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Alkner S, Wieslander E, Lundstedt D, Berg M, Kristensen I, Andersson Y, Bergkvist L, Frisell J, Olofsson Bagge R, Sund M, Christiansen P, Davide Gentilini O, Kontos M, Kühn T, Reimer T, Rydén L, Filtenborg Tvedskov T, Vrou Offersen B, Dahl Nissen H, de Boniface J. Quality assessment of radiotherapy in the prospective randomized SENOMAC trial. Radiother Oncol 2024; 197:110372. [PMID: 38866204 DOI: 10.1016/j.radonc.2024.110372] [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: 04/03/2024] [Revised: 05/15/2024] [Accepted: 06/04/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND AND PURPOSE Recommendations for regional radiotherapy (RT) of sentinel lymph node (SLN)-positive breast cancer are debated. We here report a RT quality assessment of the SENOMAC trial. MATERIALS AND METHODS The SENOMAC trial randomized clinically node-negative breast cancer patients with 1-2 SLN macrometastases to completion axillary lymph node dissection (cALND) or SLN biopsy only between 2015-2021. Adjuvant RT followed national guidelines. RT plans for patients included in Sweden and Denmark until June 2019 were collected (N = 1176) and compared to case report forms (CRF). Dose to level I (N = 270) and the humeral head (N = 321) was analyzed in detail. RESULTS CRF-data and RT plans agreed in 99.3 % (breast/chest wall) and in 96.6 % of patients (regional RT). Congruence for whether level I was an intended RT target was lower (78 %). In accordance with Danish national guidelines, level I was more often an intended target in the SLN biopsy only arm (N = 334/611, 55 %,) than in the cALND arm (N = 174/565, 31 %,). When an intended target, level I received prescribed dose to 100 % (IQR 98-100 %) of the volume. However, even when not an intended target, full dose was delivered to > 80 % of level I (IQR 75-90 %). The intentional inclusion of level I in the target volume more than doubled the dose received by ≥ 50 % of the humeral head. CONCLUSION Congruence between CRF data and RT plans was excellent. Level I received a high dose coverage even when not intentionally included in the target. Including level I in target significantly increased dose to the humeral head.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Faculty of Medicine, Institute of Clinical Sciences Lund, Lund University, Lund, Sweden; Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden.
| | - Elinore Wieslander
- Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Oncology at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Berg
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Ingrid Kristensen
- Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Yvette Andersson
- Department of Surgery, Vastmanland Hospital Vasteras, Vasteras, Sweden; Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Leif Bergkvist
- Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Malin Sund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Finland; Department of Diagnostics and Intervention/ Surgery, Umeå University, Sweden
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Oreste Davide Gentilini
- Breast Surgery, IRCCS Ospedale San Raffaele, Milano, Italy; Vita-Salute San Raffaele University, Milano, Italy
| | - Michalis Kontos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Kühn
- Die Filderklinik, Breast Center, Filderstadt, Germany; Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Lisa Rydén
- Department of Oncology, Faculty of Medicine, Institute of Clinical Sciences Lund, Lund University, Lund, Sweden; Skåne University Hospital , Department of Gastroenterology and Surgery, Malmö, Sweden
| | - Tove Filtenborg Tvedskov
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Breast Surgery, Gentofte Hospital, Gentofte, Denmark
| | - Birgitte Vrou Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark; Department of Experimental Clinical Oncology, Danish Center for Particle Therapy, Aarhus, Denmark
| | - Henrik Dahl Nissen
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Capio St. Goran's Hospital, Stockholm, Sweden
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2
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de Wild SR, van Roozendaal LM, de Wilt JHW, van Dalen T, van der Hage JA, van Duijnhoven FH, Simons JM, Schipper RJ, de Munck L, van Kuijk SMJ, Boersma LJ, Linn SC, Lobbes MBI, Poortmans PMP, Tjan-Heijnen VCG, van de Vijver KKBT, de Vries J, Westenberg AH, Strobbe LJA, Smidt ML. De-escalation of axillary treatment in the event of a positive sentinel lymph node biopsy in cT1-2 N0 breast cancer treated with mastectomy: nationwide registry study (BOOG 2013-07). Br J Surg 2024; 111:znae077. [PMID: 38597154 PMCID: PMC11004788 DOI: 10.1093/bjs/znae077] [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: 10/18/2023] [Revised: 12/12/2023] [Accepted: 03/01/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Trials have demonstrated the safety of omitting completion axillary lymph node dissection in patients with cT1-2 N0 breast cancer operated with breast-conserving surgery who have limited metastatic burden in the sentinel lymph node. The aim of this registry study was to provide insight into the oncological safety of omitting completion axillary treatment in patients operated with mastectomy who have limited-volume sentinel lymph node metastasis. METHODS Women diagnosed in 2013-2014 with unilateral cT1-2 N0 breast cancer treated with mastectomy, with one to three sentinel lymph node metastases (pN1mi-pN1a), were identified from the Netherlands Cancer Registry, and classified by axillary treatment: no completion axillary treatment, completion axillary lymph node dissection, regional radiotherapy, or completion axillary lymph node dissection followed by regional radiotherapy. The primary endpoint was 5-year regional recurrence rate. Secondary endpoints included recurrence-free interval and overall survival, among others. RESULTS In total, 1090 patients were included (no completion axillary treatment, 219 (20.1%); completion axillary lymph node dissection, 437 (40.1%); regional radiotherapy, 327 (30.0%); completion axillary lymph node dissection and regional radiotherapy, 107 (9.8%)). Patients in the group without completion axillary treatment had more favourable tumour characteristics and were older. The overall 5-year regional recurrence rate was 1.3%, and did not differ significantly between the groups. The recurrence-free interval was also comparable among groups. The group of patients who did not undergo completion axillary treatment had statistically significantly worse 5-year overall survival, owing to a higher percentage of non-cancer deaths. CONCLUSION In this registry study of patients with cT1-2 N0 breast cancer treated with mastectomy, with low-volume sentinel lymph node metastasis, the 5-year regional recurrence rate was low and comparable between patients with and without completion axillary treatment.
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Affiliation(s)
- Sabine R de Wild
- Maastricht University Medical Centre+, Department of Surgery, GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | | | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Thijs van Dalen
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Jos A van der Hage
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgery, Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Janine M Simons
- Maastricht University Medical Centre+, Department of Surgery, GROW School for Oncology and Reproduction, Maastricht, The Netherlands
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | - Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Liesbeth J Boersma
- Maastricht University Medical Centre+, Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Sabine C Linn
- Department of Medical Oncology, Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Marc B I Lobbes
- Department of Medical Imaging, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - Philip M P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Koen K B T van de Vijver
- Department of Pathology, Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- Department of Pathology, University Hospital Ghent—Cancer Research Institute Ghent, Ghent, Belgium
| | - Jolanda de Vries
- Department of Psychology and Health, Tilburg University, Tilburg, the Netherlands
| | - A Helen Westenberg
- Department of Radiation Oncology, Radiotherapiegroep Arnhem, Arnhem, the Netherlands
| | - Luc J A Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marjolein L Smidt
- Maastricht University Medical Centre+, Department of Surgery, GROW School for Oncology and Reproduction, Maastricht, The Netherlands
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Wintraecken VM, Boersma LJ, van Roozendaal LM, de Vries J, van Kuijk SMJ, Vane MLG, van Dalen T, van der Hage JA, Strobbe LJA, Linn SC, Lobbes MBI, Poortmans PMP, Tjan-Heijnen VCG, van de Vijver KKBT, Westenberg AH, de Wilt JHW, Smidt ML, Simons JM. Quality assurance of radiation therapy after breast-conserving surgery among patients in the BOOG 2013-08 trial. Radiother Oncol 2024; 191:110069. [PMID: 38141879 DOI: 10.1016/j.radonc.2023.110069] [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: 11/02/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND AND PURPOSE In the BOOG 2013-08 trial (NCT02271828), cT1-2N0 breast cancer patients were randomized between breast conserving surgery with or without sentinel lymph node biopsy (SLNB) followed by whole breast radiotherapy (WBRT). While awaiting primary endpoint results (axillary recurrence rate), this study aims to perform a quality assurance analysis on protocol adherence and (incidental) axillary radiation therapy (RT) dose. MATERIALS AND METHODS Patients were enrolled between 2015 and 2022. Data on prescribed RT and (in 25% of included patients) planning target volumes (PTV) parameters were recorded for axillary levels I-IV and compared between treatment arms. Multivariable linear regression analysis was performed to determine prognostic variables for incidental axillary RT dose. RESULTS 1,439/1,461 included patients (98.5%) were treated according to protocol and 87 patients (5.9%) received regional RT (SLNB 10.9%, no-SLNB 1.5 %). In 326 patients included in the subgroup analysis, the mean incidental PTV dose at axilla level I was 59.5% of the prescribed breast RT dose. In 5 patients (1.5%) the mean PTV dose at level I was ≥95% of the prescribed breast dose. No statistically or clinically significant differences regarding incidental axillary RT dose were found between treatment arms. Tumour bed boost (yes/no) was associated with a higher incidental mean dose in level I (R2 = 0.035, F(6, 263) = 1.532, p 0.168). CONCLUSION The results indicate that RT-protocol adherence was high, and that incidental axillary RT dose was low in the BOOG 2013-08 trial. Potential differences between treatmentarms regarding the primary endpoint can thus not be attributed to different axillary radiation doses.
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Affiliation(s)
- V M Wintraecken
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - L J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - L M van Roozendaal
- Department of Surgical Oncology, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - J de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands; Board member Adrz, Goes, the Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - M L G Vane
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - T van Dalen
- Division of Surgical Oncology, Diakonessenhuis Hospital, Utrecht, the Netherlands; Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - J A van der Hage
- Division of Surgical Oncology, Leids University Medical Center, Leiden, the Netherlands
| | - L J A Strobbe
- Division of Surgical Oncology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - S C Linn
- Division of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - M B I Lobbes
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - P M P Poortmans
- Department of Radiation Oncology, Iridium Network, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - V C G Tjan-Heijnen
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Division of Medical Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - K K B T van de Vijver
- Department of Pathology, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium; Center for Gynecological Oncology Amsterdam (CGOA), Department of Gynecology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - A H Westenberg
- Radiation Oncology, Radiotherapiegroep location Arnhem, Arnhem, the Netherlands
| | - J H W de Wilt
- Division of Surgical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M L Smidt
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - J M Simons
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
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4
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Gentilini OD. Lessons from the SOUND trial and future perspectives on axillary staging in breast cancer. Br J Surg 2024; 111:znad391. [PMID: 38059555 PMCID: PMC10771253 DOI: 10.1093/bjs/znad391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Oreste D Gentilini
- Breast Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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Alkner S, de Boniface J, Lundstedt D, Mjaaland I, Ryden L, Vikstrom J, Bendahl PO, Holmberg E, Sackey H, Wieslander E, Karlsson P. Protocol for the T-REX-trial: tailored regional external beam radiotherapy in clinically node-negative breast cancer patients with 1-2 sentinel node macrometastases - an open, multicentre, randomised non-inferiority phase 3 trial. BMJ Open 2023; 13:e075543. [PMID: 37751948 PMCID: PMC10533703 DOI: 10.1136/bmjopen-2023-075543] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Modern systemic treatment has reduced incidence of regional recurrences and improved survival in breast cancer (BC). It is thus questionable whether regional radiotherapy (RT) is still beneficial in patients with sentinel lymph node (SLN) macrometastasis. Postoperative regional RT is associated with an increased risk of arm morbidity, pneumonitis, cardiac disease and secondary cancer. Therefore, there is a need to individualise regional RT in relation to the risk of recurrence. METHODS AND ANALYSIS In this multicentre, prospective randomised trial, clinically node-negative patients with oestrogen receptor-positive, HER2-negative BC and 1-2 SLN macrometastases are eligible. Participants are randomly assigned to receive regional RT (standard arm) or not (intervention arm). Regional RT includes the axilla level I-III, the supraclavicular fossa and in selected patients the internal mammary nodes. Both groups receive RT to the remaining breast. Chest-wall RT after mastectomy is given in the standard arm, but in the intervention arm only in cases of widespread multifocality according to national guidelines. RT quality assurance is an integral part of the trial.The trial aims to include 1350 patients between March 2023 and December 2028 in Sweden and Norway. Primary outcome is recurrence-free survival (RFS) at 5 years. Non-inferiority will be declared if outcome in the de-escalation arm is not >4.5 percentage units below that with regional RT, corresponding to an HR of 1.41 assuming 88% 5-year RFS with standard treatment. Secondary outcomes include locoregional recurrence, overall survival, patient-reported arm morbidity and health-related quality of life. Gene expression analysis and tumour tissue-based studies to identify prognostic and predictive markers for benefit of regional RT are included. ETHICS AND DISSEMINATION The trial protocol is approved by the Swedish Ethics Authority (Dnr-2022-02178-01, 2022-05093-02, 2023-00826-02, 2023-03035-02). Results will be presented at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05634889.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Ingvil Mjaaland
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Lisa Ryden
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Johan Vikstrom
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Pär-Ola Bendahl
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Helena Sackey
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Elinore Wieslander
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
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Weber WP, Davide Gentilini O, Morrow M, Montagna G, de Boniface J, Fitzal F, Wyld L, Rubio IT, Matrai Z, King TA, Saccilotto R, Galimberti V, Maggi N, Andreozzi M, Sacchini V, Castrezana López L, Loesch J, Schwab FD, Eller R, Heidinger M, Haug M, Kurzeder C, Di Micco R, Banys-Paluchowski M, Ditsch N, Harder Y, Paulinelli RR, Urban C, Benson J, Bjelic-Radisic V, Potter S, Knauer M, Thill M, Vrancken Peeters MJ, Kuemmel S, Heil J, Gulluoglu BM, Tausch C, Ganz-Blaettler U, Shaw J, Dubsky P, Poortmans P, Kaidar-Person O, Kühn T, Gnant M. Uncertainties and controversies in axillary management of patients with breast cancer. Cancer Treat Rev 2023; 117:102556. [PMID: 37126938 PMCID: PMC10752145 DOI: 10.1016/j.ctrv.2023.102556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/27/2023] [Accepted: 04/01/2023] [Indexed: 05/03/2023]
Abstract
The aims of this Oncoplastic Breast Consortium and European Breast Cancer Research Association of Surgical Trialists initiative were to identify uncertainties and controversies in axillary management of early breast cancer and to recommend appropriate strategies to address them. By use of Delphi methods, 15 questions were prioritized by more than 250 breast surgeons, patient advocates and radiation oncologists from 60 countries. Subsequently, a global virtual consensus panel considered available data, ongoing studies and resource utilization. It agreed that research should no longer be prioritized for standardization of axillary imaging, de-escalation of axillary surgery in node-positive cancer and risk evaluation of modern surgery and radiotherapy. Instead, expert consensus recommendations for clinical practice should be based on current evidence and updated once results from ongoing studies become available. Research on de-escalation of radiotherapy and identification of the most relevant endpoints in axillary management should encompass a meta-analysis to identify knowledge gaps, followed by a Delphi process to prioritize and a consensus conference to refine recommendations for specific trial designs. Finally, treatment of residual nodal disease after surgery was recommended to be assessed in a prospective register.
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Affiliation(s)
- Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | | | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Unit, Capio St Göran's Hospital, Stockholm, Sweden
| | - Florian Fitzal
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Austria; Austrian Breast and Colorectal Study Group ABCSG, Vienna, Austria
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Isabel T Rubio
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Madrid, Spain
| | - Zoltan Matrai
- Hamad Medical Corporation, Dept of Oncoplastic Breast Surgery, Doha, Qatar
| | - Tari A King
- Division of Breast Surgery, Brigham and Women's Hospital, Dana Farber/Brigham Cancer Center, Boston, MA, USA
| | - Ramon Saccilotto
- University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Mariacarla Andreozzi
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Julie Loesch
- Gynecology Department, University Hospital Zurich, Zurich, Switzerland
| | - Fabienne D Schwab
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Ruth Eller
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Haug
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Christian Kurzeder
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Rosa Di Micco
- Breast Surgery, San Raffaele University and Research Hospital, Milan, Italy
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Nina Ditsch
- Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Régis R Paulinelli
- Federal University of Goias, Goias, Brazil; Breast Unit, Araújo Jorge Hospital, Goias, Brazil
| | - Cicero Urban
- Breast Unit, Hospital Nossa Senhora Das Graças, Curitiba, Brazil
| | - John Benson
- Cambridge Breast Unit, Addenbrooke's Hospital Cambridge, Cambridge, UK; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation TRUST, School of Medicine, Anglia Ruskin University, Cambridge, UK
| | - Vesna Bjelic-Radisic
- Breast Unit, University Hospital Helios Wuppertal, University Witten/Herdecke, Wuppertal, Germany; Medical University Graz, Graz, Austria
| | | | - Michael Knauer
- Tumor and Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Marc Thill
- Department of Gynaecology and Gynaecological Oncology, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Surgery, University Medical Center, Amsterdam, Netherlands
| | - Sherko Kuemmel
- Breast Unit, Hospital Essen-Mitte, Germany; Charité - Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Joerg Heil
- Department of Obstetrics and Gynecology, University of Heidelberg, Medical School, Heidelberg, Germany
| | | | | | | | - Jane Shaw
- Patient Advocacy Group, Oncoplastic Breast Consortium, Basel, Switzerland
| | - Peter Dubsky
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland; Breast Centre, Hirslanden Clinic St. Anna, Lucerne, Switzerland
| | - Philip Poortmans
- Iridium Netwerk and University of Antwerp, Wilrijk-Antwerpen, Belgium
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, at Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Dept. Radiation Oncologv (Maastro), Maastricht, Netherlands
| | - Thorsten Kühn
- Department of Gynecology, Hospital Esslingen, Esslingen, Germany
| | - Michael Gnant
- Austrian Breast and Colorectal Study Group ABCSG, Vienna, Austria; Comprehensive Cancer Center Medical University Vienna, Vienna, Austria
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Jatoi I, Kunkler IH. Omission of sentinel node biopsy for breast cancer: Historical context and future perspectives on a modern controversy. Cancer 2021; 127:4376-4383. [PMID: 34614216 DOI: 10.1002/cncr.33960] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022]
Abstract
For older patients with clinically lymph node-negative breast cancer who have estrogen receptor-positive tumors and are treated with tamoxifen, randomized trials comparing axillary lymph node dissection (ALND) versus no ALND show that the omission of ALND improves patient quality of life and has no adverse effects on mortality. These results have served to justify sentinel node biopsy (SNB) omission in selected older patients with breast cancer. More recently, clinical trials were launched to assess SNB omission in younger patients, with recurrence and survival as the primary outcomes of interest. Three important considerations serve as the basis for these ongoing trials. First, it is assumed that SNB omission will improve patient quality of life, although, to date, there is no level I evidence to support this assumption. Second, axillary surgery has never been shown to reduce breast cancer mortality, but it does reduce the risk of axillary recurrences, although adjuvant systemic therapy and radiotherapy also reduce these recurrence risks. Finally, nodal status is losing importance as a guide for adjuvant systemic therapy decision making because these decisions are now increasingly predicated on tumor biomarkers and gene profiling, but it is gaining importance for adjuvant radiotherapy decision making. Because quality-of-life considerations are the primary motivation for abandoning SNB, there is a need for randomized trials comparing SNB versus no SNB/no axillary surgery, with quality of life as the primary end point (level I evidence). Moreover, suitable alternatives to guide adjuvant radiotherapy decision making will require validation before SNB omission can be justified for patients of all ages who have clinically node-negative breast cancer. LAY SUMMARY: In this review article, the authors provide a brief historical overview of the role of axillary surgery in breast cancer management and discuss additional studies and ramifications that should be considered before abandoning the sentinel node biopsy (SNB) procedure. Specifically, there is a need for level I evidence demonstrating that omission of the SNB procedure will improve patient quality of life and a need to validate suitable alternatives to SNB as a guide for adjuvant radiotherapy decision making.
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Affiliation(s)
- Ismail Jatoi
- Division of Surgical Oncology and Endocrine Surgery, University of Texas Health Science Center, San Antonio, Texas
| | - Ian H Kunkler
- Edinburgh Cancer Research Center, University of Edinburgh, Edinburgh, United Kingdom
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Saksena M, Jimenez R, Coopey S, Harris K. Axillary Ultrasound Evaluation in Breast Cancer Patients: A Multidisciplinary Viewpoint and Middle Ground. JOURNAL OF BREAST IMAGING 2021; 3:672-675. [PMID: 38424932 DOI: 10.1093/jbi/wbab070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Indexed: 03/02/2024]
Abstract
Over the past decade, there has been a trend toward de-escalation of axillary surgery. Certain patients may now forego axillary lymph node dissection even in the setting of a positive sentinel lymph node biopsy (SLNB), and some patients may not even undergo a SLNB. However, there is wide variability in the imaging approach to assessing axillary lymph nodes in patients with breast cancer. Approaches range from performing axillary US in all patients with newly diagnosed breast cancer to omitting axillary imaging evaluation in all patients. This article provides a multidisciplinary middle ground approach for axillary nodal evaluation. The clinical impact and rationale for appropriate axillary nodal imaging are discussed and an imaging algorithm is proposed.
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Affiliation(s)
- Mansi Saksena
- Massachusetts General Hospital, Department of Imaging, Boston, MA, USA
| | - Rachel Jimenez
- Massachusetts General Hospital, Department of Radiation Oncology, Boston, MA, USA
| | - Suzanne Coopey
- Massachusetts General Hospital, Department of Breast Surgery, Boston, MA, USA
| | - Katherine Harris
- Massachusetts General Hospital, Department of Medical Oncology, Boston, MA, USA
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Thivalapill N, Lockman S, Powis K, Zash R, Leidner J, Ajibola G, Mmalane M, Makhema J, Shapiro RL. Are morbidity and mortality estimates from randomized controlled trials externally valid? A comparison of outcomes among infants enrolled into an RCT or a cohort study in Botswana. BMC Med Res Methodol 2021; 21:212. [PMID: 34657589 PMCID: PMC8520637 DOI: 10.1186/s12874-021-01343-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background The external validity of the randomized controlled trial (RCT) refers to the extent to which the results of the RCT apply to the relevant, non-trial population and is impacted by its eligibility criteria, its organization, and its delivery of the intervention. Here, we compared the outcomes of mortality and hospitalization between an RCT and a cohort study that concurrently enrolled HIV-exposed uninfected (HEU) newborns in Botswana. Methods The Mpepu Study (the RCT) was a clinical trial which determined that co-trimoxazole (CTX) provided no survival benefit for HEUs, allowing both arms of the RCT to be used. The Maikaelelo study (the cohort study) was a prospective observational study that enrolled HEU newborns with telephone follow-up and no in-person visits. Rates of death and hospitalization in the pooled population, were modeled using cox-proportional hazards models for time to death or time to first hospitalization, with study setting (RCT vs. cohort study) as an independent variable. The causal effect of study setting on morbidity and mortality was obtained through a treatment effects approach. Results In total, 4,010 infants were included; 1,306 were enrolled into the cohort study and 2,704 were enrolled into the RCT. No significant differences in mortality were observed between the two study settings (HR: 1.28, 95% CI: 0.76, 2.13), but RCT participants had a lower risk of hospitalization (HR: 0.72, 95% CI: 0.58, 0.89) that decreased with age. However, RCT participants had a higher risk of hospitalization within the first six months of life. The causal risk difference in hospitalizations attributable to the RCT setting was -0.03 (95% CI: -0.05, -0.01). Conclusions Children in an RCT with rigorous application of national standard of care guidelines experienced a significantly lower risk of hospitalization than children participating in a cohort study that did not alter clinical care. Future research is needed to further investigate outcome disparities when real-world results fail to mirror those achieved in a clinical trial. Trial registration The Mpepu Trial was funded by the U.S. National Institutes of Health (No. NCT01229761) and the Maikaelelo Study was funded primarily by the U.S. Centers for Disease Control and Prevention (32AI007433-21).
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Affiliation(s)
- Neil Thivalapill
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, 651 Huntington Ave FXB 401, Boston, MA, 02115, USA.
| | - Shahin Lockman
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, 651 Huntington Ave FXB 401, Boston, MA, 02115, USA.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Kathleen Powis
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, 651 Huntington Ave FXB 401, Boston, MA, 02115, USA.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Massachusetts General Hospital, Boston, MA, USA
| | - Rebecca Zash
- Harvard Medical School, Boston, MA, USA.,Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Roger L Shapiro
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, 651 Huntington Ave FXB 401, Boston, MA, 02115, USA.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Harvard Medical School, Boston, MA, USA.,Beth Israel Deaconess Medical Center, Boston, MA, USA
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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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