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Kustić D. Size of Extranodal Extension in the Sentinel Lymph Node as a Predictor of Prognosis in Early-Stage Breast Cancer. Clin Breast Cancer 2024; 24:e560-e570. [PMID: 38871577 DOI: 10.1016/j.clbc.2024.05.005] [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: 03/07/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION The presence of extranodal extension (ENE) in sentinel lymph nodes (SLNs) can predict non-SLN metastases in breast cancer (BC) patients; however, the prognostic relevance of its extent remains controversial. The purpose of this study was to examine the predictive role of ENE in SLNs measured by its widest dimension (WD), highest dimension (HD), and the WD/HD ratio for non-SLN involvement, overall, and disease-free survival (OS, DFS) in cT1-2N0 BC patients with positive SLNs. MATERIALS AND METHODS A total of 511 women with cT1-2N0 BC and positive SLNs undergoing axillary lymph node dissection were retrospectively enrolled. The associations of ENE's WD, HD, and WD/HD ratio with non-SLN metastases, 5-year OS, and DFS were established through a multivariable modeling approach. RESULTS SLNs were ENE-positive in 149 (29.16%) participants, and 133 (26.03%) had non-SLN metastases. During the median 60 (16-60)-month follow-up, 69 (13.50%) patients experienced recurrences, and 62 (12.13%) died. The numbers of SLNs, non-SLNs, and total axillary LNs involved differed between the ENE-negative and ENE-positive groups, as well as between the WD/HD ≤ 1.2 and WD/HD > 1.2 subgroups (all P-values were < .001). Multivariable analyses showed significant associations of the WD/HD ratio > 1.2 with non-SLN involvement, OS, and DFS (P-values were .003, < .001, and .005, respectively). DISCUSSION Despite no predictive value of ENE's WD and HD, the WD/HD ratio > 1.2 was an independent predictor of non-SLN involvement, mortality, and recurrence. ENE's WD/HD ratio could be a valuable indicator for cT1-2N0 BC individuals with positive SLNs for whom further axillary treatment may be beneficial.
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Affiliation(s)
- Domagoj Kustić
- Department of Nuclear Medicine, Clinical Hospital Center Rijeka, Rijeka, Croatia.
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Newman LA. Importance of Cooperation Between Cooperative Group Clinical Trialists. JAMA Surg 2024:2824193. [PMID: 39320930 DOI: 10.1001/jamasurg.2024.3926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Affiliation(s)
- Lisa A Newman
- Department of Surgery, Weill Cornell Medicine, New York, New York
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Skarping I, Bendahl PO, Szulkin R, Alkner S, Andersson Y, Bergkvist L, Christiansen P, Filtenborg Tvedskov T, Frisell J, Gentilini OD, Kontos M, Kühn T, Lundstedt D, Vrou Offersen B, Olofsson Bagge R, Reimer T, Sund M, Rydén L, de Boniface J. Prediction of High Nodal Burden in Patients With Sentinel Node-Positive Luminal ERBB2-Negative Breast Cancer. JAMA Surg 2024:2824187. [PMID: 39320882 PMCID: PMC11425194 DOI: 10.1001/jamasurg.2024.3944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
Importance In patients with clinically node-negative (cN0) breast cancer and 1 or 2 sentinel lymph node (SLN) macrometastases, omitting completion axillary lymph node dissection (CALND) is standard. High nodal burden (≥4 axillary nodal metastases) is an indication for intensified treatment in luminal breast cancer; hence, abstaining from CALND may result in undertreatment. Objective To develop a prediction model for high nodal burden in luminal ERBB2-negative breast cancer (all histologic types and lobular breast cancer separately) without CALND. Design, Setting, and Participants The prospective Sentinel Node Biopsy in Breast Cancer: Omission of Axillary Clearance After Macrometastases (SENOMAC) trial randomized patients 1:1 to CALND or its omission from January 2015 to December 2021 among adult patients with cN0 T1-T3 breast cancer and 1 or 2 SLN macrometastases across 5 European countries. The cohort was randomly split into training (80%) and test (20%) sets, with equal proportions of high nodal burden. Prediction models were developed by multivariable logistic regression in the complete luminal ERBB2-negative cohort and a lobular breast cancer subgroup. Nomograms were constructed. The present diagnostic/prognostic study presents the results of a prespecified secondary analysis of the SENOMAC trial. Herein, only patients with luminal ERBB2-negative tumors assigned to CALND were selected. Data analysis for this article took place from June 2023 to April 2024. Exposure Predictors of high nodal burden. Main Outcomes and Measures High nodal burden was defined as ≥4 axillary nodal metastases. The luminal prediction model was evaluated regarding discrimination and calibration. Results Of 1010 patients (median [range] age, 61 [34-90] years; 1006 [99.6%] female and 4 [0.4%] male), 138 (13.7%) had a high nodal burden and 212 (21.0%) had lobular breast cancer. The model in the training set (n = 804) included number of SLN macrometastases, presence of SLN micrometastases, SLN ratio, presence of SLN extracapsular extension, and tumor size (not included in lobular subgroup). Upon validation in the test set (n = 201), the area under the receiver operating characteristic curve (AUC) was 0.74 (95% CI, 0.62-0.85) and the calibration was satisfactory. At a sensitivity threshold of ≥80%, all but 5 low-risk patients were correctly classified corresponding to a negative predictive value of 94%. The prediction model for the lobular subgroup reached an AUC of 0.74 (95% CI, 0.66-0.83). Conclusions and Relevance The predictive models and nomograms may facilitate systemic treatment decisions without exposing patients to the risk of arm morbidity due to CALND. External validation is needed. Trial Registration ClinicalTrials.gov Identifier: NCT02240472.
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Affiliation(s)
- Ida Skarping
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Clinical Physiology and Nuclear Medicine, Skane University Hospital, Lund, Sweden
| | - Pär-Ola Bendahl
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Robert Szulkin
- Cytel Inc, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
| | - Sara Alkner
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Yvette Andersson
- Department of Surgery, Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Västmanland Hospital Västerås, Sweden
| | - Leif Bergkvist
- Centre for Clinical Research Uppsala University, Västmanland Hospital Västerås, Sweden
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hosoital, Denmark
| | - Tove Filtenborg Tvedskov
- Department of Breast Surgery, Gentofte Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Oreste D Gentilini
- Università Vita-Salute San Raffaele, Milano, Italy
- IRCCS Ospedale San Raffaele, Milano, Italy
| | - Michalis Kontos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Thorsten Kühn
- Interdisciplinary Breast Center, University of Ulm, Ulm, Germany
- Breast Center Die Filderklinik, Filderstadt, Germany
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Aarhus University, Faculty of Health, Aarhus, Denmark
| | - Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Malin Sund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Diagnostics and Intervention/Surgery, Umeå University, Umeå, Sweden
| | - Lisa Rydén
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Surgery and Gastroenterology, Skane University Hospital, Lund, Sweden
| | - Jana de Boniface
- Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Xie X, Fang Y, He L, Chen Z, Chen C, Zeng H, Chen B, Huang G, Guo C, Zhang Q, Wu J. Individualized prediction of non-sentinel lymph node metastasis in Chinese breast cancer patients with ≥ 3 positive sentinel lymph nodes based on machine-learning algorithms. BMC Cancer 2024; 24:1090. [PMID: 39223574 PMCID: PMC11370100 DOI: 10.1186/s12885-024-12870-x] [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: 06/09/2024] [Accepted: 08/28/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Axillary lymph node dissection (ALND) is a standard procedure for early-stage breast cancer (BC) patients with three or more positive sentinel lymph nodes (SLNs). However, ALND can lead to significant postoperative complications without always providing additional clinical benefits. This study aims to develop machine-learning (ML) models to predict non-sentinel lymph node (non-SLN) metastasis in Chinese BC patients with three or more positive SLNs, potentially allowing the omission of ALND. METHODS Data from 2217 BC patients who underwent SLN biopsy at Shantou University Medical College were analyzed, with 634 having positive SLNs. Patients were categorized into those with ≤ 2 positive SLNs and those with ≥ 3 positive SLNs. We applied nine ML algorithms to predict non-SLN metastasis. Model performance was evaluated using ROC curves, precision-recall curves, and calibration curves. Decision Curve Analysis (DCA) assessed the clinical utility of the models. RESULTS The RF model showed superior predictive performance, achieving an AUC of 0.987 in the training set and 0.828 in the validation set. Key predictive features included size of positive SLNs, tumor size, number of SLNs, and ER status. In external validation, the RF model achieved an AUC of 0.870, demonstrating robust predictive capabilities. CONCLUSION The developed RF model accurately predicts non-SLN metastasis in BC patients with ≥ 3 positive SLNs, suggesting that ALND might be avoided in selected patients by applying additional axillary radiotherapy. This approach could reduce the incidence of postoperative complications and improve patient quality of life. Further validation in prospective clinical trials is warranted.
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Affiliation(s)
- Xiangli Xie
- The Breast Center, Jieyang People's Hospital, Jieyang, Guangdong, 522000, People's Republic of China
| | - Yutong Fang
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China
| | - Lifang He
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China
| | - Zexiao Chen
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China
| | - Chunfa Chen
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China
| | - Huancheng Zeng
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China
| | - Bingfeng Chen
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China
| | - Guangsheng Huang
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China
| | - Cuiping Guo
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China
| | - Qunchen Zhang
- Department of Breast, Jiangmen Central Hospital, Jiangmen, Guangdong, 529030, People's Republic of China.
| | - Jundong Wu
- The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, 515041, People's Republic of China.
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Li Z, Gao J, Zhou H, Li X, Zheng T, Lin F, Wang X, Chu T, Wang Q, Wang S, Cao K, Liang Y, Zhao F, Xie H, Xu C, Zhang H, Niu Q, Ma H, Mao N. Multiregional dynamic contrast-enhanced MRI-based integrated system for predicting pathological complete response of axillary lymph node to neoadjuvant chemotherapy in breast cancer: multicentre study. EBioMedicine 2024; 107:105311. [PMID: 39191174 PMCID: PMC11400626 DOI: 10.1016/j.ebiom.2024.105311] [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: 04/04/2024] [Revised: 08/11/2024] [Accepted: 08/12/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND The accurate evaluation of axillary lymph node (ALN) response to neoadjuvant chemotherapy (NAC) in breast cancer holds great value. This study aimed to develop an artificial intelligence system utilising multiregional dynamic contrast-enhanced MRI (DCE-MRI) and clinicopathological characteristics to predict axillary pathological complete response (pCR) after NAC in breast cancer. METHODS This study included retrospective and prospective datasets from six medical centres in China between May 2018 and December 2023. A fully automated integrated system based on deep learning (FAIS-DL) was built to perform tumour and ALN segmentation and axillary pCR prediction sequentially. The predictive performance of FAIS-DL was assessed using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. RNA sequencing analysis were conducted on 45 patients to explore the biological basis of FAIS-DL. FINDINGS 1145 patients (mean age, 50 years ±10 [SD]) were evaluated. Among these patients, 506 were in the training and validation sets (axillary pCR rate of 40.3%), 127 in the internal test set (axillary pCR rate of 37.8%), 414 in the pooled external test set (axillary pCR rate of 48.8%), and 98 in the prospective test set (axillary pCR rate of 43.9%). For predicting axillary pCR, FAIS-DL achieved AUCs of 0.95, 0.93, and 0.94 in the internal test set, pooled external test set, and prospective test set, respectively, which were also significantly higher than those of the clinical model and deep learning models based on single-regional DCE-MRI (all P < 0.05, DeLong test). In the pooled external and prospective test sets, the FAIS-DL decreased the unnecessary axillary lymph node dissection rate from 47.9% to 6.8%, and increased the benefit rate from 52.2% to 86.5%. RNA sequencing analysis revealed that high FAIS-DL scores were associated with the upregulation of immune-mediated genes and pathways. INTERPRETATION FAIS-DL has demonstrated satisfactory performance in predicting axillary pCR, which may guide the formulation of personalised treatment regimens for patients with breast cancer in clinical practice. FUNDING This study was supported by the National Natural Science Foundation of China (82371933), National Natural Science Foundation of Shandong Province of China (ZR2021MH120), Mount Taishan Scholars and Young Experts Program (tsqn202211378), Key Projects of China Medicine Education Association (2022KTM030), China Postdoctoral Science Foundation (314730), and Beijing Postdoctoral Research Foundation (2023-zz-012).
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Affiliation(s)
- Ziyin Li
- School of Medical Imaging, Binzhou Medical University, No. 346 Guanhai Road, Yantai, Shandong, 264003, China; Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Jing Gao
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Heng Zhou
- School of Information and Electronic Engineering, Shandong Technology and Business University, Yantai, Shandong, 264005, China
| | - Xianglin Li
- School of Medical Imaging, Binzhou Medical University, No. 346 Guanhai Road, Yantai, Shandong, 264003, China
| | - Tiantian Zheng
- School of Medical Imaging, Binzhou Medical University, No. 346 Guanhai Road, Yantai, Shandong, 264003, China; Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Fan Lin
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Xiaodong Wang
- School of Medical Imaging, Binzhou Medical University, No. 346 Guanhai Road, Yantai, Shandong, 264003, China; Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Tongpeng Chu
- Big Data and Artificial Intelligence Laboratory, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China; Shandong Provincial Key Medical and Health Laboratory of Intelligent Diagnosis and Treatment for Women's Diseases, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Qi Wang
- Big Data and Artificial Intelligence Laboratory, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China; Shandong Provincial Key Medical and Health Laboratory of Intelligent Diagnosis and Treatment for Women's Diseases, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Simin Wang
- Department of Radiology, Fudan University Cancer Center, Shanghai, 200433, China
| | - Kun Cao
- Department of Radiology, Beijing Cancer Hospital, Beijing, 100142, China
| | - Yun Liang
- Department of Radiology, Guilin Municipal Hospital of Traditional Chinese Medicine, Guilin, Yunnan, 541002, China
| | - Feng Zhao
- School of Computer Science and Technology, Shandong Technology and Business University, Yantai, Shandong, 264005, China
| | - Haizhu Xie
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Cong Xu
- Physical Examination Center, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Haicheng Zhang
- Big Data and Artificial Intelligence Laboratory, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China; Shandong Provincial Key Medical and Health Laboratory of Intelligent Diagnosis and Treatment for Women's Diseases, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China
| | - Qingliang Niu
- Weifang NO.2 People's Hospital, Weifang, Shandong, 261041, China.
| | - Heng Ma
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China.
| | - Ning Mao
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, 264000, China.
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de Boniface J, Appelgren M, Szulkin R, Alkner S, Andersson Y, Bergkvist L, Frisell J, Gentilini OD, Kontos M, Kühn T, Lundstedt D, Offersen BV, Olofsson Bagge R, Reimer T, Sund M, Christiansen P, Rydén L, Filtenborg Tvedskov T. Completion axillary lymph node dissection for the identification of pN2-3 status as an indication for adjuvant CDK4/6 inhibitor treatment: a post-hoc analysis of the randomised, phase 3 SENOMAC trial. Lancet Oncol 2024; 25:1222-1230. [PMID: 39121881 DOI: 10.1016/s1470-2045(24)00350-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/16/2024] [Accepted: 06/17/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND In luminal breast cancer, adjuvant CDK4/6 inhibitors (eg, abemaciclib) improve invasive disease-free survival. In patients with T1-2, grade 1-2 tumours, and one or two sentinel lymph node metastases, completion axillary lymph node dissection (cALND) is the only prognostic tool available that can reveal four or more nodal metastases (pN2-3), which is the only indication for adjuvant abemaciclib in this setting. However, this technique can lead to substantial arm morbidity in patients. We aimed to pragmatically describe the potential benefit and harm of this strategy on the individual patient level in patients from the ongoing SENOMAC trial. METHODS In the randomised, phase 3, SENOMAC trial, patients aged 18 years or older, of any performance status, with clinically node-negative T1-T3 breast cancer and one or two sentinel node macrometastases from 67 sites in five European countries (Denmark, Germany, Greece, Italy, and Sweden) were randomly assigned (1:1), via permutated block randomisation (random block size of 2 and 4) stratified by country, to either cALND or its omission (ie, they had a sentinel lymph node biopsy only). The primary outcome is overall survival, which is yet to be reported. In this post-hoc analysis, patients from the SENOMAC per-protocol population, with luminal oestrogen-receptor positive, HER2-negative, T1-2, histological grade 1-2 breast cancer, with tumour size of 5 cm or smaller were selected to match the characteristics of cohort 1 of the monarchE trial who would only have an indication for adjuvant abemaciclib if found to have 4 or more nodal metastases. The primary study objective was to determine the number of patients who developed patient-reported severe or very severe impairment of physical arm function after cALND (as measured by the Lymphedema Functioning, Disability, and Health [Lymph-ICF] Questionnaire) 1 year after surgery to avoid one invasive disease-free survival event at 5 years with 2 years of adjuvant abemaciclib, using invasive disease-free survival event data from cohort 1 of the monarchE trial. The SENOMAC trial is registered with ClincialTrials.gov, NCT02240472, and is closed to accrual and ongoing. FINDINGS Between Jan 31, 2015, and Dec 31, 2021, 2766 patients were enrolled in SENOMAC and randomly assigned to cALND (n=1384) or sentinel node biopsy only (n=1382), of whom 2540 were included in the per-protocol population. 1705 (67%) of 2540 patients met this post-hoc study's eligibility criteria, of whom 802 (47%) had a cALND and 903 (53%) had a sentinel lymph node biopsy only. Median age at randomisation was 62 years (IQR 52-71), 1699 (>99%) of 1705 patients were female, and six (<1%) were male. Among 1342 patients who responded to questionnaires, after a median follow-up of 45·2 months (IQR 25·6-59·8; data cutoff Nov 17, 2023), patient-reported severe or very severe impairment of physical arm function was reported in 84 (13%) of 634 patients who had cALND versus 30 (4%) of 708 who had sentinel lymph node biopsy only (χ2 test p<0·0001). To avoid one invasive disease-free survival event at 5 years with adjuvant abemaciclib, cALND would need to be performed in 104 patients, and would result in nine patients having severe or very severe impairment of physical arm function 1 year after surgery. INTERPRETATION As a method to potentially identify an indication for abemaciclib, and subsequently avoid invasive disease-free survival events at 5 years with 2 years of adjuvant abemaciclib, cALND carries a substantial risk of severe or very severe arm morbidity and so cALND should be discouraged for this purpose. FUNDING Swedish Research Council, the Swedish Cancer Society, the Nordic Cancer Union, and the Swedish Breast Cancer Association.
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Affiliation(s)
- Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Center, Capio St Göran's Hospital, Stockholm, Sweden.
| | - Matilda Appelgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Center, Capio St Göran's Hospital, Stockholm, Sweden
| | - Robert Szulkin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Cytel, Stockholm, Sweden
| | - Sara Alkner
- Faculty of Medicine, Institute of Clinical Sciences, Lund University, Lund, Sweden; Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Yvette Andersson
- Department of Surgery, Vastmanland Hospital Vasteras, Vasteras, Sweden; Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Vasteras, Sweden
| | - Leif Bergkvist
- Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Vasteras, Sweden
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Oreste Davide Gentilini
- Breast Surgery, IRCCS Ospedale San Raffaele, Milano, Italy; Vita-Salute San Raffaele University, Milano, Italy
| | - Michalis Kontos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Kühn
- Die Filderklinik, Breast Center, Filderstadt, Germany; Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Birgitte Vrou Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark; Department of Experimental Clinical Oncology, Danish Center for Particle Therapy, Aarhus, Denmark
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Malin Sund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå, Sweden
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lisa Rydén
- Faculty of Medicine, Institute of Clinical Sciences, Lund University, Lund, Sweden; Department of Gastroenterology and Surgery, Skåne University Hospital Lund, Malmö, Sweden
| | - Tove Filtenborg Tvedskov
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Breast Surgery, Gentofte Hospital, Gentofte, Denmark
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Gruber G. Escalation and De-Escalation of Adjuvant Radiotherapy in Early Breast Cancer: Strategies for Risk-Adapted Optimization. Cancers (Basel) 2024; 16:2946. [PMID: 39272804 PMCID: PMC11394564 DOI: 10.3390/cancers16172946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/12/2024] [Accepted: 08/20/2024] [Indexed: 09/15/2024] Open
Abstract
Postoperative radiotherapy (RT) is recommended after breast-conserving surgery and mastectomy (with risk factors). Consideration of pros and cons, including potential side effects, demands the optimization of adjuvant RT and a risk-adapted approach. There is clear de-escalation in fractionation-hypofractionation should be considered standard. For selected low-risk situations, PBI only or even the omission of RT might be appropriate. In contrast, tendencies toward escalating RT are obvious. Preoperative RT seems attractive for patients in whom breast reconstruction is planned or for defining the tumor location more precisely with the potential of giving ablative doses. Dose escalation by a (simultaneous integrated) boost or the combination with new compounds/systemic treatments may increase antitumor efficacy but also toxicity. Despite low evidence, RT for oligometastatic disease is becoming increasingly popular. The omission of axillary dissection in node-positive disease led to an escalation of regional RT. Studies are ongoing to test if any axillary treatment can be omitted and which oligometastatic patients do really benefit from RT. Besides technical improvements, the incorporation of molecular risk profiles and also the response to neoadjuvant systemic therapy have the potential to optimize the decision-making concerning if and how local and/or regional RT should be administered.
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Affiliation(s)
- Guenther Gruber
- Institute for Radiotherapy, Klinik Hirslanden, Witellikerstrasse 40, CH-8032 Zurich, Switzerland
- Medical School, University of Nicosia, CY-1700 Nicosia, Cyprus
- Medical Faculty, University of Berne, CH-3000 Berne, Switzerland
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Oyama Y, Kittaka N, Higuchi A, Togashi Y, Taniguchi A, Seto Y, Soma A, Park S, Okuno J, Watanabe N, Matsui S, Ishihara M, Nishio M, Honma K, Nakayama T. Long-Term Survival Outcomes and Risk Factors for Axillary and Locoregional Recurrence in Japanese Patients with Sentinel Node-Positive Breast Cancer Treated in Accordance with the ACOSOG Z0011 Strategy. Oncology 2024:1-13. [PMID: 39159619 DOI: 10.1159/000540363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 07/09/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION In 2018, we reported the results of a study to assess the feasibility of applying the ACOSOG Z0011 criteria to Japanese patients with early-stage breast cancer (median follow-up, 3 years). Their results over the longer term can now be presented. Risk factors for axillary and locoregional recurrence in Z0011-eligible patients are unknown. METHODS Long-term survival outcomes were investigated by analyzing data from patients enrolled in the feasibility study. Data from the feasibility study patients, and from patients eligible for the Z0011 strategy after its introduction into clinical practice, were subjected to multivariate logistic regression analysis to identify risk factors for axillary and locoregional recurrence. RESULTS Regarding long-term outcomes for the feasibility study patients (n = 189), distant disease-free survival rates at 5 and 7 years were 90.4 ± 2.1% and 85.9 ± 2.6%, respectively, and overall survival rates at 5 and 7 years were 97.3 ± 1.2% and 95.3 ± 1.7%, respectively. Analysis of data from these patients plus the 93 who received Z0011 in clinical practice (total, n = 282) identified the following independent risk factors for axillary recurrence: absence of high axillary tangential irradiation (OR, 5.87 [95% CI, 1.09-31.35], p = 0.04) and number of positive sentinel lymph nodes (OR, 4.65 [95% CI, 1.11-19.48], p = 0.04). Only high Ki67 labeling index (OR, 5.92 [95% CI, 1.31-26.70], p = 0.02) was identified as an independent risk factor for locoregional recurrence. CONCLUSION Long-term survival outcome results of the feasibility study show that the Z0011 strategy can be used to treat Japanese patients with early-stage breast cancer. Our findings regarding risk factors suggest that high axillary tangent irradiation is necessary for the prevention of axillary recurrence and that irradiation, including of the regional lymph nodes, should be considered, especially in patients with high Ki67 index values.
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Affiliation(s)
- Yuri Oyama
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | | | - Ayako Higuchi
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yusa Togashi
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Azusa Taniguchi
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yukiko Seto
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Ai Soma
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Sungae Park
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Jun Okuno
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Noriyuki Watanabe
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Saki Matsui
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Mikiya Ishihara
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Minako Nishio
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Keiichiro Honma
- Department of Diagnostic Pathology and Cytology, Osaka International Cancer Institute, Osaka, Japan
| | - Takahiro Nakayama
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
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Cardoso JHCO, de Lara ICA, Sobreira LER, Lôbo ADOM, Silvério IIL, Souza MEC, de Moraes FCA, Magalhães MCF. Omitting Axillary Lymph Node Dissection Is Associated With an Increased Risk of Regional Recurrence in Early Stage Breast Cancer: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Clin Breast Cancer 2024:S1526-8209(24)00211-8. [PMID: 39244391 DOI: 10.1016/j.clbc.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/25/2024] [Accepted: 07/27/2024] [Indexed: 09/09/2024]
Abstract
Breast cancer (BC) is a global problem, however, despite ALND is considered the standard treatment for early stage BC with node-positive, there is no sufficient data to determine which of these patients should undergo it. Thus, the aim of this systematic review was to clarify if there is any difference between NALND and ALND in terms of safety and prognosis of the patients. A shearch was carried in PubMed, Embase and Cochrane databases for studies that compared NALND and ALND. The statistics was performed in R software, in which fixed and random effect models were employed for outcomes with, respectively, I² < 25% and I² > 25%, to compute risk ratios and hazard ratios with 95% CI. Heterogeneity was accessed with I2 statistics. There was 9 included studies, involving 11,543patients, of whom 5831 were randomized to omission of ALND. The follow-up period ranged from 5 to 15 years, with participant ages varying from 53.4 to 70.1 years. The analysis revealed significant increase in regional recurrence at the end of the follow-up (RR 1.73; 95% CI, 1.13 to 2.66) and a significant decrease in lymphedema (RR 0.35; 95% CI, 0.24 to 0.52), however no significant result was found for OS (HR 1.01; 95% CI, 0.89 to 1.15). Our data suggest that while the NALND offers benefits in terms of preventing lymphedema, it was associated with a higher risk of of regional recurrences. Thus, further studies are necessary to fully assess the role of these techniques in BC management.
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Du Q, Guo Y, Zhu Y, Qu J, Guo Y, Zhang S, Liu D. The current diagnosis and treatment strategy of breast cancer based on multicentre retrospective data in Shaanxi province. World J Surg Oncol 2024; 22:210. [PMID: 39107766 PMCID: PMC11302247 DOI: 10.1186/s12957-024-03485-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/17/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Breast cancer is a common malignancy, and early detection coupled with standardized treatment is crucial for patient survival and recovery. This study aims to scrutinize the current state of breast cancer diagnosis and treatment in Shaanxi province, providing valuable insights into the local practices and outcomes. METHODS We selected 25 hospitals that typically represent the current diagnosis and treatment strategy of breast cancer in Shaanxi (a province in northwest China). The questionnaire comprised sections on fundamental information, outpatient consultations, breast-conserving surgery, neoadjuvant and adjuvant therapy, sentinel lymph node biopsy, breast reconstruction surgery. RESULTS A total of 6665 breast cancer operations were performed in these 25 hospitals in 2021. The overall proportion of breast-conserving surgery (BCS) is 23.6%. There was a statistically significant positive correlation between the annual volume of breast cancer surgery and the implementation rate of BCS (P = 0.004). A total of 2882 cases of neoadjuvant treatment accounted for 43.24% of breast cancer patients treated with surgery in 2017. Hospitals in Xi'an performed more neoadjuvant therapy for patients with breast cancer compared to other districts (P = 0.008). There was a significantly positive correlation between outpatient visits and the implementation rate of sentinel lymph node biopsy (SLNB) (P = 0.005). 14 hospitals in Shaanxi performed reconstructive surgery. CONCLUSIONS Breast conserving surgery, adjuvant and neoadjuvant therapy and sentinel lymph node biopsy in Shaanxi province have reached the China's average level. Moreover, hospitals in Xi 'an have surpassed this average. However, a disparity is observed in the development of breast reconstruction surgery when compared to top-tier hospitals.
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Affiliation(s)
- Qin Du
- The Comprehensive Breast Care Center, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, China
| | - Yize Guo
- The Comprehensive Breast Care Center, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, China
| | - Yuxuan Zhu
- The Comprehensive Breast Care Center, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, China
| | - Jingkun Qu
- The Comprehensive Breast Care Center, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, China
| | - Ya Guo
- Department of Radiation Oncology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, China
| | - Shuqun Zhang
- The Comprehensive Breast Care Center, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, China.
| | - Di Liu
- The Comprehensive Breast Care Center, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, China.
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11
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Mitri S, Roldan-Vasquez E, Flores R, Pardo J, Borgonovo G, ScD RBD, James TA. Axillary Management Following Neoadjuvant Chemotherapy in Clinically Node-Positive Breast Cancer. Clin Breast Cancer 2024; 24:527-532. [PMID: 38906721 DOI: 10.1016/j.clbc.2024.05.008] [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: 04/10/2024] [Revised: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Clinical trial data indicate that omitting axillary lymph node dissection (ALND) is feasible and may reduce morbidity for carefully selected patients with clinically node-positive breast cancer who achieve a pathological complete response (pCR) after neoadjuvant chemotherapy (NCT). However, there remains a need to understand how these findings translate to broader clinical practice and to identify which patients benefit most. This study utilizes a national dataset to assess outcomes in axillary management, aiming to inform best practice in axillary de-escalation. METHODS The National Cancer Data Base was used to identify women diagnosed with clinically node-positive invasive breast cancer between 2012 to 2020 who received NCT and subsequent ALND. Associations between clinicopathologic factors and axillary pCR were analyzed statistically. RESULTS Of the 59,791 patients included, 8,827 (14.76%) achieved nodal pCR. Patients with HR-negative and HER2-positive receptor status more frequently underwent ALND instead of sentinel lymph node biopsy. Conversely, patients over the age of 70, those with private or public insurance, and cases classified as ypT1 or ypT2 were less likely to undergo ALND. CONCLUSION A subset of patients with clinically node-positive breast cancer received ALND despite achieving axillary pCR following NCT. This highlights an opportunity to enhance precision in identifying candidates for axillary de-escalation, potentially reducing morbidity and tailoring treatment more closely to individual patient needs.
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Affiliation(s)
- Samir Mitri
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA
| | | | - Rene Flores
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA
| | - Jaime Pardo
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA
| | - Giulia Borgonovo
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA
| | - Roger B Davis ScD
- Division of General Medicine,Department of Medicine,Beth Israel Deaconess Medical Center - Harvard Medical School, Boston, MA
| | - Ted A James
- Department of Surgery, Beth Israel Deaconess Medical Center - Harvard Medical School Boston, MA.
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12
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Alkner S, Wieslander E, Lundstedt D, Berg M, Kristensen I, Andersson Y, Bergkvist L, Frisell J, Olofsson Bagge R, Sund M, Christiansen P, Davide Gentilini O, Kontos M, Kühn T, Reimer T, Rydén L, Filtenborg Tvedskov T, Vrou Offersen B, Dahl Nissen H, de Boniface J. Quality assessment of radiotherapy in the prospective randomized SENOMAC trial. Radiother Oncol 2024; 197:110372. [PMID: 38866204 DOI: 10.1016/j.radonc.2024.110372] [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: 04/03/2024] [Revised: 05/15/2024] [Accepted: 06/04/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND AND PURPOSE Recommendations for regional radiotherapy (RT) of sentinel lymph node (SLN)-positive breast cancer are debated. We here report a RT quality assessment of the SENOMAC trial. MATERIALS AND METHODS The SENOMAC trial randomized clinically node-negative breast cancer patients with 1-2 SLN macrometastases to completion axillary lymph node dissection (cALND) or SLN biopsy only between 2015-2021. Adjuvant RT followed national guidelines. RT plans for patients included in Sweden and Denmark until June 2019 were collected (N = 1176) and compared to case report forms (CRF). Dose to level I (N = 270) and the humeral head (N = 321) was analyzed in detail. RESULTS CRF-data and RT plans agreed in 99.3 % (breast/chest wall) and in 96.6 % of patients (regional RT). Congruence for whether level I was an intended RT target was lower (78 %). In accordance with Danish national guidelines, level I was more often an intended target in the SLN biopsy only arm (N = 334/611, 55 %,) than in the cALND arm (N = 174/565, 31 %,). When an intended target, level I received prescribed dose to 100 % (IQR 98-100 %) of the volume. However, even when not an intended target, full dose was delivered to > 80 % of level I (IQR 75-90 %). The intentional inclusion of level I in the target volume more than doubled the dose received by ≥ 50 % of the humeral head. CONCLUSION Congruence between CRF data and RT plans was excellent. Level I received a high dose coverage even when not intentionally included in the target. Including level I in target significantly increased dose to the humeral head.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Faculty of Medicine, Institute of Clinical Sciences Lund, Lund University, Lund, Sweden; Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden.
| | - Elinore Wieslander
- Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Oncology at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Berg
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Ingrid Kristensen
- Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Yvette Andersson
- Department of Surgery, Vastmanland Hospital Vasteras, Vasteras, Sweden; Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Leif Bergkvist
- Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Malin Sund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Finland; Department of Diagnostics and Intervention/ Surgery, Umeå University, Sweden
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Oreste Davide Gentilini
- Breast Surgery, IRCCS Ospedale San Raffaele, Milano, Italy; Vita-Salute San Raffaele University, Milano, Italy
| | - Michalis Kontos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Kühn
- Die Filderklinik, Breast Center, Filderstadt, Germany; Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Lisa Rydén
- Department of Oncology, Faculty of Medicine, Institute of Clinical Sciences Lund, Lund University, Lund, Sweden; Skåne University Hospital , Department of Gastroenterology and Surgery, Malmö, Sweden
| | - Tove Filtenborg Tvedskov
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Breast Surgery, Gentofte Hospital, Gentofte, Denmark
| | - Birgitte Vrou Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark; Department of Experimental Clinical Oncology, Danish Center for Particle Therapy, Aarhus, Denmark
| | - Henrik Dahl Nissen
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Capio St. Goran's Hospital, Stockholm, Sweden
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13
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Hu B, Xu Y, Gong H, Tang L, Wang L, Li H. Nomogram Utilizing ABVS Radiomics and Clinical Factors for Predicting ≤ 3 Positive Axillary Lymph Nodes in HR+ /HER2- Breast Cancer with 1-2 Positive Sentinel Nodes. Acad Radiol 2024; 31:2684-2694. [PMID: 38383259 DOI: 10.1016/j.acra.2024.01.026] [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: 11/09/2023] [Revised: 01/15/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND In HR+ /HER2- breast cancer patients with ≤ 3 positive axillary lymph nodes (ALNs), genomic tests can streamline chemotherapy decisions. Current studies, centered on tumor metrics, miss broader patient insights. Automated Breast Volume Scanning (ABVS) provides advanced 3D imaging, and its potential synergy with radiomics for ALN evaluation is untapped. OBJECTIVE This study sought to combine ABVS radiomics and clinical characteristics in a nomogram to predict ≤ 3 positive ALNs in HR+ /HER2- breast cancer patients with 1-2 positive sentinel lymph nodes (SLNs), guiding clinicians in genetic test candidate selection. METHODS We enrolled 511 early-stage breast cancer patients: 362 from A Hospital for training and 149 from B Hospital for validation. Using LASSO logistic regression, primary features were identified. A clinical-radiomics nomogram was developed to predict the likelihood of ≤ 3 positive ALNs in HR+ /HER2- patients with 1-2 positive SLNs. We assessed the discriminative capability of the nomogram using the ROC curve. The model's calibration was confirmed through a calibration curve, while its fit was evaluated using the Hosmer-Lemeshow (HL) test. To determine the clinical net benefits, we employed the Decision Curve Analysis (DCA). RESULTS In the training group, 81.2% patients had ≤ 3 metastatic ALNs, and 83.2% in the validation group. We developed a clinical-radiomics nomogram by analyzing clinical characteristics and rad-scores. Factors like positive SLNs (OR=0.077), absence of negative SLNs (OR=11.138), lymphovascular invasion (OR=0.248), and rad-score (OR=0.003) significantly correlated with ≤ 3 positive ALNs. The clinical-radiomics nomogram, with an AUC of 0.910 in training and 0.882 in validation, outperformed the rad-score-free clinical nomogram (AUCs of 0.796 and 0.782). Calibration curves and the HL test (P values 0.688 and 0.691) confirmed its robustness. DCA showed the clinical-radiomics nomogram provided superior net benefits in predicting ALN burden across specific threshold probabilities. CONCLUSION We developed a clinical-radiomics nomogram that integrated radiomics from ABVS images and clinical data to predict the presence of ≤ 3 positive ALNs in HR+ /HER2- patients with 1-2 positive SLNs, aiding oncologists in identifying candidates for genomic tests, bypassing ALND. In the era of precision medicine, combining genomic tests with SLN biopsy refines both surgical and systemic patient treatments.
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Affiliation(s)
- Bin Hu
- Department of Ultrasound, Minhang Hospital, Fudan University, 170 Xinsong Rd, Shanghai 201199, China.
| | - Yanjun Xu
- Department of Ultrasonography, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Institute of Ultrasound in Medicine, Shanghai, China
| | - Huiling Gong
- Department of Ultrasound, Minhang Hospital, Fudan University, 170 Xinsong Rd, Shanghai 201199, China
| | - Lang Tang
- Department of Ultrasound, Minhang Hospital, Fudan University, 170 Xinsong Rd, Shanghai 201199, China
| | - Lihong Wang
- Department of Ultrasound, Minhang Hospital, Fudan University, 170 Xinsong Rd, Shanghai 201199, China
| | - Hongchang Li
- Department of General Surgery, Institute of Fudan-Minhang Academic Health System, Minhang Hospital, Fudan University, Shanghai, China
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14
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Sciallis A. Intraoperative evaluation of sentinel lymph nodes in patients with breast cancer: A review emphasizing clinical concepts pathologists need to know. Semin Diagn Pathol 2024:S0740-2570(24)00064-9. [PMID: 38937191 DOI: 10.1053/j.semdp.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Andrew Sciallis
- Staff Pathologist, Pathology and Laboratory Medicine Institute (PLMI), Cleveland Clinic, Cleveland, OH 44195, United States.
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15
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Riis MLH. The Challenges of Lobular Carcinomas from a Surgeon's Point of View. Clin Breast Cancer 2024:S1526-8209(24)00172-1. [PMID: 39033066 DOI: 10.1016/j.clbc.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/13/2024] [Indexed: 07/23/2024]
Abstract
Invasive lobular breast cancer (ILC) presents unique challenges and considerations in the realm of surgical management. Characterized by its distinct histological features, including the loss of E-cadherin expression and dys-cohesive growth pattern, ILC often poses diagnostic and therapeutic dilemmas for clinicians. This abstract explores the surgical landscape of ILC, focusing on its epidemiology, clinical presentation, diagnostic modalities, and surgical interventions. Emphasizing the importance of individualized treatment strategies, this narrative delves into the nuances of surgical decision-making, including the role of breast-conserving surgery versus mastectomy, axillary staging, and the significance of margin status. Additionally, advancements in surgical techniques, such as oncoplastic approaches and sentinel lymph node biopsy, are examined in the context of optimizing oncologic outcomes and preserving cosmesis. Through a comprehensive review of current literature and clinical guidelines, this overview aims to provide a nuanced understanding of the surgical considerations inherent to the management of invasive lobular breast cancer.
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Affiliation(s)
- Margit L H Riis
- Department of Breast and Endocrine Surgery, Oslo University Hospital, Oslo, Norway.
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16
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Vuong B, Jacinto AI, Chang SB, Kuehner GE, Savitz AC. Contemporary Review of the Management and Treatment of Young Breast Cancer Patients. Clin Breast Cancer 2024:S1526-8209(24)00148-4. [PMID: 38972829 DOI: 10.1016/j.clbc.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 05/28/2024] [Accepted: 06/03/2024] [Indexed: 07/09/2024]
Abstract
Approximately 11% of all new breast cancer cases annually are diagnosed in young women, and this continues to be the leading cause of death in women age 20 to 49. Young, premenopausal breast cancer patients present with more advanced stages and with a higher proportion of aggressive subtypes such as triple negative and HER2-enriched tumors. Recently, the United States Preventive Services Task Force (USPSTF) lowered the age threshold to initiate screening mammograms to age 40 to aid in earlier detection. Young age at diagnosis increases the likelihood for a pathogenic mutation, and genetic testing is recommended for all patients age 50 and younger. This population is often underrepresented in landmark clinical trials, and data is extrapolated for the treatment of young women with breast cancer. Despite there being no survival benefit to more extensive surgical treatments, such as mastectomy or contralateral prophylactic mastectomy, many patients opt against breast conservation. Young patients with breast cancer face issues related to treatment toxicities, potential overtreatment of their disease, mental health, sexual health, and fertility preservation. This unique population requires a multidisciplinary care team of physicians, surgeons, genetic counselors, fertility specialists, mental health professionals, physical therapists, and dieticians to provide individualized, comprehensive care. Our aim is to (1) provide a narrative review of retrospective studies, relevant society guidelines, and clinical trials focused on the contemporary treatment and management of YBC patients and (2) discuss important nuances in their care as a guide for members of their multidisciplinary treatment team.
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Affiliation(s)
- Brooke Vuong
- Department of Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA.
| | - Ana I Jacinto
- Department of Surgery, University of California, Davis, Sacramento, CA
| | - Sharon B Chang
- Department of Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Gillian E Kuehner
- Department of Surgery, Kaiser Permanente Vallejo Medical Center, Vallejo, CA
| | - Alison C Savitz
- Department of Surgery, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA
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17
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Williams AD, Weiss A. Recent Advances in the Upfront Surgical Management of the Axilla in Patients with Breast Cancer. Clin Breast Cancer 2024; 24:271-277. [PMID: 38220539 DOI: 10.1016/j.clbc.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/16/2024]
Abstract
Nodal status is an important prognostic indicator. Upfront axillary surgery for patients with breast cancer has historically been both diagnostic and therapeutic-serving to determine nodal status and inform adjuvant therapies, and to remove clinically significant disease. However, trials of de-escalation or omission of axillary surgery altogether consistently demonstrate noninferior oncologic outcomes in a wide variety of patient subsets. These strategies also reduce the morbidity associated with either sentinel lymphadenectomy or axillary lymph node dissection. Here we will briefly review landmark trials that have shaped upfront axillary surgery as well as recent advances, and discuss areas of ongoing investigation and future needs.
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Affiliation(s)
- Austin D Williams
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
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18
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Bessa JDF, Novita GG, Testa L, Freitas-Junior R, Marta GN. Is my patient an appropriate candidate for sentinel node biopsy? Less axillary surgery, for the right patients. Critical review and grades of recommendation. Surg Oncol 2024; 54:102064. [PMID: 38518660 DOI: 10.1016/j.suronc.2024.102064] [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: 06/22/2023] [Revised: 02/23/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION While general conclusions of historical trials are widely recognized, the nuances regarding precise indications of Sentinel Node Biopsy (SNB) in breast cancer in complex clinical scenarios often remain a source of debate and require further elucidation. METHODS Two reviewers (JFB and GNM) independently searched electronic databases for studies including SNB as the main intervention. Filters were applied to retrieve only clinical trials (randomized or experimental non-randomized); non-oncological outcomes were excluded. The selected studies were considered to construct a narrative review focused on inclusion criteria and survival outcomes, followed by recommendations. RESULTS Fourteen (n = 14) trials were selected, including eleven (n = 11) randomized trials for upfront surgery, and three (n = 3) single-group clinical trials for surgery following neoadjuvant therapy. All trials for upfront surgery provided long-term survival data for SNB, that was equivalent or non-inferior to axillary dissection, in tumors without palpable adenopathy (caution for larger T3 and T4 tumors) - Grade of recommendation: A. In tumors up to 5 cm, complete axillary dissection is not necessary if up to two sentinel nodes are positive for macrometastasis, and radiation therapy is planned - Grade of recommendation: A. If there are more than two sentinel nodes positive for macrometastasis, or a positive node other than the sentinel one, complete axillary dissection is recommended - Grade of recommendation: A. Following neoadjuvant chemotherapy, considering 10% as an acceptable false negative rate, SNB might be offered for cN0 patients who have remained negative, and for cN1 (caution for cN2) patients become clinically negative; complete axillary dissection might not be necessary if at least two sentinel lymph nodes are retrieved, and there is no residual disease - Grade of recommendation: B. CONCLUSION SNB can be performed in most cases of clinically negative nodes. After neoadjuvant chemotherapy, SNB is feasible and may have acceptable performance for cN0 and cN1 tumors, although prospective survival data is still awaited.
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Affiliation(s)
| | | | - Laura Testa
- Instituto D'Or de Pesquisa e Ensino (IDOR), São Paulo, Brazil
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19
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Ghilli M, Becherini C, Meattini I, Angiolini C, Bengala C, Marconi A, Galli L, Angiolucci G, Coltelli L, Borghesi S, Lastrucci L, Manca G, Bianchi S, Doria M, Casella D, Marotti L, Amunni G, Roncella M. Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network. LA RADIOLOGIA MEDICA 2024; 129:945-954. [PMID: 38683499 DOI: 10.1007/s11547-024-01818-7] [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: 12/27/2023] [Accepted: 04/16/2024] [Indexed: 05/01/2024]
Abstract
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.
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Affiliation(s)
- Matteo Ghilli
- Breast Centre, Breast Surgery, University Hospital of Pisa, Via Roma 67, Pisa, Italy.
| | - Carlotta Becherini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Icro Meattini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Catia Angiolini
- Breast Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, A. Brambilla 3, 50134, Florence, Italy
| | - Carmelo Bengala
- Oncology Department, Unit of Medical Oncology, Misericordia Hospital, Grosseto, Italy
| | - Aroldo Marconi
- Breast Oncological and Reconstructive Surgery, S.Luca Hospital- V. G. Lippi Francesconi, 55100, Lucca, Italy
| | - Lorenzo Galli
- Azienda Usl Toscana Centro, Ospedale San Giovanni Di Dio, Via Di Torregalli N 3, 50143, Florence, Italy
| | - Giovanni Angiolucci
- Radiologia Senologica, Azienda Usl Toscana Sud-Est, Ospedale Arezzo, Giovanni Valdarno, Italy
| | - Luigi Coltelli
- Division of Medical Oncology, Livorno Hospital, Department of Oncology, Azienda USL Toscana Nord Ovest, Viale Alfieri 36, Leghorn, Italy
| | - Simona Borghesi
- Department of Radiation Oncology, Azienda Usl Toscana Sud-Est, Ospedale Arezzo E S., Giovanni Valdarno, Italy
| | - Luciana Lastrucci
- Department of Radiation Oncology, Livorno Hospital, Azienda USL Toscana Nord Ovest, Viale Alfieri 36, Leghorn, Italy
| | - Gianpiero Manca
- Breast Centre, Nuclear Medicine, University Hospital of Pisa, Via Roma 67, Pisa, Italy
| | - Simonetta Bianchi
- Department of Health Sciences, Division of Pathological Anatomy, University of Florence, Viale Pieraccini 6, Florence, Italy
| | - Morena Doria
- SOC Anatomia Patologica, Azienda Usl Toscana Centro, Ospedale San Giovanni Di Dio, Via Di Torregalli N° 3, 50143, Florence, Italy
| | | | - Lorenza Marotti
- European Society of Breast Cancer Specialists, Florence, Italy
| | - Gianni Amunni
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Manuela Roncella
- Breast Centre, Breast Surgery, University Hospital of Pisa, Via Roma 67, Pisa, Italy
- University Hospital of Pisa, Via Roma 67, Pisa, Italy
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20
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James J, Law M, Sengupta S, Saunders C. Assessment of the axilla in women with early-stage breast cancer undergoing primary surgery: a review. World J Surg Oncol 2024; 22:127. [PMID: 38725006 PMCID: PMC11084006 DOI: 10.1186/s12957-024-03394-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 04/28/2024] [Indexed: 05/12/2024] Open
Abstract
Sentinel node biopsy (SNB) is routinely performed in people with node-negative early breast cancer to assess the axilla. SNB has no proven therapeutic benefit. Nodal status information obtained from SNB helps in prognostication and can influence adjuvant systemic and locoregional treatment choices. However, the redundancy of the nodal status information is becoming increasingly apparent. The accuracy of radiological assessment of the axilla, combined with the strong influence of tumour biology on systemic and locoregional therapy requirements, has prompted many to consider alternative options for SNB. SNB contributes significantly to decreased quality of life in early breast cancer patients. Substantial improvements in workflow and cost could accrue by removing SNB from early breast cancer treatment. We review the current viewpoints and ideas for alternative options for assessing and managing a clinically negative axilla in patients with early breast cancer (EBC). Omitting SNB in selected cases or replacing SNB with a non-invasive predictive model appear to be viable options based on current literature.
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Affiliation(s)
- Justin James
- Eastern Health, Melbourne, Australia.
- Monash University, Melbourne, Australia.
- Department of Breast and Endocrine Surgery, Maroondah Hospital, Davey Drive, Ringwood East, Melbourne, VIC, 3135, Australia.
| | - Michael Law
- Eastern Health, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Shomik Sengupta
- Eastern Health, Melbourne, Australia
- Monash University, Melbourne, Australia
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21
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Chung AP, Dang CM, Karlan SR, Amersi FF, Phillips EM, Boyle MK, Cui Y, Giuliano AE. A Prospective Study of Sentinel Node Biopsy Omission in Women Age ≥ 65 Years with ER+ Breast Cancer. Ann Surg Oncol 2024; 31:3160-3167. [PMID: 38345718 PMCID: PMC10997698 DOI: 10.1245/s10434-024-15000-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/18/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND National guidelines recommend omitting SNB in older patients with favorable invasive breast cancer. However, there is a lack of prospective data specifically addressing this issue. This study evaluates recurrence and survival in estrogen receptor-positive/Her2- (ER+) breast cancer patients, aged ≥ 65 years who have breast-conserving surgery (BCS) without SNB. METHODS This is a prospective, observational study at a single institution where 125 patients aged ≥ 65 years with clinical T1-2N0 ER+ invasive breast cancer undergoing BCS were enrolled. Patients were treated with BCS without SNB. Primary outcome measure was axillary recurrence. Secondary outcome measures include recurrence-free survival (RFS), disease-free survival (DFS), breast cancer-specific survival (BCSS), and overall survival (OS). RESULTS From January 2016 to July 2022, 125 patients were enrolled with median follow-up of 36.7 months [95% confidence interval (CI) 35.0-38.0]. Median age was 77.0 years (range 65-93). Median tumor size was 1 cm (range 0.1-5.0). Most tumors were ductal (95/124, 77.0%), intermediate grade (60/116, 51.7%), and PR-positive (117/123, 91.7%). Radiation therapy was performed in 37 of 125 (29.6%). Only 60 of 125 (48.0%) who were recommended hormonal therapy were compliant at 2 years. Chemotherapy was administered to six of 125 (4.8%) patients. There were two of 125 (1.6%) axillary recurrences. Estimated 3-years rates of regional RFS, DFS, and OS were 98.2%, 91.2%, and 94.8%, respectively. Univariate Cox regression identified hormonal therapy noncompliance to be significantly associated with recurrence (p = 0.02). CONCLUSIONS Axillary recurrence rates were extremely low in this cohort. These results provide prospective data to support omission of SNB in this patient population TRIAL REGISTRATION: ClinicalTrials.gov ID NCT02564848.
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Affiliation(s)
- Alice P Chung
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Catherine M Dang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Scott R Karlan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Farin F Amersi
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edward M Phillips
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marissa K Boyle
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yujie Cui
- Department of Statistics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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22
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Park KH, Loibl S, Sohn J, Park YH, Jiang Z, Tadjoedin H, Nag S, Saji S, Md Yusof M, Villegas EMB, Lim EH, Lu YS, Ithimakin S, Tseng LM, Dejthevaporn T, Chen TWW, Lee SC, Galvez C, Malwinder S, Kogawa T, Bajpai J, Brahma B, Wang S, Curigliano G, Yoshino T, Kim SB, Pentheroudakis G, Im SA, Andre F, Ahn JB, Harbeck N. Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer. ESMO Open 2024; 9:102974. [PMID: 38796284 PMCID: PMC11145753 DOI: 10.1016/j.esmoop.2024.102974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 05/28/2024] Open
Abstract
The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer were updated and published online in 2023, and adapted, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with early breast cancer. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with breast cancer representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and KSMO. The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with early breast cancer across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling, as well as the age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.
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Affiliation(s)
- K H Park
- Division of Medical Oncology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea.
| | - S Loibl
- German Breast Group, Neu-Isenburg, Goethe University Centre for Haematology and Oncology, Bethanien, Frankfurt, Germany
| | - J Sohn
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul
| | - Y H Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Z Jiang
- Department of Oncology, The Fifth Medical Center of PLA General Hospital, Bejing, China
| | - H Tadjoedin
- Department of Internal Medicine, Division of Hematology-Medical Oncology, Dharmais Hospital, National Cancer Center, Jakarta, Indonesia
| | - S Nag
- Department of Medical Oncology, Sahyadri Speciality Hospitals, Pune, Maharashtra, India
| | - S Saji
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - M Md Yusof
- Cancer Centre at PHKL, Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - E M B Villegas
- Cebu Cancer Institute, Perpertual Succour Hospital, Cebu Doctors' University Hospital, Cho-ing Hua Hospital, Cebu City, Philippines
| | - E H Lim
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Y-S Lu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - S Ithimakin
- Division of Medical Oncology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - L-M Tseng
- Department of Surgery, Taipei-Veterans General Hospital, and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - T Dejthevaporn
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - T W-W Chen
- Department of Oncology, National Taiwan University Hospital and Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - S C Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore (NCIS), Singapore, Singapore
| | - C Galvez
- St. Luke's Medical Center Global City, Taguig City, Philippines
| | - S Malwinder
- Cancer Centre at PHKL, Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - T Kogawa
- Advanced Medical Development, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - J Bajpai
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - B Brahma
- Department of Surgical Oncology, Dharmais Hospital, National Cancer Center, Jakarta, Indonesia
| | - S Wang
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - G Curigliano
- Istituto Europeo di Oncologia, IRCCS, Milan, Italy; Department of Oncology and Haematology, University of Milano, Milan, Italy
| | - T Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - S-B Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - S-A Im
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - F Andre
- Breast Cancer Unit, Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - J B Ahn
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul
| | - N Harbeck
- Breast Center, Department of Obstetrics and Gynaecology and Comprehensive Cancer Center Munich, LMU University Hospital, Munich, Germany
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23
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Heidinger M, Weber WP. Axillary Surgery for Breast Cancer in 2024. Cancers (Basel) 2024; 16:1623. [PMID: 38730576 PMCID: PMC11083357 DOI: 10.3390/cancers16091623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous 'one size fits all' radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.
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Affiliation(s)
- Martin Heidinger
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Walter P. Weber
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
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24
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de Boniface J, Filtenborg Tvedskov T, Rydén L, Szulkin R, Reimer T, Kühn T, Kontos M, Gentilini OD, Olofsson Bagge R, Sund M, Lundstedt D, Appelgren M, Ahlgren J, Norenstedt S, Celebioglu F, Sackey H, Scheel Andersen I, Hoyer U, Nyman PF, Vikhe Patil E, Wieslander E, Dahl Nissen H, Alkner S, Andersson Y, Offersen BV, Bergkvist L, Frisell J, Christiansen P. Omitting Axillary Dissection in Breast Cancer with Sentinel-Node Metastases. N Engl J Med 2024; 390:1163-1175. [PMID: 38598571 DOI: 10.1056/nejmoa2313487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Trials evaluating the omission of completion axillary-lymph-node dissection in patients with clinically node-negative breast cancer and sentinel-lymph-node metastases have been compromised by limited statistical power, uncertain nodal radiotherapy target volumes, and a scarcity of data on relevant clinical subgroups. METHODS We conducted a noninferiority trial in which patients with clinically node-negative primary T1 to T3 breast cancer (tumor size, T1, ≤20 mm; T2, 21 to 50 mm; and T3, >50 mm in the largest dimension) with one or two sentinel-node macrometastases (metastasis size, >2 mm in the largest dimension) were randomly assigned in a 1:1 ratio to completion axillary-lymph-node dissection or its omission (sentinel-node biopsy only). Adjuvant treatment and radiation therapy were used in accordance with national guidelines. The primary end point was overall survival. We report here the per-protocol and modified intention-to-treat analyses of the prespecified secondary end point of recurrence-free survival. To show noninferiority of sentinel-node biopsy only, the upper boundary of the confidence interval for the hazard ratio for recurrence or death had to be below 1.44. RESULTS Between January 2015 and December 2021, a total of 2766 patients were enrolled across five countries. The per-protocol population included 2540 patients, of whom 1335 were assigned to undergo sentinel-node biopsy only and 1205 to undergo completion axillary-lymph-node dissection (dissection group). Radiation therapy including nodal target volumes was administered to 1192 of 1326 patients (89.9%) in the sentinel-node biopsy-only group and to 1058 of 1197 (88.4%) in the dissection group. The median follow-up was 46.8 months (range, 1.5 to 94.5). Overall, 191 patients had recurrence or died. The estimated 5-year recurrence-free survival was 89.7% (95% confidence interval [CI], 87.5 to 91.9) in the sentinel-node biopsy-only group and 88.7% (95% CI, 86.3 to 91.1) in the dissection group, with a country-adjusted hazard ratio for recurrence or death of 0.89 (95% CI, 0.66 to 1.19), which was significantly (P<0.001) below the prespecified noninferiority margin. CONCLUSIONS The omission of completion axillary-lymph-node dissection was noninferior to the more extensive surgery in patients with clinically node-negative breast cancer who had sentinel-node macrometastases, most of whom received nodal radiation therapy. (Funded by the Swedish Research Council and others; SENOMAC ClinicalTrials.gov number, NCT02240472.).
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Affiliation(s)
- Jana de Boniface
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Tove Filtenborg Tvedskov
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Lisa Rydén
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Robert Szulkin
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Toralf Reimer
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Thorsten Kühn
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Michalis Kontos
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Oreste D Gentilini
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Roger Olofsson Bagge
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Malin Sund
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Dan Lundstedt
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Matilda Appelgren
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Johan Ahlgren
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Sophie Norenstedt
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Fuat Celebioglu
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Helena Sackey
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Inge Scheel Andersen
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Ute Hoyer
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Per F Nyman
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Eva Vikhe Patil
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Elinore Wieslander
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Henrik Dahl Nissen
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Sara Alkner
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Yvette Andersson
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Birgitte V Offersen
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Leif Bergkvist
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Jan Frisell
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Peer Christiansen
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
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Tejedor L, Gómez-Modet S. Reducing axillary surgery in breast cancer. Cir Esp 2024; 102:220-224. [PMID: 37956715 DOI: 10.1016/j.cireng.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/23/2023] [Indexed: 11/15/2023]
Abstract
This article provides a brief account of the recent evolution of the highly controversial surgical management of the positive axilla in patients with breast cancer, an issue still open to disparate surgical procedures. This short review highlights the reports that supply the rationale for current trends in reducing the aggressiveness of this surgery and discusses the course of the trials still in progress pointing in the same direction, thus supporting the principle of not performing axillary lymph node dissection for staging purposes alone.
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Affiliation(s)
- L Tejedor
- Hospital Universitario Punta de Europa, Universidad de Cádiz, Spain.
| | - S Gómez-Modet
- Hospital Universitario Punta de Europa, Universidad de Cádiz, Spain
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Yang H, Sun Y, Wang P, Qiao J, Wang C, Liu Z. The Impact of Sentinel Lymph Node Biopsy on Female Patients With T3-4c Breast Cancer and 1-2 Positive Lymph Nodes: A Population-Based Cohort Study. Clin Breast Cancer 2024; 24:e126-e137.e3. [PMID: 38114365 DOI: 10.1016/j.clbc.2023.11.004] [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: 10/21/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE This study aimed to evaluate the efficacy of sentinel lymph node biopsy (SLNB) in patients diagnosed with cT3-4c breast cancer with no more than 2 positive sentinel lymph nodes. METHODS Using data from the Surveillance, Epidemiology, and End Results (SEER) database, this retrospective study identified patients diagnosed with T3-4c breast cancer between 2010 and 2015. These patients were then categorized into 2 groups: the SLNB group, which underwent examination of 1-5 regional lymph nodes and the axillary lymph node dissection (ALND) group, which underwent examination of ≥10 regional lymph nodes. Propensity score matching analysis was used to assess the efficacy of SLNB in cT3-4c patients. RESULTS A total of 1139 patients were included in the analysis, with 423 and 716 patients in the SLNB and ALND groups, respectively. The 10-year overall survival (OS) and breast cancer-specific survival (BCSS) rates in the SLNB group were 66.1% and 76.3%, respectively, compared with 66.0% and 73.8%, respectively. Statistical analysis revealed no significant differences between the 2 groups in terms of OS (HR = 1.00, 95% CI = 0.80-1.25, P = .997) and BCSS (HR = 1.08, 95% CI = 0.83-1.41, P = .551). Even after 1:1 propensity score matching, there were no significant differences in OS (HR = 0.87, 95% CI = 0.65-1.16, P = .341) and BCSS (HR = 0.82, 95% CI = 0.59-1.16, P = .266) between the 2 groups. CONCLUSION This study demonstrates that SLNB does not adversely affect the survival of cT3-4c breast cancer patients with 1-2 sentinel lymph node metastases.
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Affiliation(s)
- Hanzhao Yang
- Department of Breast Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yadong Sun
- Department of Breast Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Peili Wang
- Department of Breast Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Jianghua Qiao
- Department of Breast Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Chengzheng Wang
- Department of Breast Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Zhenzhen Liu
- Department of Breast Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China.
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27
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Maraldo MV, Offersen BV. Radiotherapy for breast cancer. Ugeskr Laeger 2024; 186:V02230106. [PMID: 38533873 DOI: 10.61409/v02230106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
In early breast cancer, adjuvant moderately hypofractionated regimens are recommended for both whole breast, partial breast and locoregional irradiation which abbreviates the overall treatment time, as argued in this review. Gating is recommended as well as the use of a simultaneous integrated boost when indicated. A tangential field set-up is standard, however, for challenging cases volumetric modulated arc therapy techniques, or referral for proton therapy, may be considered. In the metastatic setting, stereotactic radiotherapy is a promising treatment option for oligometastatic disease.
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Affiliation(s)
- Maja Vestmø Maraldo
- Afdeling for Kræftbehandling, Københavns Universitetshospital - Rigshospitalet
| | - Birgitte Vrou Offersen
- Kræftafdelingen, Aarhus Universitetshospital
- Institut for Klinisk Medicin, Aarhus Universitet
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Laws A, Lagendijk M, Grossmith S, Hughes M, Lin NU, Mittendorf EA, Eliassen AH, King TA, Dominici LS. Long-Term Patient-Reported Arm Symptoms in Breast Cancer Survivors. Ann Surg Oncol 2024; 31:1623-1633. [PMID: 38071708 DOI: 10.1245/s10434-023-14711-w] [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: 07/27/2023] [Accepted: 11/19/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Understanding long-term arm symptoms in breast cancer survivors is critical given excellent survival in the modern era. METHODS This cross-sectional study included patients treated for stage 0-III breast cancer at our institution from 2002 to 2012. Patient-reported arm symptoms were collected from the EORTC QLQ-BR23 questionnaire. We used linear regression to evaluate adjusted associations between locoregional treatments and the continuous Arm Symptom (AS) score (0-100; higher score reflects more symptoms). RESULTS A total of 1126 patients expressed interest in participating and 882 (78.3%) completed the questionnaire. Mean time since surgery was 10.5 years. There was a broad distribution of locoregional treatments, including axillary lymph node dissection (ALND) in 37.1% of patients, mastectomy with reconstruction in 36.5% of patients, and post-mastectomy radiation in 38.2% of patients. Overall, 64.3% (95% confidence interval [CI] 61.1-67.4%) of patients reported no arm symptoms, 17.0% (95% CI 14.7-19.6%) had one mild symptom, 9.4% (95% CI 7.7-11.5%) had two or more mild symptoms, and 9.3% (95% CI 7.6-11.4%) reported one or more severe symptoms. Adjusted AS scores were significantly higher with ALND versus sentinel node biopsy (β 3.5, p = 0.01), and with autologous reconstruction versus all other breast/reconstructive surgery types (β 4.5-5.5, all p < 0.05). There was a significant interaction between axillary and breast/reconstructive surgery, with the greatest effect of ALND in those with mastectomy with implant (β 9.7) or autologous (β 5.7) reconstruction. CONCLUSIONS One in three patients reported arm symptoms at a mean of 10 years from treatment for breast cancer, although rates of severe symptoms were low (<10%). Attention is warranted to the arm morbidity related to both axillary and breast surgery during treatment counseling and survivorship.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mirelle Lagendijk
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Samantha Grossmith
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Melissa Hughes
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Nancy U Lin
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - A Heather Eliassen
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Departments of Nutrition and Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Laura S Dominici
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Schwieger L, Postlewait LM, Subhedar PD, Geng F, Liu Y, Gillespie T, Arciero CA. Patterns of completion axillary dissection for patients with cT1-2N0 breast cancer undergoing total mastectomy with positive sentinel lymph nodes. J Surg Oncol 2024; 129:468-480. [PMID: 37955191 DOI: 10.1002/jso.27503] [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: 09/08/2023] [Revised: 10/21/2023] [Accepted: 10/21/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND AND OBJECTIVES The ACOSOGZ0011 trial found that overall survival (OS) for patients with 1-2 positive nodes undergoing sentinel lymph node biopsy-alone (SLNB) was noninferior to completion axillary lymph node dissection (ALND), but excluded patients undergoing mastectomy. Our study examined patterns of ALND and its relationship with OS for SLNB-positive patients undergoing mastectomy. METHODS The National Cancer Database was queried (2010-2017) for patients with cT1-2N0 breast cancer undergoing mastectomy with positive sentinel lymph nodes. Clinical data were compared. RESULTS Of 20 001 patients, 11 574 (57.9%) underwent SLNB + ALND, and 8427 (42.1%) had SLNB-alone. The SLNB + ALND group had more positive nodes (mean 2.6 vs. 1.3, p < 0.001) and more frequently received nodal radiation (33.4% vs. 28.9%, p < 0.001). Patients diagnosed in later years were less likely to undergo ALND (2010: reference; 2017: odds ratio: 0.29, 95% confidence interval [CI]: 0.25-0.33, p < 0.001). ALND (hazard ratio [HR]: 0.97, 95% CI: 0.89-1.06, p = 0.49) and nodal radiation (HR: 0.92, 95% CI: 0.83-1.02, p = 1.06) were not independently associated with OS. Propensity-score matched 5-year OS was similar (SLNB + ALND: 90.9% vs. SLNB-alone: 90.3%, p = 0.65). CONCLUSION For patients undergoing mastectomy for cT1-2N0 breast cancer with positive SLNB, SLNB-alone was common and increased over time. Axillary radiation was not routinely delivered in the SLNB-alone group. Completion ALND and nodal radiation were not associated with improved survival.
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Affiliation(s)
- Lara Schwieger
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Glenn Family Breast Center, Emory University, Atlanta, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Preeti D Subhedar
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Glenn Family Breast Center, Emory University, Atlanta, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Feifei Geng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Yuan Liu
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Theresa Gillespie
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Cletus A Arciero
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Glenn Family Breast Center, Emory University, Atlanta, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Novick K, Chadha M, Daroui P, Freedman G, Gao W, Hunt K, Park C, Rewari A, Suh W, Walker E, Wong J, Harris EE. American Radium Society Appropriate Use Criteria Postmastectomy Radiation Therapy: Executive Summary of Clinical Topics. Int J Radiat Oncol Biol Phys 2024; 118:458-465. [PMID: 37478956 DOI: 10.1016/j.ijrobp.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To conduct an appropriate use criteria expert panel update on clinical topics relevant to current clinical practice regarding postmastectomy radiation therapy (PMRT). METHODS AND MATERIALS An analysis of the medical literature from peer-reviewed journals was conducted from May 4, 2010 to May 4, 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to search the PubMed database to retrieve a comprehensive set of relevant articles. A well-established methodology (modified Delphi) was used by the expert panel to rate the appropriate use of procedures. RESULTS Evidence for key questions in PMRT regarding benefit in special populations and technical considerations for delivery was examined and described. Risk factors for local-regional recurrence in patients with intermediate-risk disease that indicate benefit of PMRT include molecular subtype, age, clinical stage, and pathologic response to neoadjuvant chemotherapy. Use of hypofractionated radiation in PMRT has been examined in several recent randomized trials and is under investigation for patients with breast reconstruction. The use of bolus varies significantly by practice region and has limited evidence for routine use. Adverse effects occurred with both PMRT preimplant and postimplant exchange in 2-staged breast reconstruction. CONCLUSIONS Most patients with even limited nodal involvement will likely benefit from PMRT with significant reduction in local-regional recurrence and potential survival. Patients with initial clinical stage III disease and/or any residual disease after neoadjuvant chemotherapy should be strongly considered for PMRT. Growing evidence supports the use of hypofractionated radiation for PMRT with equivalent efficacy and decreased acute side effects, but additional evidence is needed for special populations. There is limited evidence to support routine use of bolus in all patients. Timing of PMRT regarding completion of 2-staged breast reconstruction requires a discussion of increased risks with radiation postimplant exchange compared with increased risk of failure of reconstruction or surgical complications with radiation preimplant exchange.
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Affiliation(s)
- Kristina Novick
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Manjeet Chadha
- Department of Radiation Oncology, Mount Sinai, New York, New York
| | - Parima Daroui
- Department of Radiation Oncology, Southern California Permanente Medical Group, Los Angeles, California
| | - Gary Freedman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wendy Gao
- Tacoma Valley Radiation Oncology Centers, Tacoma, Washington
| | - Kelly Hunt
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Catherine Park
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Amar Rewari
- Department of Radiation Oncology, Ann Arundel Medical Center, Annapolis, Maryland
| | - Warren Suh
- Department of Radiation Oncology, Ridely Tree Cancer Center, Santa Barbara, California
| | - Eleanor Walker
- Department of Radiation Oncology, Henry Ford Health, Detroit, Michigan
| | - Julia Wong
- Department of Radiation Oncology, Dana Farber Brigham Cancer Center, Boston, Massachusetts
| | - Eleanor E Harris
- Department of Radiation Oncology, St. Luke's University Health Network, Easton, Pennsylvania
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Loibl S, André F, Bachelot T, Barrios CH, Bergh J, Burstein HJ, Cardoso MJ, Carey LA, Dawood S, Del Mastro L, Denkert C, Fallenberg EM, Francis PA, Gamal-Eldin H, Gelmon K, Geyer CE, Gnant M, Guarneri V, Gupta S, Kim SB, Krug D, Martin M, Meattini I, Morrow M, Janni W, Paluch-Shimon S, Partridge A, Poortmans P, Pusztai L, Regan MM, Sparano J, Spanic T, Swain S, Tjulandin S, Toi M, Trapani D, Tutt A, Xu B, Curigliano G, Harbeck N. Early breast cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2024; 35:159-182. [PMID: 38101773 DOI: 10.1016/j.annonc.2023.11.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Affiliation(s)
- S Loibl
- GBG Forschungs GmbH, Neu-Isenburg; Centre for Haematology and Oncology, Bethanien, Frankfurt, Germany
| | - F André
- Breast Cancer Unit, Medical Oncology Department, Gustave Roussy, Cancer Campus, Villejuif
| | - T Bachelot
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - C H Barrios
- Oncology Department, Latin American Cooperative Oncology Group and Oncoclínicas, Porto Alegre, Brazil
| | - J Bergh
- Department of Oncology-Pathology, Bioclinicum, Karolinska Institutet and Breast Cancer Centre, Karolinska Comprehensive Cancer Centre and University Hospital, Stockholm, Sweden
| | - H J Burstein
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - M J Cardoso
- Breast Unit, Champalimaud Foundation, Champalimaud Cancer Centre, Lisbon; Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - L A Carey
- Division of Medical Oncology, The University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, USA
| | - S Dawood
- Department of Oncology, Mediclinic City Hospital, Dubai, UAE
| | - L Del Mastro
- Medical Oncology Clinic, IRCCS Ospedale Policlinico San Martino, Genoa; Department of Internal Medicine and Medical Specialities, School of Medicine, University of Genoa, Genoa, Italy
| | - C Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Giessen and Marburg, Marburg
| | - E M Fallenberg
- Department of Diagnostic and Interventional Radiology, School of Medicine & Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - P A Francis
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - H Gamal-Eldin
- Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - K Gelmon
- Department of Medical Oncology, British Columbia Cancer, Vancouver, Canada
| | - C E Geyer
- Department of Internal Medicine, Hillman Cancer Center, University of Pittsburgh, Pittsburgh, USA
| | - M Gnant
- Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
| | - V Guarneri
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova; Oncology 2 Unit, Istituto Oncologico Veneto IOV IRCCS, Padova, Italy
| | - S Gupta
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - S B Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - M Martin
- Hospital General Universitario Gregorio Maranon, Universidad Complutense, GEICAM, Madrid, Spain
| | - I Meattini
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence; Department of Experimental and Clinical Biomedical Sciences 'M. Serio', University of Florence, Florence, Italy
| | - M Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - W Janni
- Department of Obstetrics and Gynaecology, University of Ulm, Ulm, Germany
| | - S Paluch-Shimon
- Sharett Institute of Oncology Department, Hadassah University Hospital & Faculty of Medicine Hebrew University, Jerusalem, Israel
| | - A Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - L Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven
| | - M M Regan
- Division of Biostatistics, Dana-Farber Cancer Institute, Harvard Medical School, Boston
| | - J Sparano
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - T Spanic
- Europa Donna Slovenia, Ljubljana, Slovenia
| | - S Swain
- Medicine Department, Georgetown University Medical Centre and MedStar Health, Washington, USA
| | - S Tjulandin
- N.N. Blokhin National Medical Research Centre of Oncology, Moscow, Russia
| | - M Toi
- Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, Bunkyo-ku, Japan
| | - D Trapani
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - A Tutt
- Breast Cancer Research Division, The Institute of Cancer Research, London; Comprehensive Cancer Centre, Division of Cancer Studies, Kings College London, London, UK
| | - B Xu
- Department of Medical Oncology, National Cancer Centre/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - G Curigliano
- Early Drug Development for Innovative Therapies Division, Istituto Europeo di Oncologia, IRCCS, Milan; Department of Oncology and Hemato-Oncology, University of Milano, Milan, Italy
| | - N Harbeck
- Breast Centre, Department of Obstetrics & Gynaecology and Comprehensive Cancer Centre Munich, LMU University Hospital, Munich, Germany
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Li C, Zhang P, Lv J, Dong W, Hu B, Zhang J, Zhu H. Axillary management in patients with clinical node-negative early breast cancer and positive sentinel lymph node: a systematic review and meta-analysis. Front Oncol 2024; 13:1320867. [PMID: 38260843 PMCID: PMC10800700 DOI: 10.3389/fonc.2023.1320867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/13/2023] [Indexed: 01/24/2024] Open
Abstract
Background The omission of axillary lymph node dissection (ALND) or axillary radiation (AxRT) remains controversial in patients with clinical node-negative early breast cancer and a positive sentinel lymph node. Methods We conducted a comprehensive review by searching PubMed, Embase, Web of Science, and Cochrane databases (up to November 2023). Our primary outcomes were overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and axillary recurrence (AR). Results We included 26 studies encompassing 145,548 women with clinical node-negative early breast cancer and positive sentinel lymph node. Pooled data revealed no significant differences between ALND and sentinel lymph node biopsy (SLNB) alone in terms of OS (hazard ratio [HR]0.99, 95% confidence interval [CI] 0.91-1.08, p=0.84), DFS (HR 1.04, 95% CI 0.90-1.19, p=0.61), LRR (HR 0.76, 95% CI 0.45-1.20, p=0.31), and AR (HR 1.01, 95% CI 0.99-1.03, p=0.35). Similarly, no significant differences were observed between AxRT and SLNB alone for OS (HR 0.57, 95% CI 0.32-1.02, p=0.06) and DFS (HR 0.52, 95% CI 0.26-1.05, p=0.07). When comparing AxRT and ALND, a trend towards higher OS was observed the AxRT group (HR 0.08, 95% CI 0.67-1.15), but the difference did not reach statistical significance (p=0.35, I2 = 0%). Additionally, no significant differences significance observed for DFS or AR (p=0.13 and p=0.73, respectively) between the AxRT and ALND groups. Conclusion Our findings suggest that survival and recurrence rates are not inferior in patients with clinical node-negative early breast cancer and a positive sentinel lymph node who receive SLNB alone compared to those undergoing ALND or AxRT.
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Affiliation(s)
- Changzai Li
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Pan Zhang
- College of Nursing and Rehabilitation, North China University of Science and Technology, Tangshan, Hebei, China
| | - Jie Lv
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Wei Dong
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Baoshan Hu
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Jinji Zhang
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Hongcheng Zhu
- Department of Oncological Surgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
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Zaborowski AM, Doogan K, Clifford S, Dowling G, Kazi F, Delaney K, Yadav H, Brady A, Geraghty J, Evoy D, Rothwell J, McCartan D, Heeney A, Barry M, Walsh SM, Stokes M, Kell MR, Allen M, Power C, Hill ADK, Connolly E, Alazawi D, Boyle T, Corrigan M, O’Leary P, Prichard RS. Nodal positivity in patients with clinically and radiologically node-negative breast cancer treated with neoadjuvant chemotherapy: multicentre collaborative study. Br J Surg 2024; 111:znad401. [PMID: 38055888 PMCID: PMC10763529 DOI: 10.1093/bjs/znad401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/06/2023] [Accepted: 11/05/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND The necessity of performing a sentinel lymph node biopsy in patients with clinically and radiologically node-negative breast cancer after neoadjuvant chemotherapy has been questioned. The aim of this study was to determine the rate of nodal positivity in these patients and to identify clinicopathological features associated with lymph node metastasis after neoadjuvant chemotherapy (ypN+). METHODS A retrospective multicentre study was performed. Patients with cT1-3 cN0 breast cancer who underwent sentinel lymph node biopsy after neoadjuvant chemotherapy between 2016 and 2021 were included. Negative nodal status was defined as the absence of palpable lymph nodes, and the absence of suspicious nodes on axillary ultrasonography, or the absence of tumour cells on axillary nodal fine needle aspiration or core biopsy. RESULTS A total of 371 patients were analysed. Overall, 47 patients (12.7%) had a positive sentinel lymph node biopsy. Nodal positivity was identified in 22 patients (29.0%) with hormone receptor+/human epidermal growth factor receptor 2- tumours, 12 patients (13.8%) with hormone receptor+/human epidermal growth factor receptor 2+ tumours, 3 patients (5.6%) with hormone receptor-/human epidermal growth factor receptor 2+ tumours, and 10 patients (6.5%) with triple-negative breast cancer. Multivariable logistic regression analysis showed that multicentric disease was associated with a higher likelihood of ypN+ (OR 2.66, 95% c.i. 1.18 to 6.01; P = 0.018), whilst a radiological complete response in the breast was associated with a reduced likelihood of ypN+ (OR 0.10, 95% c.i. 0.02 to 0.42; P = 0.002), regardless of molecular subtype. Only 3% of patients who had a radiological complete response in the breast were ypN+. The majority of patients (85%) with a positive sentinel node proceeded to axillary lymph node dissection and 93% had N1 disease. CONCLUSION The rate of sentinel lymph node positivity in patients who achieve a radiological complete response in the breast is exceptionally low for all molecular subtypes.
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Affiliation(s)
| | - Katie Doogan
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Siobhan Clifford
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gavin Dowling
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Farah Kazi
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Karina Delaney
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Himanshu Yadav
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Aaron Brady
- Department of Breast Surgery, Bon Secours Hospital Cork, Cork, Ireland
| | - James Geraghty
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Denis Evoy
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Jane Rothwell
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Damian McCartan
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Anna Heeney
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mitchel Barry
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Siun M Walsh
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Maurice Stokes
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Malcolm R Kell
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Allen
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Colm Power
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Arnold D K Hill
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Dhafir Alazawi
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Terence Boyle
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Mark Corrigan
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Peter O’Leary
- Department of Breast Surgery, Bon Secours Hospital Cork, Cork, Ireland
| | - Ruth S Prichard
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
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Sakai T, Kutomi G, Shien T, Asaga S, Aruga T, Ishitobi M, Kuba S, Sawaki M, Terata K, Tomita K, Yamauchi C, Yamamoto Y, Iwata H, Saji S. The Japanese Breast Cancer Society Clinical Practice Guidelines for surgical treatment of breast cancer, 2022 edition. Breast Cancer 2024; 31:1-7. [PMID: 37843765 DOI: 10.1007/s12282-023-01510-0] [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: 09/20/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023]
Abstract
The 2022 revision of the Japanese Breast Cancer Society (JBCS) Clinical Practice Guidelines for surgical treatment of breast cancer was updated following a systematic review of the literature using the Medical Information Network Distribution Service (MINDS) procedure, which focuses on the balance of benefits and harms for various clinical questions (CQs). Experts in surgery designated by the JBCS addressed five areas: breast surgery, axillary surgery, breast reconstruction, surgical treatment for recurrent and metastatic breast cancer, and other related topics. The revision of the guidelines encompassed 4 CQs, 7 background questions (BQs), and 14 future research questions (FRQs). A significant revision in the 2022 edition pertained to axillary management after neoadjuvant chemotherapy in CQ2. The primary aim of the 2022 JBCS Clinical Practice Guidelines is to provide evidence-based recommendations to empower patients and healthcare professionals in making informed decisions regarding surgical treatment for breast cancer.
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Affiliation(s)
- Takehiko Sakai
- Department of Breast Surgical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Goro Kutomi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University Hospital, Sapporo, Hokkaido, Japan
| | - Tadahiko Shien
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
| | - Sota Asaga
- Department of Breast Surgery, Keiyu Hospital, Yokohama, Japan
| | - Tomoyuki Aruga
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Makoto Ishitobi
- Department of Breast Surgery, Mie University School of Medicine, Mie, Japan
| | - Sayaka Kuba
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masataka Sawaki
- Department of Breast Oncology, Aichi Cancer Center Hospital, Aichi, Japan
| | - Kaori Terata
- Department of Breast and Endocrine Surgery, Akita University Hospital, Akita, Japan
| | - Koichi Tomita
- Department of Plastic and Reconstructive Surgery, Kindai University, Osaka, Japan
| | - Chikako Yamauchi
- Department of Radiation Oncology, Shiga General Hospital, Shiga, Japan
| | - Yutaka Yamamoto
- Department of Breast and Endocrine Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Aichi, Japan
| | - Shigehira Saji
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
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Turashvili G, Gjeorgjievski SG, Wang Q, Ewaz A, Ai D, Li X, Badve SS. Intraoperative assessment of axillary sentinel lymph nodes by telepathology. Breast Cancer Res Treat 2023; 202:423-434. [PMID: 37688667 DOI: 10.1007/s10549-023-07101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 08/17/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE Although axillary dissection is no longer indicated for many breast cancer patients with 1-2 positive axillary sentinel lymph nodes (ASLN), intraoperative ASLN assessment is still performed in many institutions for patients undergoing mastectomy or neoadjuvant therapy. With recent advancements in digital pathology, pathologists increasingly evaluate ASLN via remote telepathology. We aimed to compare the performance characteristics of remote telepathology and conventional on-site intraoperative ASLN assessment. METHODS Data from ASLN evaluation for breast cancer patients performed at two sites between April 2021 and October 2022 was collated. Remote telepathology consultation was conducted via the Aperio eSlideManager system. RESULTS A total of 385 patients were identified during the study period (83 telepathology, 302 on-site evaluations). Although not statistically significant (P = 0.20), the overall discrepancy rate between intraoperative and final diagnoses was slightly higher at 9.6% (8/83) for telepathology compared with 5.3% (16/302) for on-site assessment. Further comparison of performance characteristics of ASLN assessment between telepathology and conventional on-site evaluation revealed no statistically significant differences between deferral rates, discrepancy rates, interpretive or sampling errors, major or minor disagreements, false negative or false positive results as well as clinical impact and turn-around time (P ≥ 0.12). CONCLUSION ASLN assessment via telepathology is not significantly different from conventional on-site evaluation, although it shows a slightly higher overall discrepancy rate between intraoperative and final diagnoses (9.6% vs. 5.3%). Further studies are warranted to ensure accuracy of ASLN assessment via telepathology.
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Affiliation(s)
- Gulisa Turashvili
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Sandra Gjorgova Gjeorgjievski
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Qun Wang
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Abdulwahab Ewaz
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Di Ai
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Xiaoxian Li
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Sunil S Badve
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
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Banys-Paluchowski M, Hartmann S, Ditsch N, Krawczyk N, Kühn T, de Boniface J, Banys-Kotomska J, Rody A, Krug D. Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy. Breast Care (Basel) 2023; 18:428-439. [PMID: 38130814 PMCID: PMC10731028 DOI: 10.1159/000533748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer. Summary Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement. Key Messages Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, Rostock, Germany
| | - Nina Ditsch
- Breast Cancer Center, Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Die Filderklinik, Filderstadt, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St. Göran’s Hospital, Stockholm, Sweden
| | - Joanna Banys-Kotomska
- I Department and Clinic of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer. Cancers (Basel) 2023; 15:5353. [PMID: 38001613 PMCID: PMC10670757 DOI: 10.3390/cancers15225353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
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38
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Curigliano G, Burstein HJ, Gnant M, Loibl S, Cameron D, Regan MM, Denkert C, Poortmans P, Weber WP, Thürlimann B. Understanding breast cancer complexity to improve patient outcomes: The St Gallen International Consensus Conference for the Primary Therapy of Individuals with Early Breast Cancer 2023. Ann Oncol 2023; 34:970-986. [PMID: 37683978 DOI: 10.1016/j.annonc.2023.08.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
The 18th St Gallen International Breast Cancer Conference held in March 2023, in Vienna, Austria, assessed significant new findings for local and systemic therapies for early breast cancer with a focus on the evaluation of multimodal treatment options. The emergence of more effective, innovative agents in both the preoperative (primary or neoadjuvant) and post-operative (adjuvant) settings has underscored the pivotal role of a multidisciplinary approach in treatment decision making, particularly when selecting systemic therapy for an individual patient. The importance of multidisciplinary discussions regarding the clinical benefits of interventions was explicitly emphasized by the consensus panel as an integral part of developing an optimal treatment plan with the 'right' degree of intensity and duration. The panelists focused on controversies surrounding the management of common ductal/no special type and lobular breast cancer histology, which account for the vast majority of breast tumors. The expert opinion of the panelists was based on interpretations of available data, as well as current practices in their professional environments, personal and socioeconomic factors affecting patients, and cognizant of varying reimbursement and accessibility constraints around the world. The panelists strongly advocated patient participation in well-designed clinical studies whenever feasible. With these considerations in mind, the St Gallen Consensus Conference aims to offer guidance to clinicians regarding appropriate treatments for early-stage breast cancer and assist in balancing the realistic trade-offs between treatment benefit and toxicity, enabling patients and clinicians to make well-informed choices through a shared decision-making process.
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Affiliation(s)
- G Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - H J Burstein
- Medical Oncology, Dana-Farber Cancer Institute, Boston; Harvard Medical School, Boston, USA.
| | - M Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna; Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - S Loibl
- Center for Hematology and Oncology Bethanien, Frankfurt; German Breast Group, Neu-Isenburg, Germany
| | - D Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh and NHS Lothian, Edinburgh, UK
| | - M M Regan
- International Breast Cancer Study Group Statistical Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - C Denkert
- Institut für Pathologie, Philipps-Universität Marburg und Universitätsklinikum Marburg, Marburg, Germany
| | - P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - W P Weber
- Department of Surgery, University Hospital Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland
| | - B Thürlimann
- SwissBreastCare, Bethanienspital, Zürich, Switzerland; SONK Foundation, St. Gallen, Switzerland
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Wang J, Wu SG. Breast Cancer: An Overview of Current Therapeutic Strategies, Challenge, and Perspectives. BREAST CANCER (DOVE MEDICAL PRESS) 2023; 15:721-730. [PMID: 37881514 PMCID: PMC10596062 DOI: 10.2147/bctt.s432526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
Breast cancer is the most commonly diagnosed cancer and the leading cause of death among female patients, which seriously threatens the health of women in the whole world. The treatments of breast cancer require the cooperation of a multidisciplinary setting and taking tumor load and molecular makers into account. For early breast cancer, breast-conserving surgery with radiotherapy or mastectomy alone remains the standard management, and the administration of adjuvant systemic therapy is decided by the status of lymph nodes, hormone receptors, and human epidermal growth factor receptor-2. For metastatic breast cancer, the goal of treatments is to prolong survival and maintain quality of life. This review will present the current advances and controversies of surgery, chemotherapy, radiotherapy, endocrine therapy, targeted therapy, immunotherapy, gene therapy, and other innovative treatment strategies in early-stage and metastatic breast cancer.
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Affiliation(s)
- Jun Wang
- Department of Head and Neck Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - San-Gang Wu
- Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, People’s Republic of China
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Naoum GE, Taghian AG. Regional Lymph Node Radiation Is Not the Main Risk Factor for Breast Cancer Related Lymphedema: Stop Chasing Radiation Doses, Fractionation or Techniques-Focus on Axillary Surgery De-escalation or Prevention. Int J Radiat Oncol Biol Phys 2023; 117:461-464. [PMID: 37652608 DOI: 10.1016/j.ijrobp.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 09/02/2023]
Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Northwestern University Memorial Hospital, Chicago, Illinois.
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Pride RM, Glass CC, Nakhlis F, Laws A, Weiss AC, Bellon JR, Mittendorf EA, King TA, Kantor O. Intraoperative Pathology Assessment May Lead to Overtreatment of the Axilla in Clinically Node-Negative Breast Cancer Patients Undergoing Upfront Mastectomy. Ann Surg Oncol 2023; 30:5978-5987. [PMID: 37436607 DOI: 10.1245/s10434-023-13898-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Randomized trials have established the safety of observation or axillary radiation (AxRT) as an alternative to axillary lymph node dissection (ALND) in patients with limited nodal disease who undergo upfront surgery. Variability remains in axillary management strategies in cN0 patients undergoing mastectomy found to have one to two positive sentinel lymph nodes (SLNs). We examined the impact of intraoperative pathology assessment in axillary management in a national cohort of AMAROS-eligible mastectomy patients. METHODS The National Cancer Database was used to identify AMAROS-eligible cT1-2N0 breast cancer patients undergoing upfront mastectomy and SLN biopsy (SLNB) and found to have one to two positive SLNs, from 2018 to 2019. We constructed a variable defining intraoperative pathology as 'not performed/not acted on' if ALND was either not performed or performed at a later date than SLNB, or 'performed/acted on' if SLNB and ALND were completed on the same day. Adjusted multivariable analysis examined predictors of treatment with both ALND and AxRT. RESULTS Overall, 8222 patients with cT1-2N0 disease underwent upfront mastectomy and had one to two positive SLNs. Intraoperative pathology was performed/acted on in 3057 (37.2%) patients. These patients were significantly more likely to have both ALND and AxRT than those without intraoperative pathology (41.0% vs. 4.9%; p < 0.001). On multivariate analysis, the strongest predictor of receiving both ALND and AxRT was use of intraoperative pathology (odds ratio 8.99, 95% confidence interval 7.70-10.5; p < 0.001). CONCLUSIONS We advocate that consideration should be made for omission of routine intraoperative pathology in mastectomy patients likely to be recommended postmastectomy radiation to minimize axillary overtreatment with both ALND and AxRT in appropriate patients.
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Affiliation(s)
- Robert M Pride
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Charity C Glass
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Faina Nakhlis
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anna C Weiss
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jennifer R Bellon
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Chen F, Li X, Lin X, Chen L, Lin Z, Wu H, Chen J. Can Axillary Lymph Node Dissection be Omitted in Breast Cancer Patients with Metastatic Sentinel Lymph Nodes Undergoing Mastectomy? A Systematic Review and Meta-Analysis of Real-World Evidence. World J Surg 2023; 47:2446-2456. [PMID: 37249632 DOI: 10.1007/s00268-023-07072-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND The omission of axillary lymph node dissection (ALND) in patients with breast cancer who have metastatic sentinel lymph nodes (SLNs) undergoing mastectomy remains controversial. This meta-analysis explored the clinicopathological factors affecting the selection of ALND and the influences of ALND on survival outcomes in patients receiving mastectomy with positive SLNs. METHODS Eligible studies published prior to 31 December 2022 were selected by searching the Embase, Web of Science and PubMed databases. Pooled analyses were performed using the number of events for clinicopathological parameters and HRs with 95% CIs for survival outcomes including disease-free survival (DFS), overall survival (OS), distant recurrence-free survival (DRFS) and locoregional recurrence-free survival (LRFS). RESULTS A total of 10 retrospective studies enrolling only breast cancer patients with limited SLN metastases (no more than 3 positive SLNs or micrometastatic SLNs) undergoing mastectomy were included. Performing ALND in mastectomy patients who had limited SLN metastases was significantly correlated with invasive ductal carcinomas, larger tumors, lymphovascular invasion, higher tumor grade, macrometastatic SLNs, more positive SLNs, extranodal extension, positive surgical margins, negative ER, administration of adjuvant chemotherapy and nonwhite race (P < 0.05). However, performing ALND did not result in significantly longer OS, DFS, LRFS or DRFS (P > 0.05) in these patients. CONCLUSION The present meta-analysis indicated that ALND may be safely avoided in patients with breast cancer who had limited SLN metastases undergoing mastectomy. Further well-designed randomized clinical trials are warranted to validate our results.
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Affiliation(s)
- Fulong Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Xiaowen Li
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Xianjun Lin
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Lijia Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Zhaoling Lin
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Hao Wu
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China
| | - Jishang Chen
- Department of Breast Surgery, Yangjiang People's Hospital (Affiliated Yangjiang Hospital of Guangdong Medical University), No. 42 of Dongshan Road, Jiangcheng District, Yangjiang, 529500, China.
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Healy E, Beyer S, Jhawar S, White JR, Bazan JG. The Axillary Lateral Vessel Thoracic Junction Is Not an Organ at Risk for Breast Cancer-Related Lymphedema. Int J Radiat Oncol Biol Phys 2023; 117:452-460. [PMID: 37059233 DOI: 10.1016/j.ijrobp.2023.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/21/2023] [Accepted: 04/03/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) is a treatment complication that significantly reduces patient quality of life. Regional nodal irradiation (RNI) may increase the risk of BCRL. Recently, a region of the axilla known as the axillary-lateral thoracic vessel juncture (ALTJ) was identified as a potential organ at risk (OAR). Here, we set out to validate whether radiation dose to the ALTJ is associated with BCRL. METHODS AND MATERIALS We identified patients with stage II-III breast cancer treated with adjuvant RNI from 2013 to 2018, excluding those with BCRL preradiation. We defined BCRL as difference in arm circumference between the ipsilateral and contralateral limb >2.5 cm at any 1 encounter or ≥2 cm on ≥2 visits. All patients suspected of having BCRL at routine follow-up visits were referred to physical therapy for confirmation. The ALTJ was retrospectively contoured and dose metrics were collected. Cox proportional hazards regression models were used to test the association between clinical and dosimetric parameters with the development of BCRL. RESULTS The study population included 378 patients with a median age of 53 years, median body mass index of 28.4 kg/m2, and median of 18 axillary nodes removed; 71% underwent mastectomy. Median follow-up was 70 months (interquartile range, 55-89.7 months). BCRL developed in 101 patients at a median of 18.9 months (interquartile range, 9.9-32.4 months), with a corresponding 5-year cumulative incidence BCRL of 25.8%. On multivariate analysis, none of the ALTJ metrics were associated with BCRL risk. Only increasing age, increasing body mass index, and increasing number of nodes were associated with a higher risk of developing BCRL. The 6-year locoregional recurrence rate was 3.2%, the axillary recurrence rate was 1.7%, and the isolated axillary recurrence rate was 0%. CONCLUSIONS The ALTJ is not validated as a critical OAR for reducing BCRL risk. Until such an OAR is discovered, the axillary PTV should not be modified or dose reduced in efforts to reduce BCRL.
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Affiliation(s)
- Erin Healy
- Department of Radiation Oncology, UCI Chao Family Comprehensive Cancer Center, Orange, California; Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sachin Jhawar
- Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Julia R White
- Department of Radiation Oncology, University of Kansas Comprehensive Cancer Center, Kansas City, Kansas
| | - Jose G Bazan
- Department of Radiation Oncology, UCI Chao Family Comprehensive Cancer Center, Orange, California; Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio; Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California.
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Alkner S, de Boniface J, Lundstedt D, Mjaaland I, Ryden L, Vikstrom J, Bendahl PO, Holmberg E, Sackey H, Wieslander E, Karlsson P. Protocol for the T-REX-trial: tailored regional external beam radiotherapy in clinically node-negative breast cancer patients with 1-2 sentinel node macrometastases - an open, multicentre, randomised non-inferiority phase 3 trial. BMJ Open 2023; 13:e075543. [PMID: 37751948 PMCID: PMC10533703 DOI: 10.1136/bmjopen-2023-075543] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Modern systemic treatment has reduced incidence of regional recurrences and improved survival in breast cancer (BC). It is thus questionable whether regional radiotherapy (RT) is still beneficial in patients with sentinel lymph node (SLN) macrometastasis. Postoperative regional RT is associated with an increased risk of arm morbidity, pneumonitis, cardiac disease and secondary cancer. Therefore, there is a need to individualise regional RT in relation to the risk of recurrence. METHODS AND ANALYSIS In this multicentre, prospective randomised trial, clinically node-negative patients with oestrogen receptor-positive, HER2-negative BC and 1-2 SLN macrometastases are eligible. Participants are randomly assigned to receive regional RT (standard arm) or not (intervention arm). Regional RT includes the axilla level I-III, the supraclavicular fossa and in selected patients the internal mammary nodes. Both groups receive RT to the remaining breast. Chest-wall RT after mastectomy is given in the standard arm, but in the intervention arm only in cases of widespread multifocality according to national guidelines. RT quality assurance is an integral part of the trial.The trial aims to include 1350 patients between March 2023 and December 2028 in Sweden and Norway. Primary outcome is recurrence-free survival (RFS) at 5 years. Non-inferiority will be declared if outcome in the de-escalation arm is not >4.5 percentage units below that with regional RT, corresponding to an HR of 1.41 assuming 88% 5-year RFS with standard treatment. Secondary outcomes include locoregional recurrence, overall survival, patient-reported arm morbidity and health-related quality of life. Gene expression analysis and tumour tissue-based studies to identify prognostic and predictive markers for benefit of regional RT are included. ETHICS AND DISSEMINATION The trial protocol is approved by the Swedish Ethics Authority (Dnr-2022-02178-01, 2022-05093-02, 2023-00826-02, 2023-03035-02). Results will be presented at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05634889.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Ingvil Mjaaland
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Lisa Ryden
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Johan Vikstrom
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Pär-Ola Bendahl
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Helena Sackey
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Elinore Wieslander
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
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Bollet MA, Racadot S, Rivera S, Arnaud A, Bourgier C. [Breast cancer radiation therapy: Current questions in 2023]. Cancer Radiother 2023; 27:524-530. [PMID: 37541797 DOI: 10.1016/j.canrad.2023.07.005] [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: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 08/06/2023]
Abstract
Radiation therapy is a corner stone of breast cancer treatment as it has been shown postoperatively that it improves local control and overall survival. In recent years, multidisciplinary therapeutic strategies have evolved considerably for early-stage breast cancer, both surgically and in terms of systemic treatments or radiation therapy. Each of these developments affects other treatment components and open up new questions allowing even more personalized treatments. Essentially normofractionated a few years ago, breast radiation therapy is today very largely moderately or even ultra hypofractionated. De-escalation of the surgery of the axilla has changed the indications for lymph node radiation therapy keeping similar efficacy with reduced toxicity. Indications for radiation therapy after neoadjuvant chemotherapy remain based on pre-chemotherapy staging pending the results of ongoing randomized studies. The addition of a boost to the tumor bed significantly reduces the risk of local recurrence, but the magnitude of this benefit decreases with increasing age. The main risk factors for local recurrence are young age, the associated extended ductal in situ component, hormone receptor negative and high-grade status. The results of the simultaneous integrated boost (SIB) seem similar with normo- or moderately hypofractionated radiation therapy regimen.
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Affiliation(s)
- M A Bollet
- Institut de radiothérapie Hartmann, 4, rue Kléber, 92300 Levallois-Perret, France; Institut français du sein, 15, rue Jean-Nicot, 75007 Paris, France
| | - S Racadot
- Département d'oncologie radiothérapie, centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - S Rivera
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; UMR 1030, université Paris-Saclay, Gustave-Roussy, 94805 Villejuif, France.
| | - A Arnaud
- Institut du cancer Sainte-Catherine, Avignon, France
| | - C Bourgier
- Fédération universitaire d'oncologie radiothérapie de Méditerranée Occitanie, Institut du cancer de Montpellier (ICM), université de Montpellier, Inserm U1194, IRCM, Montpellier, France
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De Rose F, Colciago RR, Lucidi S, La Rocca E, Prisco A, Bonzano E, Meduri B, De Santis MC, Dicuonzo S, Pasinetti N, Palumbo I, Meattini I, Franco P. Axillary Management in Breast Cancer Patients Undergoing Upfront Surgery: Results from a Nationwide Survey on Behalf of the Clinical Oncology Breast Cancer Group (COBCG) and the Breast Cancer Study Group of the Italian Association of Radiotherapy and Clinical Oncology (AIRO). Curr Oncol 2023; 30:7489-7498. [PMID: 37623023 PMCID: PMC10453508 DOI: 10.3390/curroncol30080542] [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: 06/12/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND We assessed the current practice concerning the axillary management of breast cancer (BC) patients undergoing upfront surgery among radiation oncologists (ROs) practising in Italy. METHODS An online survey via SurveyMonkey (including 21 questions) was distributed amongst ROs in Italy through personal contacts and the Italian Association for Radiotherapy and Clinical Oncology (AIRO) network from August to September 2022. We particularly focused on the emerging omission of axillary lymph node dissection (ALND) in the presence of 1-2 sentinel node-positive patients and the consequent change in the role of regional nodal irradiation (RNI). RESULTS A total of 101/195 (51% response rate) Italian Radiotherapy Cancer Care Centres answered the survey. With respect to patients with 1-2 sentinel node-positive, the relative proportion of respondents that offer patients ALND a) always, b) only in selected cases, and c) never was 37.6%, 60.4%, and 2.0%, respectively, with no significant geographical (North vs. Centre-South Italy; p = 0.92) or institutional (Academic vs. non-Academic; p = 0.49) differences. Radiation therapy indications varied widely in patients who did not undergo ALND. Among these, about a third of the respondents (17/56, 30.4%) stated that RNI was constantly performed. On the other hand, half of the respondents offered RNI in selected cases, stating that an unfavourable biologic tumour profile and extracapsular nodal extension were considered drivers of their decision. CONCLUSIONS Results of the present survey show the variability of axillary management offered in clinical practice for BC patients undergoing conserving surgery upfront in Italy. Analysis of these attitudes may trigger the modification of some clinical approaches through multidisciplinary collaboration and create the background for future clinical investigations.
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Affiliation(s)
- Fiorenza De Rose
- Department of Radiation Oncology, Santa Chiara Hospital, 38122 Trento, Italy;
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
| | - Riccardo Ray Colciago
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milano, Italy
| | - Sara Lucidi
- Department of Radiation Oncology, Santa Chiara Hospital, 38122 Trento, Italy;
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
| | - Eliana La Rocca
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Integrata, 37126 Verona, Italy
| | - Agnese Prisco
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Department of Radiation Oncology, University Hospital of Udine, ASUFC, 33100 Udine, Italy
| | - Elisabetta Bonzano
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Radiation Oncology Department, Fondazione IRCCS Policlinico San Matteo and University of Pavia, 27100 Pavia, Italy
| | - Bruno Meduri
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Department of Radiation Oncology, University Hospital of Modena, 41125 Modena, Italy
| | - Maria Carmen De Santis
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milano, Italy
| | - Samantha Dicuonzo
- Division of Radiotherapy, IEO, European Institute of Oncology IRCCS, 20122 Milan, Italy;
- Breast Cancer Group, Italian Association of Radiotherapy and Clinical Oncology (AIRO), 20124 Milano, Italy;
| | - Nadia Pasinetti
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Radiation Oncology Department, ASST Valcamonica Esine, University of Brescia, 25121 Brescia, Italy
| | - Isabella Palumbo
- Breast Cancer Group, Italian Association of Radiotherapy and Clinical Oncology (AIRO), 20124 Milano, Italy;
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Perugia General Hospital, 06156 Perugia, Italy
| | - Icro Meattini
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, 50121 Florence, Italy
- Radiation Oncology Unit—Oncology Department, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy
| | - Pierfrancesco Franco
- Clinical Oncology Breast Cancer Group (COBCG), 50134 Firenze, Italy; (R.R.C.); (E.L.R.); (A.P.); (E.B.); (B.M.); (M.C.D.S.); (N.P.); (I.M.)
- Department of Translational Medicine, University of Eastern Piedmont & Radiation Oncology Unit, AOU “Maggiore della Carita”, 28100 Novara, Italy
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Cebrecos I, Mension E, Alonso I, Castillo H, Sanfeliu E, Vidal-Sicart S, Ganau S, Vidal M, Schettini F. Nonsentinel Axillary Lymph Node Status in Clinically Node-Negative Early Breast Cancer After Primary Systemic Therapy and Positive Sentinel Lymph Node: A Predictive Model Proposal. Ann Surg Oncol 2023; 30:4657-4668. [PMID: 36809608 PMCID: PMC10319670 DOI: 10.1245/s10434-023-13231-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/24/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND In clinically node-negative (cN0) early stage breast cancer (EBC) undergoing primary systemic treatment (PST), post-treatment positive sentinel lymph node (SLN+) directs axillary lymph node dissection (ALND), with uncertain impacts on outcomes and increased morbidities. PATIENTS AND METHODS We conducted an observational study on imaging-confirmed cN0 EBC, who underwent PST and breast surgery that resulted in SLN+ and underwent ALND. The association among baseline/postsurgical clinic-pathological factors and positive nonsentinel additional axillary lymph nodes (non-SLN+) was analyzed with logistic regression. LASSO regression (LR) identified variables to include in a predictive score of non-SLN+ (ALND-predict). The accuracy and calibration were assessed, an optimal cut-point was then identified, and in silico validation with bootstrap was undertaken. RESULTS Non-SLN+ were detected in 22.2% cases after ALND. Only progesterone receptor (PR) levels and macrometastatic SLN+ were independently associated to non-SLN+. LR identified PR, Ki67, and type and number of SLN+ as the most efficient covariates. The ALND-predict score was built based on their LR coefficients, showing an area under the curve (AUC) of 0.83 and an optimal cut-off of 63, with a negative predictive value (NPV) of 0.925. Continuous and dichotomic scores had a good fit (p = 0.876 and p = 1.00, respectively) and were independently associated to non-SLN+ [adjusted odds ratio (aOR): 1.06, p = 0.002 and aOR: 23.77, p < 0.001, respectively]. After 5000 bootstrap-adjusted retesting, the estimated bias-corrected and accelerated 95%CI included the aOR. CONCLUSIONS In cN0 EBC with post-PST SLN+, non-SLN+ at ALND are infrequent (~22%) and independently associated to PR levels and macrometastatic SLN. ALND-predict multiparametric score accurately predicted absence of non-SLN involvement, identifying most patients who could be safely spared unnecessary ALND. Prospective validation is required.
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Affiliation(s)
- Isaac Cebrecos
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Eduard Mension
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Inmaculada Alonso
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Helena Castillo
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Esther Sanfeliu
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Department of Pathology, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Diagnosis Imaging Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergi Ganau
- Department of Radiology, Diagnosis Imaging Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Maria Vidal
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Medical Oncology Department, Hospital Clinic of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francesco Schettini
- Faculty of Medicine, University of Barcelona, Barcelona, Spain.
- Medical Oncology Department, Hospital Clinic of Barcelona, Barcelona, Spain.
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
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Luo S, Fu W, Lin J, Zhang J, Song C. Prognosis and local treatment strategies of breast cancer patients with different numbers of micrometastatic lymph nodes. World J Surg Oncol 2023; 21:202. [PMID: 37430331 DOI: 10.1186/s12957-023-03082-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/17/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Lymph node micrometastasis is an important prognostic factor in breast cancer, but patients with different numbers of involved lymph nodes are all divided into the same N1mi stage without distinction. We designed this study to compare the prognosis and local treatment recommendations of N1mi breast cancer patients with different numbers of micrometastatic lymph nodes. PATIENTS AND METHODS A total of 27,032 breast cancer patients with T1-2N1miM0 stage from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2019) who underwent breast surgery were included in this retrospective study. Patients were divided into three groups for prognosis comparison according to the number of micrometastatic lymph nodes: N1mi with 1 (Nmi = 1), 2 (Nmi = 2), or more (Nmi ≥ 3) involved lymph nodes. We explored the characteristics and survival outcomes of the population receiving different local treatments, including different axillary surgery types and whether receiving radiotherapy or not. Univariate and multivariate Cox proportional hazards regression analysis were used to compare the overall survival (OS) and breast cancer-specific survival (BCSS) in different groups. Stratified analyses and interaction analyses were also applied to explore the predictive significance of different involved lymph nodes numbers. Propensity score matching (PSM) method was utilized to balance the differences between groups. RESULTS Univariate and multivariate Cox regression analysis indicated that nodal status was an independent prognostic factor. After adjustment for other prognostic factors, there was a significant difference in prognosis between Nmi = 1 group and Nmi = 2 group [adjusted hazard ratio (HR) 1.145, 95% confidence interval (CI): 1.047-1.251, P = 0.003], and patients with Nmi ≥ 3 group had a significantly poorer prognosis (adjusted HR 1.679, 95% CI 1.589-2.407; P < 0.001). The proportion of N1mi patients only underwent sentinel lymph nodes biopsy (SLNB) gradually increased from 2010 (Ptrend < 0.001). After adjusting for other factors, N1mi patients who underwent axillary lymph nodes dissection (ALND) was associated with significant survival benefit than SLNB (adjusted HR 0.932, 95%CI 0.874-0.994; P = 0.033), the same goes for receiving radiotherapy (adjusted HR 1.107, 95%CI 1.030-1.190; P = 0.006). Further stratified analysis showed that in the SLNB subgroup, radiotherapy was associated with a significant survival benefit (HR 1.695, 95%CI 1.534-1.874; P < 0.001), whereas in the ALND subgroup, there was no significant prognostic difference with or without radiotherapy (HR 1.029, 95%CI 0.933-1.136; P = 0.564). CONCLUSION Our study indicates that the increasing number of lymph node micrometastases was associated a worse prognosis of N1mi breast cancer patients. In addition, ALND does provide a significant survival benefit for these patients, while the benefit from local radiotherapy may be of even greater importance.
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Affiliation(s)
- Shiping Luo
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Wenfen Fu
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Jingyi Lin
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Jie Zhang
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
| | - Chuangui Song
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
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Kaidar-Person O, Pfob A, Gentilini OD, Borisch B, Bosch A, Cardoso MJ, Curigliano G, De Boniface J, Denkert C, Hauser N, Heil J, Knauer M, Kühn T, Lee HB, Loibl S, Mannhart M, Meattini I, Montagna G, Pinker K, Poulakaki F, Rubio IT, Sager P, Steyerova P, Tausch C, Tramm T, Vrancken Peeters MJ, Wyld L, Yu JH, Weber WP, Poortmans P, Dubsky P. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus. EClinicalMedicine 2023; 61:102085. [PMID: 37528842 PMCID: PMC10388578 DOI: 10.1016/j.eclinm.2023.102085] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy ( ± targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - André Pfob
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Bettina Borisch
- Department of Histopathology, University of Geneva, 1202 Geneva, Switzerland
| | - Ana Bosch
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23A, 22241, Lund, Sweden
| | - Maria João Cardoso
- Breast Unit, Champalimaud Foundation and University of Lisbon Faculty of Medicine, Lisbon, Portugal
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Via Giuseppe Ripamonti, 435, 20141 Milano MI, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Jana De Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden
| | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg, Marburg, Germany
| | - Nik Hauser
- Breast Center, Hirslanden Clinic Aarau, Frauenarztzentrum Aargau AG, Baden, Switzerland
| | - Jörg Heil
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- Breast Center Heidelberg, Klinik St. Elisabeth, Heidelberg, Germany
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Sibylle Loibl
- German Breast Group (GBG), C/o GBG Forschungs GmbH 63263 - Neu-Isenberg/, Germany
- Centre for Haematology and Oncology Bethanien, Frankfurt, Germany
| | | | - Icro Meattini
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Isabel T. Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Patrizia Sager
- Breast Center Bern-Biel, Hirslanden Clinic Salem, Bern, Switzerland
| | - Petra Steyerova
- Breast Cancer Screening and Diagnostic Center, Clinic of Radiology, General University Hospital in Prague, Prague, Czech Republic
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology Netherlands Cancer Institute, Antoni van Leeuwenhoek & Amsterdam University Medical Center, Netherlands
| | - Lynda Wyld
- Department of Oncology and Metabolism, The University of Sheffield, The Medical School, Sheffield, UK
| | - Jong Han Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Walter Paul Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp 2610, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Peter Dubsky
- Breast Center, Hirslanden Clinic St Anna, 6006, Lucerne, Switzerland
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland
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50
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Elumalai T, Jain U, Coles CE, Benson JR. The role of irradiation in the management of the axilla in early breast cancer patients. Front Oncol 2023; 13:1151460. [PMID: 37434967 PMCID: PMC10332143 DOI: 10.3389/fonc.2023.1151460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/06/2023] [Indexed: 07/13/2023] Open
Abstract
The need for axillary radiotherapy in patients with invasive breast cancer (IBC) has been a topic of great debate in the last decade. Management of the axilla has evolved significantly over the past four decades with a trend towards de-escalation of surgical interventions and the aim of reducing morbidity and enhancing QOL without compromising long-term oncology outcomes. This review article will address the role of axillary irradiation with a focus on the omission of completion axillary lymph node dissection in selected patients with sentinel lymph node (SLN) positive early breast cancer (EBC) with reference to current guidelines based on evidence to date.
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Affiliation(s)
- Thiraviyam Elumalai
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambiridge, United Kingdom
| | - Urvashi Jain
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambiridge, United Kingdom
| | - Charlotte E. Coles
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambiridge, United Kingdom
- Department of Oncology, University of Cambridge, Cambiridge, United Kingdom
| | - John R. Benson
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambiridge, United Kingdom
- School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, Cambiridge, United Kingdom
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