Which sentinel lymph-node (SLN) positive breast cancer patient needs an axillary lymph-node dissection (ALND) – ACOSOG Z0011 results and beyond

Long-Term Survival Outcomes and Risk Factors for Axillary and Locoregional Recurrence in Japanese Patients with Sentinel Node-Positive Breast Cancer Treated in Accordance with the ACOSOG Z0011 Strategy

INTRODUCTION

In 2018, we reported the results of a study to assess the feasibility of applying the ACOSOG Z0011 criteria to Japanese patients with early-stage breast cancer (median follow-up, 3 years). Their results over the longer term can now be presented. Risk factors for axillary and locoregional recurrence in Z0011-eligible patients are unknown.

METHODS

Long-term survival outcomes were investigated by analyzing data from patients enrolled in the feasibility study. Data from the feasibility study patients, and from patients eligible for the Z0011 strategy after its introduction into clinical practice, were subjected to multivariate logistic regression analysis to identify risk factors for axillary and locoregional recurrence.

RESULTS

Regarding long-term outcomes for the feasibility study patients (n = 189), distant disease-free survival rates at 5 and 7 years were 90.4 ± 2.1% and 85.9 ± 2.6%, respectively, and overall survival rates at 5 and 7 years were 97.3 ± 1.2% and 95.3 ± 1.7%, respectively. Analysis of data from these patients plus the 93 who received Z0011 in clinical practice (total, n = 282) identified the following independent risk factors for axillary recurrence: absence of high axillary tangential irradiation (OR, 5.87 [95% CI, 1.09-31.35], p = 0.04) and number of positive sentinel lymph nodes (OR, 4.65 [95% CI, 1.11-19.48], p = 0.04). Only high Ki67 labeling index (OR, 5.92 [95% CI, 1.31-26.70], p = 0.02) was identified as an independent risk factor for locoregional recurrence.

CONCLUSION

Long-term survival outcome results of the feasibility study show that the Z0011 strategy can be used to treat Japanese patients with early-stage breast cancer. Our findings regarding risk factors suggest that high axillary tangent irradiation is necessary for the prevention of axillary recurrence and that irradiation, including of the regional lymph nodes, should be considered, especially in patients with high Ki67 index values.

Omitting Axillary Lymph Node Dissection Is Associated With an Increased Risk of Regional Recurrence in Early Stage Breast Cancer: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Breast cancer (BC) is a global problem, however, despite ALND is considered the standard treatment for early stage BC with node-positive, there is no sufficient data to determine which of these patients should undergo it. Thus, the aim of this systematic review was to clarify if there is any difference between NALND and ALND in terms of safety and prognosis of the patients. A shearch was carried in PubMed, Embase and Cochrane databases for studies that compared NALND and ALND. The statistics was performed in R software, in which fixed and random effect models were employed for outcomes with, respectively, I² < 25% and I² > 25%, to compute risk ratios and hazard ratios with 95% CI. Heterogeneity was accessed with I2 statistics. There was 9 included studies, involving 11,543patients, of whom 5831 were randomized to omission of ALND. The follow-up period ranged from 5 to 15 years, with participant ages varying from 53.4 to 70.1 years. The analysis revealed significant increase in regional recurrence at the end of the follow-up (RR 1.73; 95% CI, 1.13 to 2.66) and a significant decrease in lymphedema (RR 0.35; 95% CI, 0.24 to 0.52), however no significant result was found for OS (HR 1.01; 95% CI, 0.89 to 1.15). Our data suggest that while the NALND offers benefits in terms of preventing lymphedema, it was associated with a higher risk of of regional recurrences. Thus, further studies are necessary to fully assess the role of these techniques in BC management.

Electrical lymph node scanning (ELS) system for real-time intra-operative detection of involved axillary lymph nodes in adjuvant breast cancer patients

Lymph node (LN) status is an essential prognostic factor in breast cancer (BC) patients, with an important role in the surgical and therapeutic plan. Recently, we have been developed a novel system for real-time intra-operative electrical LN scanning in BC patients. The ELS scores were calibrated by pathological evaluation of the LNs. Herein, we evaluated the efficacy of ELS in a prospective study for non-chemo-treated breast cancer patients. This is a prospective study in which ELS scores are blind for pathologists who declare the clearance or involvement of LNs based on permanent pathology as the gold standard. ELS and frozen-section (FS) pathology results were achieved intra-operatively, and samples were sent for the permanent pathology. The score of ELS did not affect the surgeons' decision, and the treatment approach was carried out based on FS pathology and pre-surgical data, such as imaging and probable biopsies. Patients were recruited from October 2021 through November 2022, and 381 lymph nodes of 97 patients were included in the study. In this study we recruited 38 patients (39.2%) with sentinel lymph node biopsy (SLNB) and 59 patients (60.8%) with ALND. Of the 381 LNs scored by ELS, 329 sentinel LNs underwent routine pathology, while others (n = 52) underwent both FS and permanent pathology. ELS showed a sensitivity of 91.4% for node-positive patients, decreasing to 84.8% when considering all LNs. Using ROC analysis, ELS diagnosis showed a significant AUC of 0.878 in relation to the permanent pathology gold standard. Comparison of ELS diagnosis for different tumor types and LN sizes demonstrated no significant differences, while increasing LN size correlated with enhanced ELS sensitivity. This study confirmed ELS's efficacy in real-time lymph node detection among non-chemo-treated breast cancer patients. The use of ELS's pathological scoring for intra-operative LN diagnosis, especially in the absence of FS pathology or for non-sentinel LN involvement, could improve prognosis and reduce complications by minimizing unnecessary dissection.

A multi-dimensional nomogram to predict non-sentinel lymph node metastases in T1-2HR+ breast cancer

Background

Axillary lymph node dissection (ALND) could be omitted for T1-2 breast cancer patients with 1-2 positive sentinel lymph node (SLN) after breast-conserving surgery when radiation is planned. However, whether ALND could be replaced by radiation in patients with 1-3 positive SLNs when no more non-SLN metastasis were observed after mastectomy are still controversial. The aim of our study was to develop and validate a nomogram for predicting the possibility of non-SLN metastasis in T1-2 and hormone receptor (HR) positive breast cancer patients with 1-3 positive SLNs after mastectomy.

Methods

We retrospectively reviewed and analyzed the data including the basic information, preoperative sonographic characteristics, and pathological features in breast cancer patients with 1-3 positive SLNs in our medical center between Jan 2016 and Dec 2021. The Chi-square, Fisher's exact test, and t test were used for comparison of categorical and qualitative variables among patients with or without non-SLN metastasis. Univariate and multivariate logistic regression were used to determine the risk factors for non-SLN metastasis. These predictors were used to build the nomogram. The C-index and area under the receiver operating characteristic curve (AUC) was calculated to assess the accuracy of the model.

Results

A total of 49 in 107 (45.8%) patients were identified with non-SLN metastasis. In multivariate analysis, four variables including younger age, lower estrogen receptor (ER) expression, higher histological score, and cortex thickening of the lymph nodes were determined to be significantly associated with non-SLN metastasis. An individualized nomogram was consequently established with a favorable C-index of 0.822 and verified via two internal validation cohorts.

Conclusions

The current study developed a nomogram predicting non-SLN metastasis for T1-2 and HR+ breast cancer with 1-3 positive SLNs after mastectomy and found that patients in the high-risk group exhibited worse relapse-free survival. The novel nomogram may further help surgeons to determine whether ALND could be omitted when 1-3 positive SLNs were observed in T1-2 and HR+ breast cancer patients.

Risk factors of non-sentinel lymph node metastasis in 443 breast cancer patients with sentinel lymph node-positive

Axillary lymph node dissection is the standard surgical procedure for breast cancer patients with sentinel lymph node (SLN) positive. In clinical practice, axillary lymph node dissection may be an unnecessary treatment for some breast cancer patients with non-sentinel lymph node (NSLN) negative. The aim of this study was to analyze the risk factors of NSLN metastasis in breast cancer patients with SLN positive. Four hundred fifty-six clinical early stage breast cancer patients with SLN positive were collected and analyzed in the oncological surgery department of Fujian Provincial Hospital during 2013 to 2018. All these patients underwent surgical treatment. The average age and tumor size of 443 patients with SLN positive breast cancer were (49.8 ± 10.8) years and (2.42 ± 0.94) cm. Univariate analysis showed that the size of primary tumor, the number of positive SLN, the number of negative SLN, the ratio of positive SLNs, and the type of metastases in SLN were the influencing factors of NSLN metastasis. Multivariate regression analysis showed that primary tumor size T > 2 cm (P < .001, OR = 2.609), the positive number of SLNs ≥3 (P = .002, OR = 5.435), the ratio of positive SLNs ≥ 50% (P = .017, OR = 1.770), and SLN macrometastases (P < 0.001, OR = 16.099) were independent risk factors for NSLN metastasis. Combined with the 4 independent risk factors, the area under the curve to predict NSLN metastasis was 0.747 > 0.7. For clinical early breast cancer with positive SLN, primary tumor size T > 2 cm,the positive number of SLNs ≥ 3, the ratio of positive SLNs ≥ 50%, and SLN macrometastases could predict NSLN metastasis well, and guide surgery to avoid overtreatment.

Trends in axillary surgery and clinical outcomes among breast cancer patients with sentinel node metastasis

Background

There is a lack of studies examining the long-term trend and survival of axillary surgery for breast cancer patients with sentinel node metastasis, especially for the patients with 3–5 node metastases.

Methods

Breast cancer patients with 1–5 sentinel node metastases from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2016. Our study presented the trend of axillary surgery and assessed the long-term survival of sentinel lymph node biopsy (SLNB) alone vs axillary lymph node dissection (ALND) for those patients.

Results

Of the 41,996 patients diagnosed with T_1-2 breast cancer after lumpectomy and radiation included, 34,940 had 1-2 sentinel node metastases and 7056 had 3-5 sentinel node metastases. The percentage of patients undergoing SLNB alone increased from 22.4% in 2000 to 81.0% in 2016 for patients with 1–2 sentinel node metastases, and quadrupled from 5.2% in 2009 to 20.6% in 2016 for those with 3–5 sentinel node metastases. Completion of ALND did not benefit the long-term survival of 1–2 sentinel node metastasis patients (hazard ratio [HR] = 1.02, P = 0.539), but improved the long-term survival of 3–5 node metastasis patients (HR = 0.73, P < 0.001). Subgroup analysis demonstrated the inferiority of SLNB to ALND in all subgroups of 3–5 sentinel node metastases.

Conclusion

For patients with T_1-2 breast cancer after lumpectomy and radiation, SLNB alone was an efficient and safe surgical choice for 1–2 sentinel node metastases but not for 3–5 sentinel node metastases. It is worth noting that for patients with 3–5 node metastasis, the proportion of omitted ALND quadrupled after 2009.

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Using SEER database, the research presents the long-term trend and survival of axillary surgery for breast cancer patients with 1-2 and 3-5 sentinel nodes metastasis.

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For patients with T1-2 breast cancer after lumpectomy and radiation, SLNB alone was efficient for 1–2 sentinel node metastases but not for 3–5 sentinel node metastases.

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Among patients with 3–5 node metastasis, the proportion of omitted ALND quadrupled from 2009 to 2016.

Intraoperative pathologically-calibrated diagnosis of lymph nodes involved by breast cancer cells based on electrical impedance spectroscopy; a prospective diagnostic human model study

BACKGROUND

Nodal status evaluation is a crucial step in determining prognostic factors and managing treatment strategies for breast cancer patients. Preoperative (CNB), intraoperative (SLNB), and even postoperative techniques (Formalin-Fixed Paraffin-Embedded sectioning, FFPE) have definite limitations of precision or sometimes are time-consuming for the result declaration. The primary purpose of this prospective study is to provide a precise complementary system for distinguishing lymph nodes (LNs) involved by cancerous cells in breast cancer patients intraoperatively.

METHODS

The proposed system, Electrical Lymph Scoring(ELS), is designed based on the dielectric properties of the under-test LNs. The system has a needle-shaped 2-electrode probe entered into SLNs or ALNs dissected from patients through standard surgical guidelines. Impedance magnitude in f = 1 kH (Z_1kHz) and Impedance Phase Slope in frequency ranges of 100 kHz-500 kHz (IPS) were then extracted from the impedance spectroscopy data in a cohort study of 77 breast cancer patients(totally 282 dissected LNs) who had been undergone surgery before (n = 55) or after (n = 22) chemical therapies (non-neoadjuvant or neoadjuvant chemotherapy). A new admittance parameter(Y_n^') also proposed for LN detection in neoadjuvant chemotherapy patients.

RESULTS

Considering the permanent pathology result as the gold standard checked by two independent expert pathologists, a significant correlation was observed between the presence of cancerous cells in LNs and individual ranges of the ELS electrical responses. Compared with normal LNs containing fatty ambient and immune cells, LNs involved by cancerous clusters would reduce the Z_1kHz and increase the IPS. These changes correlate with fat metabolism by cancer cells due to their Fatty Acid Oxidation (FAO) in LN, which results in different dielectric properties between high and low-fat content of normal and cancerous LNs, respectively.

CONCLUSIONS

By finding the best correlation between our defined impedimetric parameters and pathological states of tested LNs, a real-time intraoperative detection approach was developed for highly-sensitive (92%, P<0.001) diagnosis of involved sentinel or axillary LNs. The impact of real-time intraoperative scoring of SLNs would make a pre-estimation about the necessity of excising further LNs to help the surgeon for less invasive surgery, especially in the absence of frozen-section equipment.

Survival and recurrence with or without axillary dissection in patients with invasive breast cancer and sentinel node metastasis

To evaluate overall survival and locoregional recurrence between patients with invasive breast tumours and sentinel node metastasis undergoing sentinel lymph node dissection (SLND) alone and those undergoing complete axillary lymph node dissection (ALND). In this retrospective cohort study, we reviewed the medical records of patients with invasive breast carcinoma who underwent lumpectomy at a public university hospital in Brazil between 2008 and 2018. We evaluated the overall survival and the locoregional recurrence using Kaplan-Meier and Cox regression analyses, respectively. Overall, 97 participants who underwent lumpectomy were enroled; 41 in the ALND group, and 56 in the SLND group, according to Z0011 criteria. Only 17% of the patients in the ALND group had an additional biopsy-proven axillary disease, and 83% were treated with complete dissection unnecessarily. The 5-year survival rates were 80.1% and 87.5% for SLND and ALND, respectively (p = 0.376). Locoregional recurrence was rare (1.7% and 7.3% in the SLND and ALND, respectively; p = 0.3075). Overall survival and locoregional recurrence were similar between the two groups. The de-escalation of ALND to SLND in women with metastasis in the sentinel lymph node treated with conservative surgery and radiotherapy that meet the Z0011 criteria is feasible even in developing countries.

Predicting Nonsentinel Lymph Node Metastasis in Breast Cancer: A Multicenter Retrospective Study

BACKGROUND

Sentinel lymph node (SLN) biopsy has been the standard modality for breast cancer patients with clinically node negative disease. In patients who undergo axillary lymph node dissection (ALND) due to SLN metastasis, the harvested nodes (non-SLNs) often contain no metastasis. Here, we evaluated the predictive factors associated with non-SLN metastasis in breast cancer patients.

MATERIALS AND METHODS

This was a retrospective study of patients with operable cT1-3, cN0 invasive breast cancer who underwent SLN biopsy followed by ALND due to SLN metastasis. The clinicopathologic factors and predictive factors of non-SLN metastasis were analyzed. The optimal cutoff for the Ki67 index and the number of positive and negative SLNs that were predictive of non-SLN metastasis were evaluated using receiver operating characteristic curves.

RESULTS

The median number of SLN and non-SLN was 3 and 11, respectively. Of the 150 patients, 52 (35.0%) had metastases in non-SLNs. The optimal cutoffs for the Ki67 index and the number of positive and negative SLNs were of 12%, 2, and 1, respectively. In the univariate analysis, the Ki67 index and the number of positive SLNs≥2 and negative SLNs≤1 were higher in the non-SLN + group than that in the non-SLN - group. The number of negative SLNs was as a predictive factor for non-SLNs metastasis in the multivariate analysis.

CONCLUSIONS

The number of negative SLNs predicts the risk of non-SLN metastasis in breast cancer. When deciding on whether to omit ALND, the number of positive and negative SLNs should be considered.

The prognostic impact of mode of detection of axillary metastases for women with invasive breast cancer: A retrospective observational study

AIM

To identify the breast cancer specific survival (BCSS) associated with nodal metastasis identified by axillary core biopsy (ACB), and by sentinel node biopsy (SNB) compared with node negative patients. A further aim was to assess the prognostic effects of axillary ultrasound (US) features and amount of tumour in ACB specimens.

METHODS

Consecutive patients with cancer were identified from a database of US lesions undergoing breast biopsy. The three study groups were: a) those with metastasis identified by ACB, b) those undergoing immediate surgery with positive SNB and c) those undergoing immediate surgery with a negative SNB. US features and the amount of tumour in the ACB specimen were assessed by review of US images and pathological reports. BCSS was assessed using Kaplan Meier survival curves.

RESULTS

967 patients were included, with mean follow-up of 6.0 yrs. There were 90 breast cancer deaths: 26% of those with a positive ACB, 11% with a positive SNB and 4% of those with a negative SNB. BCSS was significantly different between the groups (p < 0.001) with hazard ratio, compared with the negative SNB group, of 7.8 (95% CI 4.4-13.7) for patients with positive ACB and 2.5 (95% CI 1.3-4.6) for positive SNB. Axillary US findings and assessment of the amount of tumour in the ACB did not influence survival.

CONCLUSION

This study suggests that women with a positive ACB have a worse BCSS compared to those with a positive SNB. This should be borne in mind when systemic therapy is being considered.

Axillary Clearance Following Positive Sentinel Lymph Node Biopsy in Symptomatic Breast Cancer

BACKGROUND/AIM

Symptomatic cancers display a different biological behaviour from screen-detected cancers, which may impact the management of axillary metastases. We aimed to determine the role of unselected axillary nodal clearance (ANC) in symptomatic patients with positive sentinel node biopsies (SNBs).

PATIENTS AND METHODS

A case-note review was performed on 95 symptomatic breast cancer patients who underwent ANC following positive SNB.

RESULTS

Thirty-eight (40%) patients were treated with a mastectomy and 57 (60%) with breast-conserving surgery. At ANC, 25 patients (26.3%) showed evidence of further lymph node metastases, with 15 (60%) having two or fewer macrometastases. The presence of more than 2 SNB macrometastases was associated with further ANC metastases (p<0.001). The presence of further metastases at ANC was not associated with either reduced overall survival or disease-free survival.

CONCLUSION

A number of symptomatic breast cancer patients with positive SNBs may be overtreated. Ongoing trials examining the management of low volume SNB macrometastases need to consider the symptomatic subgroup in their conclusions.

Omitting ALND Is Not Safe for a Cohort of Early-Stage Breast Cancer Patients with 1-2 SLNs Macro-Metastases and Breast-Conserving Therapy: A Single-Center Retrospective Study

Background:

Omitting axillary lymph node dissection (ALND) is recommended for early-stage breast cancer patients with 1–2 sentinel lymph nodes (SLNs) macro-metastases and breast-conserving therapy. However, it is not safe for part of patients, so it is significant to find risk factors and develop a predictive model of non-SLNs metastases in breast cancer patients with 1–2 SLNs macro-metastases and breast-conserving therapy.

Methods:

This retrospective study enrolled 228 breast cancer patients with 1–2 SLNs macro-metastases who underwent ALND and breast-conserving surgery between Jan 2012 and Dec 2017 at Cancer Hospital Chinese Academy of Medical Sciences. Chi-square test and backward stepwise binary logistic regression were used to find factors that influenced non-SLN metastases, then a predictive model was formulated and obtained its area under the curve.

Results:

Tumor pathologic invasion size, number of positive SLNs and ALN status on imaging was associated with non-SLNs metastases. The predictive model was also formulated based on these three factors to assess and the area under the curve of model was 0.708.

Conclusion:

We developed a predictive model to assess the high-risk cohort of patients of non-SLNs metastases which can be an auxiliary tool for doctors.

Axillary Management in Women with Early Breast Cancer and Limited Sentinel Node Metastasis: A Systematic Review and Metaanalysis of Real-World Evidence in the Post-ACOSOG Z0011 Era

BACKGROUND

After the publication of the Z0011 trial, the American Society of Clinical Oncology published an updated clinical practice guideline stating that clinicians should not recommend axillary lymph node dissection (ALND) for early-stage breast cancer patients with the involvement of one or two sentinel lymph nodes (SLNs). However, these recommendations have been challenged because they were mainly based on data from limited studies. The aim of the current study is to systematically compare the real-world outcomes of SLN biopsy (SLNB) alone and SLNB + ALND in patients with early-stage breast cancers and limited positive SLN metastasis in the post-Z0011 era PATIENTS AND METHODS: We searched articles in the PubMed, EMBASE, and Cochrane library databases. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were recurrence rate and the incidence of lymphedema.

RESULTS

One randomized controlled trial and six retrospective studies with 8864 patients were retrieved. For patients with early-stage breast cancer with one or two SLN metastases, receiving SLNB alone showed no significant difference in OS, DFS, and recurrence rate compared with receiving SLNB + ALND. The incidence of lymphedema in patients who received SLNB alone was significantly lower than those who received SLNB + ALND (odds ratio 1.95, 95% confidence interval 1.02-3.71).

CONCLUSIONS

Current real-world evidence proved that the Z0011 strategy is safe with respect to survival outcomes and effective in reducing the incidence of lymphedema. ALND should be avoided in patients with early-stage breast cancer with one or two SLN metastases in the post-Z0011 era.

Risk factors and a predictive nomogram for non-sentinel lymph node metastases in Chinese breast cancer patients with one or two sentinel lymph node macrometastases and mastectomy

Background

Two ongoing prospective randomized trials are evaluating whether omitting axillary lymph node dissection (alnd) in patients with breast cancer (bca) and sentinel lymph node (sln) macrometastases undergoing mastectomy is safe. Determining predictive risk factors for non-sln metastases and developing a model to predict the probability of those patients having non-sln metastases is also important.

Methods

This retrospective study enrolled 396 patients with bca and 1-2 slns with macrometastases who underwent alnd and mastectomy between January 2012 and December 2016. Factors influencing the non-sln metastases were determined, and a predictive nomogram was formulated. Performance of the nomogram was evaluated by its area under the curve (auc).

Results

We developed a predictive nomogram with an auc of 0.81 (cross-validation 95% confidence interval: 0.75 to 0.86) that included 4 factors (tumour size, histologic grade, and number of negative slns and axillary lymph nodes on imaging).

Conclusions

Our predictive nomogram assesses the risk of non-sln metastases in patients with bca and 1-2 sln macrometastases undergoing mastectomy.

Clinical risk analysis of non-visualized sentinel lymph node in breast cancer

OBJECTIVE

This study aimed to explore the positive rate of non-visualized sentinel lymph nodes (non-vSLN) [1] in breast cancer (BC) patients and the discrepancy of non-vSLN among different molecular subtypes, in order to further evaluate the clinical risk of non-vSLNs.

METHODS

A total of 627 patients were retrospectively analyzed. These patients were pathologically confirmed with invasive breast cancer and underwent sentinel lymph node biopsy (SLNB). Various factors were compared using chi-square test. The positive rate of SLNs between non-vSLNs and visible sentinel lymph nodes (vSLNs) were compared. Moreover, factors that influenced the prognosis, such as ER, PR, HER-2, histological grade and lymph node metastasis were compared between these two groups.

RESULTS

Among the 627 patients who underwent SLNB, 196 patients had non-vSLNs, accounting for 31.26% (196/627) and 113 patients had positive SLNs, accounting for 18.02% (113/627). Furthermore, 40.71% (46/113) of patients with positive SLNs had non-vSLN, and 17.39% (8/46) of patients with non-vSLN had HER-2+BC. In contrast, 35.82% (24/67) of patients with vSLNs had HER-2+BC. Moreover, 23.91% (11/46) of patients with non-vSLN and 5.97% (4/67) of patients with vSLNs had triple-negative breast cancer (TNBC). The metastasis rate was 41.30% (19/46) in the non-vSLN group and 43.28% (29/67) in the vSLN group. The difference in the rate of positive SLNs between the non-vSLN and the vSLN groups was statistically significant (P< 0.05), in which the positive rate of SLNs in the non-vSLN group was remarkably higher than that in the vSLN group. The differences in the proportion of HER-2+BC and TNBC between the non-vSLN and the vSLN groups were statistically significant (P< 0.05), in which HER-2+BCwas evidently higher in the vSLN group than in the non-vSLN group. Meanwhile, TNBC was markedly higher in non-vSLN group than in the vSLN group. Furthermore, differences in Luminal A subtype, Luminal B subtype and non-SLN metastasis between these two groups was not statistically significant. In addition, the difference in non-SLN metastasis rate was not statistically significant among breast cancers of different molecular subtypes and between the non-vSLN and the vSLN groups.

CONCLUSION

Breast cancer patients with positive non-vSLNs are more likely to have a TNBC subtype relative to patients with positive vSLN. Breast cancer patients with non-vSLN have higher positive rate of SLNs. The non-SLN metastasis rate in positive SLN patients was not correlated to the molecular subtype of breast cancer.

Treatment Intensity Differences After Early-Stage Breast Cancer (ESBC) Diagnosis Depending on Participation in a Screening Program

BACKGROUND

While population mammographic screening identifies early-stage breast cancers (ESBCs; ductal carcinoma in situ [DCIS] and invasive disease stages 1-3A), commentaries suggest that harms from overdiagnosis and overtreatment may outweigh the benefits. Apparent benefits to patients with screen-detected cancers may be due to selection bias from exclusion of interval cancers (ICs). Treatment intensity is rarely discussed, with an assumption that all ESBCs are treated similarly. We hypothesized that women diagnosed while in a screening program would receive less-intense treatment than those never or not recently screened (NRS).

METHODS

This was a retrospective analysis of all women aged 50-69 years managed for ESBC (invasive or DCIS) during the period 2007-2013 within a single service, comparing treatment according to screening status. Data on demographics, detection, pathology, and treatment were derived from hospital, cancer registry, and screening service records.

RESULTS

Overall, 622 patients were active screeners (AS) at diagnosis (569 screen-detected and 53 ICs) and 169 patients were NRS. AS cancers were smaller (17 mm vs. 26 mm, p < 0.0001), less likely to involve nodes (26% vs. 48%, p < 0.0001), and lower grade. For invasive cancer, NRS patients were more likely to be recommended for mastectomies [35% vs. 16%; risk ratio(RR) 2.2, p < 0.0001], axillary dissection (43% vs. 19%; RR 2.3, p < 0.0001), adjuvant chemotherapy (65% vs. 37%; RR 1.7, p < 0.0001), and postmastectomy radiotherapy (58% vs. 39%; RR 1.5, p = 0.04).

CONCLUSION

Participants in population screening diagnosed with ESBC receive substantially less-intense treatment than non-participants. Differences persist when potential overdiagnosis is taken into account; these differences should be factored into debates around mammographic screening.

Preoperative predictors of high and low axillary nodal burden in Z0011 eligible breast cancer patients with a positive lymph node needle biopsy result

BACKGROUND

Z0011 trial showed that early breast cancer patients with low axillary nodal burden, may be spared an axillary lymph node dissection with no survival compromise. Axillary lymph node dissection can be reserved for patients with a high axillary nodal burden. We aim to determine the preoperative factors that could distinguish between low and high axillary nodal burden in Z0011 eligible patients with a needle biopsy proven metastatic node.

METHOD

Patients who fulfilled Z0011 trial criteria with a positive lymph node needle biopsy and had axillary lymph node dissection (ALND) were recruited. These patients were classified into low and high nodal burden subgroups, defined as having 1-2 and ≥3 metastatic lymph nodes, respectively. The clinical, radiological and pathological features between the 2 subgroups were compared.

RESULTS

70 (40%) and 105 (60%) patients had low and high nodal burden respectively. The high nodal burden subgroup was more likely to have on ultrasound ≥3 abnormal lymph nodes (37.14% versus 4.29%) (P < 0.0001) and maximum cortical thickness >4 mm (31.43% versus 10.0%) (P = 0.0036). Multivariate analysis revealed abnormal lymph nodes ≥3 to have an odds ratio of 20.72 (95% CI 5.91-72.65) P < 0.0001.

CONCLUSION

≥3 abnormal lymph nodes on ultrasound was the most significant predictor of high nodal burden subgroup in Z0011 eligible patients with a positive lymph node needle biopsy. This information could allow this subgroup to proceed to an upfront ALND and avoid the need of a sentinel lymph node biopsy in the post Z0011 trial era.

Analysis of factors related to non-sentinel lymph node metastasis in 296 sentinel lymph node-positive Chinese breast cancer patients

Objective:

Axillary lymph node dissection (ALND) may be unnecessary in 20%–60% of breast cancer patients with sentinel lymph node (NSLN) metastasis. The aim of the present study was to review the medical records of Chinese patients with early-stage breast cancer and positive NSLN metastasis to identify clinicopathological characteristics as risk factors for non-NSLN metastasis.

Methods:

The medical records of 2008 early-stage breast cancer patients who received intraoperative sentinel lymph node biopsy (SLNB) between 2006 and 2016 were retrospectively reviewed. These patients were clinically and radiologically lymph node-negative and had no prior history of receiving neoadjuvant chemotherapy or endocrinotherapy. The clinicopathological characteristics of patients with positive NSLN metastasis who underwent ALND were investigated.

Results:

In the present study, 296 patients with positive NSLN metastases underwent ALND. Positive non-NSLN metastases were confirmed in 95 patients (32.1%). On univariate analysis, ≥ 3 positive NSLN metastases (P <0.01), NSLN macrometastases ( P = 0.023), and lymphovascular invasion (P = 0.04) were associated with non-NSLN metastasis (P <0.05). In multivariate analysis, the number of positive SLNs was the most significant predictor of non-SLN metastasis. For patients with 0, 1, 2, or 3 associated risk factors, the non-SLN metastatic rates were 11.5%, 22.5%, 35.2%, and 73.1%, respectively.

Conclusions:

The number of positive NSLNs, NSLN macrometastases, and lymphovascular invasion were correlated with non-SLN metastasis. The number of positive SLNs was an independent predictor for non-NSLN metastasis. When 2 or 3 risk factors were present in one patient, the probability of non-NSLN was higher than that in the American College of Surgeons Oncology Group Z0011 trial (27.3%); thus, avoiding ALND should be considered carefully.

Development of a Nomogram to Predict N2 or N3 Stage in T1-2 Invasive Breast Cancer Patients with No Palpable Lymphadenopathy

Purpose

Subsequent to the American College of Surgeons Oncology Group (ACOSOG) Z0011 and After Mapping of the Axilla: Radiotherapy or Surgery (AMAROS) trials, complete axillary lymph node dissection is not routinely performed, even in cases where metastatic sentinel lymph nodes are detected. We investigated the percentage of N2 or N3 stages in T1–2 invasive breast cancer patients with no lymphadenopathy and developed a nomogram to predict the possibility of N2 or N3 stages in these patients.

Methods

We retrospectively reviewed the charts of invasive breast cancer patients who were clinically N0 stage, but had a positive sentinel or non-sentinel lymph node detected on sentinel lymph node biopsy. The association of potential risk factors with known outcomes (N2 or N3 stages) was tested using logistic regression analysis. Variables with p<0.05 in the multivariate analysis were included in the nomogram. Internal performance validation was carried out using a 5-fold cross validation method.

Results

Among a total of 1,437 patients, 1,355 patients had stage N1 disease (94.3%), while 82 had stage N2 or N3 disease (5.7%). Multivariate stepwise logistic regression analysis revealed lymphovascular invasion (p=0.008), T2 stage (p=0.026), metastatic lymph node ratio (p<0.001), and perinodal extension (p<0.001) as independent predictors of N2 or N3 stages. A nomogram was developed based on these factors. The area under the curve estimated from the receiver operating characteristic graph was 0.8050 in the model set and 0.8246 in the test set.

Conclusion

Our nomogram can be employed for the prediction of N2 or N3 stage among cases fulfilling the ACOSOG Z0011 or AMAROS criteria.

Different outcome in node-positive breast cancer patients found by axillary ultrasound or sentinel node procedure

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.

Prognostic impact of macrometastasis linear size in sentinel node biopsy for breast carcinoma

AIM

The aim of the present study was to evaluate the risk of axillary non-sentinel lymph-node metastases (ALN) in breast cancer patients presenting macrometastasis (Mac-m) in the sentinel lymph node (SN).

MATERIALS AND METHODS

A retrospective series of 1464 breast cancers from patients who underwent ALN dissection following the diagnosis of Mac-m in the sentinel node (SN) was studied. In all the cases the MAC-m linear size was evaluated and correlated with presence or absence of non-SN ALN metastases.

RESULTS

Non-SN metastases were detected in 644∖1464 cases (43.98%). The risk of further axillary metastases ranged from 20.2% (37/183) in cases with Mac-m between 2 and 2.9 mm, to 65.3% (262/401) in cases with Mac-m measuring > 10 mm. The risk of non-SN ALN metastases showed a 3% increase, parallel to each mm increment in SN metastasis size. The data evaluated with the receiver operating characteristic (ROC) curve showed that the Mac-m could be subdivided according to a new cut-off of 7 mm. pT1 tumours, with Mac-m < 7 mm had a risk of non-SN ALN metastases of <30%. Furthermore 109/127 of these (85.8%) had 3 or less non-SN ALN -metastases.

CONCLUSIONS

The present data give a detailed description on the risk of non-SN ALN involvement, that may be useful in the evaluation of breast cancer patients. It is suggested that a Mac-m size of <7 mm is related to a low residual axillary disease burden in breast cancer patients with small (pT1) tumours.

Is it time to relook the management of axilla in post-neoadjuvant breast cancer cases in a re-evolving era of current axillary management?

Aim: Axillary node dissection (AND) is an established practice, recently a conservative approach to axilla has resurged but there is reluctance to pass this benefit to neoadjuvant chemotherapy (NAC) cases, even in complete responders. Present study aims to look whether this approach is applicable to post-NAC cases. Patients & methods: Prospective study of 100 cases of NAC for breast cancer. Results: The core positive axillary nodes at diagnosis (66) after NAC had AND, 25 (38%) showed pathological complete response (pCR) in axillary nodes and 41 (62%) have residual disease. While, 34 with radiologically normal nodes, incidence of positive sentinel lymph node biopsy after NAC is lower as compared with patients without NAC. Conclusion: We conclude that it is time to re-examine axillary management in post-NAC cases with pCR, and possibly avoiding AND in 30–40% cases. Also, there is no place for upfront sentinel lymph node biopsy which offers no gain.

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

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.

Management of Early Node-Positive Breast Cancer in Australia: A Multicentre Study

To examine practice patterns for breast cancer patients with limited sentinel node (SN) disease in light of the ACOSOG Z0011 results. Retrospective analysis of patients with T1-2 breast cancer and positive sentinel lymph node biopsy (SLNB) admitted between January 2009 and December 2012. Patient demographics, tumor characteristics, and treatments were recorded. Eight hundred positive SLNBs were identified. A total of 452 (56.5%) proceeded to completion axillary lymph node dissection (cALND). cALND rate decreased from 65.1% to 49.7% from 2009-2010 to 2011-2012. cALND was performed for micrometastasis or isolated tumor cells in 39.3% in 2009-2010 and 22.2% in 2011-2012, whereas for macrometastases the rates were 83.1% and 68.6%, respectively. cALND rates diminished for both Z0011-eligible and -ineligible patients. The ACOSOG Z0011 trial presentation and publication coincided with a reduction in cALND for breast cancer with limited nodal disease. There appears equipoise regarding management of macrometastatic SN disease.

Histological pattern of Merkel cell carcinoma sentinel lymph node metastasis improves stratification of Stage III patients

Sentinel lymph node biopsy is used to stage Merkel cell carcinoma, but its prognostic value has been questioned. Furthermore, predictors of outcome in sentinel lymph node positive Merkel cell carcinoma patients are poorly defined. In breast carcinoma, isolated immunohistochemically positive tumor cells have no impact, but in melanoma they are considered significant. The significance of sentinel lymph node metastasis tumor burden (including isolated tumor cells) and pattern of involvement in Merkel cell carcinoma are unknown. In this study, 64 Merkel cell carcinomas involving sentinel lymph nodes and corresponding immunohistochemical stains were reviewed and clinicopathological predictors of outcome were sought. Five metastatic patterns were identified: (1) sheet-like (n=38, 59%); (2) non-solid parafollicular (n=4, 6%); (3) sinusoidal, (n=11, 17%); (4) perivascular hilar (n=1, 2%); and (5) rare scattered parenchymal cells (n=10, 16%). At the time of follow-up, 30/63 (48%) patients had died with 21 (33%) attributable to Merkel cell carcinoma. Patients with pattern 1 metastases had poorer overall survival compared with patients with patterns 2-5 metastases (P=0.03), with 22/30 (73%) deaths occurring in pattern 1 patients. Three (10%) deaths occurred in patients showing pattern 5, all of whom were immunosuppressed. Four (13%) deaths occurred in pattern 3 patients and 1 (3%) death occurred in a pattern 2 patient. In multivariable analysis, the number of positive sentinel lymph nodes (1 or 2 versus >2, P<0.0001), age (<70 versus ≥70, P=0.01), sentinel lymph node metastasis pattern (patterns 2-5 versus 1, P=0.02), and immune status (immunocompetent versus suppressed, P=0.03) were independent predictors of outcome, and could be used to stratify Stage III patients into three groups with markedly different outcomes. In Merkel cell carcinoma, the pattern of sentinel lymph node involvement provides important prognostic information and utilizing this data with other clinicopathological features facilitates risk stratification of Merkel cell carcinoma patients who may have management implications.

Widespread Implications of ACOSOG Z0011: Effect on Total Mastectomy Patients

The ACOSOG Z0011 trial demonstrated that axillary lymph node dissection (ALND) is not necessary for all breast cancer patients. Patients who underwent breast conservation surgery (BCS) or total mastectomy (TM) and met Z0011 criteria were identified and sorted into pre- and post-Z0011 cohorts. Four hundred ninety four patients had breast cancer surgery from July 2008 to February 2013. Of these, 255 were pre-Z0011 and 239 were post. Pre-Z0011, 14 patients met Z0011 inclusion criteria in BCS subgroup. ALND was performed in 10 of these patients (71%). Post-Z0011, 14 patients met inclusion criteria, only 1 received ALND (7%). The decrease in ALND rate was significant (p=0.001). Pre-Z0011, 28 patients in TM subgroup met extrapolated inclusion criteria, twenty-three of which received ALND (82%). Post-Z0011, 14 patients in TM subgroup met extrapolated criteria, five of which underwent ALND (36%). The decrease in rate of ALND was significant (p=0.005). This study demonstrates that the Z0011 trial significantly altered management of the axilla in all breast cancer patients with positive sentinel lymph nodes, not just those receiving BCS.

Factors Influencing Non-sentinel Node Involvement in Sentinel Node Positive Patients and Validation of MSKCC Nomogram in Indian Breast Cancer Population

Current guidelines recommend completion axillary lymphnode dissection (ALND) when sentinel lymphnode (SLN) contains metastatic tumor deposit. In consequent ALND sentinel node is the only node involved by tumor in 40-70 % of cases. Recent studies demonstrate the oncologic safety of omitting completion ALND in low risk patients. Several nomograms (MSKCC, Stanford, MD Anderson score, Tenon score) had been developed in predicting the likelihood of additional nodes metastatic involvement. We evaluated accuracy of MSKCC nomogram and other clinicopathologic variables associated with additional lymph node metastasis in our patients. A total of 334 patients with primary breast cancer patients underwent SLN biopsy during the period Jan 2007 to June 2014. Clinicopathologic variables were prospectively collected. Completion ALND was done in 64 patients who had tumor deposit in SLN. The discriminatory accuracy of nomogram was analyzed using Area under Receiver operating characteristic curve (ROC). SLN was the only node involved with tumor in 69 % (44/64) of our patients. Additional lymph node metastasis was seen in 31 % (20/64). On univariate analysis, extracapsular infiltration in sentinel node and multiple sentinel nodes positivity were significantly associated (p < 0.05) with additional lymph node metastasis in the axilla. Area under ROC curve for nomogram was 0.58 suggesting poor performance of the nomogram in predicting NSLN involvement. Sentinel nodes are the only nodes to be involved by tumor in 70 % of the patients. Our findings indicate that multiple sentinel node positivity and extra-capsular invasion in sentinel node significantly predicted the likelihood of additional nodal metastasis. MSKCC nomogram did not reliably predict the involvement of additional nodal metastasis in our study population.

Two decades of axillary management in breast cancer

Background

Axillary lymph node dissection (ALND) in patients with breast cancer provides prognostic information. For many years, positive nodes were the most important indication for adjuvant systemic therapy. It was also believed that regional control could not be achieved without axillary clearance in a positive axilla. However, during the past 20 years the treatment and staging of the axilla has undergone many changes. This large population-based study was conducted in the south-east of the Netherlands to evaluate the changing patterns of care regarding the axilla, including the introduction of sentinel lymph node biopsy (SLNB) in the late 1990s, implementation of the results of the American College of Surgeons Oncology Group Z0011 study, and the initial effects of the European Organization for Research and Treatment of Cancer AMAROS study.

Methods

Data from the population-based Eindhoven Cancer Registry of all women diagnosed with invasive breast cancer in the south of the Netherlands between January 1993 and July 2014 were used.

Results

The proportion of 34 037 women staged by SLNB without completion ALND increased from 0 per cent in 1993–1994 to 69·0 per cent in 2013–2014. In the same period the proportion undergoing ALND decreased from 88·8 to 18·7 per cent. Among women with one to three positive lymph nodes, the proportion undergoing SLNB alone increased from 10·6 per cent in 2011–2012 to 37·6 per cent in 2013–2014.

Conclusion

This population-based study demonstrated the radical transformation in management of the axilla since the introduction of SLNB and following the recent publication of trials on management of the axilla with a low metastatic burden.

Partial axillary lymph node dissection inferior to the intercostobrachial nerves complements sentinel node biopsy in patients with clinically node-negative breast cancer

Background

The practice of breast cancer diagnosis and treatment in China varies to that in western developed countries. With the unavailability of radioactive tracer technique for sentinel lymph nodes biopsy (SLNB), using blue dye alone has been the only option in China. Also, the diagnosis of breast malignant tumor in most Chinese centres heavily relies on intraoperative instant frozen histology which is normally followed by sentinel lymph nodes mapping, SLNB and the potential breast and axillary operations in one consecutive session. This practice appears to cause a high false negative rate (FNR) for SLNB. The present study aimed to investigate the impact of the current practice in China on the accuracy of SLNB, and whether partial axillary lymph node dissection (PALND), dissection of lymph nodes inferior to the intercostobrachial nerve (ICBN), was a good complementary procedure following SLNB using blue dye.

Methods

289 patients with clinically node-negative breast cancer were identified and recruited. Tumorectomy, intraoperative instant frozen histological diagnosis, SLNB using methylene blue dye, and PALND or complete axillary node dissection (ALND) were performed in one consecutive operative session. The choice of SLNB only, SLNB followed by PALND or by ALND was based on the pre-determined protocol and preoperative choice by the patient. Clinical parameters were analyzed and survival analysis was performed.

Results

37 % patients with clinically negative nodes were found nodes positive. 59 patients with positive SLN underwent ALND, including 47 patients with up to two positive nodes which were all located inferior to the ICBN. 9 patients had failed SLNB and underwent PALND. Among them, 3 (33.3 %) patients were found to have one metastatic node. 149 patients showed negative SLNB but chose PALND. Among them, 30 (20.1 %), 14 (9.4) and 1 (0.7 %) patients were found to have one, two and three metastatic node(s), respectively. PALND detected 48 (30.4 %) patients who had either failed SLNB or negative SLNB to have additional positive nodes. All the patients with up to two positive nodes had their nodes located inferior to the ICBN. The FNR of SLNB was 43 %. The accuracy rate was 58 %. The follow-up ranged 12–33 months. The incidence of lymphedema for SLNB, PALND, and ALND was 0 %, 0 %, and 25.4 %, respectively (P < 0.005). The disease-free survivals for SLNB, PALND, and ALND groups were 95.8 %, 96.8 %, and 94.9 %, respectively (p > 0.05).

Conclusions

Under the circumstances of current practice in China, PALND is a good complementary procedure following SLNB in clinically node-negative breast cancer.

The clinical utility of assessment of the axilla in women with suspicious screen detected breast lesions in the post Z0011 era

Axillary ultrasound (AUS) and biopsy are now part of the preoperative assessment of breast cancer based on the assumption that any nodal disease is an indication for axillary clearance (AC). The Z0011 trial erodes this assumption. We applied Z0011 eligibility criteria to patients with screen detected cancers and positive axillary assessment to determine the relevance of AUS to contemporary practice. Women screened between 1/1/2012 and 30/6/2013 and assessed for lesions with highly suspicious imaging features are included. We analysed demographic and assessment data and ascertained the final histopathology with particular reference to axillary nodal status. Among 449 lesions, AUS was recorded in 303 lesions (67.5 %). 290 (96 %) were carcinomas, 30.3 % with nodal disease. AUS was abnormal in 46 (15.9 %). AUS had a sensitivity of 39.8 %, specificity 94.6 %, positive predictive value (PPV) 79.2 % and negative predictive value (NPV) 78.1 %. Axillary FNAB was positive in 27 women, suspicious in two, benign in 16 and not performed in one. In one FNA positive case, the lesion was a nodular breast primary in the axillary tail in a multifocal breast cancer. Combining AUS and FNAB, the sensitivity was 76.5 %, specificity 90.9 %, PPV 96.3 % and NPV 55.6 %. Applying the Z0011 inclusion criteria, 24 of the 27 (88.9 %) women with abnormal AUS and positive FNA were ineligible for Z0011-based management. Of three women eligible for Z0011, one proceeded to AC after SN biopsy, leaving only two women (7.4 %) who might have been considered for SN only management had it not been for the results of the axillary assessment. Among women with negative AUS, nodal metastasis was demonstrated in 21.7 %, 86.8 % of these women having only 1-2 positive nodes. Abnormal AUS and FNA preferentially identify candidates for AC. Negative AUS predicts negative or low nodal burden. Axillary assessment streamlines care.

Histological examination of sentinel lymph nodes: significance of macrometastasis, micrometastasis, and isolated tumor cells

Sentinel lymph node biopsy has been started in 1990s and has become one of the standard diagnostic procedures used to treat patients with early breast cancer in this century. In Japan, for the microscopic diagnosis of metastasis to sentinel lymph nodes, intraoperative frozen section diagnosis is widely used in combination with subsequent permanent section diagnosis of the residual specimens. Metastatic foci to sentinel lymph nodes have been classified into macrometastasis, micrometastasis, and isolated tumor cells in 2002, and the definition of isolated tumor cells was modified in 2010. Clinical significance of occult sentinel lymph node metastases, being mostly composed of micrometastasis and isolated tumor cells, has been clarified in terms of predictive factors for non-sentinel lymph node metastasis and patient prognosis by large-scale retrospective studies and prospective randomized clinical trials. In the present review, clinical implications of micrometastases and isolated tumor cells in sentinel lymph nodes and the methods for pathological examination of SLN metastases employed in these studies were overviewed.

Sentinel lymph node status and axillary lymph node dissection in the surgical treatment of breast cancer

Axillary lymph node dissection has been traditionally perceived as a therapeutic and a staging procedure and unselectively removes all axillary lymph nodes. There still remains some controversy as concerns the survival benefit associated with axillary clearance. Sentinel lymph node biopsy removes the most likely sites of regional metastases, the lymph nodes directly connected with the primary tumour. It allows a more accurate staging and a selective indication for clearing the axilla, restricting this to patients who may benefit of it. Axillary dissection was performed in all patients during the learning phase of sentinel lymphadenectomy, but later only patients with metastasis to a sentinel node underwent this operation. Currently, even some patients with minimal sentinel node involvement, including some with macrometastasis may skip axillary clearance. This review summarizes the changes that have occurred in the surgical management of the axilla, the evidences and controversies behind these changes, along with current recommendations. Orv. Hetil., 2014, 155(6), 203–215.