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Capasso K, Mitri S, Roldan-Vasquez E, Flores R, Bhasin S, Borgonovo G, Davis RB, James T. Axillary de-escalation after neoadjuvant chemotherapy for advanced lymph node involvement in breast cancer. Am J Surg 2024; 236:115893. [PMID: 39153469 DOI: 10.1016/j.amjsurg.2024.115893] [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: 05/12/2024] [Revised: 08/06/2024] [Accepted: 08/08/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Sentinel lymph node biopsy reduces morbidity in patients with clinically node-positive breast cancer who achieve axillary pathologic complete response following neoadjuvant therapy (NACT). De-escalation trials primarily addressed cN1 disease, with underrepresentation of cN2 disease. This study evaluates the role of de-escalation in patients with cN2 breast cancer. METHODS A retrospective analysis of the National Cancer Database (2013-2020) included women over 18 with T1-2 invasive breast cancer and clinical N2 disease who received NACT followed by ALND or SLNB then ALND. The primary outcome was pathologic nodal status post-NACT. RESULTS Of 5852 cN2 patients treated, 18.15 % achieved ypN0, 0.97 % had isolated tumor cells, 19.14 % were ypN1, 49.64 % were ypN2, and 12.20 % were ypN3 following NACT. Achieving ypN0 was associated with pCR in the breast, HER2-positive and triple-negative receptor status, cT2 tumors, and younger age. CONCLUSION Despite some patients with cN2 disease achieving ypN0, most exhibited residual axillary disease post-NACT. These findings indicate that axillary de-escalation may not be feasible for most patients with cN2 disease, underscoring the importance of meticulous patient selection and assessment.
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Affiliation(s)
- Kathryn Capasso
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA, USA
| | - Samir Mitri
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA, USA
| | - Estefania Roldan-Vasquez
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA, USA
| | - Rene Flores
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA, USA
| | - Shreya Bhasin
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA, USA; School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Giulia Borgonovo
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA, USA
| | - Roger B Davis
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA, USA
| | - Ted James
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA, USA.
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2
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van Amstel FJG, de Mooij CM, Simons JM, Mitea C, van Diest PJ, Nelemans PJ, van der Pol CC, Luiten EJT, Koppert LB, Smidt ML, van Nijnatten TJA. Disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and molecular subtype: prediction of axillary treatment response after neoadjuvant systemic therapy for breast cancer. Br J Surg 2024; 111:znae203. [PMID: 39302345 PMCID: PMC11414043 DOI: 10.1093/bjs/znae203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/19/2024] [Accepted: 07/23/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT combined with pathological axillary treatment response has been proposed to guide de-escalation of axillary treatment for clinically node-positive breast cancer patients treated with neoadjuvant systemic therapy. The aim of this study was to assess whether axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and breast cancer molecular subtype are predictors of axillary pCR. METHODS This study included clinically node-positive patients treated with neoadjuvant systemic therapy in the prospective Radioactive Iodine Seed placement in the Axilla with Sentinel lymph node biopsy ('RISAS') trial (NCT02800317) with baseline [18F]fluorodeoxyglucose PET/CT imaging available. The predictive value of axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT and breast cancer molecular subtype to estimate axillary pCR was evaluated using logistic regression analysis. Discriminative ability is expressed using ORs with 95% confidence intervals. RESULTS Overall, 185 patients were included, with an axillary pCR rate of 29.7%. The axillary pCR rate for patients with limited versus advanced baseline axillary disease according to [18F]fluorodeoxyglucose PET/CT was 31.9% versus 26.1% respectively. Axillary disease extent was not a significant predictor of axillary pCR (OR 0.75 (95% c.i. 0.38 to 1.46) (P = 0.404)). There were significant differences in axillary pCR rates between breast cancer molecular subtypes. The lowest probability (7%) was found for hormone receptor+/human epidermal growth factor receptor 2- tumours. Using this category as a reference group, significantly increased ORs of 14.82 for hormone receptor+/human epidermal growth factor receptor 2+ tumours, 40 for hormone receptor-/human epidermal growth factor receptor 2+ tumours, and 6.91 for triple-negative tumours were found (P < 0.001). CONCLUSION Molecular subtype is a significant predictor of axillary pCR after neoadjuvant systemic therapy, whereas axillary disease extent according to baseline [18F]fluorodeoxyglucose PET/CT is not.
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Affiliation(s)
- Florien J G van Amstel
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW – Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Cornelis M de Mooij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW – Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Janine M Simons
- GROW – Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
- Department of Radiotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Cristina Mitea
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW – Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patty J Nelemans
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | | | - Ernest J T Luiten
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
- Tawam Breast Care Center, Tawam Hospital, Al Ain, United Arab Emirates
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW – Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Thiemo J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW – Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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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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Bae SJ, Chun JW, Lee SB, Ryu JM, Nam SJ, Jeong J, Park HS, Ahn SG. Outcomes of sentinel node biopsy according to MRI response in an association with the subtypes in cN1-3 breast cancer after neoadjuvant systemic therapy, multicenter cohort study. Breast Cancer Res 2024; 26:66. [PMID: 38632652 PMCID: PMC11022328 DOI: 10.1186/s13058-024-01807-8] [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: 06/07/2023] [Accepted: 03/06/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND This study investigated the feasibility of sentinel lymph node biopsy (SLNB) after neoadjuvant systemic therapy (NAST) in patients with initially high nodal burden. METHODS In the multicenter retrospective cohort, 388 individuals with cN1-3 breast cancer who underwent NAST and had SLNB followed by completion axillary lymph node dissection were included. In an external validation cohort, 267 patients with HER2+ or triple-negative breast cancer (TNBC) meeting similar inclusion criteria were included. Primary outcome was the false-negative rates (FNRs) of SLNB according to the MRI response and subtypes. We defined complete MRI responders as patients who experienced disappearance of suspicious features in the breast and axilla after NAST. RESULTS In the multicenter retrospective cohort, 130 (33.5%) of 388 patients were of cN2-3, and 55 (14.2%) of 388 patients showed complete MRI responses. In hormone receptor-positive HER2- (n = 207), complete and non-complete responders had a high FNRs (31.3% [95% CI 8.6-54.0] and 20.9% [95% CI 14.1-27.6], respectively). However, in HER2+ or TNBC (n = 181), the FNR of complete MRI responders was 0% (95% CI 0-0), whereas that of non-complete responders was 33.3% (95% CI 20.8-45.9). When we validated our findings in the external cohort with HER2+ or TNBC (n = 267), of which 34.2% were cN2-3, the FNRs of complete were 7.1% (95% CI 0-16.7). CONCLUSIONS Our findings suggest that SLNB can be a reliable option for nodal status evaluation in selected patients who have responded well to NAST, especially in HER2+ and TNBC patients who show a complete MRI response.
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Affiliation(s)
- Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Whan Chun
- Department of Surgery, Asan Medical Center, Seoul, Republic of Korea
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sae Byul Lee
- Department of Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Jai Min Ryu
- Department of Surgery, Samsung Medical Center, Seoul, Republic of Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Seoul, Republic of Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute for Breast Cancer Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Grašič Kuhar C, Geiger J, Schwab FD, Heinzelmann-Schwartz V, Vetter M, Weber WP, Kurzeder C. Prognostic Importance of Axillary Lymph Node Response to Neoadjuvant Systemic Therapy on Axillary Surgery in Breast Cancer-A Single Center Experience. Cancers (Basel) 2024; 16:1306. [PMID: 38610984 PMCID: PMC11010874 DOI: 10.3390/cancers16071306] [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: 02/11/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Neoadjuvant systemic treatment (NST) is the standard treatment for HER2+, triple-negative (TN), and highly proliferative luminal HER2- early breast cancer. Pathologic complete response (pCR) after NST is associated with improved outcomes. We evaluated the predictive factors for axillary-pCR (AXpCR) and its impact on the extent of axillary node surgery. This retrospective study included 92 patients (median age of 50.4 years) with an initially node-positive disease. Patients were treated with molecular subtype-specific NST (4.3% were luminal A-like, 28.3% luminal HER2-, 26.1% luminal HER2+, 18.5% HER2+ non-luminal, and 22.8% TN). Axillary-, breast- and total-pCR were achieved in 52.2%, 48.9%, and 38% of patients, respectively. In a binary logistic regression model for the whole population, the only independent factor significantly associated with AXpCR was breast-pCR (OR 7.4; 95% CI 2.6-20.9; p < 0.001). In patients who achieved breast-pCR, aggressive subtypes (HER2+ and TN; OR 11.24) and clinical tumor stage (OR 0.10) had a significant impact on achieving AXpCR. Axillary lymph node dissection was avoided in 53.3% of patients. In conclusion, in node-positive patients with HER2+ and TN subtypes, who achieved breast-pCR after NST, de-escalation of axillary surgery could be considered in most cases.
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Affiliation(s)
- Cvetka Grašič Kuhar
- Department of Medical Oncology, Institute of Oncology, 1000 Ljubljana, Slovenia
- Faculty of Medicine Ljubljana, University of Ljubljana, 1000 Ljubljana, Slovenia
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
| | - James Geiger
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
| | - Fabienne Dominique Schwab
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
- Department of Gynecologic Oncology, University Hospital Basel, 4031 Basel, Switzerland;
| | | | - Marcus Vetter
- Medical Faculty, University of Basel, 4001 Basel, Switzerland;
- Department of Hematology and Oncology, Cantonal Hospital Basel-Land, 4410 Liestal, Switzerland
| | - Walter Paul Weber
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
| | - Christian Kurzeder
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
- Department of Gynecologic Oncology, University Hospital Basel, 4031 Basel, Switzerland;
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Guo X, Zhang J, Gong X, Wang J, Dai H, Jiao D, Ling R, Zhao Y, Yang H, Liu Y, Liu K, Zhang J, Mao D, He J, Yu Z, Liu Y, Fu P, Wang J, Jiang H, Zhao Z, Tian X, Cao Z, Wu K, Song A, Jin F, Fan Z, Liu Z. Axillary lymph node dissection in triple-negative or HER2-positive breast cancer patients with clinical N2 achieving pathological complete response after neoadjuvant therapy: Is it necessary? Breast 2024; 73:103671. [PMID: 38277714 PMCID: PMC10832498 DOI: 10.1016/j.breast.2024.103671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/26/2023] [Accepted: 01/05/2024] [Indexed: 01/28/2024] Open
Abstract
AIM This study aims to identify suitable candidates for axillary sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) among clinical N2 (cN2) triple-negative (TN) or HER2 positive (HER2+)breast cancer patients following neoadjuvant therapy(NAT). BACKGROUND Despite the substantial axillary burden in cN2 breast cancer patients, high pathological response rates can be achieved with NAT in TN or HER2+ subtypes, thus enabling potential downstaging of axillary surgery. METHODS A retrospective analysis was conducted on data from the CSBrS-012 study, screening 709 patients with initial cN2, either HER2+ or TN subtype, from January 1, 2010 to December 31, 2020. The correlation between axillary pathologic complete response (pCR) (yPN0) and breast pCR was examined. RESULTS Among the 177 cN2 patients who achieved breast pCR through NAT, 138 (78.0 %) also achieved axillary pCR. However, in the 532 initial clinical N2 patients who did not achieve breast pCR, residual axillary lymph node metastasis persisted in 77.4 % (412/532) of cases. The relative risk of residual axillary lymph node metastasis in patients who did not achieve breast pCR was 12.4 (8.1-19.1), compared to those who did achieve breast pCR, P < 0.001. CONCLUSION For cN2 TN or HER2+ breast cancer patients who achieve breast pCR following NAT, consideration could be given to downstaging and performing an axillary SLNB or TAD.
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Affiliation(s)
- Xuhui Guo
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Jiao Zhang
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Xilong Gong
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Jia Wang
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Hao Dai
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Dechuang Jiao
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China
| | - Rui Ling
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Yi Zhao
- Surgical Oncology Department, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110022, China
| | - Hongjian Yang
- Department of Breast Surgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang Province, 310022, China
| | - Yunjiang Liu
- Department of Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 052360, China
| | - Ke Liu
- Fourth Department of Breast Surgery, Jilin Cancer Hospital. Changchun, Jilin Province, 130012, China
| | - Jianguo Zhang
- Department of Breast Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150086, China
| | - Dahua Mao
- Department of Breast Surgery, Affiliated Wudang Hospital of Guizhou Medical University, Guiyang, Guizhou Province, 550009, China
| | - Jianjun He
- Department of Breast Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China
| | - Zhigang Yu
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, 250033, China
| | - Yinhua Liu
- Breast Disease Center, Peking University First Hospital, Beijing, 100034, China
| | - Peifen Fu
- Department of Breast Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, 310003, China
| | - Jiandong Wang
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, 100852, China
| | - Hongchuan Jiang
- Department of Breast Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Zuowei Zhao
- Department of Breast Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, 116023, China
| | - Xingsong Tian
- Department of Breast and Thyroid Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, 250021, China
| | - Zhongwei Cao
- Department of Thyroid, Breast, Hernia Surgery, The Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia Autonomous Region, 010017, China
| | - Kejin Wu
- Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200433, China
| | - Ailin Song
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu Province, 730000, China
| | - Feng Jin
- Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, 110002, China
| | - Zhimin Fan
- Department of Breast Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, 130021, China
| | - Zhenzhen Liu
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Dongming Road, Zhengzhou, Henan Province, 450008, China.
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7
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Garcia-Tejedor A, Ortega-Exposito C, Salinas S, Luzardo-González A, Falo C, Martinez-Pérez E, Pérez-Montero H, Soler-Monsó MT, Bajen MT, Benitez A, Ortega R, Petit A, Guma A, Campos M, Plà MJ, Pernas S, Peñafiel J, Yeste C, Gil-Gil M, Guedea F, Ponce J, Laplana M. Axillary lymph node dissection versus radiotherapy in breast cancer with positive sentinel nodes after neoadjuvant therapy (ADARNAT trial). Front Oncol 2023; 13:1184021. [PMID: 37621686 PMCID: PMC10446877 DOI: 10.3389/fonc.2023.1184021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/04/2023] [Indexed: 08/26/2023] Open
Abstract
Introduction Breast cancer surgery currently focuses on de-escalating treatment without compromising patient survival. Axillary radiotherapy (ART) now replaces axillary lymph node dissection (ALND) in patients with limited sentinel lymph node (SLN) involvement during the primary surgery, and this has significantly reduced the incidence of lymphedema without worsening the prognosis. However, patients treated with neoadjuvant systemic treatment (NST) cannot benefit from this option despite the low incidence of residual disease in the armpit in most cases. Data regarding the use of radiotherapy instead of ALND in this population are lacking. This study will assess whether ART is non-inferior to ALND in terms of recurrence and overall survival in patients with positive SLN after NST, including whether it reduces surgery-related adverse effects. Methods and analyses This multicenter, randomized, open-label, phase 3 trial will enroll 1660 patients with breast cancer and positive SLNs following NST in approximately 50 Spanish centers over 3 years. Patients will be stratified by NST regimen and nodal involvement (isolated tumoral cells or micrometastasis versus macrometastasis) and randomly assigned 1:1 to ART without ALND (study arm) or ALND alone (control arm). Level 3 and supraclavicular radiotherapy will be added in both arms. The primary outcome is the 5-year axillary recurrence determined by clinical and radiological examination. The secondary outcomes include lymphedema or arm dysfunction, quality of life based (EORTC QLQ-C30 and QLQ-BR23 questionnaires), disease-free survival, and overall survival. Discussion This study aims to provide data to confirm the efficacy and safety of ART over ALND in patients with a positive SLN after NST, together with the impact on morbidity. Ethics and dissemination The Research Ethics Committee of Bellvitge University Hospital approved this trial (Protocol Record PR148/21, version 3, 1/2/2022) and all patients must provide written informed consent. The involvement of around 50 centers across Spain will facilitate the dissemination of our results. Trial registration ClinicalTrials.gov, identifier number NCT04889924.
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Affiliation(s)
- Amparo Garcia-Tejedor
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Carlos Ortega-Exposito
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Sira Salinas
- Rehabilitation Service, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Ana Luzardo-González
- Rehabilitation Service, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Catalina Falo
- Department of Medical Oncology, Multidisciplinary Breast Cancer Unit, Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Evelyn Martinez-Pérez
- Department of Radiation Oncology, Multidisciplinary Breast Cancer Unit. Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Héctor Pérez-Montero
- Department of Radiation Oncology, Multidisciplinary Breast Cancer Unit. Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - M. Teresa Soler-Monsó
- Department of Pathology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Maria-Teresa Bajen
- Department of Nuclear Medicine, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Ana Benitez
- Department of Nuclear Medicine, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Raul Ortega
- Department of Radiology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Anna Petit
- Department of Pathology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Anna Guma
- Department of Radiology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Miriam Campos
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Maria J. Plà
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Sonia Pernas
- Department of Medical Oncology, Multidisciplinary Breast Cancer Unit, Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Judith Peñafiel
- Biostatistics Unit, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Carlos Yeste
- Degree in Biology, Monitoring, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Miguel Gil-Gil
- Department of Medical Oncology, Multidisciplinary Breast Cancer Unit, Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Ferran Guedea
- Department of Radiation Oncology, Multidisciplinary Breast Cancer Unit. Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Jordi Ponce
- Department of Gynaecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Maria Laplana
- Department of Radiation Oncology, Multidisciplinary Breast Cancer Unit. Institut Català d’Oncología, Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
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8
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Li S, Qi W, Cao L, Xu C, Cai R, Chen J, Cai G. Nodal response to primary systemic therapy predicts prognosis of cN3c breast cancer patients receiving multimodality therapy. Breast 2023; 70:92-99. [PMID: 37423063 DOI: 10.1016/j.breast.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/22/2023] [Accepted: 06/18/2023] [Indexed: 07/11/2023] Open
Abstract
AIM To investigate the survival outcomes, patterns and risks of recurrence in cN3c breast cancer patients after multimodality therapy, as well as the predictors of candidates for ipsilateral supraclavicular (SCV) area boosting. METHOD Consecutive cN3c breast cancer patients from January 2009 to December 2020 were retrospectively reviewed. Based on nodal response to primary systemic therapy (PST), patients were categorized into three groups: clinical complete response (cCR) not achieved in SCV lymph nodal (SCLN, Group A), SCLN cCR but axillary node (ALN) did not achieve pathological complete response (pCR, Group B), cCR in SCLN and pCR in ALN (Group C). RESULTS The median follow-up time was 32.7 months. The 5-year overall survival (OS) and recurrence-free survival (RFS) were 64.6% and 43.7% respectively. Multivariate analysis showed cumulative SCV dose and ypT stage, ALN response and SCV response to PST were significantly associated with OS and RFS respectively. Compared with Group A or B, Group C showed significantly improved 3 y-RFS (53.8% vs 73.6% vs 100%, p = 0.003), and the lowest rate of DM as first failure (37.9% vs 23.5% vs 0%, p = 0.010). In Group A, the 3 y-OS for patients receiving the cumulative SCV dose of ≥60 Gy versus <60 Gy was 78.0% versus 57.3% (p = 0.029). CONCLUSION Nodal response to PST is an independent prognostic factor for survival and pattern of failure. A cumulative SCV dose of ≥60 Gy is positively associated with improved OS, especially in Group A. Our data supports the perspective of optimizing radiotherapeutic strategy based on nodal response.
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Affiliation(s)
- Shuyan Li
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weixiang Qi
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Cheng Xu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rong Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiayi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Gang Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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9
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Huang X, Shi Z, Mai J, Liu C, Liu C, Chen S, Lu H, Li Y, He B, Li J, Cun H, Han C, Chen X, Liang C, Liu Z. An MRI-based Scoring System for Preoperative Prediction of Axillary Response to Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: A Multicenter Retrospective Study. Acad Radiol 2022:S1076-6332(22)00513-X. [DOI: 10.1016/j.acra.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/17/2022] [Accepted: 09/26/2022] [Indexed: 11/29/2022]
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10
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Liu Y, Luo H, Wang C, Chen X, Wang M, Zhou P, Ren J. Diagnostic performance of T2-weighted imaging and intravoxel incoherent motion diffusion-weighted MRI for predicting metastatic axillary lymph nodes in T1 and T2 stage breast cancer. Acta Radiol 2022; 63:447-457. [PMID: 33779304 DOI: 10.1177/02841851211002834] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Non-invasive modalities for assessing axillary lymph node (ALN) are needed in clinical practice. PURPOSE To investigate the suspicious ALN on unenhanced T2-weighted (T2W) imaging and intravoxel incoherent motion diffusion-weighted imaging (IVIM DWI) for predicting ALN metastases (ALNM) in patients with T1-T2 stage breast cancer and clinically negative ALN. MATERIAL AND METHODS Two radiologists identified the most suspicious ALN or the largest ALN in negative axilla by T2W imaging features, including short axis (Size-S), long axis (Size-L)/S ratio, fatty hilum, margin, and signal intensity on T2W imaging. The IVIM parameters of these selected ALNs were also obtained. The Mann-Whitney U test or t-test was used to compare the metastatic and non-metastatic ALN groups. Finally, logistic regression analysis with T2W imaging and IVIM features for predicting ALNM was conducted. RESULTS This study included 49 patients with metastatic ALNs and 50 patients with non-metastatic ALNs. Using the above conventional features on T2W imaging, the sensitivity and specificity in predicting ALNM were not high. Compared with non-metastatic ALNs, metastatic ALNs had lower pseudo-diffusion coefficient (D*) (P = 0.043). Logistic regression analysis showed that the most useful features for predicting ALNM were signal intensity and D*. The sensitivity and specificity predicting ALNM that satisfied abnormal signal intensity and lower D* were 73.5% and 84%, respectively. CONCLUSIONS The abnormal signal intensity on T2W imaging and one IVIM feature (D*) were significantly associated with ALNM, with sensitivity of 73.5% and specificity of 84%.
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Affiliation(s)
- Yuanyuan Liu
- Division of Radiology, 92293Sichuan Cancer Hospital and Research Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology, Chengdu 61004, Sichuan, PR China
| | - Hongbing Luo
- Division of Radiology, 92293Sichuan Cancer Hospital and Research Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology, Chengdu 61004, Sichuan, PR China
| | - Chunhua Wang
- Division of Radiology, 92293Sichuan Cancer Hospital and Research Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology, Chengdu 61004, Sichuan, PR China
| | - Xiaoyu Chen
- Division of Radiology, 92293Sichuan Cancer Hospital and Research Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology, Chengdu 61004, Sichuan, PR China
| | - Min Wang
- Division of Radiology, 92293Sichuan Cancer Hospital and Research Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology, Chengdu 61004, Sichuan, PR China
| | - Peng Zhou
- Division of Radiology, 92293Sichuan Cancer Hospital and Research Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology, Chengdu 61004, Sichuan, PR China
| | - Jing Ren
- Division of Radiology, 92293Sichuan Cancer Hospital and Research Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology, Chengdu 61004, Sichuan, PR China
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11
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Lim DW, Greene BD, Look Hong NJ. Relationship Between Breast and Axillary Pathologic Complete Response in Women Receiving Neoadjuvant Chemotherapy for Breast Cancer. Ann Surg Oncol 2021; 28:5495-5506. [PMID: 34374914 DOI: 10.1245/s10434-021-10519-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We aim to delineate the relationship between breast and axillary pathologic complete response (pCR) in patients receiving neoadjuvant chemotherapy for breast cancer. METHODS We performed a retrospective cohort study of patients with clinical T1-4N0-3M0 breast cancer receiving neoadjuvant chemotherapy followed by surgical therapy at Sunnybrook Health Sciences Centre in Toronto, Canada between 2014 and 2019. Clinicopathologic data were abstracted from the electronic medical record. Women were stratified into receptor subtypes as follows: hormone receptor positive (HR+)/human epidermal growth factor receptor 2 negative (HER2-), HR+/HER2+, HR-/HER2+ and HR-/HER2- (triple negative) and compared with Fisher's exact test. Our primary outcome was to assess the positive predictive value of breast pCR for determining axillary pCR, and vice versa. RESULTS There were 374 breast cancers, with 109 (29.1%) achieving breast pCR (ypT0/Tis). Amongst node-positive tumours achieving breast pCR, rates of associated axillary pCR (ypN0/0i+) were as follows: HR+/HER2- (2/6, 33.3%), HR+/HER2+ (12/13, 92.3%), HR-/HER2+ (15/17, 88.2%) and triple negative (15/17, 88.2%) (P = 0.02). Conversely, amongst node-positive tumours achieving axillary pCR, rates of associated breast pCR were: HR+/HER2- (2/10, 20.0%), HR+/HER2+ (12/23, 52.2%), HR-/HER2+ (15/24, 62.5%) and triple negative (15/26, 57.7%) (P = 0.1). CONCLUSIONS Breast pCR is a strong predictor of axillary pCR in women with HER2-positive and triple-negative breast cancers. Conversely, axillary pCR is a modest predictor of breast pCR for these subtypes. There is a poor relationship between breast and axillary pCR in women with hormone receptor-positive disease. These data may inform future de-escalation of surgery in women with HER2-positive and triple-negative disease.
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Affiliation(s)
- David W Lim
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. .,Department of Surgery, Women's College Hospital, Toronto, Ontario, Canada. .,Division of General Surgery, Department of Surgery, University Health Network, Toronto, Ontario, Canada.
| | - Brittany D Greene
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nicole J Look Hong
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Odette Cancer Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Surgical Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
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12
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Wang C, Padgett KR, Su MY, Mellon EA, Maziero D, Chang Z. Multi-parametric MRI (mpMRI) for treatment response assessment of radiation therapy. Med Phys 2021; 49:2794-2819. [PMID: 34374098 DOI: 10.1002/mp.15130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 11/11/2022] Open
Abstract
Magnetic resonance imaging (MRI) plays an important role in the modern radiation therapy (RT) workflow. In comparison with computed tomography (CT) imaging, which is the dominant imaging modality in RT, MRI possesses excellent soft-tissue contrast for radiographic evaluation. Based on quantitative models, MRI can be used to assess tissue functional and physiological information. With the developments of scanner design, acquisition strategy, advanced data analysis, and modeling, multiparametric MRI (mpMRI), a combination of morphologic and functional imaging modalities, has been increasingly adopted for disease detection, localization, and characterization. Integration of mpMRI techniques into RT enriches the opportunities to individualize RT. In particular, RT response assessment using mpMRI allows for accurate characterization of both tissue anatomical and biochemical changes to support decision-making in monotherapy of radiation treatment and/or systematic cancer management. In recent years, accumulating evidence have, indeed, demonstrated the potentials of mpMRI in RT response assessment regarding patient stratification, trial benchmarking, early treatment intervention, and outcome modeling. Clinical application of mpMRI for treatment response assessment in routine radiation oncology workflow, however, is more complex than implementing an additional imaging protocol; mpMRI requires additional focus on optimal study design, practice standardization, and unified statistical reporting strategy to realize its full potential in the context of RT. In this article, the mpMRI theories, including image mechanism, protocol design, and data analysis, will be reviewed with a focus on the radiation oncology field. Representative works will be discussed to demonstrate how mpMRI can be used for RT response assessment. Additionally, issues and limits of current works, as well as challenges and potential future research directions, will also be discussed.
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Affiliation(s)
- Chunhao Wang
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Kyle R Padgett
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA.,Department of Radiology, University of Miami, Miami, Florida, USA
| | - Min-Ying Su
- Department of Radiological Sciences, University of California, Irvine, California, USA.,Department of Medical Imaging and Radiological Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Eric A Mellon
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA
| | - Danilo Maziero
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA
| | - Zheng Chang
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
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13
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Weiss A, Campbell J, Ballman KV, Sikov WM, Carey LA, Hwang ES, Poppe MM, Partridge AH, Ollila DW, Golshan M. Factors Associated with Nodal Pathologic Complete Response Among Breast Cancer Patients Treated with Neoadjuvant Chemotherapy: Results of CALGB 40601 (HER2+) and 40603 (Triple-Negative) (Alliance). Ann Surg Oncol 2021; 28:5960-5971. [PMID: 33821344 DOI: 10.1245/s10434-021-09897-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND De-escalation of axillary surgery after neoadjuvant chemotherapy (NAC) requires careful patient selection. We seek to determine predictors of nodal pathologic complete response (ypN0) among patients treated on CALGB 40601 or 40603, which tested NAC regimens in HER2+ and triple-negative breast cancer (TNBC), respectively. PATIENTS AND METHODS A total of 760 patients with stage II-III HER2+ or TNBC were analyzed. Those who had axillary surgery before NAC (N = 122), or who had missing pretreatment clinical nodal status (cN) (N = 58) or ypN status (N = 41) were excluded. The proportion of patients with ypN0 disease was estimated for those with and without breast pathologic complete response (pCR) according to pretreatment nodal status. RESULTS In 539 patients, the overall ypN0 rate was 76.3% (411/539) to 93.2% (245/263) in patients with breast pCR and 60.1% (166/276) with residual breast disease (RD) (P < 0.0001). For patients who were cN0 pretreatment, the ypN0 rate was 88.8% (214/241), 96.3% (104/108) with breast pCR, and 82.7% (110/133) with RD. For patients who were cN1, 66.2% (157/237) converted to ypN0, 91.7% (111/121) with breast pCR and 39.7% (46/116) with RD. For patients who were cN2/3, 65.6% (40/61) converted to ypN0, 88.2% (30/34) with breast pCR and 37.0% (10/27) with RD. On multivariable analysis, only pretreatment clinical nodal status and breast pCR/RD were associated with ypN0 status (both P < 0.0001). CONCLUSIONS Breast pCR and pretreatment nodal status are predictive of ypN0 axillary nodal involvement, with < 5% residual nodal disease among cN0 patients who experience breast pCR. These findings support the incorporation of axillary surgery de-escalation strategies into NAC trials.
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Affiliation(s)
- Anna Weiss
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | - Jordan Campbell
- Alliance Statistics and Data Center, Weill Cornell Medicine, New York, NY, USA
| | - Karla V Ballman
- Alliance Statistics and Data Center, Weill Cornell Medicine, New York, NY, USA
| | - William M Sikov
- Women and Infants Hospital of Rhode Island and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lisa A Carey
- Division of Oncology, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Division of Surgical Oncology, Duke University, Durham, NC, USA
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Ann H Partridge
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - David W Ollila
- Department of Surgery, Division of Surgical Oncology, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Mehra Golshan
- Department of Surgery, Division of Surgical Oncology, Yale Cancer Center, New Haven, CT, USA
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