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Varghese J, Patani N, Wazir U, Novintan S, Michell MJ, Malhotra A, Mokbel K, Mokbel K. Wire-Free Targeted Axillary Dissection: A Pooled Analysis of 1300+ Cases Post-Neoadjuvant Systemic Therapy in Node-Positive Early Breast Cancer. Cancers (Basel) 2024; 16:2172. [PMID: 38927878 PMCID: PMC11201777 DOI: 10.3390/cancers16122172] [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: 05/20/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Recent advances in neoadjuvant systemic therapy (NST) have significantly improved pathologic complete response rates in early breast cancer, challenging the role of axillary lymph node dissection in nose-positive patients. Targeted axillary dissection (TAD) integrates marked lymph node biopsy (MLNB) and tracer-guided sentinel lymph node biopsy (SLNB). The introduction of new wire-free localisation markers (LMs) has streamlined TAD and increased its adoption. The primary endpoints include the successful localisation and retrieval rates of LMs. The secondary endpoints include the pathological complete response (pCR), SLNB, and MLNB concordance, as well as false-negative rates. Seventeen studies encompassing 1358 TAD procedures in 1355 met the inclusion criteria. The localisation and retrieval rate of LMs were 97% and 99%. A concordance rate of 67% (95% CI: 64-70) between SLNB and MLNB was demonstrated. Notably, 49 days (range: 0-272) was the average LM deployment time to surgery. pCR was observed in 46% (95% CI: 43-49) of cases, with no significant procedure-related complications. Omitting MLNB or SLNB would have under-staged the axilla in 15.2% or 5.4% (p = 0.0001) of cases, respectively. MLNB inclusion in axillary staging post-NST for initially node-positive patients is crucial. The radiation-free Savi Scout, with its minimal MRI artefacts, is the preferred technology for TAD.
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Affiliation(s)
- Jajini Varghese
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Royal Free London NHS Trust, Pond Street, London NW3 2QG, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Neill Patani
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Umar Wazir
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
| | - Shonnelly Novintan
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- East Suffolk North Essex NHS Foundation Trust, Turner Road, Colchester CO4 5JL, UK
| | - Michael J. Michell
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Kings College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Anmol Malhotra
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Royal Free London NHS Trust, Pond Street, London NW3 2QG, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Kinan Mokbel
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Health and Care Profession Department, Faculty of Health and Life Sciences, University of Exeter Medical School, Exeter EX1 2HZ, UK
| | - Kefah Mokbel
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
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Alamoodi M, Wazir U, Sakr RA, Venkataraman J, Mokbel K, Mokbel K. Evaluating Magnetic Seed Localization in Targeted Axillary Dissection for Node-Positive Early Breast Cancer Patients Receiving Neoadjuvant Systemic Therapy: A Comprehensive Review and Pooled Analysis. J Clin Med 2024; 13:2908. [PMID: 38792449 PMCID: PMC11122577 DOI: 10.3390/jcm13102908] [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: 04/04/2024] [Revised: 04/25/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: De-escalation of axillary surgery is made possible by advancements in both neoadjuvant systemic therapy (NST) and in localisation technology for breast lesions. Magseed®, developed in 2013 by Dr. Michael Douk of Cambridge, United Kingdom, is a wire-free localisation technology that facilitates the localisation and retrieval of lymph nodes for staging. Targeted axillary dissection (TAD), which entails marked lymph node biopsy (MLNB) and sentinel lymph node biopsy (SLNB), has emerged as the preferred method to assess residual disease in post-NST node-positive patients. This systematic review and pooled analysis evaluate the performance of Magseed® in TAD. Methods: The search was carried out in PubMed and Google Scholar. An assessment of localisation, retrieval rates, concordance between MLNB and SLNB, and pathological complete response (pCR) in clinically node-positive patients post NST was undertaken. Results: Nine studies spanning 494 patients and 497 procedures were identified, with a 100% successful deployment rate, a 94.2% (468/497) [95% confidence interval (CI), 93.7-94.7] localisation rate, a 98.8% (491/497) retrieval rate, and a 68.8% (247/359) [95% CI 65.6-72.0] concordance rate. pCR was observed in 47.9% (220/459) ) [95% CI 43.3-52.6] of cases. Subgroup analysis of studies reporting the pathological status of MLNB and SLNB separately revealed an FNR of 4.2% for MLNB and 17.6% for SLNB (p = 0.0013). Mean duration of implantation was 37 days (range: 0-188). Conclusions: These findings highlight magnetic seed localisation's efficacy in TAD for NST-treated node-positive patients, aiding in accurate axillary pCR identification and safe de-escalation of axillary surgery in excellent responders.
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Affiliation(s)
- Munaser Alamoodi
- London Breast Institute, The Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (U.W.); (J.V.); (K.M.)
- Department of Surgery, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Umar Wazir
- London Breast Institute, The Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (U.W.); (J.V.); (K.M.)
| | - Rita A. Sakr
- College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates;
- Department of Oncoplastic Surgery, King’s College Hospital London, Dubai P.O. Box 340901, United Arab Emirates
| | - Janhavi Venkataraman
- London Breast Institute, The Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (U.W.); (J.V.); (K.M.)
| | - Kinan Mokbel
- London Breast Institute, The Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (U.W.); (J.V.); (K.M.)
- Health and Care Profession Department, College of Medicine and Health, University of Exeter Medical School, Exeter B3183, UK
| | - Kefah Mokbel
- London Breast Institute, The Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (U.W.); (J.V.); (K.M.)
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Wazir U, Michell MJ, Alamoodi M, Mokbel K. Evaluating Radar Reflector Localisation in Targeted Axillary Dissection in Patients Undergoing Neoadjuvant Systemic Therapy for Node-Positive Early Breast Cancer: A Systematic Review and Pooled Analysis. Cancers (Basel) 2024; 16:1345. [PMID: 38611023 PMCID: PMC11011109 DOI: 10.3390/cancers16071345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/23/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
SAVI SCOUT® or radar reflector localisation (RRL) has proven accurate in localising non-palpable breast and axillary lesions, with minimal interference with MRI. Targeted axillary dissection (TAD), combining marked lymph node biopsy (MLNB) and sentinel lymph node biopsy (SLNB), is becoming a standard post-neoadjuvant systemic therapy (NST) for node-positive early breast cancer. Compared to SLNB alone, TAD reduces the false negative rate (FNR) to below 6%, enabling safer axillary surgery de-escalation. This systematic review evaluates RRL's performance during TAD, assessing localisation and retrieval rates, the concordance between MLNB and SLNB, and the pathological complete response (pCR) in clinically node-positive patients post-NST. Four studies (252 TAD procedures) met the inclusion criteria, with a 99.6% (95% confidence [CI]: 98.9-100) successful localisation rate, 100% retrieval rate, and 81% (95% CI: 76-86) concordance rate between SLNB and MLNB. The average duration from RRL deployment to surgery was 52 days (range:1-202). pCR was observed in 42% (95% CI: 36-48) of cases, with no significant migration or complications reported. Omitting MLNB or SLNB would have under-staged the axilla in 9.7% or 3.4% (p = 0.03) of cases, respectively, underscoring the importance of incorporating MLNB in axillary staging post-NST in initially node-positive patients in line with the updated National Comprehensive Cancer Network (NCCN) guidelines. These findings underscore the excellent efficacy of RRL in TAD for NST-treated patients with positive nodes, aiding in accurate axillary pCR identification and the safe omission of axillary dissection in strong responders.
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Affiliation(s)
| | | | | | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK; (U.W.); (M.J.M.); (M.A.)
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Brousse S, Lafond C, Schmitt M, Guillermet S, Molière S, Mathelin C. [Can we avoid axillary lymph node dissection in patients with node positive invasive breast carcinoma?]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:132-141. [PMID: 38190968 DOI: 10.1016/j.gofs.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVES The indications and modalities of breast and axillary surgery are undergoing profound change, with the aim of personalizing surgical management while avoiding over-treatment. To update best practices for axillary surgery, four questions were selected by the Senology Commission of the Collège National des Gynécologues et Obstétriciens Français (CNGOF), focusing on, firstly, the definition and evaluation of targeted axillary dissection (TAD) techniques; secondly, the possibility of surgical de-escalation in case of initial lymph node involvement while performing initial surgery; thirdly, in case of surgery following neo-adjuvant systemic therapy (NAST), and fourthly, contra-indications to de-escalation of axillary surgery to allow access to particular adjuvant systemic therapies. METHODS The Senology Commission based its responses primarily on an analysis of the international literature, clinical practice recommendations and national and international guidelines. RESULTS Firstly, TAD is a technique that combines excision of clipped metastatic axillary node(s) and the axillary sentinel lymph nodes (ASLNs). The detection rate and sensitivity are increased but it still needs to be standardized and practices better evaluated. Secondly, TAD represents an alternative to axillary clearance in cases of metastatic involvement of a single node that can be resected. Thirdly, neither TAD nor ASLN alone is recommended in France after NAST outside of clinical trials, although it is used in several countries in cases of complete pathological response in the lymph nodes, and when at least three lymph nodes have been removed. Fourthly, as some adjuvant targeted therapies are indicated in cases of lymph node invasion of more than three lymph nodes, the place of TAD in this context remains to be defined. CONCLUSION Axillary surgical de-escalation can limit the morbidity of axillary clearance. Having proved that TAD does not reduce patient survival, it will most probably replace axillary clearance in well-defined indications. This will require prior standardization of the method and its indications and contra-indications, particularly to enable the use of new targeted therapies.
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Affiliation(s)
- Susie Brousse
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France.
| | - Clémentine Lafond
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France; Service de gynécologie-obstétrique, CHU de Rennes, 35000 Rennes, France
| | - Martin Schmitt
- Service de radiothérapie, CHR-Metz-Thionville, hôpital de Mercy, 1, allée du Château, 57085 Metz cedex, France
| | - Sophie Guillermet
- Service de chirurgie, centre Eugène-Marquis, avenue de la Bataille Flandres-Dunkerque, 35042 Rennes cedex, France
| | - Sébastien Molière
- Service d'imagerie de la femme, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France; Service de radiologie B, CHU de Strasbourg, avenue Molière, 67200 Strasbourg, France
| | - Carole Mathelin
- Service de chirurgie, ICANS, CHRU, avenue Molière, 67200 Strasbourg, France
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Hartmann S, Banys-Paluchowski M, Stickeler E, de Boniface J, Gentilini OD, Kontos M, Seitz S, Kaltenecker G, Wärnberg F, Zetterlund LH, Kolberg HC, Fröhlich S, Kühn T. Applicability of magnetic seeds for target lymph node biopsy after neoadjuvant chemotherapy in initially node-positive breast cancer patients: data from the AXSANA study. Breast Cancer Res Treat 2023; 202:497-504. [PMID: 37684426 PMCID: PMC10564814 DOI: 10.1007/s10549-023-07100-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE Currently, various techniques are available to mark and selectively remove initially suspicious axillary lymph nodes (target lymph nodes, TLNs) in breast cancer patients receiving neoadjuvant chemotherapy (NACT). To date, limited data are available on whether the use of magnetic seeds (MS) is suitable for localizing TLNs. This study aimed to investigate the feasibility of MS in patients undergoing target lymph node biopsy (TLNB) or targeted axillary dissection (TAD) after NACT. METHODS Prospective data from the ongoing multicentric AXSANA study were extracted from selected patients in whom the TLN had been marked with an MS before NACT and who were enrolled from June 2020 to June 2023. The endpoints of the analysis were the detection rate, the rate of lost markers, and the potential impairment on magnetic resonance imaging (MRI) assessment. RESULTS In 187 patients from 27 study sites in seven countries, MS were placed into the TLN before NACT. In 151 of these, post-NACT surgery had been completed at the time of analysis. In 146 patients (96.0%), a TLN could successfully be detected. In three patients, the seed was removed but no lymphoid tissue was detected on histopathology. The rate of lost markers was 1.2% (2 out of 164 MS). In 15 out of 151 patients (9.9%), MRI assessment was reported to be compromised by MS placement. CONCLUSION MS show excellent applicability for TLNB/TAD when inserted before NACT with a high DR and a low rate of lost markers. Axillary MS can impair MRI assessment of the breast. TRIAL REGISTRATION NUMBER NCT04373655 (date of registration May 4, 2020).
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Affiliation(s)
- Steffi Hartmann
- Department of Obstetrics and Gynecology, University Hospital Rostock, Rostock, Germany.
| | - Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Elmar Stickeler
- Department of Obstetrics and Gynecology, University Hospital Aachen, Aachen, Germany
| | - Jana de Boniface
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Stephan Seitz
- Department of Obstetrics and Gynecology, University Medical Center Regensburg, Regensburg, Germany
| | - Gabriele Kaltenecker
- Department of Obstetrics and Gynecology, City Hospital Karlsruhe, Karlsruhe, Germany
| | - Fredrik Wärnberg
- Department of Surgery, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Linda Holmstrand Zetterlund
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Sarah Fröhlich
- Department of Obstetrics and Gynecology, University Hospital Rostock, Rostock, Germany
| | - Thorsten Kühn
- Department of Obstetrics and Gynecology, Die Filderklinik, Filderstadt, Germany
- Department of Obstetrics and Gynecology, University Hospital Ulm, Ulm, Germany
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Wärnberg F, Obondo C, Chin K. The Magnetic Technique-A Novel and Promising Method to Improve Axillary Staging Localisation from a Swedish Perspective. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1727. [PMID: 37893446 PMCID: PMC10608746 DOI: 10.3390/medicina59101727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/13/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
The magnetic technique using superparamagnetic nanoparticles of iron oxide has been well established for sentinel lymph node detection. Its main advantage is in the context of logistics, with the possibility to inject several weeks before surgery and the possibility to give access to sentinel lymph node biopsy for women worldwide in places without nuclear medicine facilities. We have not yet seen the full potential of this technique, and new implications have been developed for breast tumour localisation with paramagnetic clips and axillary staging after neoadjuvant chemotherapy using paramagnetic clips inserted in lymph node metastases before chemotherapy. In this report, we have presented our experience of the magnetic technique starting in 2014, and we have highlighted our current and future research directions.
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Affiliation(s)
- Fredrik Wärnberg
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345 Gothenburg, Sweden
| | | | - Kian Chin
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345 Gothenburg, Sweden
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