Ten-year locoregional recurrence risks in women with nodal micrometastatic breast cancer staged with axillary dissection

Evaluation of adjuvant therapy for T1-2N1miM0 breast cancer without further axillary lymph node dissection

Background

For breast cancer (BC) with sentinel lymph node micrometastases (SLNMs), there are limited data to guide the selection of postoperative adjuvant therapy. This study aimed to identify target populations who might benefit most from adjuvant therapy and examine prognostic factors among patients with T1-2N1miM0 BC with one or two SLNMs who underwent sentinel lymph node biopsy (SLNB) alone.

Methods

There were 7,423 patients diagnosed with T1-2N1miM0 BC between 2010 and 2015, and patients with one or two SLNMs were extracted from the Surveillance, Epidemiology, and End Results database. All the patients underwent SLNB alone without further axillary lymph node dissection, and they were stratified according to adjuvant therapy. The statistical significance of categorical variables was analyzed using the χ ² test. Univariable and multivariable Cox analyses were used to analyze characteristics predictive of Breast-cancer-specific survival and overall survival (OS). Kaplan-Meier methods with the log-rank test was analyzed to compare survival difference between the different treatments.

Results

Adjuvant chemotherapy and radiotherapy improved 5-year OS rates. Multivariate analysis revealed that age ≥70 years, high grade, T2 stage, triple-negative subtype, and absence of radiotherapy were poor prognostic factors for OS. Patients who received breast-conserving surgery (BCS), and those with invasive ductal carcinoma (IDC), luminal A, luminal B, or basal-like subtype, and T1c or T2 stage benefited from adjuvant radiotherapy. Patients who received BCS, and those with IDC, luminal A subtype, and T1b, T1c, or T2 stage benefited from adjuvant chemotherapy.

Conclusion

Our findings provide a clinical evaluation of treatment choice after surgery, which may help clinicians make individualized clinical decisions.

Role of Sentinel Lymph Node Biopsy in Microinvasive Breast Cancer

BACKGROUND

Microinvasive ductal carcinoma (DCISM), defined as DCIS with a focus of invasive carcinoma ≤ 1 mm, can be managed similarly to pure DCIS; however, management of the axilla in DCISM has been a subject of debate. Reports in the literature differ on the utility and necessity of sentinel lymph node biopsy (SLNB) for DCISM. The aim of the present study was to identify risk factors for nodal disease in patients with DCISM, which can help develop a selective approach to SLNB in this patient population.

METHODS

The National Cancer Database was used to select patients with DCISM (pT1mi), diagnosed from 2012 to 2015, who underwent SLNB. Multivariable regression analysis was performed to determine associations between sentinel lymph node metastasis and relevant clinical variables.

RESULTS

Our cohort comprised of 2609 patients with pT1mi who underwent SLNB. Of these, 76 (2.9%) were found to have sentinel lymph node metastases on final pathology. Low/intermediate grade tumors were associated with decreased SLN metastasis (OR 0.50, CI 0.28-0.92). Age and receptor status of the tumor did not have a clear association in predicting SLN metastases.

CONCLUSIONS

The rate of sentinel node metastases in DCISM is low at only 2.9% in this national study. Tumor grade was identified as influencing the risk of SLN metastases. This information can factor into shared decision-making for SLNB in patients with DCISM.

Postmastectomy radiation therapy in early breast cancer: Utility or futility?

Postmastectomy radiation therapy (PMRT) has been shown to reduce the risk of locoregional recurrence (LRR), in patients with locally advanced breast cancer who are considered of high-risk because of large tumors (>5 cm) or presence of axillary lymph-node involvement, as well as to reduce breast cancer mortality. However, controversy still remains with respect to indication of PMRT in case of early-stages invasive tumors. This review aims to analyze the impact that PMRT has on final results in women with breast tumors in different scenarios that would otherwise be considered as early breast cancer, such as extensive DCIS, tumors without axillary lymph-node involvement or with minimal microscopic nodal-involvement. The existence of risk factors including young age, premenopausal status, and presence of lymphovascular invasion (LVI), high grade or tumor size >2 cm has been associated with an increased risk of LRR in these patients at early-stages and advises to consider PMRT in selected cases.

Locoregional treatment of early breast cancer with isolated tumor cells or micrometastases on sentinel lymph node biopsy

The advent of sentinel lymph-node technique has led to a shift in lymph-node staging, due to the emergence of new entities namely micrometastases (pN1mi) and isolated tumor cells [pN0(i+)]. The prognostic significance of this low positivity in axillary lymph nodes is currently debated, as is, therefore its management. This article provides updates evidence-based medicine data to take into account for treatment decision-making in this setting, discussing the locoregional treatment in pN0(i+) and pN1mi patients (completion axillary dissection, axillary irradiation with or without regional nodes irradiation, or observation), according to systemic treatment, with the goal to help physicians in their daily practice.

[Regional treatment for axillary lymph node micrometastases of breast cancer]

In patients with breast cancer, axillary lymph node micrometastasis detection has been more frequent with a better definition since the introduction of the sentinel node procedure. In this review, we focus on pN1mi micrometastasis and review the literature in order to determine factors involved in making the decision of a regional treatment.

DEGRO practical guidelines: radiotherapy of breast cancer III--radiotherapy of the lymphatic pathways

AIM

The purpose of this work is to update the practical guidelines for adjuvant radiotherapy of the regional lymphatics of breast cancer published in 2008 by the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO).

METHODS

A comprehensive survey of the literature concerning regional nodal irradiation (RNI) was performed using the following search terms: "breast cancer", "radiotherapy", "regional node irradiation". Recent randomized trials were analyzed for outcome as well as for differences in target definition. Field arrangements in the different studies were reproduced and superimposed on CT slices with individually contoured node areas. Moreover, data from recently published meta-analyses and guidelines of international breast cancer societies, yielding new aspects compared to 2008, provided the basis for defining recommendations according to the criteria of evidence-based medicine. In addition to the more general statements of the German interdisciplinary S3 guidelines updated in 2012, this paper addresses indications, targeting, and techniques of radiotherapy of the lymphatic pathways after surgery for breast cancer.

RESULTS

International guidelines reveal substantial differences regarding indications for RNI. Patients with 1-3 positive nodes seem to profit from RNI compared to whole breast (WBI) or chest wall irradiation alone, both with regard to locoregional control and disease-free survival. Irradiation of the regional lymphatics including axillary, supraclavicular, and internal mammary nodes provided a small but significant survival benefit in recent randomized trials and one meta-analysis. Lymph node irradiation yields comparable tumor control in comparison to axillary lymph node dissection (ALND), while reducing the rate of lymph edema. Data concerning the impact of 1-2 macroscopically affected sentinel node (SN) or microscopic metastases on prognosis are conflicting.

CONCLUSION

Recent data suggest that the current restrictive use of RNI should be scrutinized because the risk-benefit relationship appears to shift towards an improvement of outcome.

Consensus on the regional lymph nodes irradiation in breast cancer

Standard locoregional treatment of early-stage breast cancer currently consists of the conservative surgery and sentinel lymph node biopsy. In the event of positive sentinel node biopsy, an axillary level I-II lymphadenectomy should be carried out. However, recent publications have increasingly supported a tendency not to apply the surgical lymphadenectomy, but simultaneously, it has been developed a new role of regional radiotherapy, even if there is only 1-3 axillary lymph nodes involved. Given these new trends, radiation oncologists are facing the dilemma with regard to deciding about regional irradiation of breast cancer. For such purpose, The Spanish Group of Breast Cancer Radiation Oncology (GEORM as per its Spanish acronym) decided to reach a consensus to issue the respective guidelines for such types of cases. GEORM Managing Commission, gathering 13 members of different Spanish regional communities, issued a questionnaire including different clinical situations. These questions were set as key questions seeking responses, which were answered by 66 % out of the 75 members of the group. Following the response, the guidelines were drafted based on the replies to the mentioned questionnaire. All the respective issues were discussed by means of a virtual platform. In this article, we show the levels of consensus for different clinical situations, depending on the number of nodes involved and the type of surgical procedure performed on the axillary lymph nodes. The ongoing evolution of the oncological treatments obliges the radiation oncologists to take decisions without any existing clarifying evidence, and therefore, the consensus is necessary, which can assist in the decision-making process by the practitioners in such kinds of clinical situations.

[A case of cutaneous mammary re-irradiation]

In early-stage breast cancer, radiotherapy delivered after conservative surgery leads to a reduction in the risk of local recurrences by approximately two thirds. However, some local recurrences can occur in a previously irradiated region and be relevant for a second radiotherapy, exposing to an increased risk of adverse effects. We describe here the observation of a 66-year-old woman treated for a triple negative ductal infiltrative carcinoma of the left breast, who presented an early locoregional recurrence, notably as skin nodules, developed within the irradiated volume and progressing on chemotherapy. The patient was treated by re-irradiation performed concomitantly to oral chemotherapy by capecitabine.

[Proposal for a new multidisciplinary therapeutic strategy in the breast cancer patient with sentinel lymph node metastasis]

Sentinel lymph node (SLN) biopsy is the standard of practice for assessing axillary spread in clinically node-negative breast cancer patients. On the other hand, axillary lymph node dissection (ALND) is the ideal procedure for patients with SLN metastasis. Different studies over the last few years have suggested that some patients with positive SLN can be treated without ALND. This article presents a literature review carried out by our multidisciplinary group and its strategy for avoiding routine ALND in women with SLN metastases. In this new strategy ALND should not be performed on women with T1 tumours, with 1-2 positive SLN and undergoing breast conservative surgery. On the other hand, ALND would be indicated in those patients with three or more positive SLN, presence of extracapsular invasion, mastectomised women and triple negative subtype or HER2+ tumours that have not received biological treatment with antibodies.

Principles of surgical oncology in the elderly

Elderly patients constitute the largest group in oncologic medical practice, despite the fact that in solid cancers treated operatively, many patients are denied standard therapies and where such decision making is based solely on age. The “natural” assumptions that we have are often misleading; namely, that the elderly cannot tolerate complex or difficult procedures, chemotherapy, or radiation schedules; that their overall predictable medical health determines survival (and not the malignancy); or that older patients typically have less aggressive tumors. Clearly, patient selection and a comprehensive geriatric assessment is key where well-selected cases have the same cancer-specific survival as younger cohorts in a range of tumors as outlined including upper and lower gastrointestinal malignancy, head and neck cancer, and breast cancer. The assessment of patient fitness for surgery and adjuvant therapies is therefore critical to outcomes, where studies have clearly shown that fit older patients experience the same benefits and toxicities of chemotherapy as do younger patients and that when normalized for preexisting medical conditions,that older patients tolerate major operative procedures designed with curative oncological intent. At present, our problem is the lack of true evidence-based medicine specifically designed with age in mind, which effectively limits surgical decision making in disease-based strategies. This can only be achieved by the utilization of more standardized, comprehensive geriatric assessments to identify vulnerable older patients, aggressive pre-habilitation with amelioration of vulnerability causation, improvement of patient-centered longitudinal outcomes, and an improved surgical and medical understanding of relatively subtle decreases in organ functioning, social support mechanisms and impairments of health-related quality of life as a feature specifically of advanced age.