70.7), respectively. For those in the Mic group, AUC values for 3-, 5-, and 10-year OS were 72.9 (95% CI 70.7-75.1), 72.4 (95% CI 70.6-74.1), and 71.3 (95% CI 69.6-73.1), respectively, and AUC values for BCSS were 77.8 (95% CI 74.9-80.7), 75.7 (95% CI 73.5-77.9), and 70.3 (95% CI 68.0-72.6), respectively. In the IMLN group, AUC values for 3-, 5-, and 10-year OS were 75.2 (95% CI 71.7-78.7), 73.4 (95% CI 70.0-76.8), and 74.0 (95% CI 69.6-78.5), respectively, and AUC values for BCSS were 76.6 (95% CI 73.0-80.3), 74.1 (95% CI 70.5-77.7), and 74.7 (95% CI 69.8-79.5), respectively. The ROC, calibration, and DCA curves verified that the nomogram had better predictability and benefits. CONCLUSION This study is the first to investigate the predictive value of different axillary lymph node statuses and internal mammary lymph node metastases in breast cancer, providing clinicians with additional aid in treatment decisions.
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Affiliation(s)
- Lizhi Teng
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Juntong Du
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Shuai Yan
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Peng Xu
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Jiangnan Liu
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Xinyang Zhao
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China
| | - Weiyang Tao
- Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China.
- Key Laboratory of Acoustic, Optical and Electromagnetic Diagnosis and Treatment of Cardiovascular Diseases, Harbin, Heilongjiang, China.
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang, China.
- NHC Key Laboratory of Cell Transplantation, Heilongjiang, China.
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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Pride RM, Glass CC, Nakhlis F, Laws A, Weiss AC, Bellon JR, Mittendorf EA, King TA, Kantor O. Intraoperative Pathology Assessment May Lead to Overtreatment of the Axilla in Clinically Node-Negative Breast Cancer Patients Undergoing Upfront Mastectomy. Ann Surg Oncol 2023; 30:5978-5987. [PMID: 37436607 DOI: 10.1245/s10434-023-13898-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Randomized trials have established the safety of observation or axillary radiation (AxRT) as an alternative to axillary lymph node dissection (ALND) in patients with limited nodal disease who undergo upfront surgery. Variability remains in axillary management strategies in cN0 patients undergoing mastectomy found to have one to two positive sentinel lymph nodes (SLNs). We examined the impact of intraoperative pathology assessment in axillary management in a national cohort of AMAROS-eligible mastectomy patients. METHODS The National Cancer Database was used to identify AMAROS-eligible cT1-2N0 breast cancer patients undergoing upfront mastectomy and SLN biopsy (SLNB) and found to have one to two positive SLNs, from 2018 to 2019. We constructed a variable defining intraoperative pathology as 'not performed/not acted on' if ALND was either not performed or performed at a later date than SLNB, or 'performed/acted on' if SLNB and ALND were completed on the same day. Adjusted multivariable analysis examined predictors of treatment with both ALND and AxRT. RESULTS Overall, 8222 patients with cT1-2N0 disease underwent upfront mastectomy and had one to two positive SLNs. Intraoperative pathology was performed/acted on in 3057 (37.2%) patients. These patients were significantly more likely to have both ALND and AxRT than those without intraoperative pathology (41.0% vs. 4.9%; p < 0.001). On multivariate analysis, the strongest predictor of receiving both ALND and AxRT was use of intraoperative pathology (odds ratio 8.99, 95% confidence interval 7.70-10.5; p < 0.001). CONCLUSIONS We advocate that consideration should be made for omission of routine intraoperative pathology in mastectomy patients likely to be recommended postmastectomy radiation to minimize axillary overtreatment with both ALND and AxRT in appropriate patients.
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Affiliation(s)
- Robert M Pride
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Charity C Glass
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Faina Nakhlis
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anna C Weiss
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jennifer R Bellon
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Broman KK, Hughes TM, Bredbeck BC, Sun J, Kirichenko D, Carr MJ, Sharma A, Bartlett EK, Nijhuis AAG, Thompson JF, Hieken TJ, Kottschade L, Downs J, Gyorki DE, Stahlie E, van Akkooi A, Ollila DW, O'shea K, Song Y, Karakousis G, Moncrieff M, Nobes J, Vetto J, Han D, Hotz M, Farma JM, Deneve JL, Fleming MD, Perez M, Baecher K, Lowe M, Bagge RO, Mattsson J, Lee AY, Berman RS, Chai H, Kroon HM, Teras J, Teras RM, Farrow NE, Beasley GM, Hui JYC, Been L, Kruijff S, Sinco B, Sarnaik AA, Sondak VK, Zager JS, Dossett LA. International Center-Level Variation in Utilization of Completion Lymph Node Dissection and Adjuvant Systemic Therapy for Sentinel Lymph Node-Positive Melanoma at Major Referral Centers. Ann Surg 2023; 277:e1106-e1115. [PMID: 35129464 PMCID: PMC10097464 DOI: 10.1097/sla.0000000000005370] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine overall trends and center-level variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel lymph node (SLN)-positive melanoma. SUMMARY BACKGROUND DATA Based on recent clinical trials, management options for SLN-positive melanoma now include effective adjuvant systemic therapy and nodal observation instead of CLND. It is unknown how these findings have shaped practice or how these contemporaneous developments have influenced their respective utilization. METHODS We performed an international cohort study at 21 melanoma referral centers in Australia, Europe, and the United States that treated adults with SLN-positive melanoma and negative distant staging from July 2017 to June 2019. We used generalized linear and multinomial logistic regression models with random intercepts for each center to assess center-level variation in CLND and adjuvant systemic treatment, adjusting for patient and disease-specific characteristics. RESULTS Among 1109 patients, performance of CLND decreased from 28% to 8% and adjuvant systemic therapy use increased from 29 to 60%. For both CLND and adjuvant systemic treatment, the most influential factors were nodal tumor size, stage, and location of treating center. There was notable variation among treating centers in management of stage IIIA patients and use of CLND with adjuvant systemic therapy versus nodal observation alone for similar risk patients. CONCLUSIONS There has been an overall decline in CLND and simultaneous adoption of adjuvant systemic therapy for patients with SLN-positive melanoma though wide variation in practice remains. Accounting for differences in patient mix, location of care contributed significantly to the observed variation.
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Affiliation(s)
- Kristy K Broman
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | | | | | - Amanda A G Nijhuis
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | | | | | | | | | - Emma Stahlie
- Netherlands Cancer institute, Amsterdam, The Netherlands
| | | | | | | | - Yun Song
- University of Gothenburg, Gothenburg, Sweden
| | | | - Marc Moncrieff
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Jenny Nobes
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - John Vetto
- Oregon Health & Science University, Portland, OR
| | - Dale Han
- Oregon Health & Science University, Portland, OR
| | | | | | | | | | | | | | | | | | - Jan Mattsson
- University Medical Center, Groningen, Netherlands
| | | | | | - Harvey Chai
- Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | - Hidde M Kroon
- Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | - Juri Teras
- North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Roland M Teras
- North Estonia Medical Centre Foundation, Tallinn, Estonia
| | | | | | | | | | | | | | - Amod A Sarnaik
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Vernon K Sondak
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Jonathan S Zager
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
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Nguyen HT, De Allegri M, Heil J, Hennigs A. Population-Level Impact of Omitting Axillary Lymph Node Dissection in Early Breast Cancer Women: Evidence from an Economic Evaluation in Germany. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:275-287. [PMID: 36409454 PMCID: PMC9676848 DOI: 10.1007/s40258-022-00771-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The American College of Surgeons Oncology Group Z0011 trial showed that complete axillary lymph node dissection (cALND) did not improve survival benefits in patients with one or two tumour-involved sentinel lymph nodes and undergoing breast conservation. Still, a considerable number of the Z0011-eligible patients continue to be treated with cALND in various countries. Given the potential economic gain from implementation of the Z0011 recommendations, we quantified population-level impacts of omitting cALND among Z0011-eligible patients in clinical practice. METHODS This 2-year economic analysis adopted both the perspective of patients under statutory insurance and the societal perspective, using data collected prospectively from 179 German breast cancer units between 2008 and 2015. The estimation of cost savings and health gain relied on a single decision tree, which considered three scenarios: clinical practice at the baseline; actual implementation in routine care; and hypothetical full implementation in all eligible patients. RESULTS Data for 188,909 patients with primary breast cancer were available, 13,741 (7.3%) of whom met the Z0011 inclusion criteria. The use of cALND decreased from 94.3% in 2010 to 46.9% in 2015, resulting in a gain of 335 quality-adjusted life-years and a saving of EUR50,334,756 for the society. Had cALND been omitted in all eligible patients, the total gain would have been more than double. CONCLUSIONS The implementation of the Z0011 recommendations resulted in substantial savings and health gain in Germany. Our findings suggest that it is beneficial to introduce additional policy measures to promote further uptake of the Z0011 recommendations in clinical practice.
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Affiliation(s)
- Hoa Thi Nguyen
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany.
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany
| | - Jörg Heil
- Breast Unit, University Hospital, Heidelberg University, Heidelberg, Germany
- Breast Unit, Klinik St. Elisabeth, Heidelberg, Germany
| | - André Hennigs
- Breast Unit, University Hospital, Heidelberg University, Heidelberg, Germany
- Breast Unit, Klinik St. Elisabeth, Heidelberg, Germany
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Krivorotko PV, Mortada VV, Pesotskiy RS, Artemyeva AS, Emelyanov AS, Ereshchenko SS, Dashyan GA, Amirov NS, Tabagua TT, Gigolaeva LP, Komyakhov AV, Nikolaev KS, Mortada MM, Zernov KY, Zhiltsova EK, Smirnova VO, Bondarchuk YI, Enaldieva DA, Novikov SN, Busko EA, Chernaya AV, Krzhivitskiy PI, Paltuev RM, Semiglazova TY, Semiglazov VF, Belyaev AM. Accuracy of core biopsy image-guided post-neoadjuvant chemotherapy breast to predict pathologic complete response. TUMORS OF FEMALE REPRODUCTIVE SYSTEM 2022. [DOI: 10.17650/1994-4098-2022-18-3-29-39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background. Achieving a pathologic complete response (pCR) after neoadjuvant systemic therapy (NST) is a predictive factor for improving disease free and overall survival. In triple negative (TN) and HER2-positive breast cancer (BC), the pCR rate exceeds 60 %. Patients with TN and HER2-positive BC who demonstrate an excellent response to NST are likely ideal candidates for downsizing surgery. The condition for reducing the volume of surgical intervention is a reliable determination of pathologic complete response using instrumental imaging and biopsy methods.Aim. To further assess the accuracy of post-NST image-guided biopsy to predict pCR.Materials and methods. Sixty one patients with T1-3N0-3 triple negative or HER2-positive BC receiving NST in the Department of Breast Tumors of the NMRC of Oncology named after N.N. Petrov in the period from 2017 to 2019 were enrolled in this single-center retrospective trial. Patients underwent ultrasound-guided core-biopsy of the initial breast tumor region before surgery. Findings were compared with findings on pathologic evaluation of surgical specimens to determine the performance of biopsy in predicting pCR after NST.Results. After neoadjuvant systemic therapy, clinical partial response (cPR) was diagnosed in 47 (77 %) patients, clinical complete response (cCR) in 14 (23 %) patients. pCR in the core-biopsy tissue and surgical material was achieved in 46 (75.4 %) and 37 (60.7 %), respectively. Performance of image-guided core-biopsy: sensitivity 100 % (95 % confldence interval (CI) 90.51-100), specificity 62.5 % (95 % CI 40.59-81.20), false-negative rate (FNR) 0 %, positive-predictive value (PPV) 75.00 % (95 % CI 59.46-85.99), negative predictive value (NPV) 100.00 %.Conclusion. This retrospective trial showed that ultrasound-guided core biopsies are accurate enough to identify breast pCR in patients with triple-negative or HER2-positive BC with good response after NST (FNR 0 %). Based on these results, a prospective clinical trial has commenced in which breast surgery is omitted in patients with a breast pCR after NST according to image-guided biopsy.
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Affiliation(s)
- P. V. Krivorotko
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - V. V. Mortada
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - R. S. Pesotskiy
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - A. S. Artemyeva
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - A. S. Emelyanov
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - S. S. Ereshchenko
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - G. A. Dashyan
- D.D. Pletnev City Clinical Hospital, Moscow Healthcare Department
| | - N. S. Amirov
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - T. T. Tabagua
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia; I.P. Pavlov First Saint Petersburg State Medical University
| | - L. P. Gigolaeva
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - A. V. Komyakhov
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - K. S. Nikolaev
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - M. M. Mortada
- Saint Petersburg Research Institute of Phthisiopulmonology, Ministry of Health of Russia
| | - K. Yu. Zernov
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - E. K. Zhiltsova
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - V. O. Smirnova
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - Ya. I. Bondarchuk
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - D. A. Enaldieva
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - S. N. Novikov
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - E. A. Busko
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia; Saint Petersburg State University
| | - A. V. Chernaya
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - P. I. Krzhivitskiy
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - R. M. Paltuev
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - T. Yu. Semiglazova
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - V. F. Semiglazov
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
| | - A. M. Belyaev
- N.N. Petrov Research Institute of Oncology, Ministry of Health of Russia
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Teles RHG, Hiroki CT, Freitas VM. Bibliometric analysis of an important diagnostic technique for the treatment of breast cancer. Transl Cancer Res 2022; 11:3440-3442. [PMID: 36388052 PMCID: PMC9641074 DOI: 10.21037/tcr-22-2120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/16/2022] [Indexed: 01/25/2023]
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Pfob A, Sidey-Gibbons C, Rauch G, Thomas B, Schaefgen B, Kuemmel S, Reimer T, Hahn M, Thill M, Blohmer JU, Hackmann J, Malter W, Bekes I, Friedrichs K, Wojcinski S, Joos S, Paepke S, Degenhardt T, Rom J, Rody A, van Mackelenbergh M, Banys-Paluchowski M, Große R, Reinisch M, Karsten M, Golatta M, Heil J. Intelligent Vacuum-Assisted Biopsy to Identify Breast Cancer Patients With Pathologic Complete Response (ypT0 and ypN0) After Neoadjuvant Systemic Treatment for Omission of Breast and Axillary Surgery. J Clin Oncol 2022; 40:1903-1915. [PMID: 35108029 DOI: 10.1200/jco.21.02439] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/24/2021] [Accepted: 01/05/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Neoadjuvant systemic treatment (NST) elicits a pathologic complete response in 40%-70% of women with breast cancer. These patients may not need surgery as all local tumor has already been eradicated by NST. However, nonsurgical approaches, including imaging or vacuum-assisted biopsy (VAB), were not able to accurately identify patients without residual cancer in the breast or axilla. We evaluated the feasibility of a machine learning algorithm (intelligent VAB) to identify exceptional responders to NST. METHODS We trained, tested, and validated a machine learning algorithm using patient, imaging, tumor, and VAB variables to detect residual cancer after NST (ypT+ or in situ or ypN+) before surgery. We used data from 318 women with cT1-3, cN0 or +, human epidermal growth factor receptor 2-positive, triple-negative, or high-proliferative Luminal B-like breast cancer who underwent VAB before surgery (ClinicalTrials.gov identifier: NCT02948764, RESPONDER trial). We used 10-fold cross-validation to train and test the algorithm, which was then externally validated using data of an independent trial (ClinicalTrials.gov identifier: NCT02575612). We compared findings with the histopathologic evaluation of the surgical specimen. We considered false-negative rate (FNR) and specificity to be the main outcomes. RESULTS In the development set (n = 318) and external validation set (n = 45), the intelligent VAB showed an FNR of 0.0%-5.2%, a specificity of 37.5%-40.0%, and an area under the receiver operating characteristic curve of 0.91-0.92 to detect residual cancer (ypT+ or in situ or ypN+) after NST. Spiegelhalter's Z confirmed a well-calibrated model (z score -0.746, P = .228). FNR of the intelligent VAB was lower compared with imaging after NST, VAB alone, or combinations of both. CONCLUSION An intelligent VAB algorithm can reliably exclude residual cancer after NST. The omission of breast and axillary surgery for these exceptional responders may be evaluated in future trials.
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Affiliation(s)
- André Pfob
- University Breast Unit, Department of Obstetrics & Gynecology, Heidelberg University Hospital, Heidelberg, Germany
- MD Anderson Center for INSPiRED Cancer Care (Integrated Systems for Patient-Reported Data), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chris Sidey-Gibbons
- MD Anderson Center for INSPiRED Cancer Care (Integrated Systems for Patient-Reported Data), The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bettina Thomas
- Coordination Centre for Clinical Trials (KKS), University Heidelberg, Heidelberg, Germany
| | - Benedikt Schaefgen
- University Breast Unit, Department of Obstetrics & Gynecology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Toralf Reimer
- Department of Gynecology/Breast Unit, University Hospital Rostock, Rostock, Germany
| | - Markus Hahn
- Department of Gynecology/Breast Unit, University Hospital Tuebingen, Tuebingen, Germany
| | - Marc Thill
- Department of Gynecology and Gynecological Oncology/Breast Unit, Agaplesion Markus Hospital Frankfurt, Frankfurt, Germany
| | - Jens-Uwe Blohmer
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - John Hackmann
- Department of Gynecology/Breast Unit, Marienhospital, Witten, Germany
| | - Wolfram Malter
- Department of Gynecology and Obstetrics, Breast Cancer Center, Medical Faculty, University of Cologne, Cologne, Germany
| | - Inga Bekes
- Department of Gynecology/Breast Unit, University Hospital Ulm, Ulm, Germany
| | - Kay Friedrichs
- Department of Gynecology/Breast Unit, Jerusalem Hospital Hamburg, Hamburg, Germany
| | - Sebastian Wojcinski
- Department of Gynecology and Obstetrics, Breast Cancer Center, Klinikum Bielefeld Mitte GmbH, Bielefeld, Germany
| | - Sylvie Joos
- Radiologische Allianz Hamburg, Hamburg, Germany
| | - Stefan Paepke
- Department of Gynecology/Breast Unit, Hospital rechts der Isar, Munich, Germany
| | - Tom Degenhardt
- Department of Gynecology/Breast Unit, University Hospital Munich, Munich, Germany
| | - Joachim Rom
- Department of Gynecology/Breast Unit, Klinikum Frankfurt-Höchst, Frankfurt, Germany
| | - Achim Rody
- Department of Gynecology/Breast Unit, University Hospital Schleswig-Holstein, Luebeck, Germany
| | | | - Maggie Banys-Paluchowski
- Department of Gynecology/Breast Unit, University Hospital Schleswig-Holstein, Luebeck, Germany
- Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Regina Große
- Department of Gynecology/Breast Unit, University Hospital Halle, Halle, Germany
| | | | - Maria Karsten
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Michael Golatta
- University Breast Unit, Department of Obstetrics & Gynecology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joerg Heil
- University Breast Unit, Department of Obstetrics & Gynecology, Heidelberg University Hospital, Heidelberg, Germany
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9
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Omitting axillary lymph node dissection after positive sentinel lymph node in the post-Z0011 era: Compliance with NCCN and ASCO clinical guidelines and Z0011 criteria in a large prospective cohort. Bull Cancer 2021; 109:268-279. [PMID: 34838310 DOI: 10.1016/j.bulcan.2021.09.018] [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: 06/01/2021] [Accepted: 09/23/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE In the ACOSOG Z0011 trial, patients with primary breast cancer and 1-2 tumor-involved sentinel lymph nodes (SLNs) undergoing breast-conserving surgery had no oncological outcome benefit after axillary lymph node dissection (ALND), despite a relevant rate of non-SLN metastases of 27%. According to the St Gallen expert consensus, and NCCN and ASCO clinical guidelines, ALND may be avoided in patients who meet all ACOSOG Z0011 inclusion criteria. This recommendation can also be extended to patients undergoing mastectomy, with 1 or 2 positive SLNs and an indication for chest wall radiation, in whom axillary radiotherapy can be proposed as an alternative to completion ALND. The aim of this study was to assess non-compliance with the NCCN and ASCO clinical guidelines and Z0011 criteria, namely the rate of performance of completion ALND when it was not recommended, and the rate of failure to perform completion ALND when recommended. METHODS Data were prospectively analysed from T1-2 N0 breast cancer patients undergoing an SLN procedure and treated at the Georges-François Leclerc Cancer Center between November 2015 and May 2017. Factors associated with non-compliance treatment decisions were identified using logistic regression. RESULTS Among 563 patients included, 122 (21.7%) had at least one positive SLN. ALND was not recommended for 76 patients (62.3%), and was recommended in 46 patients (37.7%). The rate of non-compliant treatment was 32% (39/122) overall: ALND was performed despite not being recommended in 16/76 patients (21.1%) and was not performed in 50% of patients in whom it was recommended (23/46). By multivariate analyses, lymphovascular invasion ((Odds Ratio (OR)=6.1; 95% confidence interval (CI): 1.4-26.7; P=0.02)) and only one SLN removed (OR=9.1; 95%CI: 2.2-33.3; P=0.002) were associated with performance of completion ALND when not recommended. Conversely, >1 SLN removed (OR=5.1; 95%CI: 1.2-22.2; P=0.03) was associated with the failure to perform completion ALND when recommended. CONCLUSION Almost one third of patients with invasive breast cancer receive treatment that is not in compliance with recommendations regarding completion ALND.
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10
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Maggi N, Nussbaumer R, Holzer L, Weber WP. Axillary surgery in node-positive breast cancer. Breast 2021; 62 Suppl 1:S50-S53. [PMID: 34511332 PMCID: PMC9097794 DOI: 10.1016/j.breast.2021.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 10/24/2022] Open
Abstract
Long-term follow-up data from multicenter phase III non-inferiority trials confirmed the safety of omission of axillary dissection in selected patients with clinically node-negative, sentinel node-positive breast cancer. Several ongoing trials investigate extended eligibility of the Z0011 protocol in the adjuvant setting. De-escalation of axillary surgery in patients with clinically node-positive breast cancer is currently limited to the neoadjuvant setting, where the sentinel procedure is used to determine nodal pathological complete response. Targeted axillary dissection lowers the false-negative rate of the sentinel procedure, which, however, is consistently associated with a very low risk of axillary recurrence in several recent single-center series. Axillary dissection remains standard care in patients with residual disease after neoadjuvant chemotherapy while the results of Alliance A011202 are pending. The TAXIS trial investigates the role of tailored axillary surgery in patients with clinically node-positive breast cancer, a novel concept designed to selectively remove positive nodes in the adjuvant and neoadjuvant setting.
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Affiliation(s)
- Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Rahel Nussbaumer
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Liezl Holzer
- Department of Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
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11
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Breast and axillary surgery in malignant breast disease: a review focused on literature of 2018 and 2019. Curr Opin Obstet Gynecol 2021; 32:91-99. [PMID: 31833973 DOI: 10.1097/gco.0000000000000593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW There have been fundamental changes in the surgical approach to breast cancer management over the last decades. The primary objective of achieving locoregional control, however, remains unchanged. RECENT FINDINGS In addition to strategies optimizing systemic treatment and radiotherapy, current discussions focus on improving the surgical approach to breast cancer. Especially in view of the increasingly pivotal role of neoadjuvant chemotherapy NAT/NAC (NACT), gauging the extent of tissue removal in the breast and the width of resection margins in breast-conserving surgery is highly important, as is the extent of axillary surgery. Although sentinel lymph node (SLN)-positive patients always underwent axillary lymph node dissection in the past, this paradigm has been challenged in recent years. Targeted axillary dissection (TAD) has emerged as a new staging option in biopsy-proven node-positive patients who convert to clinical node negativity (cN0) after NACT. TAD combines the removal of the SLN and of the target lymph node marked prior to NACT. The accuracy of axillary staging both before and after NACT plays an important role for prognostication and multidisciplinary treatment plans, while its extent has significant effects on patients' arm morbidity and quality of life. SUMMARY The current review focuses on recent evidence regarding surgical management of the breast and axilla in patients with primary breast cancer based on a PubMed and EMBASE literature search for publication years 2018 and 2019.
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12
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Hui JYC, Burke E, Broman KK, Marmor S, Jensen E, Tuttle TM, Zager JS. Surgeon decision-making for management of positive sentinel lymph nodes in the post-Multicenter Selective Lymphadenectomy Trial II era: A survey study. J Surg Oncol 2021; 123:646-653. [PMID: 33289125 PMCID: PMC7902320 DOI: 10.1002/jso.26302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/01/2020] [Accepted: 11/04/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Completion lymph node dissection (CLND) did not improve melanoma-specific survival for patients with sentinel lymph node (SLN)-positive melanoma in the second Multicenter Selective Lymphadenectomy Trial (MSLT-II). We assessed surgeons' awareness of MSLT-II and its impact on CLND recommendations. METHODS An anonymous online cross-sectional survey of the Society of Surgical Oncology membership evaluated surgeon thresholds in offering CLND using patient scenarios and clinicopathologic characteristics ranking. RESULTS Of the 2881 e-mails delivered, 146 surgeons (5.1%) completed all seven scenarios. Most (129 of 131, 98%) were aware of MSLT-II and 125 (95%) found it practice-changing. Specifically, 52% (65 of 125) always, 40% usually, 6% rarely, and 3% never offered CLND before MSLT-II. Meanwhile, 4% always, 9% usually, 78% rarely, and 8% never offer CLND now, after MSLT-II (p < .0001). The most important clinicopathologic factors in determining CLND recommendations were extracapsular extension, number of positive SLN, and SLN tumor deposit size, while primary tumor mitotic index and nodal basin location were the least important. Surgical oncology fellowship training, melanoma patient volume, and academic center practice also influenced CLND recommendations. CONCLUSIONS Most surgeon respondents are aware of MSLT-II, but its application in practice varies according to several clinicopathologic and surgeon factors.
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Affiliation(s)
| | - Erin Burke
- Department of Surgery, University of Kentucky, Lexington KY
| | - Kristy K. Broman
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center, Tampa FL
- Department of Oncological Sciences, University of South Florida, Morsani College of Medicine, Tampa FL
- Department of Surgery, University of Alabama at Birmingham, Birmingham AL
| | - Schelomo Marmor
- Department of Surgery, University of Minnesota, Minneapolis MN
| | - Eric Jensen
- Department of Surgery, University of Minnesota, Minneapolis MN
| | - Todd M. Tuttle
- Department of Surgery, University of Minnesota, Minneapolis MN
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center, Tampa FL
- Department of Oncological Sciences, University of South Florida, Morsani College of Medicine, Tampa FL
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13
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Riedel F, Heil J, Feisst M, Moderow M, von Au A, Domschke C, Michel L, Schaefgen B, Golatta M, Hennigs A. Analyzing non-sentinel axillary metastases in patients with T3-T4 cN0 early breast cancer and tumor-involved sentinel lymph nodes undergoing breast-conserving therapy or mastectomy. Breast Cancer Res Treat 2020; 184:627-636. [PMID: 32816190 PMCID: PMC7599150 DOI: 10.1007/s10549-020-05876-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 08/10/2020] [Indexed: 11/12/2022]
Abstract
Purpose In the ACOSOG Z0011 trial, completing axillary lymph node dissection (cALND) did not benefit patients with T1–T2 cN0 early breast cancer and 1–2 positive sentinel lymph nodes (SLN) undergoing breast-conserving surgery (BCT). This paper reports cALND rates in the clinical routine for patients who had higher (T3–T4) tumor stages and/or underwent mastectomy but otherwise met the ACOSOG Z0011 eligibility criteria. Aim of this study is to determine cALND time trends and non-sentinel axillary metastases (NSAM) rates to estimate occult axillary tumor burden. Methods Data were included from patients treated in 179 German breast cancer centers between 2008 and 2015. Time-trend rates were analyzed for cALND of patients with T3–T4 tumors separated for BCT and mastectomy and regarding presence of axillary macrometastases or micrometastases. Results Data were available for 188,909 patients, of whom 19,009 were identified with 1–2 positive SLN. Those 19,009 patients were separated into 4 cohorts: (1) Patients with T1–T2 tumors receiving BCT (ACOSOG Z0011 eligible; n = 13,741), (2) T1–T2 with mastectomy (n = 4093), (3) T3–T4 with BCT (n = 269), (4) T3–T4 with mastectomy (n = 906). Among patients with T3–T4 tumors, cALND rates declined from 2008 to 2015: from 88.2 to 62.6% for patients receiving mastectomy and from 96.6 to 58.1% in patients receiving BCT. Overall rates for any NSAM after cALND for cohorts 1–4 were 33.4%, 42.3%, 46.9%, 58.8%, respectively. Conclusions The cALND rates have decreased substantially in routine care in patients with ‘extended’ ACOSOG Z0011 eligibility criteria. Axillary tumor burden is higher in these patients than in the ACOSOG Z0011 trial.
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Affiliation(s)
- Fabian Riedel
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Joerg Heil
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Mareike Moderow
- West German Breast Center GmbH, Bahlenstr. 180, 40589, Düsseldorf, Germany
| | - Alexandra von Au
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Christoph Domschke
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Laura Michel
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Benedikt Schaefgen
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Michael Golatta
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - André Hennigs
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
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14
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Gao W, Zeng Y, Fei X, Chen X, Shen K. Axillary lymph node and non-sentinel lymph node metastasis among the ACOSOG Z0011 eligible breast cancer patients with invasive ductal, invasive lobular, or other histological special types: a multi-institutional retrospective analysis. Breast Cancer Res Treat 2020; 184:193-202. [PMID: 32740809 DOI: 10.1007/s10549-020-05842-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/28/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Given the histological special types (HST) of breast carcinoma accounted for minority of the Z0011 study population, this study aimed to assess the rates of axillary lymph node (ALN) involvement and non-sentinel lymph node (SLN) metastasis in patients with invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), or other HST. METHODS Patients with cT1-2N0M0 breast cancer treated between 2009 and 2018 were retrospectively included from a multi-institutional database. Rates of nodal involvement were analyzed among different histological subgroups. The impact of ALN dissection (ALND) on adjuvant treatment decisions and prognosis were also analyzed among patients with 1-2 + SLNs. RESULTS A total of 8294 patients were included: 6854 (82.6%), 257 (3.1%), and 1183 (14.3%) patients with IDC, ILC, and other HST, respectively. IDC patients had a significantly higher rate of ALN metastasis compared with ILC or other HST (31.9% vs. 22.6% vs. 16.4%, P < 0.001). However, in patients with 1-2 + SLNs, rates of non-SLN metastasis were similar among three groups (IDC: n = 182, 28.6% vs. ILC: n = 5, 31.2% vs. other HST: n = 29, 34.9%, P = 0.481). For patients with 1-2 + SLNs, rates of adjuvant chemotherapy and the estimated 3-year recurrence-free survival were similar between the SLN biopsy and ALND arms, regardless of the histological types. CONCLUSION Among patients with 1-2 + SLNs, ILC or other HST had similar rates of non-SLN metastasis compared with IDC. Omission of ALND may not influence adjuvant chemotherapy usage or disease outcome regardless of histological types.
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Affiliation(s)
- Weiqi Gao
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Second Road, Shanghai, 200025, China
| | - Yufei Zeng
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Second Road, Shanghai, 200025, China
| | - Xiaochun Fei
- Department of Pathology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Xiaosong Chen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Second Road, Shanghai, 200025, China.
| | - Kunwei Shen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Second Road, Shanghai, 200025, China.
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15
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Ataş H, Altun Özdemir B, Menekşe E, Özden S, Yüksek YN, Dağlar G. Associated Features with Non-Sentinel Lymph Node Involvement in Early Stage Breast Cancer Patients who Have Positive Macrometastatic Sentinel Lymph Node. Eur J Breast Health 2020; 16:192-197. [PMID: 32656519 DOI: 10.5152/ejbh.2020.5332] [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: 12/07/2019] [Accepted: 01/28/2020] [Indexed: 11/22/2022]
Abstract
Objective The main goal of this study is to determine the clinico-pathological factors that correlate non-sentinel lymph nodes (LNs) involvement in clinically node negative breast cancer (BC) patients with positive macrometastatic sentinel lymph node (SLN) in order to derive future evidence to define a subgroup where completion axillary lymph node dissection (cALND) might not be recommended. Materials and Methods Total 289 SLN biopsies were performed in clinically node negative BC patients between March 2014 and April 2017. Seventy patients who performed cALND due to positive macrometastatic SLN were retrospectively selected and classified into two groups, according to non-SLN involvement (NSLNI). Clinico-pathological features of patients were examined computerized and documentary archives. Results Extracapsular extension (ECE) of SLN, number of harvested SLNs, metastatic rate of SLNs, absence of ductal carcinoma in situ (DCIS) and presence of multilocalization were significantly associated with the likelihood of non-SLN involvement after univariate analysis (p<0,05). Absence of DCIS and presence of multilocalization were found to be significant after multivariate analysis. Conclusion Careful examination of clinico-pathological features can help to decide avoiding cALND if enough LNs are removed and the rate of SLN metastases is low, particularly in case DCIS accompanying invasive cancer in patients without multi localized tumour.
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Affiliation(s)
- Hakan Ataş
- Clinic of Breast and Endocrine Surgery, Ankara City Hospital, Ankara, Turkey
| | - Buket Altun Özdemir
- Clinic of Breast and Endocrine Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ebru Menekşe
- Clinic of Breast and Endocrine Surgery, Ankara City Hospital, Ankara, Turkey
| | - Sabri Özden
- Clinic of Breast and Endocrine Surgery, Ankara City Hospital, Ankara, Turkey
| | - Yunus Nadi Yüksek
- Clinic of Breast and Endocrine Surgery, Ankara City Hospital, Ankara, Turkey
| | - Gül Dağlar
- Clinic of Breast and Endocrine Surgery, Ankara Numune Research and Training Hospital, Ankara, Turkey
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16
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Heil J, Pfob A, Kuerer HM. De-escalation towards omission is the tipping point of individualizing breast cancer surgery. Eur J Surg Oncol 2020; 46:1543-1545. [PMID: 32241595 DOI: 10.1016/j.ejso.2020.03.208] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Tailoring of breast cancer treatment to the individual has especially occurred in breast cancer surgery: paradigms have changed from Halsted's radical mastectomy in 1882, to simple mastectomy, to lumpectomy. Within the next decade, we might face another paradigm change of omitting breast cancer surgery at all in case of a complete response after neoadjuvant systemic treatment. In this article, we provide an overview of the reasoning for this new paradigm change, the criticism it has evoked, and under which conditions it might be incorporated into clinical practice. We also take a look at previous paradigm changes in breast cancer surgery and the insights they provide us in the current situation on a statistical but also on a psychological level.
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Affiliation(s)
- Joerg Heil
- Department of Gynecology/ Breast Unit, Heidelberg University, Heidelberg, Germany.
| | - André Pfob
- Department of Gynecology/ Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Henry Mark Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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17
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Costaz H, Rouffiac M, Boulle D, Arnould L, Beltjens F, Desmoulins I, Peignaux K, Ladoire S, Vincent L, Jankowski C, Coutant C. [Strategies in case of metastatic sentinel lymph node in breast cancer]. Bull Cancer 2019; 107:672-685. [PMID: 31699399 DOI: 10.1016/j.bulcan.2019.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
Abstract
Management strategy of micro or macro metastatic sentinel lymph node(s) (SLNs) in breast cancer has dramatically changed over the past ten years and the publication of five randomized trials results: ACOSOG Z0011, IBCSG 23-01, and AATRM comparing axillary lymph node dissection (ALND) versus SLNs biopsy alone; and AMAROS and OTOASOR comparing ALND versus axillary radiotherapy. Despite methodological limitations of several of these trials, notably ACOSOG Z0011, the international recommendations (ASCO, NCCN) and the expert consensus of St Gallen do not recommend the performance of a complementary ALND in case of macro or micro metastatic SLN, if all ACOSOG Z0011 inclusion criteria are met. Moreover, in the context of a mastectomy, with one or two positive SLN and a wall irradiation indication, an axillary radiotherapy can be proposed as an alternative to ALND. Additionally, ALND is also indicated in extracapsular involvement or when three or more SLNs are metastatic. This change in strategy led to a significant decrease on the number of ALNDs performed and resulted on the abandon of SLNs extemporaneous examination. In France, there are no national recommendations on axillary management in the context of SLN involvement. Moreover, a multitude of different local guidelines, led to very heterogeneous practices in our country. The next evolution on axillary management strategy will be the implementation of a SLNs procedure after neoadjuvant chemotherapy (NAC) for patients with lymph node involvement proven before NAC and for whom NAC has allowed axillary downstaging.
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Affiliation(s)
- Hélène Costaz
- Centre de lutte contre le cancer Georges-François Leclerc, département de chirurgie oncologique, 21000 Dijon, France
| | - Magali Rouffiac
- Centre de lutte contre le cancer Georges-François Leclerc, département d'oncologie radiothérapie, 21000 Dijon, France
| | - Delphine Boulle
- Centre de lutte contre le cancer Georges-François Leclerc, département de chirurgie oncologique, 21000 Dijon, France
| | - Laurent Arnould
- Centre de lutte contre le cancer Georges-François Leclerc, département de biologie et de pathologie des tumeurs, 21000 Dijon, France
| | - Françoise Beltjens
- Centre de lutte contre le cancer Georges-François Leclerc, département de biologie et de pathologie des tumeurs, 21000 Dijon, France
| | - Isabelle Desmoulins
- Centre de lutte contre le cancer Georges-François Leclerc, département d'oncologie médicale, 21000 Dijon, France
| | - Karine Peignaux
- Centre de lutte contre le cancer Georges-François Leclerc, département d'oncologie radiothérapie, 21000 Dijon, France
| | - Sylvain Ladoire
- Centre de lutte contre le cancer Georges-François Leclerc, département d'oncologie médicale, 21000 Dijon, France; Université de Bourgogne, UFR des Sciences de Santé, 21000 Dijon, France
| | - Laura Vincent
- Centre de lutte contre le cancer Georges-François Leclerc, département de chirurgie oncologique, 21000 Dijon, France; Université de Bourgogne, UFR des Sciences de Santé, 21000 Dijon, France
| | - Clémentine Jankowski
- Centre de lutte contre le cancer Georges-François Leclerc, département de chirurgie oncologique, 21000 Dijon, France
| | - Charles Coutant
- Centre de lutte contre le cancer Georges-François Leclerc, département de chirurgie oncologique, 21000 Dijon, France; Université de Bourgogne, UFR des Sciences de Santé, 21000 Dijon, France.
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18
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Montagna G, Ritter M, Weber WP. News in surgery of patients with early breast cancer. Breast 2019; 48 Suppl 1:S2-S6. [DOI: 10.1016/s0960-9776(19)31114-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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19
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Ditsch N, Untch M, Thill M, Müller V, Janni W, Albert US, Bauerfeind I, Blohmer J, Budach W, Dall P, Diel I, Fasching PA, Fehm T, Friedrich M, Gerber B, Hanf V, Harbeck N, Huober J, Jackisch C, Kolberg-Liedtke C, Kreipe HH, Krug D, Kühn T, Kümmel S, Loibl S, Lüftner D, Lux MP, Maass N, Möbus V, Müller-Schimpfle M, Mundhenke C, Nitz U, Rhiem K, Rody A, Schmidt M, Schneeweiss A, Schütz F, Sinn HP, Solbach C, Solomayer EF, Stickeler E, Thomssen C, Wenz F, Witzel I, Wöckel A. AGO Recommendations for the Diagnosis and Treatment of Patients with Early Breast Cancer: Update 2019. Breast Care (Basel) 2019; 14:224-245. [PMID: 31558897 PMCID: PMC6751475 DOI: 10.1159/000501000] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nina Ditsch
- Brustzentrum, Klinik für Gynäkologie und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Michael Untch
- Klinik für Gynäkologie und Geburtshilfe, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Marc Thill
- Klinik für Gynäkologie und Gynäkologische Onkologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Janni
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Germany
| | - Ute-Susann Albert
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Kassel, Kassel, Germany
| | | | - Jens Blohmer
- Klinik für Gynäkologie mit Brustzentrum der Charité, Berlin, Germany
| | - Wilfried Budach
- Strahlentherapie, Radiologie Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Peter Dall
- Frauenklinik Städtisches Klinikum Lüneburg, Lüneburg, Germany
| | - Ingo Diel
- Praxisklinik am Rosengarten, Mannheim, Germany
| | | | - Tanja Fehm
- Klinik für Gynäkologie und Geburtshilfe Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Friedrich
- Klinik für Frauenheilkunde und Geburtshilfe Helios Klinikum Krefeld, Krefeld, Germany
| | - Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt, Rostock, Germany
| | - Volker Hanf
- Frauenklinik Nathanstift, Klinikum Fürth, Fürth, Germany
| | - Nadia Harbeck
- Brustzentrum, Klinik für Gynäkologie und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Jens Huober
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Germany
| | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach, Offenbach, Germany
| | | | | | - David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Thorsten Kühn
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Esslingen, Esslingen, Germany
| | - Sherko Kümmel
- Klinik für Senologie, Kliniken Essen Mitte, Essen, Germany
| | - Sibylle Loibl
- German Breast Group Forschungs GmbH, Neu-Isenburg, Germany
| | - Diana Lüftner
- Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Charité, Berlin, Germany
| | - Michael Patrick Lux
- Klinik für Gynäkologie und Geburtshilfe, St. Vinzenz-Krankenhaus GmbH Paderborn, Paderborn, Germany
| | - Nicolai Maass
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Volker Möbus
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Frankfurt Höchst GmbH, Frankfurt am Main, Germany
| | - Markus Müller-Schimpfle
- Klinik für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Frankfurt Höchst GmbH, Frankfurt am Main, Germany
| | - Christoph Mundhenke
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ulrike Nitz
- Senologie, Evangelisches Krankenhaus Bethesda, Mönchengladbach, Germany
| | - Kerstin Rhiem
- Zentrum Familiärer Brust- und Eierstockkrebs, Universitätsklinikum Köln, Köln, Germany
| | - Achim Rody
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marcus Schmidt
- Klinik und Poliklinik für Geburtshilfe und Frauengesundheit der Johannes-Gutenberg-Universität Mainz, Mainz, Germany
| | - Andreas Schneeweiss
- Gynäkologische Onkologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Florian Schütz
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Hans-Peter Sinn
- Sektion Gynäkopathologie, Pathologisches Institut, Heidelberg, Germany
| | - Christine Solbach
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Erich-Franz Solomayer
- Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Universitätsklinikum Aachen, Aachen, Germany
| | - Christoph Thomssen
- Universitätsfrauenklinik, Martin-Luther-Universität Halle-Wittenberg, Halle/Saale, Germany
| | | | - Isabell Witzel
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Achim Wöckel
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Würzburg, Würzburg, Germany
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20
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Riedel F, Heil J, Feißt M, Rezai M, Moderow M, Sohn C, Schütz F, Golatta M, Hennigs A. Non-sentinel axillary tumor burden applying the ACOSOG Z0011 eligibility criteria to a large routine cohort. Breast Cancer Res Treat 2019; 177:457-467. [DOI: 10.1007/s10549-019-05327-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 11/25/2022]
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21
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Altundag K. Extranodular extension in sentinel lymph node-positive breast cancer might predict further initiation of completion axillary lymph node dissection. Breast Cancer Res Treat 2018; 173:485. [PMID: 30341463 DOI: 10.1007/s10549-018-5019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 10/16/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Kadri Altundag
- MKA Breast Cancer Clinic, Tepe Prime, Cankaya, 06800, Ankara, Turkey.
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