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Brousse S, Lafond C, Schmitt M, Guillermet S, Molière S, Mathelin C. [Can we avoid axillary lymph node dissection in patients with node positive invasive breast carcinoma?]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:132-141. [PMID: 38190968 DOI: 10.1016/j.gofs.2023.12.010] [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: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVES The indications and modalities of breast and axillary surgery are undergoing profound change, with the aim of personalizing surgical management while avoiding over-treatment. To update best practices for axillary surgery, four questions were selected by the Senology Commission of the Collège National des Gynécologues et Obstétriciens Français (CNGOF), focusing on, firstly, the definition and evaluation of targeted axillary dissection (TAD) techniques; secondly, the possibility of surgical de-escalation in case of initial lymph node involvement while performing initial surgery; thirdly, in case of surgery following neo-adjuvant systemic therapy (NAST), and fourthly, contra-indications to de-escalation of axillary surgery to allow access to particular adjuvant systemic therapies. METHODS The Senology Commission based its responses primarily on an analysis of the international literature, clinical practice recommendations and national and international guidelines. RESULTS Firstly, TAD is a technique that combines excision of clipped metastatic axillary node(s) and the axillary sentinel lymph nodes (ASLNs). The detection rate and sensitivity are increased but it still needs to be standardized and practices better evaluated. Secondly, TAD represents an alternative to axillary clearance in cases of metastatic involvement of a single node that can be resected. Thirdly, neither TAD nor ASLN alone is recommended in France after NAST outside of clinical trials, although it is used in several countries in cases of complete pathological response in the lymph nodes, and when at least three lymph nodes have been removed. Fourthly, as some adjuvant targeted therapies are indicated in cases of lymph node invasion of more than three lymph nodes, the place of TAD in this context remains to be defined. CONCLUSION Axillary surgical de-escalation can limit the morbidity of axillary clearance. Having proved that TAD does not reduce patient survival, it will most probably replace axillary clearance in well-defined indications. This will require prior standardization of the method and its indications and contra-indications, particularly to enable the use of new targeted therapies.
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Affiliation(s)
- Susie Brousse
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France.
| | - Clémentine Lafond
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France; Service de gynécologie-obstétrique, CHU de Rennes, 35000 Rennes, France
| | - Martin Schmitt
- Service de radiothérapie, CHR-Metz-Thionville, hôpital de Mercy, 1, allée du Château, 57085 Metz cedex, France
| | - Sophie Guillermet
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France
| | - Sébastien Molière
- Service d'imagerie de la femme, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France; Service de radiologie B, CHU de Strasbourg, avenue Molière, 67200 Strasbourg, France
| | - Carole Mathelin
- Service de chirurgie, ICANS, CHRU, avenue Molière, 67200 Strasbourg, France
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Del Castillo A, Gomez-Modet S, Mata JM, Tejedor L. Targeted axillary dissection using Radioguided Occult Lesion Localization technique in the clinically negative marked lymph node after neoadjuvant treatment in breast cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1184-1188. [PMID: 36958951 DOI: 10.1016/j.ejso.2023.03.208] [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: 11/04/2022] [Revised: 12/27/2022] [Accepted: 03/09/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE To be aware of the feasibility of targeted axillary dissection (TAD) injecting 99mTechnetium-labeled macroaggregated albumin (99mTc-MAA) preoperatively into the clipped lymph node of patients with axillary complete clinical response (ycN0), after neoadjuvant chemotherapy (NAC) for breast cancer. PATIENTS AND METHODS A retrospective observational study was performed on N1 patients with a clipped positive node and a clinically negative axilla (ycN0) after NAC in one center. The pretreatment positive lymph node was injected with 99mTc-MAA the day before surgery and identified intraoperatively with a radioguided occult lesion localization (ROLL) technique. Patients were subjected to a TAD with the intent of identifying the clipped node and other/s sentinel nodes through a standard sentinel lymph node biopsy (SLNB). RESULTS 54 patients and 55 axillary clipped nodes were included. The clip was intraoperatively encountered in every patient, accomplishing a 100% detection rate, although in one case no lymphatic tissue could be found in the intraoperative frozen section. An axillary lymph node dissection (ALND) was avoided in 62.9% of the cases (34/54). CONCLUSION The use of the ROLL technique is a highly valuable tool since it allows a 100% success rate in retrieving the marker (and a 98.1% rate in detecting the clipped lymph node) in ycN0 breast cancer patients.
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Affiliation(s)
- Ana Del Castillo
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - Susana Gomez-Modet
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - José María Mata
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - Luis Tejedor
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
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Clinical utility of axillary nodal markers in breast cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:709-715. [PMID: 36764880 DOI: 10.1016/j.ejso.2022.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/18/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND De-escalation of axillary surgery for lymph node (LN) positive breast cancer is facilitated by marking involved nodes which, when removed with sentinel nodes constitute risk-adapted targeted axillary dissection (TAD). Whether after chemotherapy or for primary surgery, selected patients with biopsy-proven involvement of nodes may be eligible for axillary conservation. Likewise, impalpable recurrence or stage 4 patients with localised axillary disease may benefit. In these contexts, several devices are used to mark biopsied nodes to facilitate their accurate surgical removal. We report our experience using the paramagnetic MAGSEED (Endomag®, Cambridge, UK). METHODS Local approval (BR2021_149) was obtained to interrogate a prospective database of all axillary markers. The primary endpoint was successful removal of the marked LN. RESULTS Of 241 markers (in 221 patients) inserted between October 2018 and July 2022, all were retrieved. Of 74 patients who had Magseeds® inserted after completion of NACT (involved nodes initially marked using an UltraCor™Twirl™ marker), the Magseeds® were found outside the node in neighbouring axillary tissue in 18 (24.3%) patients. When Magseeds® were placed at commencement of NACT in 54 patients, in only 1 (1.8%) was the marker found outside the node - a statistically significantly lower rate (Chi2 10.7581 p = 0.001038). For 'primary TAD' patients and those localised for recurrent or stage IV disease, all 93 had the Magseed® found within the biopsied node. CONCLUSION This series supports our axillary nodal marking technique as safe and reliable. For TAD following NACT, placement at the start of treatment led to a significantly higher localisation rate.
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Feinberg JA, Axelrod D, Guth A, Maldonado L, Darvishian F, Pourkey N, Goodgal J, Schnabel F. Radar reflector guided axillary surgery in node positive breast cancer patients. Expert Rev Med Devices 2022; 19:791-795. [DOI: 10.1080/17434440.2022.2139177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Deborah Axelrod
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Amber Guth
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | | | | | - Nakisa Pourkey
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Jenny Goodgal
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Freya Schnabel
- Department of Surgery, NYU Langone Health, New York, NY, USA
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5
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Mansour KP, Thornton C. A pioneer Australian case of Savi-Scout™ assisted resection for breast cancer recurrence. J Surg Case Rep 2022; 2022:rjac418. [PMID: 36158251 PMCID: PMC9491868 DOI: 10.1093/jscr/rjac418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/23/2022] [Indexed: 11/19/2022] Open
Abstract
This case describes a 48-year-old female who the first patient in Australia treated surgically with Savi-Scout™ assisted breast cancer localization, utilizing electromagnetic wave signalling for accurate depth guidance. After initial breast cancer diagnosis at age 44 treated with bilateral mastectomies and DIEP flap reconstructions, clinical surveillance found recurrent right chest wall disease. US and MRI identified a 4–6 mm interpectoral lesion; poorly differentiated metastatic micropapillary carcinoma on core biopsy. Savi-Scout™ was selected to assist localization and removal of the lesion due it’s technically challenging location. Informed consent was gained and one month pre-operatively a 12× 1.6 mm electromagnetic wave Savi-Scout™ reflector was inserted via US-guidance. A Savi-Scout™ probe guided marking, incision and dissection of subcutaneous tissues and pectoralis muscles, through localization to the reflector. The lesion and reflection were excised and confirmed on specimen radiograph, with clear histopathology margins. This technology has potential applications for challenging breast cancer cases.
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Affiliation(s)
| | - Chantel Thornton
- Melbourne Health Department of General Surgery, Melbourne, Victoria, Australia
- Epworth Richmond Department of General Surgery, Breast Surgery, Richmond, Victoria, Australia
- Specialist Breast Cancer Surgery, Richmond, Victoria, Australia
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Yang J, He T, Wu Y, Fu Z, Lv Q, Lu S, Wang X, Li H, Wang J, Chen J. Nanoparticle-assisted axillary staging: an alternative approach after neoadjuvant chemotherapy in patients with pretreatment node-positive breast cancers. Breast Cancer Res Treat 2022; 192:573-582. [PMID: 35129717 DOI: 10.1007/s10549-022-06539-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/29/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE In order to achieve an optimized method of axillary staging after neoadjuvant chemotherapy (NAC) in breast cancer patients with pretreatment positive axillary lymph nodes, we evaluated the feasibility and accuracy of nanoparticle-assisted axillary staging (NAAS) which combines carbon nanoparticles with standard sentinel lymph node biopsy (SLNB) with radioisotope and blue dye. METHODS Invasive breast cancer patients with pre-NAC positive axillary lymph nodes who converted to ycN0 and received surgeries from November 2020 to March 2021 were included. All patients underwent ipsilateral NAAS followed by axillary lymph node dissection. Detection rate (DR), false-negative rate (FNR), negative predictive value (NPV) and accuracy of axillary staging were calculated. RESULTS Eighty of 136 (58.8%) breast cancer patients converted to ycN0 after NAC and received NAAS. The DR, NPV and accuracy was 95.0%, 93.3% and 97.4% for NAAS, respectively. And the FNR was 4.2% (2/48) for NAAS, which was lower than that of standard dual-tracer SLNB (SD-SLNB) (9.5%, 4/42). Pretreatment clinical T4 classification was a risk factor for detection failure in NAAS (p = 0.016). When patients with pretreatment inflammatory breast cancers were excluded from analysis, FNR dropped to 2.2% (1/45) for NAAS. CONCLUSION NAAS revealed great performance in invasive breast cancer patients with pre-NAC positive axillary lymph nodes who converted to ycN0. The application of NAAS reached a better balance between more accurate axillary evaluation and less intervention. Trial registration Chictr.org.cn (ChiCTR2000039814). Registered Nov 11, 2020.
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Affiliation(s)
- Jiqiao Yang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China.,Clinical Research Center for Breast Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Tao He
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Yunhao Wu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Zhoukai Fu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Qing Lv
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Shan Lu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Xiaodong Wang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Hongjiang Li
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Jing Wang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Jie Chen
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China.
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de Wild SR, Simons JM, Vrancken Peeters MJTFD, Smidt ML, Koppert LB. De-Escalating Axillary Surgery in Node-Positive Breast Cancer Treated with Neoadjuvant Systemic Therapy. Breast Care (Basel) 2022; 16:584-589. [PMID: 35087361 DOI: 10.1159/000518376] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/03/2021] [Indexed: 11/19/2022] Open
Abstract
Background There is a trend towards de-escalating axillary staging and treatment in breast cancer patients. On account of neoadjuvant systemic therapy, node-positive breast cancer patients can achieve a pathological complete response of the axilla. It is hypothesized that these patients do not benefit from an axillary lymph node dissection (ALND), and thus may be spared the risk of severe post-surgical morbidity. In an effort to omit standard ALND, less invasive axillary staging procedures are being implemented to establish response-guided treatment. However, it is unclear which less invasive staging procedure is most accurate, and long-term data are missing with regard to their oncologic safety. Summary This article provides an overview of the literature on currently used less invasive axillary staging procedures, the accuracy and feasibility of these procedures in clinical practice, important issues concerning axillary treatment, and issues to be addressed in ongoing or future studies. Key messages More evidence is needed regarding the safety of replacing standard ALND by less invasive axillary staging procedures in terms of long-term prognosis. These less invasive staging procedures not only serve to select patients who may benefit from treatment de-escalation, but also to select patients who may benefit from treatment escalation.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Janine M Simons
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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8
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Dialani V, Dogan B, Dodelzon K, Dontchos BN, Modi N, Grimm L. Axillary Imaging Following a New Invasive Breast Cancer Diagnosis-A Radiologist's Dilemma. JOURNAL OF BREAST IMAGING 2021; 3:645-658. [PMID: 38424939 DOI: 10.1093/jbi/wbab082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Indexed: 03/02/2024]
Abstract
Traditionally, patients with newly diagnosed invasive breast cancer underwent axillary US to assess for suspicious axillary lymph nodes (LNs), which were then targeted for image-guided needle biopsy to determine the presence of metastasis. Over the past decade, there has been a shift towards axillary preservation. For patients with palpable lymphadenopathy, the decision to perform axillary imaging with documentation of the number and location of abnormal LNs in preparation for image-guided LN sampling is straightforward. Since LN involvement correlates with cancer size, it is reasonable to image the axilla in patients with tumors larger than 5 cm; however, for tumors smaller than 5 cm, axillary imaging is often deferred until after the tumor molecular subtype and treatment plan are established. Over the last decade, neoadjuvant chemotherapy (NACT) is increasingly used for smaller cancers with more aggressive molecular subtypes. In most cases, detecting axillary metastasis is critical when deciding whether the patient would benefit from NACT. There is increasing evidence that abnormal axillary US findings correlates with LN metastases and reliably establishes a baseline to monitor response to NACT. Depending on hormone receptor status, practices may choose to image the axilla in the setting of clinical stage T1 and T2 cancers to evaluate nodal status and help determine further steps in care. Radiologists should understand the nuances of axillary management and the scope and challenges of LN marking techniques that significantly increase the precision of limited axillary surgery.
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Affiliation(s)
- Vandana Dialani
- Beth Israel Lahey Hospital, Department of Radiology, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Basak Dogan
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, TX, USA
| | - Katerina Dodelzon
- Weill Cornell Medical College, Department of Radiology, New York, NY, USA
| | - Brian N Dontchos
- Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Neha Modi
- Saint Vincent Hospital at Worcester Medical Center, Department of Radiology, Worcester, MA, USA
| | - Lars Grimm
- Duke University Hospital, Department of Radiology, Durham, NC, USA
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9
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Kirkilesis G, Constantinidou A, Kontos M. False Negativity of Targeted Axillary Dissection in Breast Cancer. Breast Care (Basel) 2021; 16:532-538. [PMID: 34720813 DOI: 10.1159/000513037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/13/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction Targeted axillary dissection (TAD) has been proposed as an alternative method for the staging of patients with node-positive breast cancer who undergo neoadjuvant chemotherapy. However, not much is known yet about the false-negative rate (FNR) of the method and the subsequent risk of underestimation of residual axillary disease. Methods This study reviews published articles with calculations of false negativity of TAD and potential factors that may influence it. Results The FNR of TAD is usually reported as being <10%, but this calculation is usually based on small study populations. Lower FNR is a common finding along with lower N status, while not enough data are available yet for greater axillary involvement. When a marked node is revealed to be a sentinel lymph node (SLN) at surgery after neoadjuvant chemotherapy (NAC), this seems to be another factor that contributes to reliable TAD. With regard to the methods used to mark the positive node before chemotherapy and retrieval at surgery, there is no clear advantage of one over the other. The availability of relevant resources, the costs, and local legislation must all be taken into account for the selection of the optimal strategy. Conclusion Although still in its early days, the FNR of TAD can be low, at least in patients with relatively little axillary involvement and when the marked node is the SLN. All reported methods of lymph node marking seem reliable.
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Affiliation(s)
- George Kirkilesis
- 3rd Department of Surgery, National and Kapodistrian University of Athens, "Attiko" University Hospital, Athens, Greece
| | | | - Michalis Kontos
- 1st Department of Surgery, National and Kapodistrian University of Athens, "Laiko" University Hospital, Athens, Greece
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10
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Kiruparan N, Kiruparan P, Debnath D. Use of wire guided localisation and radio-guided occult lesion localisation for non-palpable breast lesions: A systematic literature review and meta-analysis of current evidence. Asian J Surg 2021; 45:79-88. [PMID: 34479779 DOI: 10.1016/j.asjsur.2021.06.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/06/2021] [Accepted: 06/17/2021] [Indexed: 12/24/2022] Open
Abstract
Breast cancer screening has seen an increase in the detection of non-palpable breast lesions. Wire guided localisation (WGL) and Radio-guided occult lesion localisation (ROLL) are well established modalities of localisation of non-palpable breast lesions in the UK. We aimed to compare the outcomes of WGL and ROLL in this updated meta-analysis. We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words as well as relevant MESH-terms. We also searched Medline (02/03/2021), Embase and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Outcomes considered were re-excision rates, margin involvement, specimen volume and weight, accurate localisation of lesions and operative time. We assessed the risk of bias in included studies and performed random effects meta-analyses using Review Manager (version 5.3). Heterogeneity was estimated using the I2-statistic. Nine included studies enrolled 1096 patients undergoing localization in breast surgery (534 in WGL and 562 in ROLL). There was a statistically significant benefit in favour of ROLL for non-involved resection margins (OR 0.60; 95% CI, 0.44-0.97); based on seven studies. Nine trials assessed operative time favouring ROLL (OR 1.95; 95% CI, 0.27-3.63). No significant difference in re-excision rates was reported (OR 1.42; 95% CI, 0.83-2.43) based on seven studies. Current evidence favourably supports ROLL, compared to WGL, with respect to margin involvement, localisation and operative time in the treatment of non-palpable breast lesions.
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11
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Balija TM, Braz D, Hyman S, Montgomery LL. Early reflector localization improves the accuracy of localization and excision of a previously positive axillary lymph node following neoadjuvant chemotherapy in patients with breast cancer. Breast Cancer Res Treat 2021; 189:121-130. [PMID: 34159474 DOI: 10.1007/s10549-021-06281-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/31/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Clipped axillary lymph node (CALN) localization after neoadjuvant chemotherapy (NAC) for axillary node positive breast cancer can be difficult due to significant shrinkage or disappearance of the CALN after NAC. This study compares wire localization to a radar-based localization system utilizing a reflector that can be placed before or during NAC, in the months before definitive surgery, to facilitate accurate localization and excision of the CALN. METHODS Between 2016 and 2019, women with T0-4 N1-3 M0 breast cancer who underwent NAC followed by axillary surgery with planned excision of a biopsy positive or clinically suspicious axillary node via wire or reflector localization were identified. A retrospective chart review was performed comparing successful localization and CALN retrieval by each localization technique. RESULTS Ninety-nine patients met inclusion criteria. Forty-two patients underwent wire localization while 57 patients underwent reflector localization of the CALN. Successful identification of the CALN by wire or reflector was equivalent (83.3% vs 84.2%, respectively). Twenty-two reflectors placed before or during early/mid NAC (early placement) had 100% successful CALN localization and retrieval in the OR. Placement of wire or reflector localization devices within 8 weeks of surgery (late placement) only resulted in 79.2% localization success (p = .02). CONCLUSION This study suggests a benefit of axillary lymph node reflector placement in the early NAC setting. Early reflector placement allows for more accurate excision of the CALN during axillary surgery after NAC as compared to placement of localization wires or reflectors in the few weeks prior to surgery.
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Affiliation(s)
- Tara M Balija
- Department of Surgery, Division of Breast Surgery, Hackensack Meridian School of Medicine, 20 Prospect Avenue, Suite 402, Hackensack, NJ, 07601, USA.
| | - Devin Braz
- Department of Surgery, Division of Breast Surgery, Hackensack Meridian School of Medicine, 20 Prospect Avenue, Suite 402, Hackensack, NJ, 07601, USA
| | - Sara Hyman
- Department of Surgery, Division of Breast Surgery, Hackensack Meridian School of Medicine, 20 Prospect Avenue, Suite 402, Hackensack, NJ, 07601, USA
| | - Leslie L Montgomery
- Department of Surgery, Division of Breast Surgery, Hackensack Meridian School of Medicine, 20 Prospect Avenue, Suite 402, Hackensack, NJ, 07601, USA
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12
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Reflector-Guided Localisation of Non-Palpable Breast Lesions: A Prospective Evaluation of the SAVI SCOUT ® System. Cancers (Basel) 2021; 13:cancers13102409. [PMID: 34067552 PMCID: PMC8156313 DOI: 10.3390/cancers13102409] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Marking impalpable areas of breast cancer prior to surgery is an important part of the modern treatment of breast cancer. Traditionally, the target lesion would be marked by a wire just before surgery under image guidance and would help the surgeon locate the tumour during surgery. However, this method has some drawbacks, such as patient discomfort, the risk of migration and dislodgement, and the need to couple surgical and radiological schedules. Therefore, there has been a growing interest in this system, thus supporting its potential. In this study, we have evaluated one such system, SAVI SCOUT®, in 63 consecutive patients. Our experience with this system supported its potential role in modern breast surgery. Abstract Wire-guided localisation (WGL) has been the mainstay for localising non-palpable breast lesions before excision. Due to its limitations, various wireless alternatives have been developed. In this prospective study, we evaluate the role of radiation-free wireless localisation using the SAVI SCOUT® system at the London Breast Institute. A total of 72 reflectors were deployed in 67 consecutive patients undergoing breast conserving surgery for non-palpable breast lesions. The mean interval between deployment and surgery for the therapeutic cases was 18.8 days (range: 0–210). The median deployment duration was 5 min (range: 1–15 min). The mean distance from the lesion was 1.1 mm (median distance: 0; range: 0–20 mm). The rate of surgical localisation and retrieval of the reflector was 98.6% and 100%, respectively. The median operating time was 28 min (range: 15–55 min) for the therapeutic excision of malignancy and 17 min (range: 15–24) for diagnostic excision. The incidence of reflector migration was 0%. Radial margin positivity in malignant cases was 7%. The median weight for malignant lesions was 19.6 g (range: 3.5–70 g). Radiologists and surgeons rated the system higher than WGL (93.7% and 98.6%, respectively; 60/64 and 70/71). The patient mean satisfaction score was 9.7/10 (n = 47, median = 10; range: 7–10). One instance of signal failure was reported. In patients who had breast MRI after the deployment of the reflector, the MRI void signal was <5 mm (n = 6). There was no specific technique-related surgical complication. Our study demonstrates that wire-free localisation using SAVI SCOUT® is an effective and time-efficient alternative to WGL with excellent physician and patient acceptance.
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13
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Arjmandi F, Mootz A, Farr D, Reddy S, Dogan B. New horizons in imaging and surgical assessment of breast cancer lymph node metastasis. Breast Cancer Res Treat 2021; 187:311-322. [PMID: 33982209 DOI: 10.1007/s10549-021-06248-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 04/29/2021] [Indexed: 01/09/2023]
Abstract
Axillary nodal status is one of the most important prognostic factors in breast cancer. While sentinel lymph node biopsy (SLNB) is a safe and validated procedure for clinically node-negative patients, axillary management of clinically node-positive patients has been more controversial. Patients with clinically detected axillary metastases often benefit from neoadjuvant chemotherapy (NAC). Those who convert to node-negative disease following NAC are important to identify, since they can often be spared significant morbidity from axillary dissection. SLNB has shown widely varying false-negative rates (FNR) but with the use of dual mapping and surgical biopsy of 3 or more nodes, it is considered an acceptable method to stage the axilla in clinically node-positive patients who receive NAC. Various methods including targeted axillary dissection (TAD) have been shown to decrease the FNR of SLNB. We will review appropriate methods to identify a metastatic node and subsequent ultrasound-guided biopsy with tissue marking techniques. We underscore key points in monitoring axillary response, techniques to accurately localize the biopsied and clipped known metastatic node for surgical excision and the effect of various methods in reducing the FNR of SLNB, including the emerging concept of TAD on patient care.
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Affiliation(s)
- Firouzeh Arjmandi
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA.
| | - Ann Mootz
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA
| | - Deborah Farr
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA
| | - Sangeetha Reddy
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA
| | - Basak Dogan
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8896, USA
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The applicability of Magseed® for targeted axillary dissection in breast cancer patients treated with neoadjuvant chemotherapy. Breast 2021; 57:113-117. [PMID: 33813230 PMCID: PMC8050798 DOI: 10.1016/j.breast.2021.03.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/14/2021] [Accepted: 03/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background Targeted axillary dissection (TAD), the combination of sentinel lymph node biopsy (SLNB) and targeted lymph node biopsy (TLNB), can reduce the false negative rates of sentinel node biopsy alone dramatically in breast cancer patients, who received neoadjuvant chemotherapy (NAC). However methods for TAD are still under investigation. Methods Magseed®, a non-radioactive magnetic marker was used to mark the biopsied positive TLN after NAC. The SLNB with the standard technetium-based method and the selective TLNB with Magseed® localization were performed in 40 patients. The TLNs were identified with the Sentimag® probe and excised in all patients. Specimen x-ray was performed to confirm the Magseed® within the prior to NAC biopsied and clipped lymph node. Results The TLN identification rate was 100% (40/40), the SLN identification rate was 82.5% (33/40), the concordance rate between the TLN and the SLN was 65% (26/40). Complications according Magseed® deployment or identification could not be observed. Conclusion Magseed® is a reliable and feasible marker for the identification of TLNs after NAC. TLNB is an accurate method for the identification of marked lymph nodes after NAC. Selective excision of TLNs is feasible. Magseed® allows a non-radioactive, wireless marking of TLNs.
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Different strategies in marking axillary lymph nodes in breast cancer patients undergoing neoadjuvant medical treatment: a systematic review. Breast Cancer Res Treat 2021; 186:607-615. [PMID: 33611665 DOI: 10.1007/s10549-021-06118-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Marking of cytology-proven metastatic axillary lymph node in breast cancer patients before neoadjuvant treatment and its subsequent surgical retrieval have been shown to reduce the false-negative rate of sentinel lymph node biopsy. A systematic review was performed to evaluate different strategies in nodal marking and localization. METHODS PubMed, Embase, EBSCOhost, and the Cochrane library literature databases were searched systematically to address the identification rate and retrieval rate of marked axillary lymph nodes. Studies were eligible if they performed nodal marking before neoadjuvant treatment, followed by selective extirpation of these marked axillary lymph nodes in definitive surgery RESULTS: Fifteen studies with a total of 703 patients were included. Index axillary lymph nodes were marked by clips or tattooed prior to the commencement of neoadjuvant treatment. In our pooled analysis, eighty-eight percent of the clipped nodes and ninety-seven percent of the tattooed nodes were successfully retrieved. Among these patients, seventy-seven percent of these marked axillary lymph nodes were also sentinel lymph nodes. CONCLUSION Marking and selectively removing cytology-proven metastatic axillary lymph nodes after neoadjuvant treatment is feasible. An acceptably high nodal retrieval rate could be achieved using various methods of nodal marking and localization techniques.
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Targeted Axillary Dissection for Patients Who Convert to Clinically Node Negative After Neoadjuvant Chemotherapy for Node-Positive Breast Cancer. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00375-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Laws A, Specht MC. Leveraging Neoadjuvant Chemotherapy to Minimize the Burden of Axillary Surgery: a Review of Current Strategies and Surgical Techniques. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00388-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sun J, Henry DA, Carr MJ, Yazdankhahkenary A, Laronga C, Lee MC, Hoover SJ, Sun W, Czerniecki BJ, Khakpour N, Kiluk JV. Feasibility of Axillary Lymph Node Localization and Excision Using Radar Reflector Localization. Clin Breast Cancer 2020; 21:e189-e193. [PMID: 32893094 DOI: 10.1016/j.clbc.2020.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Neoadjuvant chemotherapy (NAC) is commonly used for patients with clinically detected nodal metastases. Sentinel lymph node biopsy (SLNB) after NAC is feasible. Excision of biopsy-proven positive lymph nodes in addition to SLNB, termed targeted axillary dissection (TAD), decreases the false-negative rate of SLNB alone. Positive nodes can be marked with radar reflector-localization (RRL) clips. We report our institutional experience with RRL-guided TAD and demonstrate its safety and feasibility. PATIENTS AND METHODS We performed an institutional review board-approved retrospective review of consecutive clinically node-positive female patients with breast cancer treated with NAC and RRL-guided TAD between January 2017 and September 2019. Clinicopathologic and treatment data were collected; descriptive statistics are reported. RESULTS Forty-five patients were analyzed; the median age was 55 years (range, 20-72 years), and the median body mass index was 27.2 kg/m2 (range, 16.5-40.4 kg/m2). All patients received NAC, primary breast surgery, and TAD. All clinically detected nodal metastases were confirmed with percutaneous biopsy and marked with a biopsy clip. RRL clips were implanted a median of 8 days (range, 1-167 days) prior to surgery; all were retrieved without complications. The RRL node was identified as the sentinel lymph node in 36 (80%) patients. Twenty-five patients had positive nodes, of which 24 were identified by RRL node excision, and 1 (4%) patient had a positive node identified by SLNB but not RRL. Over a median follow-up time of 29.6 months, 5 patients recurred (1 local, 4 distant). CONCLUSIONS RRL-guided TAD after NAC is safe and feasible. This technique allows for adequate assessment of the nodal basin and helps confirm excision of the previously biopsied positive axillary node.
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Affiliation(s)
- James Sun
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL; Present affiliation: Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Danielle A Henry
- Breast Care Center, Orlando Health - UF Health Cancer Center, Orlando, FL
| | - Michael J Carr
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL
| | - Adel Yazdankhahkenary
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL; Present affiliation: Tehran University of Medical Sciences, Tehran, Iran
| | | | - M Catherine Lee
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL
| | - Susan J Hoover
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL
| | - Weihong Sun
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL
| | | | | | - John V Kiluk
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL.
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Laws A, Dillon K, Kelly BN, Kantor O, Hughes KS, Gadd MA, Smith BL, Lamb LR, Specht M. Node-Positive Patients Treated with Neoadjuvant Chemotherapy Can Be Spared Axillary Lymph Node Dissection with Wireless Non-Radioactive Localizers. Ann Surg Oncol 2020; 27:4819-4827. [PMID: 32740737 DOI: 10.1245/s10434-020-08902-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/30/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Targeted axillary dissection (TAD) involves sentinel lymph node biopsy (SLNB) and excision of a biopsy-proven node marked by a clip. This study evaluates the feasibility of non-radioactive wireless localizers for targeted excision of clipped axillary lymph nodes. METHODS We identified biopsy-proven, node-positive breast cancer patients treated with neoadjuvant therapy (NAT) and TAD from 2016 to 2020, and included those with a clipped node localized using SAVI SCOUT, Magseed, or RFID Tag. Primary outcome measures were (1) successful localization (ultrasound or mammographic-guided placement < 10 mm from target), and (2) retrieval of the clipped node during TAD, documented by specimen radiography or gross visualization. Secondary outcomes included rates of completion axillary lymph node dissection (cALND) and complications. RESULTS Overall, 57 patients were included; 1 (1.8%) patient had no clip visible at the time of localization, and no radiographic confirmation of clip placement at the time of biopsy, and was therefore excluded. In the remaining 56 patients, localization was successful in 53 (94.6%) patients and the clipped node was retrieved during TAD in 51 (91.1%) patients. Twenty-three of 27 (85.2%) ypN0 patients were spared cALND; 3 (11.1%) patients had cALND for failed clipped node retrieval during TAD, and 1 (3.7%) for false-positive frozen section. In patients with TAD alone, the rates of axillary seroma and infection were 20.0% and 8.6%, respectively. CONCLUSIONS Wireless non-radioactive localizers are feasible for axillary localization after NAT, with high success rates of retrieving clipped nodes. The lack of signal decay is an advantage of these devices, allowing flexibility in timing of placement.
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Affiliation(s)
- Alison Laws
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Kayla Dillon
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Bridget N Kelly
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Olga Kantor
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Kevin S Hughes
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Michele A Gadd
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Barbara L Smith
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Leslie R Lamb
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle Specht
- Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
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Sutton TL, Johnson N, Garreau JR. Adequate sentinel node harvest is associated with low false negative rate in breast cancer managed with neoadjuvant chemotherapy and targeted axillary dissection. Am J Surg 2020; 219:851-854. [PMID: 32245609 DOI: 10.1016/j.amjsurg.2020.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/10/2020] [Accepted: 03/07/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION After neoadjuvant chemotherapy (NAC) for clinically node-positive breast cancer (NPBC), targeted axillary dissection (TAD) reduces the false negative rate (FNR) of axillary node sampling. Axillary lymph node dissection (ALND) is indicated if the clipped node cannot be identified. Prior studies have indicated that a sentinel lymph node harvest (SLNH) of ≥3 also leads to low FNR. We investigated the performance of SLNH thresholds at inferring the status of the axilla during TAD. METHODS Retrospective review of the Legacy Health System Tumor Registry was performed. We identified NPBC patients between 2011 and 2016 managed with NAC and TAD. RESULTS In 29 patients, the FNR of the SLNB component of TAD was 11% with SLNH of ≥3; with SLNH of ≤2 nodes the FNR was 20%. CONCLUSIONS In patients with NPBC receiving NAC, adequate SLNH is associated with acceptably low FNR. The decision to pursue ALND for clip identification should be made on a case-by-case basis.
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Affiliation(s)
- Thomas L Sutton
- Oregon Health & Science University, Department of Surgery, 3181 SW Sam Jackson Park Rd, Portland, 97239, OR, USA.
| | - Nathalie Johnson
- Legacy Cancer Institute, Legacy Medical Group Surgical Oncology, 1040 NW 22nd Ave, Suite 560, Portland, 97227, OR, USA.
| | - Jennifer R Garreau
- Legacy Cancer Institute, Legacy Medical Group Surgical Oncology, 1040 NW 22nd Ave, Suite 560, Portland, 97227, OR, USA.
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Lim GH, Teo SY, Gudi M, Ng RP, Pang J, Tan YS, Lee YS, Allen JC, Leong LCH. Initial results of a novel technique of clipped node localization in breast cancer patients postneoadjuvant chemotherapy: Skin Mark clipped Axillary nodes Removal Technique (SMART trial). Cancer Med 2020; 9:1978-1985. [PMID: 31970894 PMCID: PMC7064023 DOI: 10.1002/cam4.2848] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 12/21/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose Removal of clipped nodes can improve sentinel node biopsy accuracy in breast cancer patients post neoadjuvant chemotherapy (NACT). However, the current methods of clipped node localization have limitations. We evaluated the feasibility of a novel clipped node localization and removal technique by preoperative skin marking of clipped nodes and removal by the Skin Mark clipped Axillary nodes Removal Technique (SMART), with the secondary aim of assessing the ultrasound visibility of the various clips in the axillary nodes after NACT. Methods Invasive breast cancer patients with histologically metastatic axillary nodes, going for NACT, and ≤3 sonographically abnormal axillary nodes were recruited. All abnormal nodes had clips inserted. Patients with M1 disease were excluded. Post‐NACT, patients underwent SMART and axillary lymph node dissection. Specimen radiography and pathological analyses were performed to confirm the clipped node presence. Success, complication rates of SMART, and ultrasound visibility of the various clips were assessed. Results Twenty‐five clipped nodes in 14 patients underwent SMART without complications. The UltraCor Twirl, hydroMARK, UltraClip Dual Trigger, and UltraClip were removed in 13/13 (100%), 7/9 (77.8%), 1/2 (50.0%), and 0/1 (0%), respectively (P = .0103) with UltraCor Twirl having the best ultrasound visibility and removal rate. Removal of three clipped nodes in the same patient (P = .0010) and deeply seated clipped nodes (P = .0167) were associated with SMART failure. Conclusion Skin Mark clipped Axillary nodes Removal Technique is feasible for removing clipped nodes post‐NACT, with 100% observed success rate, using the UltraCor Twirl marker in patients with <3 not deeply seated clipped nodes. Larger studies are needed for validation.
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Affiliation(s)
- Geok Hoon Lim
- Breast Department, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Sze Yiun Teo
- Department of Diagnostic & Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
| | - Mihir Gudi
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Ruey Pyng Ng
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jinnie Pang
- Breast Department, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yia Swam Tan
- Breast Department, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yien Sien Lee
- Department of Diagnostic & Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
| | - John C Allen
- Duke-NUS Medical School, Centre for Quantitative Medicine, Singapore, Singapore
| | - Lester Chee Hao Leong
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
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Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer: A Systematic Review and Meta-analysis. Ann Surg 2019; 269:432-442. [PMID: 30312200 PMCID: PMC6369968 DOI: 10.1097/sla.0000000000003075] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective: The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND. Summary of Background Data: Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity. Methods: PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV). Results: Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%. Conclusion: Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.
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Simons JM, van Pelt MLMA, Marinelli AWKS, Straver ME, Zeillemaker AM, Pereira Arias‐Bouda LM, van Nijnatten TJA, Koppert LB, Hunt KK, Smidt ML, Luiten EJT, van der Pol CC. Excision of both pretreatment marked positive nodes and sentinel nodes improves axillary staging after neoadjuvant systemic therapy in breast cancer. Br J Surg 2019; 106:1632-1639. [PMID: 31593294 PMCID: PMC6856822 DOI: 10.1002/bjs.11320] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/10/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Marking the axilla with radioactive iodine seed and sentinel lymph node (SLN) biopsy have been proposed for axillary staging after neoadjuvant systemic therapy in clinically node-positive breast cancer. This study evaluated the identification rate and detection of residual disease with combined excision of pretreatment-positive marked lymph nodes (MLNs) together with SLNs. METHODS This was a multicentre retrospective analysis of patients with clinically node-positive breast cancer undergoing neoadjuvant systemic therapy and the combination procedure (with or without axillary lymph node dissection). The identification rate and detection of axillary residual disease were calculated for the combination procedure, and for MLNs and SLNs separately. RESULTS At least one MLN and/or SLN(s) were identified by the combination procedure in 138 of 139 patients (identification rate 99·3 per cent). The identification rate was 92·8 per cent for MLNs alone and 87·8 per cent for SLNs alone. In 88 of 139 patients (63·3 per cent) residual axillary disease was detected by the combination procedure. Residual disease was shown only in the MLN in 20 of 88 patients (23 per cent) and only in the SLN in ten of 88 (11 per cent), whereas both the MLN and SLN contained residual disease in the remainder (58 of 88, 66 per cent). CONCLUSION Excision of the pretreatment-positive MLN together with SLNs after neoadjuvant systemic therapy in patients with clinically node-positive disease resulted in a higher identification rate and improved detection of residual axillary disease.
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Affiliation(s)
- J. M. Simons
- Department of Surgical OncologyErasmus Medical Centre RotterdamRotterdamthe Netherlands
- Department of Surgical OncologyUniversity Medical Centre Utrecht, Utrecht UniversityUtrechtthe Netherlands
| | - M. L. M. A. van Pelt
- Department of Surgical OncologyHaaglanden Medical CentreThe Haguethe Netherlands
| | | | - M. E. Straver
- Department of Surgical OncologyHaaglanden Medical CentreThe Haguethe Netherlands
| | - A. M. Zeillemaker
- Department of Surgical OncologyAlrijne HospitalLeiderdorpthe Netherlands
| | - L. M. Pereira Arias‐Bouda
- Department of Nuclear MedicineAlrijne HospitalLeiderdorpthe Netherlands
- Section of Nuclear Medicine, Department of RadiologyLeiden University Medical CentreLeidenthe Netherlands
| | - T. J. A. van Nijnatten
- Department of Radiology and Nuclear MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - L. B. Koppert
- Department of Surgical OncologyErasmus Medical Centre RotterdamRotterdamthe Netherlands
| | - K. K. Hunt
- Department of Breast Surgical OncologyUniversity of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - M. L. Smidt
- Department of Surgical OncologyMaastricht University Medical Centre+Maastrichtthe Netherlands
- GROW – School for Oncology and Developmental BiologyMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - E. J. T. Luiten
- Department of Surgical OncologyAmphia HospitalBredathe Netherlands
| | - C. C. van der Pol
- Department of Surgical OncologyUniversity Medical Centre Utrecht, Utrecht UniversityUtrechtthe Netherlands
- Department of Surgical OncologyAlrijne HospitalLeiderdorpthe Netherlands
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Woods RW, Camp MS, Durr NJ, Harvey SC. A Review of Options for Localization of Axillary Lymph Nodes in the Treatment of Invasive Breast Cancer. Acad Radiol 2019; 26:805-819. [PMID: 30143401 DOI: 10.1016/j.acra.2018.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 02/09/2023]
Abstract
Invasive breast cancer is a common disease, and the most common initial site of metastatic disease are the axillary lymph nodes. As the standard of care shifts towards less invasive surgery in the axilla for patients with invasive breast cancer, techniques have been developed for axillary node localization that allow targeted dissection of specific lymph nodes without requiring full axillary lymph node dissection. Many of these techniques have been adapted from technologies developed for localization of lesions within the breast and include marker clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive seeds, magnetic seeds, radar reflectors, and radiofrequency identification devices.The purpose of this article is to summarize these methods and describe benefits and drawbacks of each method for performing localization of lymph nodes in the axilla.
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Cornella KN, Palafox BA, Razavi MK, Loh CT, Markle KM, Openshaw LE. SAVI SCOUT as a Novel Localization and Surgical Navigation System for More Accurate Localization and Resection of Pulmonary Nodules. Surg Innov 2019; 26:469-472. [PMID: 31027475 DOI: 10.1177/1553350619843757] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Current techniques for localization and resection of lung nodules carry many intraoperative challenges for surgeons. This article proposes a new localization method for diagnosis and treatment of pulmonary nodules, which provides a navigational system for more accurate lung resection. Methods. We report the case of a 77-year-old female with a pulmonary nodule of the right lower lobe. A nonradioactive localization technology, known as SAVI SCOUT (Cianna Medical Inc, Aliso Viejo, CA), was placed by interventional radiology under computed tomography guidance preoperatively. Using the SCOUT Wire-Free Radar Localization System, the pulmonary nodule was robotically localized and resected. SCOUT removal was confirmed using the Trident Specimen Radiology System. The efficacy of this procedure was evaluated in terms of ease of use and procedure time by interventional radiology, surgical resection accuracy, diagnostic accuracy, simplicity, and ease to implement this technology in an existing hospital. Results. The SCOUT system allowed for the first reported case of successful SCOUT placement in lung tissue, targeted the pulmonary nodule intraoperatively, and facilitated accurate lung resection. Conclusions. The SCOUT system shows promising advancements in the ability to eliminate many challenges currently seen with lung nodule localization and resection.
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