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Prathibha S, White M, Kolbow M, Hui JYC, Brauer D, Ankeny J, Jensen EH, LaRocca CJ, Marmor S, Tuttle TM. Omission of axillary lymph node dissection for breast cancer patients with three or more positive sentinel lymph nodes. Breast Cancer Res Treat 2024; 205:127-133. [PMID: 38281296 DOI: 10.1007/s10549-023-07203-8] [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: 03/31/2023] [Accepted: 11/26/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE The ACOSOG Z0011 (Z11) trial assessed the benefit of axillary dissection (ALND) for breast cancer patients with sentinel lymph node (SLN) metastases; however, Z11 excluded patients with ≥ 3 positive SLNs. We analyzed trends in ALND omission in patients with ≥ 3 positive SLNs. METHODS Women with ≥ 3 positive SLNs who underwent breast-conserving surgery (BCS) or mastectomy between 2018 and 2020 in the National Cancer Database were included using SLN codes initiated in 2018. Patients with stage IV disease, recurrent breast cancer, and who underwent neoadjuvant chemotherapy were excluded. A multivariable logistic regression model was utilized to determine the proportion who received ALND and factors associated with ALND omission. A subgroup analysis was performed among patients who met the remainder of the Z11 inclusion criteria (BCS, T1/T2 breast cancer). RESULTS We identified 3654 patients with ≥ 3 positive SLNs. ALND was omitted in 37% of patients, and omission significantly increased from 2018 to 2020 (29% vs. 41%, p < 0.0001). Older age, lower grade tumors, no radiation, non-academic facility, BCS, more SLNs examined and fewer positive SLNs were significantly associated with ALND omission. 942 patients with ≥ 3 positive SLNs met the remainder of the Z11 inclusion criteria. ALND was omitted in 49% of these patients, and omission increased from 2018 to 2020 (44% vs. 49%, p = 0.22). CONCLUSION Approximately one-third of patients with ≥ 3 positive SLNs do not undergo ALND; omission of ALND increased from 2018 to 2020. Studies assessing oncologic outcomes of patients with ≥ 3 positive SLNs who do and do not receive ALND are required.
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Affiliation(s)
- Saranya Prathibha
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - McKenzie White
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Madison Kolbow
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Jane Yuet Ching Hui
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - David Brauer
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Jacob Ankeny
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Eric H Jensen
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Christopher J LaRocca
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Schelomo Marmor
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Todd M Tuttle
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA.
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Heidinger M, Weber WP. Axillary Surgery for Breast Cancer in 2024. Cancers (Basel) 2024; 16:1623. [PMID: 38730576 PMCID: PMC11083357 DOI: 10.3390/cancers16091623] [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: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous 'one size fits all' radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.
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Affiliation(s)
- Martin Heidinger
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Walter P. Weber
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
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Nguyen HT, De Allegri M, Heil J, Hennigs A. Population-Level Impact of Omitting Axillary Lymph Node Dissection in Early Breast Cancer Women: Evidence from an Economic Evaluation in Germany. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:275-287. [PMID: 36409454 PMCID: PMC9676848 DOI: 10.1007/s40258-022-00771-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The American College of Surgeons Oncology Group Z0011 trial showed that complete axillary lymph node dissection (cALND) did not improve survival benefits in patients with one or two tumour-involved sentinel lymph nodes and undergoing breast conservation. Still, a considerable number of the Z0011-eligible patients continue to be treated with cALND in various countries. Given the potential economic gain from implementation of the Z0011 recommendations, we quantified population-level impacts of omitting cALND among Z0011-eligible patients in clinical practice. METHODS This 2-year economic analysis adopted both the perspective of patients under statutory insurance and the societal perspective, using data collected prospectively from 179 German breast cancer units between 2008 and 2015. The estimation of cost savings and health gain relied on a single decision tree, which considered three scenarios: clinical practice at the baseline; actual implementation in routine care; and hypothetical full implementation in all eligible patients. RESULTS Data for 188,909 patients with primary breast cancer were available, 13,741 (7.3%) of whom met the Z0011 inclusion criteria. The use of cALND decreased from 94.3% in 2010 to 46.9% in 2015, resulting in a gain of 335 quality-adjusted life-years and a saving of EUR50,334,756 for the society. Had cALND been omitted in all eligible patients, the total gain would have been more than double. CONCLUSIONS The implementation of the Z0011 recommendations resulted in substantial savings and health gain in Germany. Our findings suggest that it is beneficial to introduce additional policy measures to promote further uptake of the Z0011 recommendations in clinical practice.
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Affiliation(s)
- Hoa Thi Nguyen
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany.
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany
| | - Jörg Heil
- Breast Unit, University Hospital, Heidelberg University, Heidelberg, Germany
- Breast Unit, Klinik St. Elisabeth, Heidelberg, Germany
| | - André Hennigs
- Breast Unit, University Hospital, Heidelberg University, Heidelberg, Germany
- Breast Unit, Klinik St. Elisabeth, Heidelberg, Germany
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Lerttiendamrong B, Treeratanapun N, Vacharathit V, Tantiphlachiva K, Vongwattanakit P, Manasnayakorn S, Vongsaisuwon M. Is Routine Intraoperative Frozen Section Analysis of Sentinel Lymph Nodes Necessary in Every Early-Stage Breast Cancer? BREAST CANCER: TARGETS AND THERAPY 2022; 14:281-290. [PMID: 36158940 PMCID: PMC9507279 DOI: 10.2147/bctt.s380579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/08/2022] [Indexed: 11/23/2022]
Abstract
Purpose Clinical application of the ACOSOG Z0011 trial results allows clinically node-negative breast cancer patients who meet criteria to avoid axillary dissection even when 1–2 sentinel lymph nodes (SLNs) are positive for metastatic disease. Intraoperative frozen section (iFS) analyses of SLNs were thought to reduce re-operation rates despite variable reported sensitivity and possibility of a false negative result. This study evaluated the rate of re-operations prevented by SLN iFS in a tertiary care hospital in Bangkok, Thailand, over a 6-year time-frame. Patients and Methods From April 2016 to April 2022, 1284 sentinel lymph node biopsy (SLNB) procedures were performed. Of these, 214 cases were breast-conserving surgery in accordance with the ACOSOG criteria with concomitant usage of iFS. Clinicopathological features of these cases were collected and analyzed. Re-operation rates prevented by the additional intervention were reported. Results Only five additional operations were prevented with the usage of 214 iFS. The discordance rate between frozen and permanent sections in terms of presence of metastatic disease and number of total lymph nodes was around 15%. Tumor staging, node staging, Nottingham histologic grading and lymphovascular invasion are significant predictors of SLN metastasis. Conclusion iFS results in a very low prevention rate for follow-up ALND in patients with preoperative clinically negative axillary nodes and is associated with a non-negligible discordance rate with permanent sections. Our study suggests iFS may be avoided in most cases of early-stage clinically and radiographically node-negative breast cancer patients. Doing so may reduce surgical costs and total operative time without a significant impact on the overall quality of treatment and standard of care.
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Affiliation(s)
| | | | | | - Kasaya Tantiphlachiva
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Sopark Manasnayakorn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Mawin Vongsaisuwon
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Correspondence: Mawin Vongsaisuwon, Department of Surgery, Faculty of Medicine, Chulalongkorn University, 1873 King Chulalongkorn Memorial Hospital, Rama IV Road, Pathum Wan, Bangkok, 10330, Thailand, Tel +66 897158888, Email
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Hofmann A, Liu H, Copeland E, Ang D. Impact on Breast Cancer Survival by Surgical Facility Type Secondary to the ACOSOG Z0011 Trial. Am Surg 2022; 88:2141-2147. [PMID: 35486590 DOI: 10.1177/00031348221093761] [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: 11/15/2022]
Abstract
BACKGROUND Studies have reported differences between age, socioeconomic status, treatment facility, and tumor burden based on survival outcomes for breast cancer (BC). The goal of this study is to evaluate BC survival and mortality outcomes by facility type. To examine likely influence of evidence-based practices, these groups were then sub stratified by pre- and post-Z0011 trial. METHODS This is a population-based study using the National Cancer Database of Commission on Cancer (CoC) designated centers. Intergroup comparisons of demographics were performed using chi-square test. Kaplan-Meier curve and Cox Hazard Ratios were used to evaluate survival differences. Multivariable regression methods were used to evaluate risk-adjusted 30- and 90-day mortality among BC patients. A difference-in-difference (DiD) analysis was used to evaluate the change of treatment over time pre- and post-Z0011 trial. RESULTS Median survival was highest among comprehensive community facilities at 63.2 months and integrated community facilities at 62.7 months, while the lowest for community and academic facilities at 60.6 months and 61 months. Academic facilities had the lowest 30- and 90-day mortality. Community centers saw the largest improvement in overall mortality post-Z0011 trial. The benefit after the Z0011 trial was evident among community centers at the 90-day mortality period as their decrease in mortality (-1.7%) was significantly lower than the decrease of mortality among academic centers (-1.3%), P-value = .01. CONCLUSION While the Z0011 trial had a positive influence in both community and academic facilities, community programs benefited the most. Z0011 trial showed the most change in practice for the community centers.
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Affiliation(s)
- Alana Hofmann
- College of Medicine, 124506University of Central Florida/HCA Consortium- Ocala, Ocala, FL, USA
| | - Huazhi Liu
- 23703Ocala Regional Medical Center, Ocala, FL, USA
| | - Edward Copeland
- Department of Surgery, 3463University of Florida, Gainesville, FL, USA
| | - Darwin Ang
- College of Medicine, 124506University of Central Florida/HCA Consortium- Ocala, Ocala, FL, USA
- Department of Surgery, University of South Florida, Ocala Regional Medical Center, Ocala, FL, USA
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Asirvatham JR, Jorns JM. How Do Pathologists in Academic Institutions Across the United States and Canada Evaluate Sentinel Lymph Nodes in Breast Cancer? A Practice Survey. Am J Clin Pathol 2021; 156:980-988. [PMID: 34164651 DOI: 10.1093/ajcp/aqab055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There are little data on how changes in the clinical management of axillary lymph nodes in breast cancer have influenced pathologist evaluation of sentinel lymph nodes. METHODS A 14-question survey was sent to Canadian and US breast pathologists at academic institutions (AIs). RESULTS Pathologists from 23 AIs responded. Intraoperative evaluation (IOE) is performed for selected cases in 9 AIs, for almost all in 10, and not performed in 4. Thirteen use frozen sections (FSs) alone. During IOE, perinodal fat is completely trimmed in 8, not trimmed in 9, and variable in 2. For FS, in 12 the entire node is submitted at 2-mm intervals. Preferred plane of sectioning is parallel to the long axis in 8 and perpendicular in 12. In 11, a single H&E slide is obtained, whereas 12 opt for multiple levels. In 11, cytokeratin is obtained if necessary, and immunostains are routine in 10. Thirteen consider tumor cells in pericapsular lymphatics as lymphovascular invasion (LVI), and 10 consider it isolated tumor cells (ITCs). CONCLUSIONS There is dichotomy in practice with near-equal support for routine vs case-by-case multilevel/immunostain evaluation, perpendicular vs parallel sectioning, complete vs incomplete fat removal, and tumor in pericapsular lymphatics as LVI vs ITCs.
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Affiliation(s)
- Jaya Ruth Asirvatham
- Department of Pathology, Baylor, Scott & White Health, Temple, TX, USA
- College of Medicine, Texas A&M University, College Station, TX, USA
| | - Julie M Jorns
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
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DeSnyder SM, Yi M, Boccardo F, Feldman S, Klimberg VS, Smith M, Thiruchelvam PTR, McLaughlin S. American Society of Breast Surgeons' Practice Patterns for Patients at Risk and Affected by Breast Cancer-Related Lymphedema. Ann Surg Oncol 2021; 28:5742-5751. [PMID: 34333706 DOI: 10.1245/s10434-021-10494-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/01/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND In 2017, the American Society of Breast Surgeons (ASBrS) published expert panel recommendations for patients at risk for breast cancer-related lymphedema (BCRL) and those affected by BCRL. This study sought to determine BCRL practice patterns. METHODS A survey was sent to 2975 ASBrS members. Questions evaluated members' clinical practice type, practice duration, and familiarity with BCRL recommendations. Descriptive statistics, the chi-square test, and Fisher's exact test were used. RESULTS Of the ASBrS members surveyed, 390 (13.1%) responded. Most of the breast surgeons (58.5%, 228/390) indicated unfamiliarity with recommendations. Nearly all respondents (98.7%, 385/390) educate at-risk patients. Most (60.2%, 234/389) instruct patients to avoid venipuncture, injection or blood pressure measurements in the at-risk arm, and 35.6% (138/388) recommend prophylactic compression sleeve use during air travel. Nearly all (97.7%, 380/389) encourage those at-risk to exercise, including resistance exercise (86.2%, 331/384). Most do not perform axillary reverse mapping (ARM) (67.9%, 264/389) or a lymphatic preventive healing approach (LYMPHA) (84.9%, 331/390). Most (76.1%, 296/389) screen at-risk patients for BCRL. The most frequently used screening tools include self-reported symptoms (81%, 255/315), circumferential tape measure (54%, 170/315) and bioimpedance spectroscopy (27.3%, 86/315). After a BCRL diagnosis, most (90%, 351/390) refer management to a lymphedema-certified physical therapist. For affected patients, nearly all encourage exercise (98.7%, 384/389). Many (49%, 191/390) refer affected patients for consideration of lymphovenous bypass or lymph node transfer. CONCLUSION Most respondents were unfamiliar with the ASBrS expert panel recommendations for patients at risk for BCRL and those affected by BCRL. Opportunities exist to increase awareness of best practices and to acquire ARM and LYMPHA technical expertise.
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Affiliation(s)
- Sarah M DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Min Yi
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - V Suzanne Klimberg
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,The University of Texas Medical Branch, Galveston, TX, USA
| | - Mark Smith
- Northwell Health Cancer Institute, New Hyde Park, NY, USA
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Abstract
OBJECTIVE A simulator to enable safe practice and assessment of ALND has been designed, and face, content and construct validity has been investigated. SUMMARY AND BACKGROUND DATA The reduction in the number of ALNDs conducted has led to decreased resident exposure and confidence. METHODS A cross-sectional multicenter observational study was carried out between July 2017 and August 2018. Following model development, 30 surgeons of varying experience (n = "experts,' n = 11 "senior residents,' and n = 10 "junior residents") were asked to perform a simulated ALND. Face and content validity questionnaires were administered immediately after ALND. All ALND procedures were retrospectively assessed by 2 attending breast surgeons, blinded to operator identity, using a video-based assessment tool, and an end product assessment tool. RESULTS Statistically significant differences between groups were observed across all operative subphases on the axillary clearance assessment tool (P < 0.001). Significant differences between groups were observed for overall procedure quality (P < 0.05) and total number of lymph nodes harvested (P < 0.001). However, operator grade could not be distinguished across other end product variables such as axillary vein damage (P = 0.864) and long thoracic nerve injury (P = 0.094). Overall, participants indicated that the simulator has good anatomical (median score >7) and procedural realism (median score >7). CONCLUSIONS Video-based analysis demonstrates construct validity for ALND assessment. Given reduced ALND exposure, this simulation is a useful adjunct for both technical skills training and formative Deanery or Faculty administered assessments.
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van Munster JJCM, Zamanipoor Najafabadi AH, de Boer NP, Peul WC, van den Hout WB, van Benthem PPG. Impact of surgical intervention trials on healthcare: A systematic review of assessment methods, healthcare outcomes, and determinants. PLoS One 2020; 15:e0233318. [PMID: 32442235 PMCID: PMC7244162 DOI: 10.1371/journal.pone.0233318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/01/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Frameworks used in research impact evaluation studies vary widely and it remains unclear which methods are most appropriate for evaluating research impact in the field of surgical research. Therefore, we aimed to identify and review the methods used to assess the impact of surgical intervention trials on healthcare and to identify determinants for surgical impact. METHODS We searched journal databases up to March 10, 2020 for papers assessing the impact of surgical effectiveness trials on healthcare. Two researchers independently screened the papers for eligibility and performed a Risk of Bias assessment. Characteristics of both impact papers and trial papers were summarized. Univariate analyses were performed to identify determinants for finding research impact, which was defined as a change in healthcare practice. RESULTS Sixty-one impact assessments were performed in 37 included impact papers. Some surgical trial papers were evaluated in more than one impact paper, which provides a total of 38 evaluated trial papers. Most impact papers were published after 2010 (n = 29). Medical records (n = 10), administrative databases (n = 22), and physician's opinion through surveys (n = 5) were used for data collection. Those data were analyzed purely descriptively (n = 3), comparing data before and after publication (n = 29), or through time series analyses (n = 5). Significant healthcare impact was observed 49 times and more often in more recent publications. Having impact was positively associated with using medical records or administrative databases (ref.: surveys), a longer timeframe for impact evaluation and more months between the publication of the trial paper and the impact paper, data collection in North America (ref.: Europe), no economic evaluation of the intervention, finding no significant difference in surgical outcomes, and suggesting de-implementation in the original trial paper. CONCLUSIONS AND IMPLICATIONS Research impact evaluation receives growing interest, but still a small number of impact papers per year was identified. The analysis showed that characteristics of both surgical trial papers and impact papers were associated with finding research impact. We advise to collect data from either medical records or administrative databases, with an evaluation time frame of at least 4 years since trial publication.
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Affiliation(s)
- Juliëtte J. C. M. van Munster
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Amir H. Zamanipoor Najafabadi
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Nick P. de Boer
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
| | - Wilco C. Peul
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Wilbert B. van den Hout
- Department of Biomedical Data Science–Medical Decision Making, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Peter Paul G. van Benthem
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
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Muthuswamy K, Fisher R, Petrou F, Mavroveli S, Leff DR. Axillary lymph node dissection training in a post-Z0011 era: A survey of UK breast surgery trainees. Breast J 2019; 25:1037-1041. [PMID: 31237734 DOI: 10.1111/tbj.13398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 10/23/2018] [Accepted: 11/19/2018] [Indexed: 12/13/2022]
Affiliation(s)
| | - Rebecca Fisher
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Fotis Petrou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stella Mavroveli
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Daniel R Leff
- Department of Surgery and Cancer, Imperial College London, London, UK
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11
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Ngui NK, Hitos K, Hughes TMD. Effect of the American College of Surgeons Oncology Group Z0011 trial on axillary management in breast cancer patients in the Australian setting. Breast J 2019; 25:853-858. [PMID: 31134730 DOI: 10.1111/tbj.13343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 11/23/2018] [Accepted: 01/02/2019] [Indexed: 11/29/2022]
Abstract
The American College of Surgeons Oncology Group Z0011 Trial demonstrated that early breast cancer patients with positive axillary sentinel lymph nodes treated with breast-conserving surgery and breast radiotherapy had no additional oncologic benefit of proceeding to an axillary lymph node dissection (ALND). The extent to which practice has changed in Australia remains unclear. The aim of this study was to investigate the effect of the Z0011 trial on the management of positive axillary sentinel nodes at an Australian institutional level. We reviewed all breast cancer cases treated at the Sydney Adventist Hospital over a 10-year period from 1 January 2008 to 31 December 2017. Patients who fulfilled the Z0011 trial criteria were selected. These patients were divided into two groups according to the year of surgery, before and after 1 January 2011 when the Z0011 study was published. Clinicopathologic data and axillary surgical management were compared. Of the 237 patients fulfilling the Z0011 trial criteria, there were 73 patients before and 158 patients after 1 January 2011. In the earlier group the rate of proceeding to an ALND following a positive sentinel node was 78.1% compared to 43.7% in the latter group (P < 0.0001). There was a significant decline in the rate of ALND over this 10-year period (r = -0.79, P = 0.006). The Z0011 trial has influenced the surgical management of the axilla leading to a significant reduction in the rate of an ALND in patients fulfilling the Z0011 trial criteria at our institution.
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Affiliation(s)
- Nicholas K Ngui
- Breast Multidisciplinary Team, Sydney Adventist Hospital, Sydney, New South Wales, Australia.,Division of Surgery, Sydney Adventist Hospital, Sydney, New South Wales, Australia.,Sydney Adventist Hospital Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kerry Hitos
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - T Michael D Hughes
- Breast Multidisciplinary Team, Sydney Adventist Hospital, Sydney, New South Wales, Australia.,Division of Surgery, Sydney Adventist Hospital, Sydney, New South Wales, Australia.,Sydney Adventist Hospital Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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García-Novoa A, Acea-Nebril B, Casal-Beloy I, Bouzón-Alejandro A, Cereijo Garea C, Gómez-Dovigo A, Builes-Ramírez S, Santiago P, Mosquera-Oses J. El declive de la linfadenectomía axilar en el cáncer de mama. Evolución de su indicación durante los últimos 20 años. Cir Esp 2019; 97:222-229. [DOI: 10.1016/j.ciresp.2019.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 11/28/2022]
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13
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Daugherty MW, Niell BL. Utility of Routine Axillary Ultrasound Surveillance in Breast Cancer Survivors with Previously Diagnosed Metastatic Axillary Adenopathy. JOURNAL OF BREAST IMAGING 2019; 1:25-31. [PMID: 38424874 DOI: 10.1093/jbi/wby009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVE The purpose of this study is to evaluate the utility of routine axillary ultrasound surveillance in asymptomatic T1 or T2 breast cancer patients with 1 to 2 positive axillary nodes that did not undergo axillary lymph node dissection. METHODS A retrospective review of our institutional database identified axillary and breast ultrasound examinations performed between February 1, 2011, and August 31, 2017, in asymptomatic T1 or T2 breast cancer patients with 1 to 2 positive axillary nodes that did not undergo axillary lymph node dissection. From the electronic medical record, patient demographics, imaging data, pathology results, and surgical reports were extracted. Positive predictive values (PPVs) 2 and 3 and cancer detection rate (CDR) were calculated with exact 95% confidence intervals (CIs). RESULTS An average of 2.1 surveillance examinations was performed in 77 unique patients, yielding 160 total examinations. For 7 patients, 7 biopsies were recommended, and 5 biopsies were performed. No malignancy was diagnosed, yielding a PPV2 of 0% (0/7) (95% CI = 0% to 35%); PPV3 of 0% (0/5) (95% CI = 0% to 45%), and CDR of zero per 1000 (0/160) examinations (95% CI = 0 to 19). CONCLUSION Given the low frequency of axillary recurrence, routine axillary surveillance ultrasound in women with T1 or T2 breast cancers and 1 to 2 positive lymph nodes would be expected to have a low incremental CDR compared to clinical evaluation alone. Axillary surveillance ultrasound should not be routinely recommended or performed.
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Affiliation(s)
| | - Bethany L Niell
- H. Lee Moffitt Cancer Center and Research Institute, Department of Diagnostic Imaging, Tampa, FL
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14
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Khan AA, Rakinic J, Kim RH, Mellinger JD, Ganai S. National Trends in General Surgery Resident Exposure to Complex Oncology-Relevant Cases. JOURNAL OF SURGICAL EDUCATION 2019; 76:378-386. [PMID: 30253983 DOI: 10.1016/j.jsurg.2018.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/19/2018] [Accepted: 09/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To evaluate trends in surgical resident exposure to complex oncologic procedures in order to determine whether additional fellowship training is necessary. DESIGN An observational study of national Accreditation Council for Graduate Medical Education case log statistical reports was conducted to determine the average number of cases for selected oncology-relevant procedures completed during training. Linear regression and Cusick trend tests were used to assess temporal trends with the null hypothesis assuming an estimated slope of zero. Instrumental variable estimation was used to study the effect of duty-hour restrictions on oncologic cases per year. SETTING United States general surgery residency training programs. PARTICIPANTS Graduating surgical residents completing their training between 2000 and 2016. RESULTS Across the study interval, mean case volume was 950.6 ± 29.7 (standard deviation) cases with 38.9 ± 3.1 complex oncologic cases per graduating resident. Decreasing trends were noted for average exposure to lymphadenectomies (-7.8 cases/decade; 95% confidence interval [CI] -8.8 to -6.8) and low rectal procedures (-0.9 cases/decade; 95% CI -1.2 to -0.6). There was no clinically important change in complex soft-tissue resections and foregut cases. A significant increase was seen in number of hepatopancreaticobiliary procedures (+3.9 cases/decade; 95% CI 3.1-4.7). Using instrumental variable estimation, there was a modest decline in cancer-relevant cases by 5.0 cases/decade (95% CI 4.5-5.6), while there was an increase in 38.5 total cases/decade (95% CI 10.4-66.7) associated with duty-hour restrictions. CONCLUSIONS Case numbers for several complex oncologic procedures remain low, justifying a need for further fellowship training depending on individual resident experience.
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Affiliation(s)
- Amir A Khan
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Jan Rakinic
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Roger H Kim
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - John D Mellinger
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Sabha Ganai
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois; Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, Illinois.
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15
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de Gregorio A, Widschwendter P, Albrecht S, de Gregorio N, Friedl TWP, Huober J, Janni W, Ebner FK. Axillary Surgery in Breast Cancer Patients Treated with Breast-Conserving Surgery at German Breast Cancer Centers Within the Last 14 Years - Comparison of a University Center and a Community Hospital. Geburtshilfe Frauenheilkd 2018; 78:1138-1145. [PMID: 30498281 PMCID: PMC6255741 DOI: 10.1055/a-0750-1880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/21/2018] [Accepted: 09/25/2018] [Indexed: 11/12/2022] Open
Abstract
Background
Guideline recommendations for axillary surgical approach in breast cancer (BC) treatment changed over the last decade.
Methods
Data from all invasive BC patients (n = 5344) treated with breast conserving surgery (BCS) at the breast cancer centers of the University Hospital Ulm (U-BCC) and the community hospital Dachau (D-BCC) were included into a retrospective analysis for assessing information on axillary surgery between 2003 and 2016 based on the documented cancer registry data.
Results
The average annual rate of sentinel node biopsy (SNB) was 85.5% and 87.2% in Ulm and Dachau, respectively. SNB was performed more precisely at the U-BCC with a median of 2.4 resected lymph nodes (LN) compared to a median of 3.2 resected LN in Dachau. Median number of resected LN for axillary lymph node dissection (ALNE) showed a statistically significant reduction over time in Ulm (r
s
= − 0.82; p < 0.001) and Dachau (r
s
= − 0.76; p = 0.002). The rate of secondary ALNE (after SNB; 2° ALNE) decreased significantly in U-BCC (r
s
= − 0.76; p = 0.002) while it remained stable in D-BCC. The influential publication of the Z0011 study in 2010 resulted in a significant reduction of secondary ALNE (24.1% preZ0011 and 14.4% postZ0011; p < 0.001) in Ulm.
Conclusion
Changes in axillary surgery over time can be seen in the annual statistics of the reviewed BCCs. With BCS, mostly SNB was performed and numbers of removed LN in ALNE have decreased. In the U-BCC, the rate of 2° ALNE dropped after the publication of the Z0011 data. The fact that no such decrease for 2° ALNE was found in D-BCC suggests that university hospitals implement new data and research results into clinical routine earlier than peripheral community hospitals.
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Affiliation(s)
- Amelie de Gregorio
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | - Peter Widschwendter
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | - Susanne Albrecht
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | | | - Thomas W P Friedl
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | - Jens Huober
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | - Florian K Ebner
- Department of Gynecology and Obstetrics, Helios Hospital Amper, Dachau, Germany
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16
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Lee J, Choi JE, Kim SJ, Lee SB, Seong MK, Jeong J, Yoon CS, Kim BK, Sun WY. Comparative Study between Sentinel Lymph Node Biopsy and Axillary Dissection in Patients with One or Two Lymph Node Metastases. J Breast Cancer 2018; 21:306-314. [PMID: 30275859 PMCID: PMC6158162 DOI: 10.4048/jbc.2018.21.e44] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 08/12/2018] [Indexed: 12/29/2022] Open
Abstract
Purpose Sentinel lymph node biopsy (SLNB) is a standard axillary surgery in early breast cancer. If the SLNB result is positive, subsequent axillary lymph node dissection (ALND) is a routine procedure. In 2011, the American College of Surgeons Oncology Group Z0011 trial revealed that ALND may not be necessary in early breast cancer with one or two positive sentinel lymph nodes. The purpose of this study was to compare outcomes among Korean patients with one or two positive axillary lymph nodes in the final pathology who did and did not undergo ALND. Methods A total of 131,717 patients from the Korea Breast Cancer Society registry database received breast cancer surgery from January 1995 to December 2014. Inclusion criteria were T stage 1 or 2, one or two positive lymph nodes, and having received breast-conserving surgery (BCS), whole breast radiation therapy, and no neoadjuvant therapy. We analyzed the differences in disease-specific survival (DSS) and overall survival (OS) between patients who received SLNB only and those who underwent SLNB+ALND. Results A total 4,442 patients met the inclusion criteria, with 1,268 (28.6%) in the SLNB group and 3,174 (71.4%) in the SLNB+ALND group. There were no differences in DSS and OS between the two groups (p=0.378 and p=0.925, respectively). The number of patients who underwent SLNB alone for one or two positive lymph nodes increased continuously from 2004 to 2014. Conclusion Korean patients with early breast cancer and 1 or 2 positive axillary lymph nodes who received BCS plus SLNB showed no significant difference in DSS and OS regardless of whether they received ALND. The findings of this retrospective study demonstrate that omitting ALND can be considered when treating selected patients with early breast cancer who have one or two positive lymph nodes.
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Affiliation(s)
- Jina Lee
- Department of Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Jung Eun Choi
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Sei Joong Kim
- Department of Surgery, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Sae Byul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Ki Seong
- Department of Surgery, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chan Seok Yoon
- Department of Surgery, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea
| | - Bong Kyun Kim
- Department of Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Woo Young Sun
- Department of Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
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17
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Nocera NF, Pyfer BJ, De La Cruz LM, Chatterjee A, Thiruchelvam PT, Fisher CS. NSQIP Analysis of Axillary Lymph Node Dissection Rates for Breast Cancer: Implications for Resident and Fellow Participation. JOURNAL OF SURGICAL EDUCATION 2018; 75:1281-1286. [PMID: 29605705 DOI: 10.1016/j.jsurg.2018.02.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/11/2018] [Accepted: 02/25/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Management of the axilla in invasive breast cancer (IBC) has shifted away from more radical surgery such as axillary lymph node dissection (ALND), towards less invasive procedures, such as sentinel lymph node biopsy. Because of this shift, we hypothesize that there has been a national downward trend in ALND procedures, subsequently impacting surgical trainee exposure to this procedure using the ACS-NSQIP database to evaluate this. METHODS Women with IBC were identified in the ACS-NSQIP database from 2007 to 2014. Procedures including ALND were identified using CPT codes. This number was divided by total cases, given a varying number of participating institutions each year. Next, cases involving resident participation were identified and divided by training level: junior (post graduate year-[PGY] 1-2), senior (PGY 3-5) and fellow (PGY ≥ 6). Two tailed z tests were used to compare proportions, with significance determined when p < 0.05. RESULTS A total of 128,372 women were identified with IBC with 36,844 ALND. ALND rates decreased by an average of 2.43% yearly from 2007 to 2014. Resident participation significantly drops in 2011, from 49.3% before to 29.4% after (p < 0.01). Junior residents experienced a significant decrease in participation rate (43.3%-32.2%, p < 0.05). Senior residents and fellows experienced an upward trend in their participation, although not significant (51.2%-56.3%, p = 0.35, and 5.6%-11.6%, p = 0.056, respectively). CONCLUSIONS Using the ACS-NSQIP database, we demonstrate the downward trend in rate of ALND for IBC with subsequent decrease in resident participation. Junior residents experienced a significant decrease in their participation with no significant change for senior or fellow-level trainees. Awareness of this trend is important when creating future surgical curriculum changes for general surgery and fellowship training programs.
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Affiliation(s)
- Nadia F Nocera
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
| | - Bryan J Pyfer
- Division of Plastic, Maxillofacial and Oral Surgery, Duke University Hospital, Durham, North Carolina
| | - Lucy M De La Cruz
- Comprehensive Breast Care Program, Jupiter Medical Center, Jupiter, Florida
| | | | - Paul T Thiruchelvam
- Department of Breast Surgery, Imperial College London, London, United Kingdom
| | - Carla S Fisher
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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18
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Delgado-Bocanegra RE, Millen EC, do Nascimento CM, Bruno KDA. Intraoperative imprint cytology versus histological diagnosis for the detection of sentinel lymph nodes in breast cancer treated with neoadjuvant chemotherapy. Clinics (Sao Paulo) 2018; 73:e363. [PMID: 30088537 PMCID: PMC6038057 DOI: 10.6061/clinics/2018/e363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/08/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To compare imprint cytology and paraffin section histology for sentinel lymph node detection in women with breast cancer treated with neoadjuvant chemotherapy. METHOD A cross-sectional study and report of the sentinel lymph node statuses of 64 patients with breast cancer who underwent intraoperative imprint cytology and neoadjuvant chemotherapy in a referral cancer institute in Rio de Janeiro, Brazil, between 2014 and 2016. RESULTS The mean age was 51 years. The most common histological type was invasive ductal carcinoma (93.75%), and the most common differentiation grade was 2 (62.5%). Overall, 153 lymph nodes were identified, with a mean of 2.39/case. Thirty-four lymph nodes tested positive for malignancy by imprint cytology, and 55 tested positive by histology. Of the 55 positive lymph nodes, 41 (74.5%) involved macrometastases, and 14 (25.5%) involved micrometastases. There were 21 false negatives with imprint cytology, namely, 7 for macrometastases and 14 for micrometastases, resulting in a rate of 17.6%. The sensitivity of imprint cytology was 61.8%, with a specificity and positive predictive value of 100%, a negative predictive value of 82.4% and an accuracy of 86.3%. The method presented null sensitivity for the identification of micrometastases. CONCLUSIONS The false-negative rate with imprint cytology was associated with the number of sentinel lymph nodes obtained. The rate found for complete response to neoadjuvant chemotherapy was comparable to the rates reported in the literature. The accuracy of imprint cytology was good, and its specificity was excellent for sentinel lymph node detection; however, the method was unable to detect lymph node micrometastases.
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19
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Lei X, Liu F, Luo S, Sun Y, Zhu L, Su F, Chen K, Li S. Evaluation of guidelines regarding surgical treatment of breast cancer using the AGREE Instrument: a systematic review. BMJ Open 2017; 7:e014883. [PMID: 29138191 PMCID: PMC5695453 DOI: 10.1136/bmjopen-2016-014883] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Many clinical practice guidelines and consensus statements (CPGs/consensus statements) have been developed for the surgical treatments for breast cancer. This study aims to evaluate the quality of these CPGs/consensus statements. METHODS We systematically searched the PubMed and EMBASE databases, as well as four guideline repositories, to identify CPGs and consensus statements regarding surgical treatments for breast cancer between January 2009 and December 2016. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument to assess the quality of the CPGs and consensus statements included. The overall assessment scores from the AGREE instrument and radar maps were used to evaluate the overall quality. We also evaluated some factors that may affect the quality of CPGs and consensus statements using the Mann-Whitney U test or Kruskal-Wallis H test. All analyses were performed using SPSS V.19.0. This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS A total of 19 CPGs and four consensus statements were included. In general, the included CPGs/consensus statements (n=23) performed well in the 'Scope and Purpose' and 'Clarity and Presentation' domains, but performed poorly in the 'Applicability' domain. The American Society of Clinical Oncology (ASCO), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), New Zealand Guidelines Group (NZGG) and Belgium Health Care Knowledge Centre (KCE) guidelines had the highest overall quality, whereas the Saskatchewan Cancer Agency, Spanish Society of Medical Oncology (SEOM), Japanese Breast Cancer Society (JBCS) guidelines and the D.A.C.H and European School of Oncology (ESO) consensus statements had the lowest overall quality. The updating frequency of CPGs/consensus statements varied, with the quality of consensus statements generally lower than that of CPGs. A total of six, eight and five CPGs were developed in the North American, European and Asian/Pacific regions, respectively. However, geographic region was not associated with overall quality. CONCLUSIONS The ASCO, NICE, SIGN, NZGG and KCE guidelines had the best overall quality, and the quality of consensus statements was generally lower than that of CPGs. More efforts are needed to identify barriers and facilitators for CPGs/consensus statement implementation and to improve their applicability.
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Affiliation(s)
- Xin Lei
- Breast Tumour Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Thyroid and Breast SurgeryDepartment, The First AffliatedHospital, Guangzhou, Guangdong, China
| | - Fengtao Liu
- Breast Tumour Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shuying Luo
- Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Pharmacy, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ya Sun
- Breast Tumour Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Liling Zhu
- Breast Tumour Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Fengxi Su
- Breast Tumour Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Kai Chen
- Breast Tumour Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shunrong Li
- Breast Tumour Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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20
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Mann JM, Wu X, Christos P, Nagar H. The State of Surgical Axillary Management and Adjuvant Radiotherapy for Early-stage Invasive Breast Cancer in the Modern Era. Clin Breast Cancer 2017; 18:e477-e493. [PMID: 29031423 DOI: 10.1016/j.clbc.2017.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND For clinical T1-2N0 breast cancer, sentinel lymph node biopsy (SLNB) has been shown in American College of Surgeons Oncology Group (ACOSOG) Z0011 to be sufficient for women with 1 to 2 positive sentinel lymph nodes with no added benefit for completion axillary lymph node dissection (ALND). Z0011 specified whole breast radiotherapy (RT) using standard tangential fields; however, later analysis showed variation in field design. We assessed nationwide practice patterns and examined factors associated with patients undergoing completion ALND and subsequent radiation field design. PATIENTS AND METHODS Women with clinical T1-2N0 breast cancer who underwent breast-conserving surgery, axillary staging, and whole breast RT in 2012 to 2013 were identified in the National Cancer Database. Multivariable logistic regression modeling was used to examine axillary management and RT, adjusting for demographic and clinicopathologic factors. RESULTS Among 83,555 patients meeting criteria, 9.3% underwent upfront ALND, 75.8% underwent SLNB only, and 14.9% underwent SLNB with completion ALND. From 2012 to 2013, upfront SLNB increased from 90.1% to 91.4% (odds ratio, 1.14; P < .001). Among 9474 patients that underwent SLNB with 1 to 2 positive sentinel nodes, 31.2% received completion ALND. Among patients with 1 to 2 positive sentinel nodes, SLNB increased from 65.8% to 72.1% from 2012 to 2013 (P < .001). For patients with 1 to 2 positive lymph nodes that underwent SLNB only, 63.4% underwent breast RT, whereas 36.6% received breast and nodal RT. CONCLUSIONS Nationwide practice patterns of axillary management vary. Despite an increasing rate of SLNB, many patients still receive upfront and completion ALND. Furthermore, there is significant variation in RT field design, and modern treatment guidelines are warranted for this patient population.
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Affiliation(s)
- Justin M Mann
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY.
| | - Xian Wu
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Paul Christos
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY
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21
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Verheuvel NC, Voogd AC, Tjan-Heijnen VCG, Siesling S, Roumen RMH. Different outcome in node-positive breast cancer patients found by axillary ultrasound or sentinel node procedure. Breast Cancer Res Treat 2017; 165:555-563. [PMID: 28656490 PMCID: PMC5602026 DOI: 10.1007/s10549-017-4342-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/13/2017] [Indexed: 12/13/2022]
Abstract
Background The Z0011 trial initiated a paradigm shift in the axillary treatment of breast cancer patients with a positive sentinel lymph node biopsy (SLNB), disregarding patients with a positive ultrasound-guided lymph node biopsy (UGLNB). We examined whether relevant differences exist between these patients to determine if the conclusions of the ACOSOG Z0011 trial are applicable to UGLNB-positive patients. Methods Patients diagnosed with invasive breast cancer in the Netherlands between January 2008 and December 2014 were selected from the Netherlands Cancer Registry. Results A total of 11,820 cases were included: 9149 cases in the SLNB group and 2671 in the UGLNB group. Multivariate analyses showed that UGLNB-positive patients were older (p < 0.001), more likely to have a poorly differentiated tumor (p < 0.001), had a negative hormone receptor status (p < 0.001), and more often had extensive nodal involvement (p < 0.001). However, they were less likely to undergo adjuvant radiation (p = 0.004) or systemic therapy (p < 0.001). Even after adjusting for these factors, UGLNB-positive patients had a worse overall survival (HR = 1.38; 95% CI 1.23–1.56) than SLNB-positive patients. Conclusion This nationwide retrospective study shows that young patients found positive by UGLNB have less favorable disease characteristics and a worse prognosis compared to patients with a positive SLNB. Selection by ultrasound plays an important role when axillary treatment strategies are considered. Hence, the conclusions of the Z0011 trial cannot unconditionally be applied to patients with a positive UGLNB.
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Affiliation(s)
- Nicole C Verheuvel
- Department of Surgery, Máxima Medical Center, PO Box 7777, 5500 MB, Veldhoven, The Netherlands.
| | - Adri C Voogd
- Department of Epidemiology, School of Oncology and Developmental Biology (GROW), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Medical Oncology, School of Oncology and Developmental Biology (GROW), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Medical Oncology, School of Oncology and Developmental Biology (GROW), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - S Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center, PO Box 7777, 5500 MB, Veldhoven, The Netherlands.,Department of Medical Oncology, School of Oncology and Developmental Biology (GROW), Maastricht University Medical Centre, Maastricht, The Netherlands
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22
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Tsao MW, Cornacchi SD, Hodgson N, Simunovic M, Thabane L, Cheng J, O'Brien MA, Strang B, Mukherjee SD, Lovrics PJ. A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Lymph Node Dissection on Axillary Surgery in Patients with Breast Cancer. Ann Surg Oncol 2016; 23:3354-64. [PMID: 27342830 DOI: 10.1245/s10434-016-5310-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Evidence from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial suggests completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy (+SLNB) does not improve outcomes in select patients, leading to practice variation. A multidisciplinary group of surgeons, oncologists, and pathologists developed a regional guideline for cALND which was disseminated in August 2012. We assessed the impact of Z0011 and the regional guideline on cALND rates. METHODS Consecutive invasive breast cancer cases undergoing SLNB were reviewed at 12 hospitals. Patient, tumor, and process measures were collected for three time periods: TP1, before publication of Z0011 (May 2009-August 2010); TP2, after publication of Z0011 (March 2011-June 2012); and TP3, after guideline dissemination (January 2013-April 2014). Cases were categorized by whether they met the guideline criteria for cALND (i.e. ≤50 years, mastectomy, T3 tumor, three or more positive sentinel lymph nodes [SLNs]) or not (e.g. age > 50 years, breast-conserving surgery, T1/T2 tumor, and one to two positive SLNs). RESULTS The SLNB rate increased from 56 % (n = 620), to 70 % (n = 774), to 78 % (n = 844) in TP1, TP2, and TP3, respectively. Among cases not recommended for cALND using the guideline criteria, cALND rates decreased significantly over time (TP1, 71 %; TP2, 43 %; TP3, 17 %) [p < 0.001]. The cALND rate also decreased over time among cases recommended to have cALND using the guideline criteria (TP1, 92 %; TP2, 69 %; TP3, 58 %) [p < 0.001]. Based on multivariable analysis, age and nodal factors appeared to be significant factors for cALND decision making. CONCLUSION Publication of ACOSOG Z0011 and regional guideline dissemination were associated with a marked decrease in cALND after +SLNB, even among several cases in which the guideline recommended cALND.
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Affiliation(s)
- Miriam W Tsao
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Nicole Hodgson
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Ji Cheng
- Biostatistics Unit, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Mary Ann O'Brien
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Barbara Strang
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Som D Mukherjee
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Peter J Lovrics
- Department of Surgery, McMaster University, Hamilton, ON, Canada. .,Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada. .,Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada.
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23
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Maguire A, Brogi E. Sentinel lymph nodes for breast carcinoma: an update on current practice. Histopathology 2016; 68:152-67. [PMID: 26768036 PMCID: PMC5027880 DOI: 10.1111/his.12853] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 08/26/2015] [Indexed: 12/12/2022]
Abstract
Sentinel lymph node (SLN) biopsy has been established as the standard of care for axillary staging in patients with invasive breast carcinoma and clinically negative lymph nodes (cN0). Historically, all patients with a positive SLN underwent axillary lymph node dissection (ALND). The ACOSOG Z0011 trial showed that women with T1-T2 disease and cN0 who undergo breast-conserving surgery and whole-breast radiotherapy can safely avoid ALND. The main goal of SLN examination should be to detect all macrometastases (>2 mm). Gross sectioning of SLNs at 2-mm intervals and microscopic examination of one haematoxylin and eosin-stained section from each SLN block is the preferred method for pathological evaluation of SLNs. The role and timing of SLN biopsy for patients who have received neoadjuvant chemotherapy is controversial, and continues to be explored in clinical trials. SLN biopsies from patients with invasive breast carcinoma who have received neoadjuvant chemotherapy pose particular challenges for pathologists.
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Affiliation(s)
- Aoife Maguire
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Joyce DP, Manning A, Carter M, Hill ADK, Kell MR, Barry M. Meta-analysis to determine the clinical impact of axillary lymph node dissection in the treatment of invasive breast cancer. Breast Cancer Res Treat 2015; 153:235-40. [DOI: 10.1007/s10549-015-3549-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022]
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