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Banys-Paluchowski M, de Boniface J. Axillary staging in node-positive breast cancer converting to node negativity through neoadjuvant chemotherapy: Current evidence and perspectives. Scand J Surg 2023; 112:117-125. [PMID: 36642957 DOI: 10.1177/14574969221145892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Over the recent years, axillary staging of initially node-positive breast cancer patients converting to clinical node negativity after neoadjuvant chemotherapy has seen rapid changes. This narrative review aims to give a contemporary overview over published evidence and clinical practice, and thus provide some guidance to the surgical community in the process of re-evaluating and re-shaping surgical practice. METHODS The search strategy aimed at finding relevant studies. Only articles in English were considered. RESULTS The introduction of modern techniques offer more precise staging surgery and thus hopefully reduced arm morbidity. Clinical practice has however diverged both within countries and internationally. While some countries have adapted de-escalated axillary staging techniques such as targeted axillary dissection, targeted lymph node biopsy or sentinel lymph node biopsy, others continue to recommend a full axillary lymph node dissection. With the implementation of new techniques, many questions arise, regarding aspects of oncological safety, technical performance, budget and practicality, patient selection and indications for different levels of axillary staging procedures. CONCLUSIONS There is a growing body of evidence on de-escalation of axillary surgery in the setting of cN+ → ycN0 breast cancer treated with neoadjuvant chemotherapy. However, standards differ between countries and future studies are necessary to fully assess the optimal strategy for these patients.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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Abstract
PURPOSE OF REVIEW The standard of care in breast surgery has changed, from mastectomy to breast conserving surgery whenever possible, and from axillary dissection to sentinel node biopsy. Neoadjuvant systemic approaches have broadened the indications for organ-conserving and less mutilating surgery, but also raise important questions of balancing locoregional treatment de-escalation and protecting excellent long-term outcomes. RECENT FINDINGS Recent studies have aimed at investigating the safety of de-escalating surgical approaches not only in the upfront breast surgery situation but also after neoadjuvant systemic therapy. This pertains to both the safety of breast conserving surgery - including more complex oncoplastic approaches - within the new (posttherapeutic) anatomical extent of the residual disease, but more controversially to de-escalating surgical treatment of the axilla. While sentinel node biopsy appears to be the standard of care for node-negative disease also after primary systemic therapy, the optimal procedure in situations of posttherapeutic node-positive disease remains highly controversial. SUMMARY Both breast and axillary surgery after neoadjuvant systemic therapy for women with breast cancer has undergone multiple paradigm changes in recent years. For the primary tumor in the breast, breast-conserving surgery constitutes the standard of care, and unnecessary mastectomies should be strongly discouraged. For axillary surgery, sentinel-node biopsy should be aimed at, and completion axillary dissections minimized for situations of extensive disease and or poor neoadjuvant treatment response. Additional techniques such as targeted axillary dissection are currently under evaluation in clinical trials.
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Affiliation(s)
- Michael Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Banys-Paluchowski M, Untch M, Krawczyk N, Thurmann M, Kühn T, Sehouli J, Gasparri ML, de Boniface J, Gentilini OD, Stickeler E, Ditsch N, Rody A, Paluchowski P, Blohmer JU. Current trends in diagnostic and therapeutic management of the axilla in breast cancer patients receiving neoadjuvant therapy: results of the German-wide NOGGO MONITOR 24 survey. Arch Gynecol Obstet 2022; 307:1547-1556. [PMID: 36214890 PMCID: PMC10110637 DOI: 10.1007/s00404-022-06804-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/21/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE In the last 2 decades, the optimal management of the axilla in breast cancer patients receiving neoadjuvant chemotherapy (NACT) has been one of the most frequently discussed topics. Little is known about the attitudes of surgeons/radiologists towards new developments such as targeted axillary dissection. Therefore, the NOGGO conducted a survey to evaluate the current approach to axillary management. METHODS A standardized digital questionnaire was sent out to > 200 departments in Germany between 7/2021 and 5/2022. The survey was supported by EUBREAST. RESULTS In total, 116 physicians completed the survey. In cN0 patients scheduled to receive NACT, 89% of respondents recommended sentinel lymph node biopsy (SLNB) after NACT. In case of ypN1mi(sn), 44% advised no further therapy, while 31% proposed ALND and 25% axillary irradiation. 64% of respondents recommended a minimally invasive axillary biopsy to cN + patients. TAD was used at the departments of 82% of respondents and was offered to all cN + patients converting to ycN0 by 57% and only to selected patients, usually based on the number of suspicious nodes at time of presentation, by 43%. The most common marking technique was a clip/coil. 67% estimated that the detection rate of their marker was very good or good. CONCLUSION This survey shows a heterogenous approach towards axillary management in the neoadjuvant setting in Germany. Most respondents follow current guidelines. Since only two-thirds of respondents experienced the detection rate of the marker used at their department as (very) good, future studies should focus on the comparative evaluation of different marking techniques.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Michael Untch
- Department of Gynecology and Obstetrics, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maria Thurmann
- Department of Gynecology and Obstetrics, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Jalid Sehouli
- Department of Gynecology With Center for Oncological Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Virchow Campus Clinic, Charité Medical University, Berlin, Germany.,Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Freie Universität Berlin, Berlin, Germany
| | - Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale Di Lugano, Lugano, Switzerland.,Faculty of Biomedicine, University of the Italian Switzerland (USI), Lugano, Switzerland
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
| | | | - Elmar Stickeler
- Department of Gynecology and Obstetrics, University Hospital Aachen, Aachen, Germany
| | - Nina Ditsch
- Department of Gynecology and Obstetrics, University of Augsburg, Augsburg, Germany
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics and Breast Cancer Center, Regio Klinikum Pinneberg, Pinneberg, Germany
| | - Jens-Uwe Blohmer
- Department of Gynecology and Breast Cancer Center, Charité Universitätsmedizin Berlin, Berlin, Germany
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