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Wanis KN, Goetz L, So A, Glencer AC, Sun SX, Teshome M, Resetkova E, Hwang RF, Hunt KK, Candelaria RP, Huo L, Singh P. The Prevalence of Sentinel Lymph Node Positivity and Implications for the Utility of Frozen Section Diagnosis Following Neoadjuvant Systemic Therapy in Patients with Clinically Node-Negative HER2-Positive or Triple-Negative Breast Cancer. Ann Surg Oncol 2024; 31:7339-7346. [PMID: 39048903 DOI: 10.1245/s10434-024-15712-z] [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: 04/18/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Axillary dissection is the standard of care for patients with positive sentinel lymph nodes (SLNs) following neoadjuvant systemic therapy. Frozen section can provide intraoperative information regarding the need for axillary dissection during the index operation. However, there are limited data on the utility of frozen section in patients with clinically node-negative (cN0) HER2-positive or triple-negative breast cancer. METHODS We conducted a single-institution observational cohort study including patients with non-inflammatory, cN0, HER2-positive or triple-negative breast cancer treated with neoadjuvant systemic therapy between 2015 and 2019. We estimated the prevalence of SLN positivity and the diagnostic test characteristics of SLN frozen section. RESULTS Overall, 662 patients were eligible for inclusion, and 44 patients had one or more positive SLNs (prevalence: 6.6%, 95% confidence interval [CI] 4.9-8.8). There were 490 (74.0%) patients who had intraoperative frozen section, and 19 (3.9%) tested positive among 33 (6.7%) with positive final pathology. Frozen section sensitivity was 57.6% (95% CI 39.2-74.5), specificity was 100% (95% CI 99.2-100), positive predictive value was 100% (95% CI 82.4-100), and negative predictive value was 97.0% (95% CI 95.1-98.4). The sensitivity of frozen section for detection of micrometastases or isolated tumor cells was 35.3% (95% CI 14.2-61.7). CONCLUSION In patients with cN0 HER2-positive or triple-negative breast cancer who have been treated with neoadjuvant therapy, positive SLNs are uncommon and frozen section sensitivity is modest. Decisions to defer SLN evaluation to final pathology, which may be reasonable in many settings, can be informed, in part, by these findings.
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Affiliation(s)
- Kerollos Nashat Wanis
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lianna Goetz
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alycia So
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexa C Glencer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susie X Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erika Resetkova
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rosa F Hwang
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rosalind P Candelaria
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lei Huo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Puneet Singh
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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De Luca A, Amabile MI, Santori F, Di Matteo S, Tomatis M, Ponti A, Frusone F, Taffurelli M, Tinterri C, Marotti L, Calabrese M, Marchiò C, Puglisi F, Palumbo I, Fortunato L. Neoadjuvant chemotherapy for breast cancer in Italy: A Senonetwork analysis of 37,215 patients treated from 2017 to 2022. Breast 2024:103790. [PMID: 39242318 DOI: 10.1016/j.breast.2024.103790] [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: 07/01/2024] [Revised: 08/16/2024] [Accepted: 08/23/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Adoption of neoadjuvant chemotherapy (NACT) in the "real world" has been poorly investigated. Aim of this study was to examine the rate of NACT in Italy, trends over time and determinants of therapeutic choices. METHODS Senonetwork, the recognized network of Breast Centers in Italy, has developed a voluntary national data warehouse with the aim to monitor and improve treatments quality. A retrospective analysis was conducted among 58,661 breast cancer (BC) patients treated between 2017 and 2022 by 24 high-volume Breast Centers participating in the project. RESULTS After subset exclusion, 37,215 primary BC patients were analysed, 32,933 underwent primary-breast-surgery and 4,282 underwent NACT. From 2017 to 2022, the overall NACT incidence increased particularly for HR-/HER2+, Triple-Negative, and HR+/HER2+ BC (p < 0.001). In cN + patients the recommendation to axillary lymph-node dissection after NACT decreased over time along with an increase of <4 lymph-nodes removed (p < 0.001). Immediate breast reconstruction and indication for nipple sparing mastectomy increased significantly over time (OR = 1.10, p = 0.011 and OR 1.14, p < 0.001, respectively). On multivariate analysis, there was a trend towards an increased adoption of conservative treatment for HR-/HER2+ (p = 0.01) and Triple Negative tumors (p = 0.06). Implementation of NACT varied significantly among Breast-Centers from 3.8 to 17.7 % (p < 0.001). CONCLUSION The impact of NACT on the subsequent surgical management is substantial and continues to evolve over time, resulting in less-extensive surgery. Even among high-volume Centers NACT implementation rate is still highly variable. Although we registered a significant increase in its use during the study period, these results need to be further improved.
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Affiliation(s)
- A De Luca
- Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - M I Amabile
- Department of Surgery, Sapienza University of Rome, Rome, Italy.
| | - F Santori
- Breast Center, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy; Surgical Residency Program, University of Tor Vergata, Rome, Italy
| | - S Di Matteo
- Breast Center, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy; Surgical Residency Program, Federico II University, Naples, Italy
| | - M Tomatis
- AOU Città della Salute e della Scienza, CPO Piemonte and SENONETWORK Data, Warehouse, Turin, Italy
| | - A Ponti
- AOU Città della Salute e della Scienza, CPO Piemonte and SENONETWORK Data, Warehouse, Turin, Italy
| | - F Frusone
- Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - M Taffurelli
- IRCCS Policlinico S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - C Tinterri
- Humanitas Research Hospital and Cancer Center, Breast Surgery, Rozzano, Italy
| | | | - M Calabrese
- Department of Radiology, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - C Marchiò
- Department of Medical Sciences, University of Turin, Turin, Italy; Pathology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - F Puglisi
- Department of Medicine, University of Udine, Udine, Italy; Department of Medical Oncology, National Cancer Institute, Centro di Riferimento Oncologico (CRO), IRCCS, Aviano, PN, Italy
| | - I Palumbo
- Internal Medicine and Oncology, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy
| | - L Fortunato
- Breast Center, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
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Cortina CS. Shifting neoadjuvant chemotherapy treatment paradigms for breast cancer and its impact on axillary nodal management for clinically node-negative patients. Gland Surg 2024; 13:1154-1158. [PMID: 39175711 PMCID: PMC11336792 DOI: 10.21037/gs-24-159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 07/03/2024] [Indexed: 08/24/2024]
Affiliation(s)
- Chandler S. Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
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Cortina CS, Lloren JI, Rogers C, Johnson MK, Cobb AN, Huang CC, Kong AL, Singh P, Teshome M. Does Neoadjuvant Chemotherapy in Clinical T1-T2 N0 Triple-Negative Breast Cancer Increase the Extent of Axillary Surgery? Ann Surg Oncol 2024; 31:3128-3140. [PMID: 38270828 PMCID: PMC11003830 DOI: 10.1245/s10434-024-14914-9] [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: 11/13/2023] [Accepted: 01/03/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Current management strategies for early-stage triple-negative breast cancer (TNBC) include upfront surgery to determine pathologic stage to guide chemotherapy recommendations, or neoadjuvant chemotherapy (NAC) to de-escalate surgery, elucidate tumor response, and determine the role of adjuvant chemotherapy. However, patients who receive NAC with residual pathological nodal (pN) involvement require axillary lymph node dissection (ALND) as they are Z11/AMAROS ineligible. We aimed to evaluate the impact of NAC compared with upfront surgery on pN status and ALND rates in cT1-2N0 TNBC. METHODS The National Cancer Database (NCDB) was queried for women with operable cT1-2N0 TNBC from 2014 to 2019. Demographic, clinicopathologic, and treatment data were collected. Multivariable linear regression analysis was performed to assess the odds of pN+ disease and undergoing ALND. RESULTS Overall, 55,624 women were included: 26.9% (n = 14,942) underwent NAC and 73.1% (n = 40,682) underwent upfront surgery. The NAC cohort was younger (mean age 52.9 vs. 61.3 years; p < 0.001) with more cT2 tumors (71.6% vs. 31.0%; p < 0.001), and had lower ALND rates (4.3% vs. 5.5%; p < 0.001). The upfront surgery cohort was more likely to have one to three pathologically positive nodes (12.1% vs. 6.5%; odds ratio [OR] 2.37, 95% confidence interval (CI) 2.17-2.58; p < 0.001) but there was no difference in the likelihood of ALND (OR 1.1, 95% CI 0.99-1.24; p = 0.08). CONCLUSION Patients who underwent upfront surgery were more likely to be pN+; however, ALND rates were similar between the two cohorts. Thus, the use of NAC does not result in a higher odds of ALND and the decision for NAC should be individualized and based on modern guidelines and systemic therapy benefits.
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Affiliation(s)
- Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
| | - Jan Irene Lloren
- Division of Biostatistics, Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Christine Rogers
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Morgan K Johnson
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Adrienne N Cobb
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chiang-Ching Huang
- Division of Biostatistics, Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Puneet Singh
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Cortina CS, Rogers CC, Teshome M. ASO Author Reflections: Neoadjuvant Systemic Therapy and Nodal Management in cT1-2 N0 Triple-Negative Breast Cancer. Ann Surg Oncol 2024; 31:3196-3197. [PMID: 38341380 PMCID: PMC11003827 DOI: 10.1245/s10434-024-15020-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/21/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
| | - Christine C Rogers
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mediget Teshome
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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