“Axillary recurrences after sentinel lymph node biopsy: A multicentre analysis and follow-up of sentinel lymph node negative breast cancer patients”

Axillary lymph node recurrence in patients with breast cancer who underwent breast reconstruction using a latissimus dorsi flap after mastectomy

At our institution (Tokyo Medical and Dental University, Medical Hospital), latissimus dorsi flap (LD flap) reconstruction without a prosthetic implant is a popular surgical strategy following total mastectomy in patients with breast cancer. The LD flap, especially the extended LD flap, is usually rotated anteriorly through the axilla. However, if future additional surgery is required for axillary recurrence after LD flap reconstruction, the flap interferes with the visual field, making the surgical procedure more difficult. Because cases of axillary lymph node recurrence alone are rare, to the best of our knowledge, no paper has reported in detail on the technique and course of lymph node recurrence after LD flap reconstruction. The present study describes two cases of successful axillary lymph node dissection without sacrificing the flap for breast cancer recurrence after LD flap reconstruction. A brief analysis of immediate breast reconstruction with an LD flap performed in patients with breast cancer at our institution is also reported.

Locoregional relapse is a strong prognostic indicator of distant metastatic progression in breast cancer patients after negative sentinel lymph node biopsy

PURPOSE

Sentinel lymph node biopsy is routinely used in breast cancer patients with clinically negative axillary lymph nodes. Locoregional relapses after negative sentinel lymph node biopsy are infrequent, occurring in up to 3% of patients.

METHODS

Six thousand and eight patients underwent breast cancer surgery in our center between 2006 and 2015. We analyzed 1466 patients with negative sentinel lymph node biopsy and no prior systemic treatment. Mastectomy without irradiation was used in 25.4% of these patients and breast-conserving surgery with adjuvant radiotherapy in 74.6%. Forty-seven (3.21%) locoregional relapses were identified within a median of 51 months (10-138 months). The molecular type was analyzed as a risk factor for locoregional relapses and distant metastases. The locoregional relapse location was then analyzed as a risk factor for distant metastases.

RESULTS

Triple-negative breast cancer (P = .003), age <40 year (P = .007), multifocality (P = .011), and mastectomy (P < .0001) were risk factors for locoregional relapses. Patients who developed locoregional relapses more frequently developed distant metastases (P < .0001). The distribution of molecular types did not differ significantly in patients with locoregional relapses and distant metastases, concentrating in triple-negative and Luminal B tumor cases with distant metastases in almost 58% of cases, while not occurring in Luminal A patients. The locoregional-to-distant metastasis interval was shorter in cases of chest wall and lymph nodes relapse compared with breast-only relapse locations(P = .028).

CONCLUSION

Molecular type, especially triple-negative, young age, mastectomy without adjuvant irradiation, and multifocality are risk factors for locoregional relapse in sentinel lymph node biopsy negative breast cancer patients. Locoregional relapse is an important risk factor for developing distant metastasis, except in Luminal A breast cancer patients and those who suffer from breast-only relapse.

Quantifying the Mitigating Effects of Whole-Breast Radiotherapy and Systemic Treatments on Regional Recurrence Incidence Among Breast Cancer Patients

Background

Despite the potential for residual lymph node metastases after a negative or positive sentinel lymph node biopsy (SLNB), breast cancer patients rarely experience regional recurrences (RRs). This study aimed to quantify the effects of nonsurgical treatments on RR incidence among SLNB-negative (SLNB N0) breast cancer patients.

Methods

All primary SLNB N0-staged breast cancer patients with a diagnosis between 2005 and 2008 and 5-year follow-up data on recurrences were selected from the Netherlands Cancer Registry. The cumulative incidence function (CIF) for RR was calculated as the first event at 5 years, taking into account any other first-event (local or distant recurrence, contralateral breast cancer, or death) as competing risk. Cox regression analysis was used to model the cause-specific hazard of RR developing as the first event to quantify the effect of adjuvant systemic therapy and whole-breast radiotherapy (RT) on RR incidence at 5 years.

Results

The study included 13,512 patients. Of these patients, 162 experienced an RR. The CIF of RR at 5 years was 1.3% (95% confidence interval [CI], 1.1–1.5%), whereas the CIFs for death and other events were 4.4% and 9.5%, respectively. Cox regression analysis showed hazard ratios (HRs) of 0.46 (95% CI 0.33–0.64), 0.31 (95% CI 0.18–0.55), and 0.40 (95% CI 0.24–0.67) respectively for patients treated by RT as a routine part of breast-conserving therapy (BCT), chemotherapy, and hormonal therapy.

Conclusion

RT as routine part of BCT, chemotherapy, and hormonal therapy independently exerted a mitigating effect on the risk for the development of RR. The three methods at least halved the risk.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08356-2) contains supplementary material, which is available to authorized users.

Predicting the extent of nodal involvement for node positive breast cancer patients: Development and validation of a novel tool

Background

This study aimed to develop an easy to use prediction model to predict the risk of having a total of 1 to 2, ≥3, or ≥4 positive axillary lymph nodes (LNs), for patients with sentinel lymph node (SLN) positive breast cancer.

Methods

Data of 911 SLN positive breast cancer patients were used for model development. The model was validated externally in an independent population of 180 patients with SLN positive breast cancer.

Results

Final pathology after ALND showed additional positive LN for 259 (28%) of the patients. A total of 726 (81%) out of 911 patients had a total of 1 to 2 positive nodes, whereas 175 (19%) had ≥3 positive LNs. The model included three predictors: the tumor size (in mm), the presence of a negative SLN, and the size of the SLN metastases (in mm). At external validation, the model showed a good discriminative ability (area under the curve = 0.82; 95% confidence interval = 0.74‐0.90) and good calibration over the full range of predicted probabilities.

Conclusion

This new and validated model predicts the extent of nodal involvement in node‐positive breast cancer and will be useful for counseling patients regarding their personalized axillary treatment.

Regional Recurrence Risk Following a Negative Sentinel Node Procedure Does Not Approximate the False-Negative Rate of the Sentinel Node Procedure in Breast Cancer Patients Not Receiving Radiotherapy or Systemic Treatment

BACKGROUND

Although the false-negative rate of the sentinel lymph node biopsy (SLNB) in breast cancer patients is 5-7%, reported regional recurrence (RR) rates after negative SLNB are much lower. Adjuvant treatment modalities probably contribute to this discrepancy. This study assessed the 5-year RR risk after a negative SLNB in the subset of patients who underwent breast amputation without radiotherapy or any adjuvant treatment.

METHODS

All patients operated for primary unilateral invasive breast cancer between 2005 and 2008 were identified in the Netherlands Cancer Registry. Patients with a negative SLNB who underwent breast amputation and who were not treated with axillary lymph node dissection, radiotherapy, or any adjuvant systemic treatment were selected. The cumulative 5-year RR rate was estimated by Kaplan-Meier analysis.

RESULTS

A total of 13,452 patients were surgically treated for primary breast cancer and had a negative SLNB, and 2012 patients fulfilled the selection criteria. Thirty-eight RRs occurred during follow-up. Multifocal disease was associated with a higher risk of developing RR (P = 0.04). The median time to RR was 27 months and was significantly shorter in patients with estrogen receptor-negative (ER-) breast cancer (9.5 months; P = 0.003). The 5-year RR rate was 2.4% in the study population compared with 1.1% in the remainder of 11,440 SLNB-negative patients (P = 0.0002).

CONCLUSIONS

Excluding the effect of radiotherapy and systemic treatment resulted in a twofold 5-year RR risk in breast cancer patients with a tumor-free SLNB. This 5-year RR rate was still much lower than the reported false-negative rate of the SLNB procedure.

Critical review of axillary recurrence in early breast cancer

Around 2% of early breast cancer cases treated with axillary lymph node dissection (ALND) underwent axillary recurrence (AR) and it has a deleterious effect in prognosis. Different scenarios have incorporated Sentinel Lymph Node (SLN) Biopsy (SLNB) instead of ALND as part of the standard treatment and more effective systemic treatment has also been incorporated in routine management after first curative surgery and after regional recurrence. However, there is concern about the effect of SLNB alone over AR risk and how to predict and treat AR. SLN biopsy (SLNB) has been largely accepted as a valid option for SLN-negative cases, and recent prospective studies have demonstrated that it is also safe for some SLN-positive cases and both scenarios carry low AR rates. Different studies have identified clinicopathological factors related to aggressiveness as well as high-risk molecular signatures can predict the development of locoregional recurrence. Other publications have evaluated factors affecting prognosis after AR and find that time between initial treatment and AR as well as tumor aggressive behavior influence patient survival. Retrospective and prospective studies indicate that treatment of AR should include local and systemic treatment for a limited time.

Risk of Regional Recurrence After Negative Repeat Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence

Background

Repeat sentinel lymph node biopsy (rSLNB) has increasingly been used in patients with ipsilateral breast tumor recurrence (IBTR). The safety in terms of regional disease control after this procedure remains unclear. This study evaluates occurrence of regional recurrence as first event in patients with IBTR and negative rSLNB, treated without additional lymph node dissection.

Patients and Methods

Data were obtained from the Sentinel Node and Recurrent Breast Cancer (SNARB) study. In 201 patients, tumor-negative rSLNB was obtained without performing additional lymph node dissections.

Results

With median follow-up of 4.7 (range 0.9–12.7) years, regional recurrence occurred after median time of 3.0 (range 0.4–6.7) years in 4.5% (N = 9) of patients as first event after IBTR and rSLNB. In four of these nine patients, the site of recurrence was in concordance with the anatomical location of rSLNB. Two of the nine recurrences were reported in the ipsilateral axilla, resulting in an ipsilateral axillary regional recurrence rate of 1.0%. In the other seven patients, regional recurrence occurred in aberrant basins. Univariable analysis showed that triple-negative IBTR and lower amount of radioactive-labeled tracer (^99mtechnetium) used during rSLNB were associated with developing regional recurrence as first event after negative rSLNB (P < 0.05).

Conclusions

The risk of developing regional recurrence after negative rSLNB is low. The low relapse rate supports the safety of rSLNB as primary nodal staging tool in IBTR. The time has come for clinical guidelines to adopt rSLNB as axillary staging tool in patients with IBTR.

Electronic supplementary material

The online version of this article (10.1245/s10434-018-6384-y) contains supplementary material, which is available to authorized users.

Superparamagnetic iron oxide nanoparticles as the sole method for sentinel node biopsy detection in patients with breast cancer

BACKGROUND

Sentinel node biopsy (SNB) using superparamagnetic iron oxide (SPIO) nanoparticles is a novel method in breast cancer. Several studies have verified the non-inferiority of SPIO compared with the standard use of radioisotope ^99m Tc with or without blue dye. The aim of the MONOS study presented here was to evaluate the use of SPIO as a sole tracer and the efficacy of tracer injection in the preoperative setting.

METHODS

This prospective cohort study was carried out in two hospitals, one using ^99m Tc and the other SPIO. ^99m Tc was injected in the morning of the day of surgery or the day before. SPIO was either injected before surgery in the outpatient clinic or 1 h before the operation.

RESULTS

A total of 338 consecutive patients with breast cancer underwent 343 procedures; SPIO nanoparticles were used in 184 procedures and ^99m Tc-labelled tracer in 159. Detection rates for SPIO and ^99m Tc were 95·6 and 96·9 per cent respectively (P = 0·537). All nodes with SPIO uptake were coloured brown. Fewer nodes were retrieved with SPIO (mean 1·35 versus 1·89), regardless of whether blue dye was used (P < 0·001). Preoperative SPIO injection (58·7 per cent of procedures), a median of 16 (range 2-27) days before the procedure, was associated with a better tracer-specific detection rate (95·3 versus 86 per cent; P = 0·031) and retrieval of more nodes (mean 1·43 versus 1·03; P < 0·001) than perioperative administration. Skin staining was present in 39·9 per cent of patients, and was related to breast-conserving surgery and periareolar injection.

CONCLUSION

The use of SPIO alone is a safe alternative, with results comparable to those of the standard dual technique using ^99m Tc and blue dye. The efficacy of injection in the preoperative setting simplifies logistics and improves performance. Skin staining can be prevented by a deeper peritumoral injection.

Factors Associated With Disease Recurrence in Breast Cancer Patients With Negative Sentinel Lymph Node Biopsy

INTRODUCTION

The objective of our study was to assess recurrence after negative sentinel lymph node biopsy (SLNB) and to determine the risk factors related to local and distant recurrence in this group of patients.

MATERIALS AND METHODS

We conducted a prospective observational study from 2006 to 2011. It included 607 patients with early-stage breast cancer and negative SLNB with a 5-year follow-up period.

RESULTS

The disease-free survival rate was 98.5% and 96.5% at 2 and 5 years, respectively. Multivariate analysis identified the following prognostic factors for disease recurrence: tumor necrosis (hazard ratio [HR], 4.89; 95% confidence interval [CI], 1.61-14.89; P = .005), lymphovascular invasion (HR, 3.46; 95% CI, 1.14-10.55; P = .029), T2 tumor size (HR, 4.35; 95% CI, 1.40-13.52; P = .011), and moderate to severe lymphoplasmacytic stromal infiltration (HR, 3.06; 95% CI, 1.18-7.96; P = .022).

CONCLUSION

Recurrence in patients with negative SLNB was satisfactorily low. Nevertheless, determining the prognostic factors related to a greater recurrence rate could help identify high-risk patients and influence systemic adjuvant therapy.

Survival impact and predictive factors of axillary recurrence after sentinel biopsy

BACKGROUND

The rate of axillary recurrence (AR) after sentinel lymph node biopsy is usually low but few studies investigated its impact on survival. Our aim was to determine the rate and predictive factors of AR in a large cohort of breast cancer patients and its impact on survival.

PATIENTS AND METHODS

From 1999 to 2013, 14,095 patients who underwent surgery for clinically N0 previously untreated breast cancer and had sentinel lymph node biopsy were analysed. A simplified score predictive of AR was established.

RESULTS

Median follow-up was 55.2 months. AR was observed in 0.51% of cases, with a median time to onset of 43.4 months. In multivariate analysis, the occurrence of AR was significantly correlated with grade 2 or 3 disease, absence of radiotherapy and tumour subtype (hormonal receptor [HR]- / human estrogen receptor [HER]+). AR rates were 1% for triple-negative tumours, 2.8% for HER2-positive tumours, 0.4% for luminal A tumours, 0.9% for HER2-negative luminal B tumours, and 0.5% for HER2-positive luminal B tumours. A simplified score predictive of the occurrence of AR was established. Patients could be divided into three different score groups (p < 0.0001). In multivariate analysis, overall survival was significantly lower in cases of AR (p < 0.0001), age >50, lymphovascular invasion, grade 3 disease, sentinel node (SN) macrometastases, tumour size >20 mm, absence of chemotherapy and triple-negative phenotype. Survival in patients with AR was significantly lower in case of early-onset (2 years) AR (p = 0.017).

CONCLUSIONS

Isolated AR is more common in Her2-positive/HR-negative triple-negative tumours with a more severe prognosis in triple-negative and Her2-positive/HR-negative tumours, and represents an independent adverse factor justifying an indication for systemic treatment for AR treatment. However, the benefit of any systemic treatment remains to be proven.

Sentinel lymph node biopsy and axillary dissection in breast cancer: results in a Latina population

Aim: we aim to evaluate accuracy of sentinel node (SN) in biopsy breast cancer (BC). Patients & methods: We reviewed 1259 early cases who underwent SN biopsy between 1996 and 2010. Results: Median age was 52 years; and 48.9, 39.7, 68.4 and 12.1% had T2, HG-III, ER+ and HER2+++, respectively. Median SN was two nodes, 34.3% had SN+ and 41.6% went to axillary dissection (AD). SN-positive is associated with AD-positive nodes (p < 0.001). Number of SN-positive were related to number of AD-positive nodes (p < 0.001). Factors predicting AD-positive nodes in the SN-positive group were lymphovascular invasion (p = 0.016) and HG III (p = 0.041). Axillary recurrence was similar in those with or without AD nodes (0.0136 vs 0.0153, p = 0.8023). Conclusion: The SN predicts AD involvement and offers a low rate of axillary recurrence in our Latina population.

A head to head comparison of nine tools predicting non-sentinel lymph node status in sentinel node positive breast cancer women

BACKGROUND AND OBJECTIVES

This study was conducted to evaluate the performance of available tools predicting non-sentinel lymph node (non-SLN) status in women with SLN positive breast cancer and to see if they can be safely used in everyday clinical practice.

METHODS

Data of 220 women with breast cancer who underwent a SLN biopsy at the Máxima Medical Centre between 2000-2008 were analysed. Tools evaluated were: the models from Memorial Sloan Kettering Cancer Centre, Stanford, Mayo, Cambridge, Gur, and MOU, and the scores from Saidi, Tenon, and MDA. Model performance was assessed using calibration, discrimination and Nagelkerke's explained variation.

RESULTS

The MSKCC nomogram showed best overall performance with best discrimination (AUC 0.69), second best calibration, and highest explained variation (31%). The 10% low risk threshold led to defining only 22% (38/176) of the women as being low risk while in fact 66% (116/176) were non-SLN negative. The false negative rate was 13% (5/38).

CONCLUSIONS

Current models for predicting non-SLN metastases in SLN positive breast cancer are not yet ready for implementation in general practice. Further research efforts should improve model performance in selecting patients or perhaps find a role in support in the paradigm shift to a "treat none unless" approach.

Breast Cancer Patients Undergoing Sentinel Node Biopsy: Additional Axillary Tumor Burden as a Function of the Total Number of Excised Sentinel Nodes-A Multicenter Study

BACKGROUND

Recent studies have challenged the long-standing assumption that breast cancer prognosis is determined by lymph node regional status. We assessed locoregional relapse, distant metastases, and mortality alongside additional axillary disease in breast cancer patients undergoing sentinel node (SN) biopsy.

PATIENTS AND METHODS

This prospective study assessed 1070 women with clinical T1-T2 invasive breast cancer with negative clinical/ultrasound axillae.

RESULTS

A total of 25.1% of patients had positive SN biopsy findings, of whom 69.2% had only 1 involved SN. The rate of axillary recurrence was 0.7%, with no significant differences found between patients with positive or negative SN (0.6% vs. 1.1%). There were also no significant differences in the rate of distant metastases or breast cancer-specific mortality. If we had applied the Z0011 trial suggestions, residual axillary disease would have reached 16.2%: 13.5% in patients over 50% and 21.3% in patients under 50. The rate of residual axillary disease would have been 25.2% in patients with only 1 SN (20.2% in patients over 50% and 38.2% in patients under 50). In patients with 2 SN, residual disease would have ranged from 12.0% in patients over 50% to 19.0% in patients under 50. From 3 SN on, residual disease seems negligible.

CONCLUSION

There were no significant differences in locoregional relapse, distant metastases, or mortality between patients with negative and positive SN. Patients with 3 or more SN have no additional axillary disease. In patients younger 50, one must be extremely cautious if the Z0011 suggestions are to be applied, especially if there is only 1 SN.

Role of SPECT/CT in sentinel lymph node detection in patients with breast cancer

AIM

The purpose of this study was to conduct a systematic review of the published literature to assess the role (indications, advantages, and limitations) of SPECT/CT for the detection of sentinel lymph node (SLN) in breast cancer.

METHODS

The authors searched PubMed for published literature in English addressing this topic.

RESULTS

Eleven studies, published since 2006, focused on the role and value of SPECT/CT for SLN detection (SLND). They showed that SPECT/CT improved sentinel node detection and anatomical localization. One study suggested that SPECT/CT may provide a more accurate staging. Limitations for SLND with SPECT/CT include extra time and inconvenience for the patient and additional radiation dose.

CONCLUSIONS

SPECT/CT is a valuable tool for SLND, especially in difficult cases, when planar lymphoscintigraphy shows no SLN or unexpected lymphatic drainage.

Lessons learned in breast cancer surgery

Changes in a professional life time

Outcome of sentinel lymph node biopsy in breast cancer using dye alone: a single center review with a median follow-up of 5 years

PURPOSE

Various techniques are used for sentinel lymph node biopsy (SLNB) in breast cancer. While subareolar injection with dye alone is a relatively easy method, few studies have reported the outcome with a follow-up period. This study presents our results of SLNB using dye alone.

METHODS

Between November 2002 and December 2010, 701 patients with breast cancer underwent SLNB using subareolar injection of indocyanine green or indigo carmine. Sentinel lymph node (SLN)-negative patients were followed without axillary lymph node dissection (ALND).

RESULTS

SLNs were detected in 654 of 701 patients (93.3%), and the rate increased to 98.1% over the course of the study. The mean number of SLNs removed was 1.5. There was no significant difference in the detection rate between two dyes. No adverse events resulted from the injection of dyes. Of the 654 patients, 136 (20.8%) had SLN metastasis. Five hundred patients were followed without ALND. Thirty-six patients experienced disease relapse during a median follow-up of 60 months. Thirteen patients (2.6%) had regional lymph node relapse, and eight of them could undergo salvage lymph node dissection. The 5-year disease-free and overall survival rates were 92.4 and 96.1 %, respectively.

CONCLUSION

SLNB using subareolar injection with dye alone was safe and feasible even after a long follow-up.