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Ke Z, Shen L, Shao J. Early Warning of Axillary Lymph Node Metastasis in Breast Cancer Patients Using Multi-Omics Signature: A Machine Learning-Based Retrospective Study. Int J Gen Med 2024; 17:6101-6114. [PMID: 39687219 PMCID: PMC11648545 DOI: 10.2147/ijgm.s499238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2024] [Accepted: 12/05/2024] [Indexed: 12/18/2024] Open
Abstract
Background Axillary lymph node (ALN) is the most common metastasis path for breast cancer, and ALN dissection directly affects the postoperative staging and prognosis of breast cancer patients. Therefore, additional research is needed to accurately predict ALN metastasis before surgery and construct predictive models to assist in surgical decision-making and optimize patient care. Methods We retrospectively analyzed the clinical data, radiomics, and pathomics of the patients diagnosed with breast cancer in the Breast Cancer Center of Hubei Cancer Hospital from January 2017 to December 2022. The study participants were randomly assigned to either the training queue (70%) or the validation queue (30%). Logistic regression (ie generalized linear regression model [GLRM]) and random forest model (RFM) were used to construct an ALN prediction model in the training queue, and the discriminant power of the model was evaluated using area under curve (AUC) and decision curve analysis (DCA). Meanwhile, the validation queue was used to evaluate the ALN prediction performance of the constructed model. Results Out of the 422 patients encompassed in the study, 18.7% were diagnosed with ALN by postoperative pathology. The logical model included shear wave elastography (SWE) related to maximum, minimum, centre, ratio 1, pathomics (Feature 1, Feature 3, and Feature 5) and a nomogram of the GLRM was drawn. The AUC of GLRM was 0.818 (95% CI: 0.757~0.879), significantly lower than that of RFM's AUC 0.893 (95% CI: 0.836~0.950). Conclusion The prediction models based on machine learning (ML) algorithms and multiomics have shown good performance in predicting ALN metastasis, and RFM shows greater advantages compared to traditional GLRM. The findings of this study can help clinicians identify patients with higher risk of ALN metastasis and provide personalized perioperative management to assist preoperative decision-making and improve patient prognosis.
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Affiliation(s)
- Zirui Ke
- Department of Breast Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei Provincial Clinical Research Center for Breast Cancer, Wuhan Clinical Research, Wuhan, 430070, People’s Republic of China
| | - Leihua Shen
- Department of General Surgery, Xi’an Central Hospital, Shaanxi, 710000, People’s Republic of China
| | - Jun Shao
- Department of Breast Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei Provincial Clinical Research Center for Breast Cancer, Wuhan Clinical Research, Wuhan, 430070, People’s Republic of China
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2
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Jung JJ, Han W. Omitting axillary surgery in breast cancer treated with neoadjuvant chemotherapy. Gland Surg 2024; 13:1670-1672. [PMID: 39421050 PMCID: PMC11480878 DOI: 10.21037/gs-24-210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 08/09/2024] [Indexed: 10/19/2024]
Affiliation(s)
- Ji-Jung Jung
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
- Cancer Research Institute, Seoul National University Hospital, Seoul, South Korea
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Yilmaz L, Kus T, Aytekin A, Aktas G, Uzun E, Maralcan G. Prediction of the number of positive axillary lymph nodes according to sentinel lymph node involvement and biological subtypes in patients receiving neoadjuvant chemotherapy. BMC Surg 2024; 24:213. [PMID: 39030524 PMCID: PMC11264838 DOI: 10.1186/s12893-024-02500-5] [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: 12/19/2023] [Accepted: 07/09/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) for assessing axillary lymph node status in clinically node-negative breast cancer patients. However, the approach to axillary surgery after neoadjuvant treatment is still controversial. In the present study, our objective was to predict the pathological nodal stage based on SLNB results and the clinicopathological characteristics of patients who initially presented with clinical N1 positivity but whose disease status was converted to clinical N0 after neoadjuvant chemotherapy (NAC). MATERIALS AND METHODS After NAC, 150 clinically node-negative patients were included. The relationships between clinicopathologic parameters and the number of positive lymph nodes in SLNBs and ALNDs were assessed through binary/multivariate logistic regression analysis. RESULTS Among 150 patients, 78 patients had negative SLNBs, and 72 patients had positive SLNBs. According to the ALND data of 21 patients with SLNB1+, there was no additional node involvement (80.8%), 1-2 lymph nodes were positive in 5 patients (19.2%), and no patient had ≥ 3 lymph nodes involved. Following the detection of SLNB1 + positivity, the rate of negative non-sentinel nodes were 75% in the luminal A/B subgroup, 100% in the HER-2-positive subgroup, and 100% in the triple-negative subgroup. Patients with a lower T stage (T1-3 vs. T4), fewer than 4 clinical nodes before NAC (< 4 vs. ≥4), and a decreased postoperative Ki-67 index (< 10% vs. stable/increase) were included. According to both univariate and multivariate analyses, being in the triple-negative or HER2-positive subgroup, compared to the luminal A/B subgroup (luminal A/B vs. HER2-positive/triple-negative), was found to be predictive of complete lymph node response. CONCLUSION The number of SLNB-positive nodes, tumor-related parameters, and response to treatment may predict no additional nodes to be positive at ALND.
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Affiliation(s)
- Latif Yilmaz
- Department of General Surgery, School of Medicine, Gaziantep University, Gaziantep, TR-27310, Turkey.
| | - Tulay Kus
- Department of Medical Oncology, School of Medicine, Gaziantep University, Gaziantep, TR-27310, Turkey
| | - Alper Aytekin
- Department of General Surgery, School of Medicine, Gaziantep University, Gaziantep, TR-27310, Turkey
| | - Gokmen Aktas
- Department of Medical Oncology, Gokmen Aktas, Assoc Prof. Gaziantep Medical Point Hospital, Gaziantep, TR-27584, Turkey
| | - Evren Uzun
- Department of Pathology, School of Medicine, Gaziantep University, Gaziantep, TR-27310, Turkey
| | - Gokturk Maralcan
- Department of General Surgery, School of Medicine, Sanko University, Gaziantep, TR-27090, Turkey
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Lee CU, Urban MW, Hesley GK, Wood BG, Meier TR, Chen B, Kassmeyer BA, Larson NB, Lee Miller A, Herrick JL, Jakub JW, Piltin MA. Long-Term Ultrasound Twinkling Detectability and Safety of a Polymethyl Methacrylate Soft Tissue Marker Compared to Conventional Breast Biopsy Markers-A Preclinical Study in a Porcine Model. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1001-1009. [PMID: 38575416 DOI: 10.1016/j.ultrasmedbio.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/21/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE We have studied the use of polymethyl methacrylate (PMMA) as an alternative biopsy marker that is readily detectable with ultrasound Doppler twinkling in cases of in vitro, ex vivo, or limited duration in vivo settings. This study investigates the long-term safety and ultrasound Doppler twinkling detectability of a PMMA breast biopsy marker following local perturbations and different dwell times in a 6-mo animal experiment. METHODS This study, which was approved by our Institutional Animal Care and Use Committee, involved three pigs and utilized various markers, including PMMA (Zimmer Biomet), 3D-printed, and Tumark Q markers. Markers were implanted at different times for each pig. Mesh material or ethanol was used to induce a local inflammatory reaction near certain markers. A semiquantitative twinkling score assessed twinkling for actionable localization during monthly ultrasounds. At the primary endpoint, ultrasound-guided localization of lymph nodes with detectable markers was performed. Following surgical resection of the localized nodes, histomorphometric analysis was conducted to evaluate for tissue ingrowth and the formation of a tissue rind around the markers. RESULTS No adverse events occurred. Twinkling scores of all markers for all three pigs decreased gradually over time. The Q marker exhibited the highest mean twinkling score followed by the PMMA marker, PMMA with mesh, and Q with ethanol. The 3D-printed marker with mesh and PMMA with ethanol had the lowest scores. All wire-localized lymph nodes were successfully resected. Despite varying percentages of tissue rind around the markers and a significant reduction in overall twinkling (p < 0.001) over time, mean PMMA twinkling scores remained clinically actionable at 6 and 5 mo using a General Electric C1-6 probe and 9L-probe, respectively. CONCLUSIONS In this porcine model, the PMMA marker demonstrates an acceptable safety profile. Clinically actionable twinkling aids PMMA marker detection even after 6 mo of dwell time in porcine lymph nodes. The Q marker maintained the greatest twinkling over time compared to all the other markers studied.
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Affiliation(s)
- Christine U Lee
- Department of Radiology, Division of Breast Imaging and Intervention, Mayo Clinic, Rochester, MD, USA.
| | - Matthew W Urban
- Department of Radiology, Division of Radiology Research, Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MD, USA
| | - Gina K Hesley
- Department of Radiology, Division of Breast Imaging and Intervention, Mayo Clinic, Rochester, MD, USA
| | | | - Thomas R Meier
- Department of Comparative Medicine, Mayo Clinic, Rochester, MD, USA
| | - Beiyun Chen
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, MD, USA
| | - Blake A Kassmeyer
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MD, USA
| | - Nicholas B Larson
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MD, USA
| | - A Lee Miller
- Biomaterials and Histomorphometry Core, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MD, USA
| | - James L Herrick
- Biomaterials and Histomorphometry Core, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MD, USA
| | - James W Jakub
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL USA
| | - Mara A Piltin
- Department of Surgery, Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MD, USA
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5
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Al-Balas M, Al-Balas H, Al-Amer Z, Ashour L, Obiedat M. Awareness, Knowledge, and Current Practice of Breast Cancer Among Surgeons in Jordan. JCO Glob Oncol 2024; 10:e2300472. [PMID: 38905578 DOI: 10.1200/go.23.00472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 04/06/2024] [Accepted: 04/23/2024] [Indexed: 06/23/2024] Open
Abstract
PURPOSE Breast cancer (BC) is the most prevalent cancer in Jordan. De-escalation in treatment reflects a paradigm shift in BC treatment. More tailored strategies and the adoption of a multidisciplinary approach are essential to apply recent changes in management. In the era of breast surgery fellowship, adopting well-structured training is essential to apply recent therapeutic guidelines and meet patients' expectations. METHODS A cross-sectional study using a customized, self-reported questionnaire was used. Data collection occurred anonymously using a link via WhatsApp in the period between February 2023 and April 2023. RESULTS A total of 89 surgeons were involved in this study, and only 14 (15.7%) completed a subspecialty in breast surgery. About 58.4% considered the age of 40 years as the starting point for screening, and 84.3% reported that mammogram screening is associated with improved BC survival. Only 10.1% and 28.1% acknowledged the applicability of both tomosynthesis and breast magnetic resonance imaging in screening, respectively. A significant difference in the mean knowledge score about BC is observed between general surgeon and those with subspecialty. Varying levels of awareness concerning different risk factors and their correlation with the likelihood of BC occurrence observed. Although 56.2% of participants could offer breast conserving surgery and consider it oncological safe, only 48.3% defined it correctly. Of the participants, 61.8% and 76.4% stated that sentinel lymph node biopsy can be safely applied in clinically negative or suspicious axillary nodes, respectively, with <50% of surgeon performing it in their practice. CONCLUSION More efforts are required to enhance the knowledge and practice of surgeons in the field of breast surgery. Adopting national guidelines can facilitate the acceptance and improvement of current practices among surgeons in Jordan.
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Affiliation(s)
- Mahmoud Al-Balas
- Department of General Surgery, Urology and Anesthesia, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Hamzeh Al-Balas
- Department of General Surgery, Urology and Anesthesia, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Zain Al-Amer
- Faculty of Medicine, Mu'tah University, Mu'tah, Jordan
| | - Laith Ashour
- Faculty of Medicine, Al-Balqa Applied University, Al-Salt, Jordan
| | - Mufleh Obiedat
- Endocrine and General Surgery, Jordanian Royal Medical Services, Amman, Jordan
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Tinterri C, Canavese G, Gentile D. To Dissect or Not to Dissect? The Surgeon's Perspective on the Prediction of Greater Than or Equal to 4 Axillary Lymph Node Metastasis in Early-Stage Breast Cancer: A Comparative Analysis of the Per-Protocol Population of the SINODAR-ONE Clinical Trial. ANNALS OF SURGERY OPEN 2024; 5:e405. [PMID: 38883951 PMCID: PMC11175877 DOI: 10.1097/as9.0000000000000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 02/19/2024] [Indexed: 06/18/2024] Open
Affiliation(s)
- Corrado Tinterri
- From the Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Giuseppe Canavese
- From the Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Damiano Gentile
- From the Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Kumar A, Kulkarni S, Pandey A, Mutalik S, Subramanian S. Nano-tracers for sentinel lymph node detection: current trends in technique and application. Nanomedicine (Lond) 2024; 19:59-77. [PMID: 38197375 DOI: 10.2217/nnm-2023-0271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
Sentinel lymph node (SLN) detection and biopsy is a critical staging component for several cancers. Apart from established methods using dyes or radiolabeled colloids, newer techniques are emerging, like near-infrared fluorescent compounds, targeted molecular radiopharmaceuticals and magnetic nano-tracers. In the overview section of this review, we categorize SLN detection tracers based on their principle of use. We discuss the merits of existing tracers and provide a glimpse of in-development formulations. A subsequent clinical section explores the expanded role of SLN detection in management of various cancers, citing current medical guidelines and the leading conclusions of long-term clinical trials. The concluding section tries to provide a perspective of promising developments and the work required to bring them to clinical fruition.
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Affiliation(s)
- Anuj Kumar
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre, Mumbai, 400085, India
| | - Sanjay Kulkarni
- Department of Pharmaceutics, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Abhijeet Pandey
- Department of Pharmaceutics, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Srinivas Mutalik
- Department of Pharmaceutics, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Suresh Subramanian
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre, Mumbai, 400085, India
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer. Cancers (Basel) 2023; 15:5353. [PMID: 38001613 PMCID: PMC10670757 DOI: 10.3390/cancers15225353] [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: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
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9
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y, Takahashi T, Shioya A, Yamada S. Axillary Reverse Mapping in Clinically Node-Positive Breast Cancer Patients. Cancers (Basel) 2023; 15:5302. [PMID: 37958475 PMCID: PMC10650122 DOI: 10.3390/cancers15215302] [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: 07/24/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Axillary reverse mapping (ARM) nodes are involved in a significant proportion of clinically node-positive (cN+) breast cancer patients. However, neoadjuvant chemotherapy (NAC) is effective at decreasing the incidence of nodal metastases in cN+ patients. PATIENTS AND METHODS One hundred forty-five cN+ patients with confirmed nodal involvement on ultrasound-guided fine needle aspiration cytology were enrolled in this study: one group underwent axillary lymph node dissection (ALND) without NAC (upfront surgery group), and the other group underwent ALND following NAC (NAC group). The patients underwent 18F-FDG-positron emission tomography/computed tomography (18F-FDG-PET/CT) before surgery, as well as an ARM procedure during ALND. RESULTS the rates of involvement of ARM nodes in the NAC group were significantly lower than those of the upfront surgery group (36.6% vs. 62.2%, p < 0.01). Notably, involvement was significantly decreased after NAC in non-luminal-type tumors as compared to the luminal-type (18.4% vs. 48.5%: p < 0.01). Moreover, there was a significant difference in ARM node involvement after NAC between patients with or without axillary uptake of 18F-FDG (61.5% vs. 32.5%: p < 0.01). CONCLUSIONS NAC significantly decreased the risk of ARM node metastases in cN+ patients, but 18F-FDG-PET/CT was not suitable to detect residual metastatic disease of the axilla after NAC.
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Affiliation(s)
- Masakuni Noguchi
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Masafumi Inokuchi
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Miki Yokoi-Noguchi
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Emi Morioka
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Yusuke Haba
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Tomoko Takahashi
- Department of Radiology, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan;
| | - Akihiro Shioya
- Department of Clinical Pathology, Kanazawa Medical University Hospital, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (A.S.); (S.Y.)
| | - Sohsuke Yamada
- Department of Clinical Pathology, Kanazawa Medical University Hospital, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (A.S.); (S.Y.)
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. The involvement of axillary reverse mapping nodes in patients with node-positive breast cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106937. [PMID: 37302899 DOI: 10.1016/j.ejso.2023.05.012] [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: 01/30/2023] [Revised: 03/27/2023] [Accepted: 05/18/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Axillary reverse mapping (ARM) procedure is useful in reducing lymphedema. However, concerns regarding oncologic safety have limited the adoption of the ARM procedure. This study aimed to evaluate the involvement of ARM nodes in node-positive breast cancer patients. MATERIALS AND METHODS Two hundred twenty-three node-positive patients were enrolled in this study: 90 were clinically node-negative, but had one or more positive sentinel lymph nodes (SLNs) (SLN-positive group); 68 were clinicopathologically node-positive (CpN-positive group); and 65 had confirmed nodal involvement and received neoadjuvant chemotherapy (NAC) (NAC group). All patients underwent axillary lymph node dissection with fluorescent ARM. RESULTS ARM nodes were involved in 33 (36.7%) patients of the SLN-group. Residual ARM nodes after SLN biopsy were involved in 11 patients (12.2%), including 5 patients (19.2%) with crossover type nodes and 6 patients (9.4%) with non-crossover type nodes. However, the difference in involvement rates between the two types was not high enough to be significant. Of these 11 patients, moreover, four patients had three or more than 3 involved SLNs. On the other hand, the involvement rate of ARM nodes in the NAC group was significantly lower than that of the CpN-positive group (35.4% vs. 64.7%: p < 0.01). Despite lower involvement, the risk of metastases in the ARM nodes was still too high to spare ARM nodes in both the NAC group and CpN-positive group. CONCLUSIONS Suspicious or involved ARM nodes should be removed even when detected in ARM procedure, particularly in NAC-group and CpN-positive-group patients.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Uchinada, Ishikawa, Japan.
| | - Masafumi Inokuchi
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Uchinada, Ishikawa, Japan
| | - Miki Yokoi-Noguchi
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Uchinada, Ishikawa, Japan
| | - Emi Morioka
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Uchinada, Ishikawa, Japan
| | - Yusuke Haba
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Uchinada, Ishikawa, Japan
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Beltran-Bless AA, Kacerovsky-Strobl S, Gnant M. Explaining risks and benefits of loco-regional treatments to patients. Breast 2023; 71:132-137. [PMID: 37634470 PMCID: PMC10472006 DOI: 10.1016/j.breast.2023.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023] Open
Abstract
Treatment for early-stage breast cancer is complex, requiring multidisciplinary care with a multitude of treatment options available for each patient. Coupled with the rising importance of shared decision-making, patient-physician conversations are progressively more complicated. These conversations require frank disclosure of risks and benefits of the different treatment modalities in a way that is individualized for each patient and simple to understand. In most patients, breast conserving therapy with radiation should be presented as the gold-standard local treatment given similar long-term and improved quality of life outcomes. De-escalation is currently at the forefront of research in loco-regional treatments, and further investigations are required to best determine the optimal patient populations for reduced sentinel lymph node sampling, omission of sentinel lymph node biopsy altogether and omission of radiation treatment. For future trials, better endpoints need to be established considering patient-centered outcomes as well as recurrence.
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Affiliation(s)
- Ana-Alicia Beltran-Bless
- Division of Medical Oncology and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Stephanie Kacerovsky-Strobl
- Breast Health Center, St. Francis Hospital, Vienna, Austria; Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria.
| | - Michael Gnant
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria; Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria.
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12
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Kuemmel S, Heil J, Bruzas S, Breit E, Schindowski D, Harrach H, Chiari O, Hellerhoff K, Bensmann E, Hanf V, Graßhoff ST, Deuschle P, Belke K, Polata S, Paepke S, Warm M, Meiler J, Schindlbeck C, Ruhwedel W, Beckmann U, Groh U, Dall P, Blohmer JU, Traut A, Reinisch M. Safety of Targeted Axillary Dissection After Neoadjuvant Therapy in Patients With Node-Positive Breast Cancer. JAMA Surg 2023; 158:807-815. [PMID: 37285140 PMCID: PMC10248815 DOI: 10.1001/jamasurg.2023.1772] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/19/2023] [Indexed: 06/08/2023]
Abstract
Importance The increasing use of neoadjuvant systemic therapy (NST) has led to substantial pathological complete response rates in patients with initially node-positive, early breast cancer, thereby questioning the need for axillary lymph node dissection (ALND). Targeted axillary dissection (TAD) is feasible for axillary staging; however, data on oncological safety are scarce. Objective To assess 3-year clinical outcomes in patients with node-positive breast cancer who underwent TAD alone or TAD with ALND. Design, Setting, and Participants The SenTa study is a prospective registry study and was conducted between January 2017 and October 2018. The registry includes 50 study centers in Germany. Patients with clinically node-positive breast cancer underwent clipping of the most suspicious lymph node (LN) before NST. After NST, the marked LNs and sentinel LNs were excised (TAD) followed by ALND according to the clinician's choice. Patients who did not undergo TAD were excluded. Data analysis was performed in April 2022 after 43 months of follow-up. Exposure TAD alone vs TAD with ALND. Main Outcomes and Measures Three-year clinical outcomes were evaluated. Results Of 199 female patients, the median (IQR) age was 52 (45-60) years. A total of 182 patients (91.5%) had 1 to 3 suspicious LNs; 119 received TAD alone and 80 received TAD with ALND. Unadjusted invasive disease-free survival was 82.4% (95% CI, 71.5-89.4) in the TAD with ALND group and 91.2% (95% CI, 84.2-95.1) in the TAD alone group (P = .04); axillary recurrence rates were 1.4% (95% CI, 0-54.8) and 1.8% (95% CI, 0-36.4), respectively (P = .56). Adjusted multivariate Cox regression indicated that TAD alone was not associated with an increased risk of recurrence (hazard ratio [HR], 0.83; 95% CI, 0.34-2.05; P = .69) or death (HR, 1.07; 95% CI, 0.31-3.70; P = .91). Similar results were obtained for 152 patients with clinically node-negative breast cancer after NST (invasive disease-free survival: HR, 1.26; 95% CI, 0.27-5.87; P = .77; overall survival: HR, 0.81; 95% CI, 0.15-3.83; P = .74). Conclusions and Relevance These results suggest that TAD alone in patients with mostly good clinical response to NST and at least 3 TAD LNs may confer survival outcomes and recurrence rates similar to TAD with ALND.
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Affiliation(s)
- Sherko Kuemmel
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
- Department of Gynecology With Breast Center Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joerg Heil
- Department of Obstetrics and Gynecology, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Simona Bruzas
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
| | - Elisabeth Breit
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
| | | | - Hakima Harrach
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
| | - Ouafaa Chiari
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
| | | | | | - Volker Hanf
- Breast Unit Klinikum Fürth, Frauenklinik Nathanstift, Fürth, Germany
| | | | - Petra Deuschle
- Breast Unit, Marienhaus Klinikum Hetzelstift Neustadt/Weinstraße, Neustadt, Germany
| | - Kerstin Belke
- Klinik für Gynäkologie und Geburtshilfe, Robert-Koch-Krankenhaus Apolda, Apolda, Germany
| | - Silke Polata
- Klinik für Innere Medizin/Onkologisches Zentrum, Evangelisches Waldkrankenhaus Spandau, Berlin, Germany
| | - Stefan Paepke
- Klinik und Poliklinik für Frauenheilkunde, Klinikum rechts der Isar, TU München, Munich, Germany
| | - Mathias Warm
- Brustzentrum Holweide, Kliniken der Stadt Köln, Cologne, Germany
| | | | | | - Wencke Ruhwedel
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Gütersloh, Gütersloh, Germany
| | - Ulrike Beckmann
- Brustzentrum der Niels-Stensen-Kliniken, Franziskus-Hospital Harderberg, Georgsmarienhütte, Germany
| | - Ulrich Groh
- Klinik für Gynäkologie, Geburtshilfe und Senologie, Hochwaldkrankenhaus Bad Nauheim, Bad Nauheim, Germany
| | - Peter Dall
- Brustzentrum und Gynäkologisches Krebszentrum, Städtisches Klinikum Lüneburg, Lüneburg, Germany
| | - Jens-Uwe Blohmer
- Department of Gynecology With Breast Center Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Traut
- Department of Gynecology and Gynecologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - Mattea Reinisch
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
- Department of Gynecology With Breast Center Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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13
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Kaidar-Person O, Pfob A, Gentilini OD, Borisch B, Bosch A, Cardoso MJ, Curigliano G, De Boniface J, Denkert C, Hauser N, Heil J, Knauer M, Kühn T, Lee HB, Loibl S, Mannhart M, Meattini I, Montagna G, Pinker K, Poulakaki F, Rubio IT, Sager P, Steyerova P, Tausch C, Tramm T, Vrancken Peeters MJ, Wyld L, Yu JH, Weber WP, Poortmans P, Dubsky P. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus. EClinicalMedicine 2023; 61:102085. [PMID: 37528842 PMCID: PMC10388578 DOI: 10.1016/j.eclinm.2023.102085] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy ( ± targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - André Pfob
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Bettina Borisch
- Department of Histopathology, University of Geneva, 1202 Geneva, Switzerland
| | - Ana Bosch
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23A, 22241, Lund, Sweden
| | - Maria João Cardoso
- Breast Unit, Champalimaud Foundation and University of Lisbon Faculty of Medicine, Lisbon, Portugal
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Via Giuseppe Ripamonti, 435, 20141 Milano MI, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Jana De Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden
| | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg, Marburg, Germany
| | - Nik Hauser
- Breast Center, Hirslanden Clinic Aarau, Frauenarztzentrum Aargau AG, Baden, Switzerland
| | - Jörg Heil
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- Breast Center Heidelberg, Klinik St. Elisabeth, Heidelberg, Germany
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Sibylle Loibl
- German Breast Group (GBG), C/o GBG Forschungs GmbH 63263 - Neu-Isenberg/, Germany
- Centre for Haematology and Oncology Bethanien, Frankfurt, Germany
| | | | - Icro Meattini
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Isabel T. Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Patrizia Sager
- Breast Center Bern-Biel, Hirslanden Clinic Salem, Bern, Switzerland
| | - Petra Steyerova
- Breast Cancer Screening and Diagnostic Center, Clinic of Radiology, General University Hospital in Prague, Prague, Czech Republic
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology Netherlands Cancer Institute, Antoni van Leeuwenhoek & Amsterdam University Medical Center, Netherlands
| | - Lynda Wyld
- Department of Oncology and Metabolism, The University of Sheffield, The Medical School, Sheffield, UK
| | - Jong Han Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Walter Paul Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp 2610, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Peter Dubsky
- Breast Center, Hirslanden Clinic St Anna, 6006, Lucerne, Switzerland
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland
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14
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Heidinger M, Knauer M, Tausch C, Weber WP. Tailored axillary surgery - A novel concept for clinically node positive breast cancer. Breast 2023; 69:281-289. [PMID: 36922305 PMCID: PMC10034500 DOI: 10.1016/j.breast.2023.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/25/2023] [Accepted: 03/07/2023] [Indexed: 03/11/2023] Open
Abstract
Axillary surgery in patients with breast cancer has been a history of de-escalation; however, surgery for clinically node-positive breast cancer remained at the dogmatic level of axillary lymph node dissection (ALND). In these patients, currently the only way to avoid ALND is neoadjuvant systemic treatment (NST) with nodal pathologic complete response (pCR) as diagnosed by selective lymph node removal. However, pCR rates are highly dependent on tumor biology, with luminal tumors being most present yet showing the lowest pCR rates. Therefore, the TAXIS trial is investigating whether in clinically node-positive patients, either with residual disease after NST or in the upfront surgical setting, ALND can be safely omitted. All patients undergo tailored axillary surgery (TAS), which includes removal of the biopsied and clipped node, the sentinel lymph nodes as well as all palpably suspicious nodes, turning a clinically positive axilla into a clinically negative. Feasibility of TAS was recently confirmed in the first pre-specified TAXIS substudy. TAS is followed by axillary radiotherapy to treat any remaining nodal disease. Disease-free survival is the primary endpoint of this non-inferiority trial, and morbidity as well as quality of life are the main secondary endpoints, with ALND being known for having a relevant negative impact on both. Currently, 663 of 1500 patients were randomized; accrual completion is projected for 2025. The TAXIS trial stands out in including clinically node-positive patients in both the neoadjuvant and upfront surgery setting, thereby investigating surgical de-escalation at the far-end of the risk spectrum of patients with breast cancer.
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Affiliation(s)
- Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | | | - Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
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15
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Lovrics O, Tao B, Parvez E. Safety and Accuracy of Sentinel Lymph Node Biopsy Alone in Clinically Node-Positive Patients Undergoing Upfront Surgery for Invasive Breast Cancer: A Systematic Review. Curr Oncol 2023; 30:3102-3110. [PMID: 36975448 PMCID: PMC10047769 DOI: 10.3390/curroncol30030235] [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: 12/29/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/09/2023] Open
Abstract
Landmark trials (Z0011 and AMAROS) have demonstrated that axillary lymph node dissection (ALND) can be safely omitted in patients with breast cancer and 1-2 positive sentinel nodes. Extrapolating from these and other cardinal studies such as NSABP B-04, guidelines state that patients with 1-2 needle biopsy-proven positive lymph nodes undergoing upfront surgery can have sentinel lymph node biopsy (SLNB) alone. The purpose of this study is to systematically review the literature to identify studies examining the direct application of SLNB in such patients. EMBASE and Ovid MEDLINE were searched from inception to 3 May 2022. Studies including patients with nodal involvement confirmed on pre-operative biopsy and undergoing SLNB were identified. Studies with neoadjuvant chemotherapy were excluded. Search resulted in 2518 records, of which 68 full-text studies were reviewed, ultimately yielding only 2 studies meeting inclusion criteria. Both studies used targeted axillary surgery (TAS) with pre-operative localization of the biopsy-proven positive node in addition to standard SLNB techniques. In a non-randomized single-center prospective study, Lee et al. report no regional recurrences in patients undergoing TAS or ALND, and no difference in distant recurrence or mortality at 5 years. In the prospective multicenter TAXIS trial by Webber et al., the median number of positive nodes retrieved with TAS in patients undergoing upfront surgery was 2 (1, 4 IQR). Within the subset of patients who underwent subsequent ALND, 61 (70.9%) had additional positive nodes, with 26 (30.2%) patients having ≥4 additional positive nodes. Our review demonstrates that there is limited direct evidence for SLNB alone in clinically node-positive patients undergoing upfront surgery. Available data suggest a high proportion of patients with residual disease in this setting. While the totality of the data, mostly indirect evidence, suggests SLNB alone may be safe, we call on clinicians and researchers to prospectively collect data on this patient population to better inform decision-making.
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Affiliation(s)
- Olivia Lovrics
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada
| | - Brendan Tao
- Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Elena Parvez
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada
- Juravinski Hospital and Cancer Centre, 711 Concession Street, Hamilton, ON L8V 1C3, Canada
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16
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Nussbaumer RL, Maggi N, Castrezana L, Zehnpfennig L, Schwab FD, Krol J, Oberhauser I, Weber WP, Kurzeder C, Haug MD, Kappos EA. The impact of neoadjuvant systemic treatment on postoperative complications in breast cancer surgery. Breast Cancer Res Treat 2023; 197:333-341. [PMID: 36403182 PMCID: PMC9823081 DOI: 10.1007/s10549-022-06811-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE The aim of the study was to analyze the impact of neoadjuvant systemic treatment (NST) on postoperative complications and the beginning of adjuvant treatment. METHODS This study includes data from a prospectively maintained database including patients with breast cancer (BC) stage I-IV with or without NST undergoing breast cancer surgery between January 2010 and September 2021. RESULTS Out of 517 enrolled patients, 77 received NST, 440 had primary breast surgery. After NST patients underwent surgery after a meantime of 34 days (26.5-40 days). No statistical significance could be found comparing the complication grading according to the Clavien Dindo classification. The complications were most frequently rated as grade 3b. There were no complications with grade 4 or higher. When differentiating into short and long-term, the overall rate of short-term complications was 20.3% with no significant difference between the two groups (20.8% vs. 20.2%). Regarding long-term complications, there was more impairment of shoulder mobility (26.0% vs. 9.5%, p ≤ 0.001) and chronic pain (42.9% vs. 28.6%, p ≤ 0.016) for patients with NST. The beginning of the administration of the adjuvant treatment was comparable in both groups (46.3 days vs. 50.5 days). CONCLUSION In our cohort, complications between both groups were comparable according to Clavien Dindo. This study shows that NST has no negative impact on postoperative short-term complications and most importantly did not lead to a delay of the beginning of adjuvant treatment. Therefore, NST can be safely admitted, even when followed by extensive breast reconstruction surgery.
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Affiliation(s)
- R. L. Nussbaumer
- grid.410567.1Department of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland ,grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland
| | - N. Maggi
- grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland
| | - L. Castrezana
- grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland
| | - L. Zehnpfennig
- grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland
| | - F. D. Schwab
- grid.410567.1Department of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland ,grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland
| | - J. Krol
- grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland
| | - I. Oberhauser
- grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland
| | - W. P. Weber
- grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland
| | - C. Kurzeder
- grid.410567.1Department of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland ,grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland
| | - M. D. Haug
- grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland ,grid.410567.1Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland
| | - Elisabeth A. Kappos
- grid.410567.1Breast Center, University Hospital of Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland ,grid.410567.1Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland
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17
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative axillary surgery is emerging in the surgical management of breast cancer. Breast Cancer 2023; 30:14-22. [PMID: 36342647 DOI: 10.1007/s12282-022-01409-2] [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] [Received: 05/09/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
Axillary lymph node dissection (ALND) has been the standard axillary treatment for breast cancer for a long time. However, ALND is associated with postoperative morbidities, including local sensory dysfunction, reduced shoulder mobility and most notably arm lymphedema. Recently, ALND can be avoided not only in clinically node-negative (cN0) patients with negative sentinel lymph nodes (SLNs), but also in patients with less than 3 positive SLNs receiving breast radiation, axillary radiation, or a combination of the two. Moreover, SLN biopsy has been adopted for use in clinically node-positive (cN +) patients presenting as cN0 after neoadjuvant chemotherapy (NAC); ALND may be avoided in cN + patients who convert to SLN-negative following NAC. Patients who undergo SLN biopsy alone have less postsurgical morbidities than those who undergo ALND. Nevertheless, ALND is still required in a select group of patients. A variety of conservative approaches to ALND have been developed to spare arm lymphatics to minimize arm lymphedema. These conservative procedures seem to decrease the incidence of lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, full conventional ALND removing all microscopic axillary disease may now be unnecessary in both cN0 patients and cN + patients. Regardless, emerging procedures for ALND should still be considered as investigational approaches, as further studies with longer follow-up are necessary to determine the safety of conservative ALND to spare arm lymphatics.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan. .,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.
| | - Masafumi Inokuchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Miki Yokoi-Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Emi Morioka
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Yusuke Haba
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
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18
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De-Escalating the Management of In Situ and Invasive Breast Cancer. Cancers (Basel) 2022; 14:cancers14194545. [PMID: 36230468 PMCID: PMC9559495 DOI: 10.3390/cancers14194545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022] Open
Abstract
Simple Summary De-escalation of breast cancer treatment reduces morbidity and toxicity for patients. De-escalation is safe if cancer outcomes, such as recurrence and survival, remain unaffected compared to more radical regimens. This review provides an overview on treatment de-escalation for ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments have facilitated de-escalation of treatment over time. Abstract It is necessary to identify appropriate areas of de-escalation in breast cancer treatment to minimize morbidity and maximize patients’ quality of life. Less radical treatment modalities, or even no treatment, have been reconsidered if they offer the same oncologic outcomes as standard therapies. Identifying which patients benefit from de-escalation requires particular care, as standard therapies will continue to offer adequate cancer outcomes. We provide an overview of the literature on the de-escalation of treatment of ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. De-escalation of breast cancer treatment is a key area of investigation that will continue to remain a priority. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments will expand this even further. Future efforts will continue to challenge us to consider the true role of various treatment modalities.
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