Uncertainties and controversies in axillary management of patients with breast cancer

Rare Breast Cancers Review

BACKGROUND/OBJECTIVES

Breast cancer is one of the most common malignancies in women, with rare subtypes presenting unique clinical challenges. This review provides a comprehensive analysis of rare breast cancers, including both epithelial and non-epithelial subtypes, and explores their epidemiology, pathology, prognosis, and treatment approaches.

METHODS

A systematic review was conducted focusing on recent advancements in the treatment of rare breast cancer subtypes. Articles were selected based on criteria emphasizing studies from the past five years, with older foundational studies included where necessary. The analysis incorporated molecular profiling, clinical trials, and advancements in targeted and immunotherapies, where possible.

RESULTS

Rare epithelial subtypes, such as tubular, mucinous, and medullary carcinomas, demonstrate distinct clinical and pathological features, with generally favorable prognoses compared to invasive ductal carcinoma (IDC). Non-epithelial cancers, including sarcomas and primary breast lymphomas, require individualized treatment due to aggressive behavior and poor prognosis in certain cases. Recent advancements in targeted therapies (e.g., HER2 inhibitors, PI3K inhibitors, and PARP inhibitors) and immunotherapies (e.g., PD-1 inhibitors) have shown promise in improving outcomes for specific molecularly characterized subtypes.

CONCLUSIONS

While the management of common breast cancers has become increasingly sophisticated, rare subtypes continue to pose challenges due to limited research and small patient populations. Advances in molecular profiling and next-generation sequencing are pivotal in identifying actionable mutations and expanding personalized treatment options. Future research should focus on clinical trials and collaborative efforts to refine treatment strategies and improve outcomes for these rare subtypes.

Association of Breast Cancer Subtypes and Clinicopathological Factors with Axillary Lymph Node Positivity Amongst Women with Breast Cancer in Rajasthan: An Observational Analytical Study

Prognostic factors by definition, are capable of providing information on clinical outcomes at the time of diagnosis, independent of therapy. The number of positive lymph nodes (number of ipsilateral axillary nodes with metastatic tumour deposits) is a strong and independent prognostic factor in breast cancer. In a meta-analysis (New England Journal of Medicine, 2017) of over 62,000 patients, the risk of distant recurrence over years 5 to 20 for those with T1 tumours was 13% in the absence of lymph node involvement, 20% among those with one to three involved lymph nodes, and 34% among those with four to nine involved nodes. In this study, we analyzed the association of clinicopathological factors and breast cancer subtypes with axillary lymph node (ALN) positivity in women with breast cancer in Rajasthan. A multivariate Logistic (Ordinal) Regression Model was used to predict the number of positive lymph nodes based on independent variables that showed 90% significance in bivariate analysis, such as total number of lymph nodes dissected, tumour necrosis, and lymphovascular invasion. The Wald criterion indicated that only LVI had a significant impact on the prediction (p < 0.05), while tumour necrosis and the total number of lymph nodes dissected were not significant predictors (p > 0.05). Patients with LVI had a 43.47 times higher risk of having positive lymph nodes (p < 0.05). Early prediction of lymph node metastasis through LVI testing can help in prognostication. Breast cancer subtypes should not be a criterion while deciding lymph nodal management.

Identification of sentinel lymph node macrometastasis in breast cancer by deep learning based on clinicopathological characteristics

The axillary lymph node status remains an important prognostic factor in breast cancer, and nodal staging using sentinel lymph node biopsy (SLNB) is routine. Randomized clinical trials provide evidence supporting de-escalation of axillary surgery and omission of SLNB in patients at low risk. However, identifying sentinel lymph node macrometastases (macro-SLNMs) is crucial for planning treatment tailored to the individual patient. This study is the first to explore the capacity of deep learning (DL) models to identify macro-SLNMs based on preoperative clinicopathological characteristics. We trained and validated five multivariable models using a population-based cohort of 18,185 patients. DL models outperform logistic regression, with Transformer showing the strongest results, under the constraint that the sensitivity is no less than 90%, reflecting the sensitivity of SLNB. This highlights the feasibility of noninvasive macro-SLNM prediction using DL. Feature importance analysis revealed that patients with similar characteristics exhibited different nodal status predictions, indicating the need for additional predictors for further improvement.

Intraoperative diagnosis of breast cancer metastasis in axillary lymph nodes: Cytological Smear vs. Frozen Section

BACKGROUND

Intraoperative evaluation of axillary lymph nodes is sometimes required to determine the extent of surgery. In this study, we wished to assess the reliability of cytologic smear (CS) in determining lymph node involvement with tumor. Theoretically, CS provides more substance for examination than touch-imprint cytology and is faster to perform than frozen section (FS). We hypothesized that CS sensitivity for tumor cell detection in the lymph nodes would be similar to FS, at least 0.90.

METHODS

This was a retrospective observational study at the Rambam Health Care Campus (January, 2013-June, 2020). Lymph nodes underwent intraoperative evaluation using either CS or FS, based on the availability of a cytologist at the time of the examination. Both intraoperative evaluations were compared to the final pathology following fixation with formalin.

RESULTS

Eighty-eight patients undergoing intraoperative analysis were analyzed (51 CS, 37 FS). False-negative tests were recorded in only 1 patient evaluated by each of the 2 methods. This resulted in sensitivity 0.91 (95%CI 0.59, 1.00) for CS and 0.88 (95%CI 0.47, 1.00) for FS, specificity 1.00 (95%CI 0.91, 1.00) for CS and 1.00 (95%CI 0.88, 1.00) for FS, positive predictive value 1.00 (95%CI 0.69, 1.00) for CS and 1.00 (95%CI 0.59, 1.00) for FS, and negative predictive value 0.98 (95%CI 0.87, 1.00) for CS and 0.97 (95%CI 0.83, 1.00) for FS.

CONCLUSIONS

The sensitivity of the CS in this study is comparable to that of FS and due to shorter analysis time required is the preferred method at our institution.

De-Escalation of Axillary Surgery in Clinically Node-Positive Breast Cancer Patients Treated with Neoadjuvant Therapy: Comparative Long-Term Outcomes of Sentinel Lymph Node Biopsy versus Axillary Lymph Node Dissection

BACKGROUNDS

This study compares the long-term outcomes of axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB) in clinically node-positive (cN+) breast cancer (BC) patients treated with neoadjuvant therapy (NAT).

METHODS

We conducted a retrospective analysis of 322 cN+ BC patients who became clinically node-negative (ycN0) post-NAT. Patients were categorized based on the final type of axillary surgery performed: ALND or SLNB. Recurrence-free survival (RFS), distant disease-free survival (DDFS), overall survival (OS), and breast cancer-specific survival (BCSS) were evaluated and compared between the two groups.

RESULTS

Patients in the SLNB group had significantly better 3-, 5-, and 10-year RFS, DDFS, OS, and BCSS compared to those in the ALND group. The SLNB group also had a higher proportion of patients achieving pathologic complete response (pCR). Multivariate analysis identified pCR, ypN0 status, and SLNB as favorable prognostic factors for all survival metrics. Axillary recurrence rates were low for both groups (0.6-2.1%).

CONCLUSIONS

SLNB may be a safe and effective alternative to ALND for selected cN+ BC patients who convert to ycN0 after NAT. These findings suggest that careful patient selection is crucial, and further research is needed to validate these results in more comparable populations.

Understanding Patient Experiences to Inform Future Studies to Optimize Personalization of Treatment for Early Breast Cancer

BACKGROUND

Breast cancer treatment is multimodal, but not all patients benefit from each treatment, and many experience morbidities significantly impacting quality of life. There is increasing interest in tailoring breast cancer treatments to optimize oncological outcomes and reduce treatment burden, but it is vital that future trials focus on treatments that most impact patients. This study was designed to explore patient experiences of treatment to inform future research.

METHODS

An online survey was co-developed with patient advocates to explore respondents' experiences of breast cancer treatment. Questions included simple demographics, treatments received, and views regarding omitting treatments if that is deemed safe. The survey was circulated via social media and patient advocacy groups. Responses were summarized by using simple statistics; free text was analyzed thematically.

RESULTS

Of the 235 participants completing the survey, 194 (82.6%) would choose to omit a specific treatment if safe to do so. The most commonly selected treatments were chemotherapy (n = 69, 35.6%) and endocrine therapy (n = 61, 31.4%) mainly due to side effects. Fewer respondents would choose to omit surgery (n = 40, 20.6%) or radiotherapy (n = 20, 10.3%). Several women commented that survival was their "absolute priority" and that high-quality evidence to support the safety of reducing treatment would be essential.

CONCLUSIONS

Patients with breast cancer are individuals who may wish to optimize different components of their treatment. A portfolio of studies co-designed with patients is needed to establish an evidence base for greater treatment personalization with studies focused on reducing avoidable chemotherapy and endocrine therapy a priority.

Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network

PURPOSE

Data from recently trials have provided practice-changing recommendations in management of the axilla in early breast cancer (eBC). However, further controversies have been raised, resulting in heterogeneous diffusion of these recommendations. Our purpose was to obtain a better homogeneity.

MATERIAL AND METHODS

In 2021, the Tuscan Breast Network (TBN) established a consensus with the aim to update recommendations in this area. We performed a literature review on axillary management in eBC patients which led to an expert Delphi consensus aiming to explore the gray areas, build consensus and propose evidence-based suggestions for an appropriate management. Thereafter, we investigate their implementation in clinical practice.

RESULTS

(1) DCIS patients should have SLN biopsy only in case of mastectomy or in conservative surgery if tumor is in a location that would preclude future nodal sampling or in case of a mass; (2) ALND may be omitted for 1-2 positive SLN patients undergoing BCS in T1-2 tumors with 1-2 SLN positive, eligible for whole-breast irradiation and adjuvant systemic therapies; (3) consider the option of RNI in patients with 1-3 positive lymph nodes and one or more high-risk characteristics; (4) the population identified in 2) should NOT undergo lymph node irradiation as an alternative to axillary surgery and (5) patients with clinically (pre-operatively) positive axilla, or undergoing primary systemic therapy, or outside the criteria reported in 2) must receive additional ALND and/or RT as per local policy.

CONCLUSION

This consensus provided a practical tool to stimulate local and national breast surgical and radiotherapy protocols.

The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus

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.