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Chen X, Lu Z, Wang C, Lyu M, Qiao J, Sun X, Li L, Zhang C, Liu Z. Targeted axillary dissection after neoadjuvant chemotherapy for highly selective patients with initial cN1 breast cancer: A single-center prospective trial. Chin Med J (Engl) 2024; 137:1421-1430. [PMID: 38557731 PMCID: PMC11188870 DOI: 10.1097/cm9.0000000000003007] [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: 11/20/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy is gradually accepted as the standard of care in breast cancer patients with down-staged axillary disease after neoadjuvant chemotherapy (NAC). However, it is still difficult to precisely define pre-NAC clinical node-positive (cN1) and post-NAC clinical node-negative (ycN0). This prospective single-center trial was designed to evaluate the feasibility and accuracy of standard targeted axillary dissection (TAD) after NAC in highly selective pre-NAC cN1 patients (not considering ultrasound-based axillary ycN staging). METHODS This prospective trial included patients with initial pre-NAC cT1-3N1M0 invasive breast cancer but with a rigorous definition of cN1 from the Affiliated Cancer Hospital of Zhengzhou University. When NAC was effective (including complete and partial responses) and preoperative axillary palpation was negative, preoperative ultrasound-based axillary staging was not considered, and all patients underwent TAD followed by axillary lymph node (LN) dissection. The detection rate (DR) and false-negative rate (FNR) of TAD were calculated. RESULTS A total of 82 patients were included, and 77 of them were eligible for data analysis. The DR for TAD was 94.8% (73/77). There were 26 patients with one abnormal LN at the time of diagnosis based on ultrasound, 45 patients with two, and 2 patients with three. One patient had one TAD LN, four patients had two TAD LNs, and 68 patients had three or more TAD LNs. Preoperative axillary palpation yielded negative results for all 73 patients who successfully underwent TAD. Preoperative ultrasound-based ycN0 and ycN+ conditions were detected for 52 and 21 cases, respectively. The FNR was 7.4% (2/27) for standard TAD (≥3 SLNs), which was lower than that of all successful TAD (≥1 SLN; 10.0%, 3/30). CONCLUSIONS In rigorously defined pre-NAC cN1 breast cancer patients, standard TAD is feasible for those with negative axillary palpation after NAC, and FNR is also less than 10%. REGISTRATION chictr.org.cn , ChiCTR2100049093.
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Affiliation(s)
- Xiuchun Chen
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Zhenduo Lu
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Chengzheng Wang
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Minhao Lyu
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Jianghua Qiao
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Xianfu Sun
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Lianfang Li
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Chongjian Zhang
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Zhenzhen Liu
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan 450008, China
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de Wild SR, Koppert LB, van Nijnatten TJA, Kooreman LFS, Vrancken Peeters MJTFD, Smidt ML, Simons JM. Systematic review of targeted axillary dissection in node-positive breast cancer treated with neoadjuvant systemic therapy: variation in type of marker and timing of placement. Br J Surg 2024; 111:znae071. [PMID: 38531689 PMCID: PMC10965400 DOI: 10.1093/bjs/znae071] [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: 10/22/2023] [Revised: 01/15/2024] [Accepted: 03/02/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND In node-positive (cN+) breast cancer treated with neoadjuvant systemic therapy, combining sentinel lymph node biopsy and targeted lymph node excision, that is targeted axillary dissection, increases accuracy. Targeted axillary dissection procedures differ in terms of the targeted lymph node excision technique. This systematic review aimed to provide an overview of targeted axillary dissection procedures regarding definitive marker type and timing of placement: before neoadjuvant systemic therapy (1-step procedure) or after neoadjuvant systemic therapy adjacent to a clip placed before the neoadjuvant therapy (2-step procedure). METHODS PubMed and Embase were searched, to 4 July 2023, for RCTs, cohort studies, and case-control studies with at least 25 patients. Studies of targeted lymph node excision only (without sentinel lymph node biopsy), or where intraoperative localization of the targeted lymph node was not attempted, were excluded. For qualitative synthesis, studies were grouped by definitive marker and timing of placement. The targeted lymph node identification rate was reported. Study quality was assessed using a National Institutes of Health quality assessment tool. RESULTS Of 277 unique records, 51 studies with a total of 4512 patients were included. Six definitive markers were identified: wire, 125I-labelled seed, 99mTc, (electro)magnetic/radiofrequency markers, black ink, and a clip. Fifteen studies evaluated one-step procedures, with the identification rate of the targeted lymph node at surgery varying from 8 of 13 to 47 of 47. Forty-one studies evaluated two-step procedures, with the identification rate of the clipped targeted lymph node on imaging after neoadjuvant systemic therapy varying from 49 to 100%, and the identification rate of the targeted lymph node at surgery from 17 of 24 to 100%. Most studies (40 of 51) were rated as being of fair quality. CONCLUSION Various targeted axillary dissection procedures are used in clinical practice. Owing to study heterogeneity, the optimal targeted lymph node excision technique in terms of identification rate and feasibility could not be determined. Two-step procedures are at risk of not identifying the clipped targeted lymph node on imaging after neoadjuvant systemic therapy.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Thiemo J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Loes F S Kooreman
- Department of Pathology, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Janine M Simons
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
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3
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Brousse S, Lafond C, Schmitt M, Guillermet S, Molière S, Mathelin C. [Can we avoid axillary lymph node dissection in patients with node positive invasive breast carcinoma?]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:132-141. [PMID: 38190968 DOI: 10.1016/j.gofs.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVES The indications and modalities of breast and axillary surgery are undergoing profound change, with the aim of personalizing surgical management while avoiding over-treatment. To update best practices for axillary surgery, four questions were selected by the Senology Commission of the Collège National des Gynécologues et Obstétriciens Français (CNGOF), focusing on, firstly, the definition and evaluation of targeted axillary dissection (TAD) techniques; secondly, the possibility of surgical de-escalation in case of initial lymph node involvement while performing initial surgery; thirdly, in case of surgery following neo-adjuvant systemic therapy (NAST), and fourthly, contra-indications to de-escalation of axillary surgery to allow access to particular adjuvant systemic therapies. METHODS The Senology Commission based its responses primarily on an analysis of the international literature, clinical practice recommendations and national and international guidelines. RESULTS Firstly, TAD is a technique that combines excision of clipped metastatic axillary node(s) and the axillary sentinel lymph nodes (ASLNs). The detection rate and sensitivity are increased but it still needs to be standardized and practices better evaluated. Secondly, TAD represents an alternative to axillary clearance in cases of metastatic involvement of a single node that can be resected. Thirdly, neither TAD nor ASLN alone is recommended in France after NAST outside of clinical trials, although it is used in several countries in cases of complete pathological response in the lymph nodes, and when at least three lymph nodes have been removed. Fourthly, as some adjuvant targeted therapies are indicated in cases of lymph node invasion of more than three lymph nodes, the place of TAD in this context remains to be defined. CONCLUSION Axillary surgical de-escalation can limit the morbidity of axillary clearance. Having proved that TAD does not reduce patient survival, it will most probably replace axillary clearance in well-defined indications. This will require prior standardization of the method and its indications and contra-indications, particularly to enable the use of new targeted therapies.
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Affiliation(s)
- Susie Brousse
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France.
| | - Clémentine Lafond
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France; Service de gynécologie-obstétrique, CHU de Rennes, 35000 Rennes, France
| | - Martin Schmitt
- Service de radiothérapie, CHR-Metz-Thionville, hôpital de Mercy, 1, allée du Château, 57085 Metz cedex, France
| | - Sophie Guillermet
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France
| | - Sébastien Molière
- Service d'imagerie de la femme, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France; Service de radiologie B, CHU de Strasbourg, avenue Molière, 67200 Strasbourg, France
| | - Carole Mathelin
- Service de chirurgie, ICANS, CHRU, avenue Molière, 67200 Strasbourg, France
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Zhao PW, Cui JX, Wang XM. Upregulation of p300 in paclitaxel-resistant TNBC: implications for cell proliferation via the PCK1/AMPK axis. THE PHARMACOGENOMICS JOURNAL 2024; 24:5. [PMID: 38378770 DOI: 10.1038/s41397-024-00324-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE To explore the role of p300 in the context of paclitaxel (PTX) resistance in triple-negative breast cancer (TNBC) cells, focusing on its interaction with the phosphoenolpyruvate carboxykinase 1 (PCK1)/adenosine monophosphate-activated protein kinase (AMPK) pathway. METHODS The expression of p300 and PCK1 at the messenger ribonucleic acid (mRNA) level was detected using a quantitative polymerase chain reaction. The GeneCards and GEPIA databases were used to investigate the relationship between p300 and PCK1. The MDA-MB-231/PTX cell line, known for its PTX resistance, was chosen to understand the specific role of p300 in such cells. The Lipofectamine™ 3000 reagent was used to transfer the p300 small interfering RNA and the overexpression of PCK1 plasmid into MDA-MB-231/PTX. The expression levels of p300, PCK1, 5'AMPK and phosphorylated AMPK (p-AMPK) were determined using the western blot test. RESULTS In TNBC cancer tissue, the expression of p300 was increased compared with TNBC paracancerous tissue (P < 0.05). In the MDA-MB-231 cell line of TNBC, the expression of p300 was lower than in the PTX-resistant TNBC cells (MDA-MB-231/PTX) (P < 0.05). The PCK1 expression was decreased in the TNBC cancer tissue compared with TNBC paracancerous tissue, and the PCK1 expression was reduced in MDA-MB-231/PTX than in MDA-MB-231 (P < 0.05) indicating that PCK1 was involved in the resistance function. Additionally, p-AMPK was decreased in MDA-MB-231/PTX compared with MDA-MB-231 (P < 0.05). The adenosine triphosphate (ATP) level was also detected and was significantly lower in MDA-MB-231/PTX than in MDA-MB-231 (P < 0.05). Additionally, cell proliferation increased significantly in MDA-MB-231/PTX at 48 and 72 h (P < 0.05) suggesting that MDA-MB-231/PTX cells obtained the resistance function which was associated with AMPK and ATP level. When p300 was inhibited, p-AMPK and ATP levels elevated in MDA-MB-231/PTX (P < 0.05). When PCK1 was suppressed, the ATP consumption rate decreased, and cell proliferation increased (P < 0.05). However, there were no changes in p300. CONCLUSIONS In MDA-MB-231/PTX, p300 can inhibit p-AMPK and ATP levels by inhibiting PCK1 expression. Our findings suggest that targeting p300 could modulate the PCK1/AMPK axis, offering a potential therapeutic avenue for overcoming PTX resistance in TNBC.
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Affiliation(s)
- Peng-Wei Zhao
- Laboratory of Microbiology and Immunology, School of Basic Medical Science, Inner Mongolia Medical University, No.5 Xinhua Street, Huimin District, Hohhot, 010059, China
| | - Jia-Xian Cui
- Laboratory of Microbiology and Immunology, School of Basic Medical Science, Inner Mongolia Medical University, No.5 Xinhua Street, Huimin District, Hohhot, 010059, China
| | - Xiu-Mei Wang
- Medical Oncology, Affiliated Cancer Hospital of Inner Mongolia Medical University, No. 42 Zhaowuda Road, Saihan District, Hohhot, 010020, Inner Mongolia, China.
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Tauber N, Bjelic-Radisic V, Thill M, Banys-Paluchowski M. Controversies in axillary management of patients with breast cancer - updates for 2024. Curr Opin Obstet Gynecol 2024; 36:51-56. [PMID: 37678325 DOI: 10.1097/gco.0000000000000916] [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: 09/09/2023]
Abstract
PURPOSE OF REVIEW For some time now, the question of de-escalation in axillary staging in breast cancer patients has been raised. The aim is to improve the patients' quality of life and reduce morbidity by optimizing surgical strategies with a high level of oncological safety. This review offers a current overview of published evidence and clinical practice, aiming to guide the surgical community as they reassess and reshape their practices. RECENT FINDINGS Years after introducing sentinel lymph node biopsy (SLNB) in clinically node negative breast cancer patients several guidelines suggest completely omitting SLNB in older patients with low-risk tumors. It is worth noting that for patients with a metastatic sentinel lymph node in the upfront surgery setting, a de-escalation of axillary surgery may in fact lead to an escalation of radiation therapy. Currently, there is limited evidence on the axillary surgical approach for patients with initially positive node status achieving complete axillary response (ycN0), resulting in heterogenous guideline recommendations. SUMMARY Innovative trials are contributing to a growing evidence on de-escalation of axillary surgery with the aim of reducing arm morbidity and improving long-term health-related quality of life.
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Affiliation(s)
- Nikolas Tauber
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck
| | | | - Marc Thill
- Department of Gynecology and Gynecological Oncology, Breast Center, AGAPLESION Markus Hospital, Frankfurt/M
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Banys-Paluchowski M, Hartmann S, Ditsch N, Krawczyk N, Kühn T, de Boniface J, Banys-Kotomska J, Rody A, Krug D. Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy. Breast Care (Basel) 2023; 18:428-439. [PMID: 38130814 PMCID: PMC10731028 DOI: 10.1159/000533748] [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: 04/25/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer. Summary Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement. Key Messages Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, Rostock, Germany
| | - Nina Ditsch
- Breast Cancer Center, Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Die Filderklinik, Filderstadt, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St. Göran’s Hospital, Stockholm, Sweden
| | - Joanna Banys-Kotomska
- I Department and Clinic of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Hartmann S, Banys-Paluchowski M, Stickeler E, de Boniface J, Gentilini OD, Kontos M, Seitz S, Kaltenecker G, Wärnberg F, Zetterlund LH, Kolberg HC, Fröhlich S, Kühn T. Applicability of magnetic seeds for target lymph node biopsy after neoadjuvant chemotherapy in initially node-positive breast cancer patients: data from the AXSANA study. Breast Cancer Res Treat 2023; 202:497-504. [PMID: 37684426 PMCID: PMC10564814 DOI: 10.1007/s10549-023-07100-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE Currently, various techniques are available to mark and selectively remove initially suspicious axillary lymph nodes (target lymph nodes, TLNs) in breast cancer patients receiving neoadjuvant chemotherapy (NACT). To date, limited data are available on whether the use of magnetic seeds (MS) is suitable for localizing TLNs. This study aimed to investigate the feasibility of MS in patients undergoing target lymph node biopsy (TLNB) or targeted axillary dissection (TAD) after NACT. METHODS Prospective data from the ongoing multicentric AXSANA study were extracted from selected patients in whom the TLN had been marked with an MS before NACT and who were enrolled from June 2020 to June 2023. The endpoints of the analysis were the detection rate, the rate of lost markers, and the potential impairment on magnetic resonance imaging (MRI) assessment. RESULTS In 187 patients from 27 study sites in seven countries, MS were placed into the TLN before NACT. In 151 of these, post-NACT surgery had been completed at the time of analysis. In 146 patients (96.0%), a TLN could successfully be detected. In three patients, the seed was removed but no lymphoid tissue was detected on histopathology. The rate of lost markers was 1.2% (2 out of 164 MS). In 15 out of 151 patients (9.9%), MRI assessment was reported to be compromised by MS placement. CONCLUSION MS show excellent applicability for TLNB/TAD when inserted before NACT with a high DR and a low rate of lost markers. Axillary MS can impair MRI assessment of the breast. TRIAL REGISTRATION NUMBER NCT04373655 (date of registration May 4, 2020).
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Affiliation(s)
- Steffi Hartmann
- Department of Obstetrics and Gynecology, University Hospital Rostock, Rostock, Germany.
| | - Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Elmar Stickeler
- Department of Obstetrics and Gynecology, University Hospital Aachen, Aachen, Germany
| | - Jana de Boniface
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Stephan Seitz
- Department of Obstetrics and Gynecology, University Medical Center Regensburg, Regensburg, Germany
| | - Gabriele Kaltenecker
- Department of Obstetrics and Gynecology, City Hospital Karlsruhe, Karlsruhe, Germany
| | - Fredrik Wärnberg
- Department of Surgery, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Linda Holmstrand Zetterlund
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Sarah Fröhlich
- Department of Obstetrics and Gynecology, University Hospital Rostock, Rostock, Germany
| | - Thorsten Kühn
- Department of Obstetrics and Gynecology, Die Filderklinik, Filderstadt, Germany
- Department of Obstetrics and Gynecology, University Hospital Ulm, Ulm, Germany
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Munck F, Jepsen P, Zeuthen P, Carstensen L, Hauerslev K, Paaskesen CK, Andersen IS, Høyer U, Lanng C, Gerlach MK, Vejborg I, Kroman NT, Tvedskov THF. Comparing Methods for Targeted Axillary Dissection in Breast Cancer Patients: A Nationwide, Retrospective Study. Ann Surg Oncol 2023; 30:6361-6369. [PMID: 37400618 PMCID: PMC10506928 DOI: 10.1245/s10434-023-13792-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/10/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Several techniques exist for performing targeted axillary dissection (TAD) after neoadjuvant chemotherapy with the removal of the sentinel node and a marked metastatic lymph node (LN). Two-step methods include coil-marking of the metastatic LN at diagnosis and re-marking with an intraoperatively identifiable marker before surgery. Because nondetection of the marked lymph node (MLN) warrants axillary clearance and many patients achieve axillary pathological complete response (ax-pCR), the success of TAD is crucial. We compare various two-step TAD methods in a Danish national cohort. METHODS We included patients who received two-step TAD between January 1, 2016 and August 31, 2021. Patients were identified from the Danish Breast Cancer Group database and cross-checked with locally accessible lists. Data were extracted from the patient's medical files. RESULTS We included 543 patients. In 79.4%, preoperative, ultrasound-guided re-marking was possible. Nonidentification of the coil-marked LN was more likely in patients with ax-pCR. The second markers used were hook-wire, iodine seeds, or ink marking on the axillary skin. Of patients with successful secondary marking, the MLN identification rate (IR) was 91%, and the sentinel node (SN) IR was 95%. Marking with iodine seeds was significantly more successful than ink marking with an odds ratio of 5.34 (95% confidence interval 1.62-17.60). The success rate of the complete TAD with the removal of MLN and SN was 82.3%. CONCLUSIONS With two-step TAD, nonidentification of the coiled LN before surgery is frequent, especially in patients with ax-pCR. Despite successful remarking, the IR of the MLN at surgery is inferior to one-step TAD.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark.
| | - Pernille Jepsen
- Department of Breast Surgery, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Pernille Zeuthen
- Department of Surgery and Plastic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | - Lena Carstensen
- Department of Surgery Esbjerg, Hospital of South West Jutland, Esbjerg, Denmark
| | - Katrine Hauerslev
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ute Høyer
- Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
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van Hemert AKE, van Duijnhoven FH, Vrancken Peeters MJTFD. This house believes that: MARI/TAD is better than sentinel node biopsy after PST for cN+ patients. Breast 2023; 71:89-95. [PMID: 37562108 PMCID: PMC10432821 DOI: 10.1016/j.breast.2023.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/03/2023] [Accepted: 06/28/2023] [Indexed: 08/12/2023] Open
Abstract
The increasing use and effectiveness of primary systemic treatment (PST) enables tailored locoregional treatment. About one third of clinically node positive (cN+) breast cancer patients achieve pathologic complete response (pCR) of the axilla, with higher rates observed in Human Epidermal growth factor Receptor (HER)2-positive or triple negative (TN) breast cancer subtypes. Tailoring axillary treatment for patients with axillary pCR is necessary, as they are unlikely to benefit from axillary lymph node dissection (ALND), but may suffer complications and long-term morbidity such as lymphedema and impaired shoulder motion. By combining pre-PST and post-PST axillary staging techniques, ALND can be omitted in most cN + patients with pCR. Different post-PST staging techniques (MARI/TAD/SN) show low or ultra-low false negative rates for detection of residual disease. More importantly, trials using the MARI (Marking Axillary lymph nodes with Radioactive Iodine seeds) procedure or sentinel lymph node biopsy (SLNB) as axillary staging technique post-PST have already shown the safety of tailoring axillary treatment in patients with an excellent response. Tailored axillary treatment using the MARI procedure in stage I-III breast cancer resulted in 80% reduction of ALND and excellent five-year axillary recurrence free interval (aRFI) of 97%. Similar oncologic outcomes were seen for post-SLNB in stage I-II patients. The MARI technique requires only one invasive procedure pre-NST and a median of one node is removed post-PST, whereas for the SLNB and TAD techniques two to four nodes are removed. A disadvantage of the MARI technique is its use of radioactive iodine, which is subject to extensive regulations.
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Affiliation(s)
- Annemiek K E van Hemert
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands; Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
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10
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Žatecký J, Coufal O, Zapletal O, Kubala O, Kepičová M, Faridová A, Rauš K, Gatěk J, Kosáč P, Peteja M. Ideal marker for targeted axillary dissection (IMTAD): a prospective multicentre trial. World J Surg Oncol 2023; 21:252. [PMID: 37596658 PMCID: PMC10439625 DOI: 10.1186/s12957-023-03147-x] [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: 07/15/2023] [Accepted: 08/15/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Targeted axillary dissection (TAD) is an established method for axillary staging in patients with breast cancer after neoadjuvant chemotherapy (NAC). TAD consists of sentinel lymph node biopsy and initially pathological lymph node excision, which must be marked by a reliable marker before NAC. METHODS The IMTAD study is a prospective multicentre trial comparing three localisation markers for lymph node localisation (clip + iodine seed, magnetic seed, carbon suspension) facilitating subsequent surgical excision in the form of TAD. The primary outcome was to prospectively compare the reliability, accuracy, and safety according to complication rate during marker implantation and detection and marker dislodgement. RESULTS One hundred eighty-nine patients were included in the study-in 135 patients clip + iodine seed was used, in 30 patients magnetic seed and in 24 patients carbon suspension. The complication rate during the marker implantation and detection were not statistically significant between individual markers (p = 0.263; p = 0.117). Marker dislodgement was reported in 4 patients with clip + iodine seed localisation (3.0%), dislodgement did not occur in other localisation methods (p = 0.999). The false-negativity of sentinel lymph node (SLN) was observed in 8 patients, the false-negativity of targeted lymph nodes (TLN) wasn´t observed at all, the false-negativity rate (FNR) from the subcohort of ypN + patients for SLN is 9.6% and for TLN 0.0%. CONCLUSION The IMTAD study indicated, that clip + iodine seed, magnetic seed and carbon suspension are statistically comparable in terms of complications during marker implantation and detection and marker dislodgement proving their safety, accuracy, and reliability in TAD. The study confirmed, that the FNR of the TLN was lower than the FNR of the SLN proving that the TLN is a better marker for axillary lymph node status after NAC. TRIAL REGISTRATION NCT04580251. Name of registry: Clinicaltrials.gov. Date of registration: 8.10.2020.
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Affiliation(s)
- Jan Žatecký
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic.
- Department of Surgery, Silesian Hospital in Opava, Opava, Czech Republic.
- Faculty of Public Policies, The Institute of Paramedical Health Studies, Silesian University, Opava, Czech Republic.
| | - Oldřich Coufal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondřej Zapletal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Otakar Kubala
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Markéta Kepičová
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Adéla Faridová
- Oncogynecology Centre, The Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Karel Rauš
- Oncogynecology Centre, The Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Jiří Gatěk
- Department of Surgery, EUC Clinic Zlín, Zlín, Czech Republic
- Tomáš Baťa University in Zlín, Zlín, Czech Republic
| | - Peter Kosáč
- Department of Surgery, EUC Clinic Zlín, Zlín, Czech Republic
| | - Matúš Peteja
- Department of Surgery, Silesian Hospital in Opava, Opava, Czech Republic
- Faculty of Public Policies, The Institute of Paramedical Health Studies, Silesian University, Opava, Czech Republic
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11
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Munck F, Andersen IS, Vejborg I, Gerlach MK, Lanng C, Kroman NT, Tvedskov THF. Targeted Axillary Dissection with 125I Seed Placement Before Neoadjuvant Chemotherapy in a Danish Multicenter Cohort. Ann Surg Oncol 2023; 30:4135-4142. [PMID: 37062781 PMCID: PMC10250439 DOI: 10.1245/s10434-023-13432-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/13/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Targeted axillary dissection (TAD), with marking of the metastatic lymph node before neoadjuvant chemotherapy (NACT), is increasingly used for breast cancer axillary staging. In the case of axillary pathological complete response (ax-pCR), axillary lymph node clearance can be omitted. Several marking methods exist, most using re-marking before surgery. Feasibility, learning curve, and identification rate (IR) vary. Marking with 125I seed before NACT makes re-marking at surgery redundant, possibly increasing feasibility and IR. Here, TAD with 125I seed placed before NACT is evaluated in a Danish multicenter cohort. METHODS Patients staged with 125I TAD in Denmark between 1 January 2016 and 31 August 2021 were included. Patients were identified in radioactivity-emitting implant registries at the radiology departments and from the Danish Breast Cancer Group database. Data were extracted from patients' medical records. Information on patient/tumor characteristics, 125I seed activity, marking period, TAD success, number of sentinel nodes (SNs), the histopathological status of excised nodes, and whether the marked lymph node (MLN) was an SN were registered. RESULTS 142 patients were included. The IR of the MLN was 99.3%, and the IR of the SLNB was 91.5%. TAD success was 91.5%. Minor challenges in marking or removal of the MLN were noted in three patients. In 72.3% of the patients, the MLN was a sentinel node. Overall, 40.8% had axillary pCR. CONCLUSION TAD with 125I seed marking before NACT is feasible without re-marking at surgery and with only minor surgical challenges. The IR is high. Staging with TAD spares 41% of breast cancer patients an axillary dissection.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark.
| | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
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12
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Banys-Paluchowski M, de Boniface J. Axillary staging in node-positive breast cancer converting to node negativity through neoadjuvant chemotherapy: Current evidence and perspectives. Scand J Surg 2023; 112:117-125. [PMID: 36642957 DOI: 10.1177/14574969221145892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Over the recent years, axillary staging of initially node-positive breast cancer patients converting to clinical node negativity after neoadjuvant chemotherapy has seen rapid changes. This narrative review aims to give a contemporary overview over published evidence and clinical practice, and thus provide some guidance to the surgical community in the process of re-evaluating and re-shaping surgical practice. METHODS The search strategy aimed at finding relevant studies. Only articles in English were considered. RESULTS The introduction of modern techniques offer more precise staging surgery and thus hopefully reduced arm morbidity. Clinical practice has however diverged both within countries and internationally. While some countries have adapted de-escalated axillary staging techniques such as targeted axillary dissection, targeted lymph node biopsy or sentinel lymph node biopsy, others continue to recommend a full axillary lymph node dissection. With the implementation of new techniques, many questions arise, regarding aspects of oncological safety, technical performance, budget and practicality, patient selection and indications for different levels of axillary staging procedures. CONCLUSIONS There is a growing body of evidence on de-escalation of axillary surgery in the setting of cN+ → ycN0 breast cancer treated with neoadjuvant chemotherapy. However, standards differ between countries and future studies are necessary to fully assess the optimal strategy for these patients.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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13
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Banys-Paluchowski M, Kühn T, Masannat Y, Rubio I, de Boniface J, Ditsch N, Karadeniz Cakmak G, Karakatsanis A, Dave R, Hahn M, Potter S, Kothari A, Gentilini OD, Gulluoglu BM, Lux MP, Smidt M, Weber WP, Aktas Sezen B, Krawczyk N, Hartmann S, Di Micco R, Nietz S, Malherbe F, Cabioglu N, Canturk NZ, Gasparri ML, Murawa D, Harvey J. Localization Techniques for Non-Palpable Breast Lesions: Current Status, Knowledge Gaps, and Rationale for the MELODY Study (EUBREAST-4/iBRA-NET, NCT 05559411). Cancers (Basel) 2023; 15:cancers15041173. [PMID: 36831516 PMCID: PMC9954476 DOI: 10.3390/cancers15041173] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Surgical excision of a non-palpable breast lesion requires a localization step. Among available techniques, wire-guided localization (WGL) is most commonly used. Other techniques (radioactive, magnetic, radar or radiofrequency-based, and intraoperative ultrasound) have been developed in the last two decades with the aim of improving outcomes and logistics. METHODS We performed a systematic review on localization techniques for non-palpable breast cancer. RESULTS For most techniques, oncological outcomes such as lesion identification and clear margin rate seem either comparable with or better than for WGL, but evidence is limited to small cohort studies for some of the devices. Intraoperative ultrasound is associated with significantly higher negative margin rates in meta-analyses of randomized clinical trials (RCTs). Radioactive techniques were studied in several RCTs and are non-inferior to WGL. Smaller studies show higher patient preference towards wire-free localization, but little is known about surgeons' and radiologists' attitudes towards these techniques. CONCLUSIONS Large studies with an additional focus on patient, surgeon, and radiologist preference are necessary. This review aims to present the rationale for the MELODY (NCT05559411) study and to enable standardization of outcome measures for future studies.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany
- Correspondence:
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Die Filderklinik, 70794 Filderstadt, Germany
| | - Yazan Masannat
- Aberdeen Breast Unit, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
| | - Isabel Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, 28027 Madrid, Spain
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17177 Stockholm, Sweden
- Department of Surgery, Capio St. Göran’s Hospital, 11219 Stockholm, Sweden
| | - Nina Ditsch
- Breast Cancer Center, University Hospital Augsburg, 86156 Augsburg, Germany
| | - Güldeniz Karadeniz Cakmak
- Breast and Endocrine Unit, General Surgery Department, Zonguldak BEUN The School of Medicine, Kozlu/Zonguldak 67600, Turkey
| | - Andreas Karakatsanis
- Department for Surgical Sciences, Faculty of Pharmacy and Medicine, Uppsala University, 75236 Uppsala, Sweden
- Section for Breast Surgery, Department of Surgery, Uppsala University Hospital, 75236 Uppsala, Sweden
| | - Rajiv Dave
- Nightingale & Genesis Breast Cancer Prevention Centre, Manchester University NHS Foundation Trust, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Markus Hahn
- Department for Women’s Health, University of Tübingen, 72076 Tübingen, Germany
| | - Shelley Potter
- Bristol Medical School (THS), Bristol Population Health Science Institute, Bristol BS8 1QU, UK
| | - Ashutosh Kothari
- Guy’s & St Thomas NHS Foundation Trust, Kings College, London SE1 9RT, UK
| | - Oreste Davide Gentilini
- Department of Breast Surgery, San Raffaele University and Research Hospital, 20132 Milan, Italy
| | - Bahadir M. Gulluoglu
- Department of Surgery, Breast Surgery Unit, Marmara University School of Medicine and SENATURK Turkish Academy of Senology, Istanbul 34854, Turkey
| | - Michael Patrick Lux
- Department of Gynecology and Obstetrics, St. Louise Frauen-und Kinderklinik, 33098 Paderborn, Germany
| | - Marjolein Smidt
- Department of Surgical Oncology, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands
| | - Walter Paul Weber
- Division of Breast Surgery, Department of Surgery, Basel University Hospital, 4031 Basel, Switzerland
| | - Bilge Aktas Sezen
- European Breast Cancer Research Association of Surgical Trialists (EUBREAST), 73730 Esslingen, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, 18059 Rostock, Germany
| | - Rosa Di Micco
- Department of Breast Surgery, San Raffaele University and Research Hospital, 20132 Milan, Italy
| | - Sarah Nietz
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Francois Malherbe
- Breast and Endocrine Surgery Unit, Groote Schuur Hospital, University of Cape Town, Cape Town 7935, South Africa
| | - Neslihan Cabioglu
- Istanbul Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul 34093, Turkey
| | - Nuh Zafer Canturk
- Department of General Surgery, Kocaeli University School of Medicine, Kocaeli 41001, Turkey
| | - Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, 6900 Lugano, Switzerland
- Centro di Senologia della Svizzera Italiana (CSSI), Ente Ospedaliero Cantonale, Via Pietro Capelli 1, 6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Via Giuseppe Buffi 13, 6900 Lugano, Switzerland
| | - Dawid Murawa
- General Surgery and Surgical Oncology Department, Collegium Medicum, University in Zielona Gora, 65-417 Zielona Góra, Poland
| | - James Harvey
- Nightingale & Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester M13 9PL, UK
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14
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Laws A, Kantor O, King TA. Surgical Management of the Axilla for Breast Cancer. Hematol Oncol Clin North Am 2023; 37:51-77. [PMID: 36435614 DOI: 10.1016/j.hoc.2022.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This review discusses the contemporary surgical management of the axilla in patients with breast cancer. Surgical paradigms are highlighted by clinical nodal status at presentation and treatment approach, including upfront surgery and neoadjuvant systemic therapy settings. This review focuses on the increasing opportunities for de-escalating the extent of axillary surgery in the era of sentinel lymph node biopsy, while also reviewing the remaining indications for axillary clearance with axillary lymph node dissection.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
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15
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Abstract
PURPOSE OF REVIEW The standard of care in breast surgery has changed, from mastectomy to breast conserving surgery whenever possible, and from axillary dissection to sentinel node biopsy. Neoadjuvant systemic approaches have broadened the indications for organ-conserving and less mutilating surgery, but also raise important questions of balancing locoregional treatment de-escalation and protecting excellent long-term outcomes. RECENT FINDINGS Recent studies have aimed at investigating the safety of de-escalating surgical approaches not only in the upfront breast surgery situation but also after neoadjuvant systemic therapy. This pertains to both the safety of breast conserving surgery - including more complex oncoplastic approaches - within the new (posttherapeutic) anatomical extent of the residual disease, but more controversially to de-escalating surgical treatment of the axilla. While sentinel node biopsy appears to be the standard of care for node-negative disease also after primary systemic therapy, the optimal procedure in situations of posttherapeutic node-positive disease remains highly controversial. SUMMARY Both breast and axillary surgery after neoadjuvant systemic therapy for women with breast cancer has undergone multiple paradigm changes in recent years. For the primary tumor in the breast, breast-conserving surgery constitutes the standard of care, and unnecessary mastectomies should be strongly discouraged. For axillary surgery, sentinel-node biopsy should be aimed at, and completion axillary dissections minimized for situations of extensive disease and or poor neoadjuvant treatment response. Additional techniques such as targeted axillary dissection are currently under evaluation in clinical trials.
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Affiliation(s)
- Michael Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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