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Detz D, Hanssen D, Whiting J, Sun W, Czerniecki B, Hoover S, Khakpour N, Kiluk J, Laronga C, Mallory M, Lee MC, Kruper L. Retrieval of the Clipped Axillary Lymph Node and Its Impact on Treatment Decisions. Cancers (Basel) 2024; 16:3001. [PMID: 39272859 PMCID: PMC11393888 DOI: 10.3390/cancers16173001] [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: 07/31/2024] [Revised: 08/22/2024] [Accepted: 08/27/2024] [Indexed: 09/15/2024] Open
Abstract
We examined clinically node-positive (cN+) breast cancer patients undergoing neoadjuvant chemotherapy and clipped lymph node (CLN) localization to determine the rate of CLN = non-sentinel lymph node (SLN), the factors associated with cN+ to pN0 conversion, and the treatment impact. We conducted a single institution review of cN+ patients receiving NAC from 2016 to 2022 with preoperative CLN localization (N = 81). Demographics, hormone receptor (HR) and HER2 status, time to surgery, staging, chemotherapy regimen, localization method, pathology, and adjuvant therapy were analyzed. Pathologic complete response (pCR) of the CLN was observed in 41 patients (50.6%): 18.8% HR+/HER2-, 75% HR+/HER2+, 75% HR-/HER2+, and 62.5% triple-negative breast cancer (p-value = 0.006). CLN = SLN in 68 (84%) patients, while CLN = non-SLN in 13 (16%). In 14 (17.3%) patients, the final treatment was altered based on +CLN status: 11 patients underwent axillary lymph node dissection (ALND), and 3 had systemic treatment changes. pCR rates varied, with the highest conversion rates observed in HER2+ disease and the lowest in HR+/HER2- disease. In 2 (2.5%) patients, adjuvant therapy changes were made based on a non-sentinel CLN, while in 97.5% of patients, a SLN biopsy alone represented the status of the axilla. This demonstrates that a +CLN often alters final plans and that, despite also being a SLN in most cases, a subset of patients will be undertreated by SLN biopsy alone.
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Affiliation(s)
- David Detz
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Diego Hanssen
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Junmin Whiting
- Department of Biostatistics & Bioinformatics, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Weihong Sun
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Brian Czerniecki
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Susan Hoover
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Nazanin Khakpour
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - John Kiluk
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Christine Laronga
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Melissa Mallory
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - M Catherine Lee
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Laura Kruper
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL 33612, USA
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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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Coogan AC, Lunt LG, O'Donoghue C, Keshwani SS, Madrigrano A. Efficacy of Targeted Axillary Dissection With Radar Reflector Localization Before Neoadjuvant Chemotherapy. J Surg Res 2024; 295:597-602. [PMID: 38096773 DOI: 10.1016/j.jss.2023.11.061] [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: 06/27/2023] [Revised: 11/04/2023] [Accepted: 11/18/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION For clinically node positive breast cancer patients treated with neoadjuvant chemotherapy (NAC), targeted axillary dissection (TAD) can be used to stage the axilla. TAD removes the sentinel lymph node (SLN) and tagged positive nodes, which can be identified via radar reflector localization (RRL). As it can be challenging to localize a previously positive node after NAC, we evaluated RRL prior to NAC. METHODS We performed a retrospective chart review of breast cancer patients with node positive disease treated with NAC who underwent TAD with RRL. We compared retrieval of radar reflector and clip, timing of localization, and, if a node was positive, whether the radar reflector node or SLN was positive. RESULTS Seventy-nine patients fulfilled inclusion criteria; 32 were placed pre-NAC (mean 187 d before surgery) and 47 were placed post-NAC (mean 7 d before surgery). For pre-NAC placement, 31 of 32 radar reflectors and 31 of 32 clips were retrieved. For post-NAC placement, 47 of 47 radar reflectors and 46 of 47 clips were retrieved. There was no significant difference in radar reflector or clip retrieval rates between pre-NAC and post-NAC groups (P = 0.41, P = 1, respectively). Thirty of 32 patients with pathologic complete response avoided an axillary lymph node dissection. Of 47 patients with a positive lymph node, 32 were both the SLN and radar reflector node, 11 were radar reflector alone, and four were the SLN. CONCLUSIONS RRL systems are an effective way to guide TAD, and RRL makers can be safely placed prior to NAC.
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Affiliation(s)
- Alison C Coogan
- Department of Surgery, Rush University Medical Center, Chicago, Illinois.
| | - Lilia G Lunt
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Sarah S Keshwani
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Andrea Madrigrano
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
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Akrida I, Michalopoulos NV, Lagadinou M, Papadoliopoulou M, Maroulis I, Mulita F. An Updated Review on the Emerging Role of Indocyanine Green (ICG) as a Sentinel Lymph Node Tracer in Breast Cancer. Cancers (Basel) 2023; 15:5755. [PMID: 38136301 PMCID: PMC10742210 DOI: 10.3390/cancers15245755] [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: 11/06/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Sentinel lymph node biopsy (SLNB) has become the standard of care for clinically node-negative breast cancer and has recently been shown by clinical trials to be also feasible for clinically node-positive patients treated with primary systemic therapy. The dual technique using both radioisotope (RI) and blue dye (BD) as tracers for the identification of sentinel lymph nodes is considered the gold standard. However, allergic reactions to blue dye as well as logistics issues related to the use of radioactive agents, have led to research on new sentinel lymph node (SLN) tracers and to the development and introduction of novel techniques in the clinical practice. Indocyanine green (ICG) is a water-soluble dye with fluorescent properties in the near-infrared (NIR) spectrum. ICG has been shown to be safe and effective as a tracer during SLNB for breast cancer and accumulating evidence suggests that ICG is superior to BD and at least comparable to RI alone and to RI combined with BD. Thus, ICG was recently proposed as a reliable SLN tracer in some breast cancer clinical practice guidelines. Nevertheless, there is lack of consensus regarding the optimal role of ICG for SLN mapping. Specifically, it is yet to be determined whether ICG should be used in addition to BD and/or RI, or if ICG could potentially replace these long-established traditional SLN tracers. This article is an updated overview of somerecent studies that compared ICG with BD and/or RI regarding their accuracy and effectiveness during SLNB for breast cancer.
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Affiliation(s)
- Ioanna Akrida
- Department of Surgery, General University Hospital of Patras, 26504 Rio, Greece; (I.A.); (I.M.)
| | - Nikolaos V. Michalopoulos
- 4th Department of Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 1 Rimini Street, Chaidari, 12462 Athens, Greece; (N.V.M.); (M.P.)
| | - Maria Lagadinou
- Department of Internal Medicine, General University Hospital of Patras, 26504 Rio, Greece;
| | - Maria Papadoliopoulou
- 4th Department of Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 1 Rimini Street, Chaidari, 12462 Athens, Greece; (N.V.M.); (M.P.)
| | - Ioannis Maroulis
- Department of Surgery, General University Hospital of Patras, 26504 Rio, Greece; (I.A.); (I.M.)
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, 26504 Rio, Greece; (I.A.); (I.M.)
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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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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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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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