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Pesapane F, Mariano L, Magnoni F, Rotili A, Pupo D, Nicosia L, Bozzini AC, Penco S, Latronico A, Pizzamiglio M, Corso G, Cassano E. Future Directions in the Assessment of Axillary Lymph Nodes in Patients with Breast Cancer. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1544. [PMID: 37763661 PMCID: PMC10534800 DOI: 10.3390/medicina59091544] [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: 07/18/2023] [Revised: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Breast cancer (BC) is a leading cause of morbidity and mortality worldwide, and accurate assessment of axillary lymph nodes (ALNs) is crucial for patient management and outcomes. We aim to summarize the current state of ALN assessment techniques in BC and provide insights into future directions. Materials and Methods: This review discusses various imaging techniques used for ALN evaluation, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. It highlights advancements in these techniques and their potential to improve diagnostic accuracy. The review also examines landmark clinical trials that have influenced axillary management, such as the Z0011 trial and the IBCSG 23-01 trial. The role of artificial intelligence (AI), specifically deep learning algorithms, in improving ALN assessment is examined. Results: The review outlines the key findings of these trials, which demonstrated the feasibility of avoiding axillary lymph node dissection (ALND) in certain patient populations with low sentinel lymph node (SLN) burden. It also discusses ongoing trials, including the SOUND trial, which investigates the use of axillary ultrasound to identify patients who can safely avoid sentinel lymph node biopsy (SLNB). Furthermore, the potential of emerging techniques and the integration of AI in enhancing ALN assessment accuracy are presented. Conclusions: The review concludes that advancements in ALN assessment techniques have the potential to improve patient outcomes by reducing surgical complications while maintaining accurate disease staging. However, challenges such as standardization of imaging protocols and interpretation criteria need to be addressed. Future research should focus on large-scale clinical trials to validate emerging techniques and establish their efficacy and cost-effectiveness. Over-all, this review provides valuable insights into the current status and future directions of ALN assessment in BC, highlighting opportunities for improving patient care.
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Affiliation(s)
- Filippo Pesapane
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Luciano Mariano
- Breast Imaging Division, AOU Città della Scienza e della Salute di Torino, 10126 Turin, Italy;
| | - Francesca Magnoni
- Division of Breast Surgery, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (F.M.); (G.C.)
- European Cancer Prevention Organization (ECP), 20122 Milan, Italy
| | - Anna Rotili
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Davide Pupo
- Radiology Division, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy;
| | - Luca Nicosia
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Anna Carla Bozzini
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Silvia Penco
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Antuono Latronico
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Maria Pizzamiglio
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Giovanni Corso
- Division of Breast Surgery, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (F.M.); (G.C.)
- European Cancer Prevention Organization (ECP), 20122 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Enrico Cassano
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
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Jiang Y, Li J, Chen B, Bao Y, Luo C, Luo Y, Li T, Lv J, Cheng X. Sentinel Lymph Node Biopsy Mapped With Carbon Nanoparticle Suspensions in Patients With Breast Cancer: A Systematic Review and Meta-Analysis. Front Oncol 2022; 12:818812. [PMID: 35419285 PMCID: PMC8995566 DOI: 10.3389/fonc.2022.818812] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/21/2022] [Indexed: 01/15/2023] Open
Abstract
Background The mapping method represents a crucial factor affecting the rate of sentinel lymph node detection in breast cancer. We carried out this meta-analysis to assess the clinical utility of carbon nanoparticle suspensions (CNSs) in guiding sentinel lymph node biopsy (SLNB) for breast cancer patients. Methods Electronic databases, which comprised the China National Knowledge Infrastructure, the Wanfang electronic database, the Cochrane Library, EMBASE, and PubMed, were explored to identify relevant studies from database inception to July 2021 that studied the detection rate of CNSs-guided SLNB. A meta-analysis was performed to generate pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), a summary receiver operator characteristic curve (SROC), and a diagnostic odds ratio (DOR). Results A total of 33 publications that enrolled 2,171 patients were analyzed. The pooled sensitivity, specificity, PLR, and NLR were 0.93 (95% CI: 0.91–0.95, I2 = 0.0%), 0.99 (95% CI: 0.98–0.99, I2 = 56.5%), 42.85 (95% CI: 29.73–61.77, I2 = 47.0%), and 0.09 (95% CI: 0.07–0.11, I2 = 0.0%), respectively. The area under the curve (AUC) of the SROC curve was 0.98. There were no significant differences when analyzed based on the dose and site of CNS injection. There was significant publication bias among the included publications based on Deeks’ funnel plot [Slope (Bias) = −7.35, P = 0.00]. Nonetheless, the sensitivity analysis identified the results to be reliable and stable. Conclusion This meta-analysis highlights the accuracy and feasibility of using CNSs for SLNB in patients with breast cancer. Clinically, the identification and predictive values of CNSs as an optimal tracer for SLNB remains undisputed.
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Affiliation(s)
- Yan Jiang
- Breast and Thyroid Surgery, Department of General Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jiayang Li
- Drug Clinical Trial Institution, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Baolin Chen
- Breast and Thyroid Surgery, Department of General Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yuxiang Bao
- Breast and Thyroid Surgery, Department of General Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Chengmin Luo
- Breast and Thyroid Surgery, Department of General Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yi Luo
- Breast and Thyroid Surgery, Department of General Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Taolang Li
- Breast and Thyroid Surgery, Department of General Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Junyuan Lv
- Breast and Thyroid Surgery, Department of General Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xiaoming Cheng
- Breast and Thyroid Surgery, Department of General Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
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Chen C, Qin Y, Chen H, Zhu D, Gao F, Zhou X. A meta-analysis of the diagnostic performance of machine learning-based MRI in the prediction of axillary lymph node metastasis in breast cancer patients. Insights Imaging 2021; 12:156. [PMID: 34731343 PMCID: PMC8566689 DOI: 10.1186/s13244-021-01034-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/02/2021] [Indexed: 02/08/2023] Open
Abstract
Background Despite that machine learning (ML)-based MRI has been evaluated for diagnosis of axillary lymph node metastasis (ALNM) in breast cancer patients, diagnostic values they showed have been variable. In this study, we aimed to assess the use of ML to classify ALNM on MRI and to identify potential covariates that might influence the diagnostic performance of ML. Methods A systematic research of PubMed, Embase, Web of Science, and the Cochrane Library was conducted until 27 December 2020 to collect the included articles. Subgroup analysis was also performed. Findings Fourteen studies assessing a total of 2247 breast cancer patients were included in the analysis. The overall AUC for ML in the validation set was 0.80 (95% confidence interval [CI] 0.76–0.83) with a negative predictive value of 0.83. The pooled sensitivity and specificity were 0.79 (95% CI 0.74–0.84) and 0.77 (95% CI 0.73–0.81), respectively. In the subgroup analysis of the validation set, T1-weighted contrast-enhanced (T1CE) imaging with ML yielded a higher sensitivity (0.80 vs. 0.67 vs. 0.76) than the T2-weighted fat-suppressed (T2-FS) imaging and diffusion-weighted imaging (DWI). Support vector machines (SVMs) had a higher specificity than linear regression (LR) and linear discriminant analysis (LDA) (0.79 vs. 0.78 vs. 0.75), whereas LDA showed a higher sensitivity than LR and SVM (0.83 vs. 0.70 vs. 0.77). Interpretation MRI sequences and algorithms were the main factors that affect the diagnostic performance of ML. Although its results were encouraging with the pooled sensitivity of around 0.80, it meant that 1 in 5 women that would go with undetected metastases, which may have a detrimental effect on the overall survival for 20% of patients with positive SLN status. Despite that a high NPV of 0.83 meant that ML could potentially benefit those with negative SLN, it might also translate to 1 in 5 tests being false negative. We would like to suggest that ML may not be yet usable in clinical routine especially when patient survival is used as a primary measurement of its outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s13244-021-01034-1.
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Affiliation(s)
- Chen Chen
- Department of Radiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yuhui Qin
- Department of Radiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Haotian Chen
- Department of Radiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Dongyong Zhu
- Department of Radiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Fabao Gao
- Department of Radiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Xiaoyue Zhou
- Siemens Healthineers Ltd., Shanghai, People's Republic of China
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Yuan Q, Wu G. ASO Author Reflections: Stepwise Limited Axillary Lymph Node Dissection Based on Lymphatic Drainage from the Breast. Ann Surg Oncol 2021; 29:509. [PMID: 34405293 DOI: 10.1245/s10434-021-10634-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/30/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Qianqian Yuan
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Gaosong Wu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China.
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Yuan Q, Hou J, Zhou R, Zheng L, Lu F, Deng T, Zhou W, Wu G. Stepwise Limited Axillary Lymph Node Dissection Based on Lymphatic Drainage from the Breast to Decrease Breast Cancer-Related Lymphedema: A Randomized Controlled Trial. Ann Surg Oncol 2021; 29:500-508. [PMID: 34331162 DOI: 10.1245/s10434-021-10526-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/14/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Comprehensive axillary surgery is associated with an elevated rate of morbidity. This trial aimed to demonstrate the feasibility of axillary dissection of lymph nodes from the breast (bALND) for the purpose of limiting the extent of surgery. METHODS Patients enrolled from two tertiary referral centers from September 2018 to September 2019 were randomly allocated to two groups: bALND and standard axillary lymph node dissection (sALND). In the bALND group, the sentinel lymph node was filled with 0.1 ml methylene blue before resection. Then, bALND based on lymphatic drainage was subsequently performed. Lymph nodes at each breast lymphatic level and lymph nodes at Berg levels were sent for separate pathological examination. Arm lymphedema, locoregional recurrence, and distant metastasis were documented. RESULTS In the bALND group, lymphatic vessels and subsequent-echelon lymph nodes from the breast were stained blue after injection of methylene blue in 404 (89.0%, 404/454) cases, and 57.8% (228/394) of the patients harbored fewer than four metastatic nodes. With a median follow-up of 18 months, the incidence of arm lymphedema was 6.6% (26/394) in the bALND group versus 13.7% (60/438) in the sALND group (p = 0.008), while regional recurrence presented no difference between the two surgical procedures (0.76% vs 0.68%, p = 0.896). CONCLUSION For node-positive breast cancer patients, bALND based on lymphatic drainage is a less radical axillary surgery that can eliminate morbidity without impairing cancer control.
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Affiliation(s)
- Qianqian Yuan
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Jinxuan Hou
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Rui Zhou
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Lewei Zheng
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Fang Lu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Tong Deng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, People's Republic of China
| | - Wenbo Zhou
- Department of Surgery, Dongfeng General Hospital affiliated with Hubei Medical College, Shiyan, Hubei, People's Republic of China
| | - Gaosong Wu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China.
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Pure Tubular Carcinoma of the Breast: Is Axillary Staging Necessary? Indian J Surg 2021. [DOI: 10.1007/s12262-019-01960-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Yuan Q, Hou J, He Y, Liao Y, Zheng L, Wu G. Minimize the extent and morbidity of axillary dissection for node-positive breast cancer patients: implementation of axillary lymph node dissection based on breast lymphatics level. BMC Cancer 2021; 21:293. [PMID: 33740930 PMCID: PMC7980601 DOI: 10.1186/s12885-021-08024-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 03/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background Breast cancer-related lymphedema (BCRL) is associated with extensive axillary dissection. Axillary lymph node dissection (ALND) based on breast lymphatics level (BLL) was proposed to minimize the surgical extent for node-positive breast cancer patients. Methods A total of 156 consecutive sentinel lymph node-positive (SLN+) or clinically node-positive (cN+) patients underwent sentinel lymph node biopsy (SLNB) with indocyanine green and methylene blue (MB). The SLNs were injected with 0.1 ml MB before removal, and a standard ALND was subsequently performed. The nodes adjacent to the blue-stained axillary lymph nodes from the breast (bALNs) were sent for pathological examination separately by resecting serial tissue every 0.5 cm away from the marginal blue-stained bALNs. Then, a pilot study comparing ALND based on BLL and standard ALND was performed. Results BLL were successfully identified in 20 SLN+ (100%) and 134 cN+ (98.5%) patients. The median number of BLL was four, ranging from three to six. A horizontal line 1.0 cm away from the superior blue-stained bALN and a vertical line 1.0 cm away from the medial blue-stained bALN formed BLL II, III, and IV. All of the additional positive nodes were within 1.0 cm of the blue-stained bALNs. The minimized axillary dissection should resect upwards from the lowest BLL that contains the first confirmed negative blue-stained bALNs. In the pilot study, no patient developed axillary recurrence. Conclusion The ALND surgical procedure based on BLL could minimize the surgical extent for pathological node-positive breast cancer patients and potentially reduce the BCRL rate. Trial registration ChiCTR1800014247. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08024-y.
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Affiliation(s)
- Qianqian Yuan
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, People's Republic of China
| | - Jinxuan Hou
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, People's Republic of China
| | - Yukun He
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, People's Republic of China
| | - Yiqian Liao
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, People's Republic of China
| | - Lewei Zheng
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, People's Republic of China
| | - Gaosong Wu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, People's Republic of China.
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Zhou P, Zheng W, Liu Y, Wang Y. Preoperative Contrast-Enhanced Ultrasound (CEUS) Combined with 125I Seeds Localization in Sentinel Lymph Node Biopsy for Breast Cancer. Cancer Manag Res 2021; 13:1853-1860. [PMID: 33658849 PMCID: PMC7917323 DOI: 10.2147/cmar.s296142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/31/2021] [Indexed: 12/24/2022] Open
Abstract
Objective To assess the clinical value of contrast-enhanced ultrasound (CEUS) technology in predicting axillary lymph nodes status before surgery, and to explore the feasibility of sentinel lymph nodes (SLNs) localization guided by CEUS combined with 125I implantation for breast cancer. Methods From August 2017 to February 2019, 115 patients were included in this prospective study. Before surgery, a microbubble (SonoVue) was injected intradermally next to the areola. The enhancement patterns of SLNs were recorded and 125I seeds were deployed into the enhanced nodes. Then, all patients underwent standard sentinel lymph node biopsy (SLNB) and all 125I seeds were found out guided by a gamma detector in surgery. The localization was considered successful if 125I seeds were implanted in/beside the nodes. Results SLNs in 103 cases were successfully identified, the success rate was 89.6% (103/115), 118 SLNs were detected in total. 125I seeds were deployed successfully in 99 cases, and all of the 125I-labeled SLNs were then successfully detected by combined method (radionuclides and blue dye). The accuracy of 125I seeds localization was 96.1% (99/103). Based on the enhancement patterns recorded, 34 cases were predicted to have SLNs metastasis (metastasis in 27 cases and no metastasis in 7 cases confirmed by postoperative pathology) and 65 cases were predicted to have no SLNs metastasis (metastasis in 5 cases and no metastasis in 60 cases by pathology). The positive predictive value and negtive predictive value of CEUS in assessing axillary status were 79.4% (27/34) and 92.3% (60/65), respectively. The axillary metastasis rate in CEUS combined with 125I seeds localization was 27.3% (27/99), while the metastasis rate in the combined method of SLNB was 32.3% (32/99). The sensitivity of 125I seeds localization was 84.4% (27/32), the false-negative rate was 15.6% (5/32), and the consistency evaluation was excellent (Kappa value=0.880, P<0.001). Conclusion CEUS combined with 125I seeds implantation can locate SLNs accurately and has excellent consistency with the combined method. The enhancement patterns can provide helpful predicting information of axillary status preoperatively. However, more studies are needed to be carried out to verify our outcomes and explore the feasibility of applying CEUS technology in clinical work.
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Affiliation(s)
- Pengpeng Zhou
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250000, Shandong, People's Republic of China.,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250000, Shandong, People's Republic of China
| | - Weizhen Zheng
- Shandong Provincial Hospital, Jinan, 250000, Shandong, People's Republic of China
| | - Yanbing Liu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250000, Shandong, People's Republic of China
| | - Yongsheng Wang
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250000, Shandong, People's Republic of China
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Bae HW, Yoon KH, Kim JH, Lim SM, Kim JY, Park HS, Park S, Kim SI, Cho YU, Park BW. Impact of Micrometastatic Axillary Nodes on Survival of Breast Cancer Patients with Tumors ≤2 cm. World J Surg 2019; 42:3969-3978. [PMID: 29959491 DOI: 10.1007/s00268-018-4725-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study investigated the impact of pN1mi disease on the survival of T1 breast cancer patients and examined the clinical usefulness of the online PREDICT tool and updated staging system. METHODS The node stages of 2344 patients were divided into pN0, pN1mi, and pN1a. Clinicopathological parameters and survival outcomes were retrospectively analyzed. Data for 111 micrometastatic diseases were applied to the PREDICT version 2.0 and re-classified using the 8th edition of the cancer staging manual. RESULTS Univariable analyses demonstrated worse disease-free and overall survival rates for patients with node-positive cancer; however, the significance was not maintained in multivariable analyses. Chemotherapy improved outcomes in patients with node-positive and non-luminal A-like subtype cancers. The PREDICT tool demonstrated good performance when estimating the 5-year overall survival for pN1mi disease (area under the receiver operating characteristic curve, 0.834). According to the updated staging system, 74% of cases were down-staged to IA, and clearly splitting survival curves were identified. CONCLUSION pN1mi disease alone did not adversely affect survival outcomes. Biologic and treatment factors determined outcomes in cases of small-volume node micrometastasis. The PREDICT tool or new staging classification could help predict the survival of patients with micrometastatic sentinel nodes.
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Affiliation(s)
- Hyeon Woo Bae
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kwang Hyun Yoon
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joo Heung Kim
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sung Mook Lim
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jee Ye Kim
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyung Seok Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seho Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Frontier Research Institute of Convergence Sports Science, Yonsei University, Seoul, Republic of Korea.
| | - Seung Il Kim
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Up Cho
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Byeong-Woo Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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Wallis M, Kilburn-Toppin F, Taylor-Phillips S. Does preoperative axillary staging lead to overtreatment of women with screen-detected breast cancer? Clin Radiol 2018; 73:467-472. [DOI: 10.1016/j.crad.2017.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/14/2017] [Indexed: 11/29/2022]
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Wallis M. How do we manage overdiagnosis/overtreatment in breast screening? Clin Radiol 2018; 73:372-380. [DOI: 10.1016/j.crad.2017.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/18/2017] [Indexed: 12/18/2022]
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Zengel B, Yararbas U, Sirinocak A, Ozkok G, Denecli AG, Postaci H, Uslu A. Sentinel Lymph Node Biopsy in Breast Cancer: Review on Various Methodological Approaches. TUMORI JOURNAL 2018; 99:149-53. [DOI: 10.1177/030089161309900205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background Sentinel lymph node biopsy has been accepted as a standard procedure for early stage breast cancer. In this retrospective analysis, the results obtained with different methodological approaches using radiocolloid with or without blue dye were examined. Methods A total of 158 sentinel lymph node biopsies were performed in 152 patients. Group A (85 patients) underwent lymphatic mapping using a combination of periareolar intradermal radiocolloid and subareolar blue dye injections. Group B (73 patients) underwent only periareolar intradermal radiocolloid injection. One large tin colloid and two small radiocolloids (nanocolloid of serum albumin -NC- and colloidal rhenium sulphide -CS-) were used. Results Successful lymphatic mapping was attained in 157 of 158 procedures (99.4%). Radiocolloids localized sentinel lymph nodes in 99.4% and blue dye in 75.3% of the cases. The number of sentinel lymph nodes removed was greater in nanocolloid and colloidal rhenium sulphide groups ( P ≤0.05). Among 60 metastatic sentinel lymph nodes, frozen section analysis using hematoxylin and eosin staining failed to detect 1 macro- and 10 micrometastasis. Radiocolloid uptake was higher in sentinel lymph nodes accumulating blue dye (1643 ± 3216 counts/10 sec vs 526 ± 1284 counts/10 sec, P <0.001). Higher count rates were obtained by using larger sized colloids (median and interquartile range: tin colloid, 2050 and 4548; nanocolloid, 835 and 1799; colloidal rhenium sulphide, 996 and 2079; P = 0.01). Only 2 extra-axillary sentinel lymph nodes were visualized using periareolar intradermal injection modality. Conclusions Radiocolloids were more successful than blue dye in sentinel lymph node detection. More sentinel lymph nodes were harvested with small colloids, but different sized radiocolloids were similarly successful. Sentinel lymph nodes having higher radiocolloid uptake tended to accumulate blue dye more frequently. Sentinel lymph nodes manifested higher count rates when a larger colloid was used. Frozen section was very successful in detecting macrometastatic disease in sentinel lymph nodes, but the technique failed in most of the micrometastates.
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Affiliation(s)
- Baha Zengel
- Turkish Ministry of Health Izmir Bozyaka Research and Training Hospital, Department of General Surgery, Izmir, Turkey
| | - Ulkem Yararbas
- Ege University, Medical Faculty, Department of Nuclear Medicine, Bornova, Izmir, Turkey
| | - Ahmet Sirinocak
- Turkish Ministry of Health Izmir Bozyaka Research and Training Hospital, Department of General Surgery, Izmir, Turkey
| | - Guliz Ozkok
- Turkish Ministry of Health Izmir Bozyaka Research and Training Hospital, Department of Pathology, Izmir, Turkey
| | - Ali Galip Denecli
- Turkish Ministry of Health Izmir Bozyaka Research and Training Hospital, Department of General Surgery, Izmir, Turkey
| | - Hakan Postaci
- Turkish Ministry of Health Izmir Bozyaka Research and Training Hospital, Department of Pathology, Izmir, Turkey
| | - Adam Uslu
- Turkish Ministry of Health Izmir Bozyaka Research and Training Hospital, Department of General Surgery, Izmir, Turkey
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Nielsen Moody A, Bull J, Culpan AM, Munyombwe T, Sharma N, Whitaker M, Wolstenhulme S. Preoperative sentinel lymph node identification, biopsy and localisation using contrast enhanced ultrasound (CEUS) in patients with breast cancer: a systematic review and meta-analysis. Clin Radiol 2017; 72:959-971. [DOI: 10.1016/j.crad.2017.06.121] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/11/2017] [Accepted: 06/26/2017] [Indexed: 01/08/2023]
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14
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Utility of single-photon emission tomography/computed tomography for sentinel lymph node localization in breast cancer patients. Nucl Med Commun 2017; 38:493-499. [DOI: 10.1097/mnm.0000000000000676] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Sentinel lymph node biopsy using indocyanine green fluorescence in early-stage breast cancer: a meta-analysis. Int J Clin Oncol 2016; 22:11-17. [PMID: 27864624 DOI: 10.1007/s10147-016-1064-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 02/05/2023]
Abstract
Sentinel lymph node (SLN) biopsy using indocyanine green (ICG) fluorescence is safe and has a high detection rate for SLNs. However, the results of this novel technique are heterogeneous. The objective of this meta-analysis was to evaluate the diagnostic performance of the ICG fluorescence method compared with the standard radioisotope (RI) method. All eligible studies were identified from 2005 through 2015. A proportion meta-analysis was performed using a fixed effects and/or random effects model based on the study heterogeneity. A total of 12 studies met the inclusion criteria and included 1736 women. There was no significant difference between ICG fluorescence and RI for SLN detection using either the fixed effects model [odds ratio (OR) 1.29, 95% confidence interval (CI) 0.87-1.90] or the random effects model (OR 1.32, 95% CI 0.54-3.18). There were seven studies reporting the detection rate for tumor-positive SLN. The ICG fluorescence method was significantly better than the RI method in the fixed effects model (OR 1.87, 95% CI 1.00-3.49) for staging axilla. However, there was no difference in the random effects model (OR 1.90, 95% CI 0.74-4.86). There was study outcome heterogeneity for the detection of SLN but not for tumor-positive SLN. There was no publication bias observed in the studies included. The ICG fluorescence method has valid diagnostic performance for SLN detection and shows a trend toward better axilla staging compared with the RI method. ICG fluorescence is a useful alternative to RI for SLN biopsy.
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16
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Matsen C, Villegas K, Eaton A, Stempel M, Manning A, Cody HS, Morrow M, Heerdt A. Late Axillary Recurrence After Negative Sentinel Lymph Node Biopsy is Uncommon. Ann Surg Oncol 2016; 23:2456-61. [PMID: 26957506 DOI: 10.1245/s10434-016-5151-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study was designed to determine the incidence of late axillary recurrence (AR) in patients with negative sentinel lymph node biopsy (SLNB) and provide a comparison with SLNB positive patients who underwent axillary lymph node dissection (ALND). METHODS Retrospective analysis of prospectively collected data on all breast cancer patients with negative SLNB from January 1997 to December 2000 was performed on a large, institutional database. Primary outcome was cumulative incidence of AR as a first event with/without concurrent local recurrence. SLNB positive patients who went on to ALND during the same timeframe were comparatively analyzed. RESULTS A total of 1529 eligible patients were identified (median age 58 years, median tumor size 1.0 cm): 1297 (85 %) underwent lumpectomy; 1099 (75 %) received adjuvant radiation; and 874 (80 %) were estrogen receptor-positive. At 10.8 (range 0-16) years median follow-up, overall incidence of AR as a first event was low (n = 13). Cumulative incidence was 0.6 % [95 % confidence interval (CI) 0.2-0.9] 5 years after SLNB, and 0.9 % (95 % CI 0.4-1.4, 95 % CI 0.5-1.6) at 10 and 15 years. Late AR (>5 years after surgery) occurred in five patients. Median overall survival after AR was 4.6 years; median distant disease-free survival after AR was 3.8 years. Late AR was also low in a contemporaneous group of SLNB positive patients undergoing ALND. In this group, cumulative incidence of AR was 0.7 % (95 % CI 0.1-1.3) 5 years after surgery, and 0.8 % (95 % CI 0.2-1.5) at 10 and 15 years. DISCUSSION Late AR after negative SLNB is rare; the majority of ARs are in the first 5 years after surgery. Prognosis after these events is poor. SLNB remains a safe and effective procedure for axillary evaluation in breast cancer.
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Affiliation(s)
- Cindy Matsen
- Breast Care Program, Department of Surgery, Hunstman Cancer Institute at the University of Utah, Salt Lake City, UT, USA.
| | - Kristine Villegas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aidan Manning
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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17
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Sollamo EMJ, Ilmonen SK, Virolainen MS, Suominen SHH. Sentinel lymph node biopsy in cN0 squamous cell carcinoma of the lip: A retrospective study. Head Neck 2015; 38 Suppl 1:E1375-80. [DOI: 10.1002/hed.24230] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 02/06/2023] Open
Affiliation(s)
- Erik Mikael Jan Sollamo
- Department of Plastic Surgery, Töölö Hospital; Helsinki University Central Hospital; Helsinki Finland
| | - Suvi Kristiina Ilmonen
- Department of Plastic Surgery, Töölö Hospital; Helsinki University Central Hospital; Helsinki Finland
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18
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Pitsinis V, Provenzano E, Kaklamanis L, Wishart GC, Benson JR. Indocyanine green fluorescence mapping for sentinel lymph node biopsy in early breast cancer. Surg Oncol 2015; 24:375-9. [PMID: 26555151 DOI: 10.1016/j.suronc.2015.10.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/06/2015] [Accepted: 10/16/2015] [Indexed: 02/05/2023]
Abstract
INTRODUCTION A recent feasibility study (ICG-10) has confirmed high sensitivity of ICG fluorescence mapping for sentinel SLN detection in early breast cancer with 95% of nodes both blue and fluorescent. This follow-on study has specifically evaluated a combination of ICG and blue dye for SLN localization. METHODS Fifty consecutive patients (49 female; 1 male) with unilateral clinically node negative invasive (37) and non-invasive (13) breast cancer underwent SLN biopsy with blue dye and ICG. Median patient age was 48 years and median invasive tumour size 19 mm for primary surgical patients. All patients had a normal pre-operative axillary ultrasound. Nodal and procedural detection rates were calculated for ICG alone and in combination with blue dye. RESULTS A total of 87 nodes were retrieved with an average nodal count of 1.8 per patient (range 1-4). Eighty four nodes were blue and fluorescent and 3 fluorescent only. Nodal detection rates for ICG alone and combined with blue dye were 100% (87/87) and 96% (84/87) respectively. Metastases were present in 18 nodes (all blue and fluorescent) with 10 patients node positive overall (20%). The procedural detection rate for blue dye and ICG was 96% (48/50) and 2 patients had fluorescent only nodes which were deemed sentinel (4%). CONCLUSION Fluorescent imaging with ICG is a sensitive, valuable and safe method for SLN biopsy. A combination of blue dye and ICG is useful dual approach when radioisotope is unavailable. ICG has the potential to be a sole tracer agent with improved patient convenience and costs.
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Affiliation(s)
- Vassilis Pitsinis
- Cambridge Breast Clinic, Mediterraneo Hospital, Athens, 16675, Greece
| | - Elena Provenzano
- Cambridge Breast Unit, Addenbrookes Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Loukas Kaklamanis
- Cambridge Breast Clinic, Mediterraneo Hospital, Athens, 16675, Greece
| | - Gordon C Wishart
- Cambridge Breast Clinic, Mediterraneo Hospital, Athens, 16675, Greece; Faculty of Medical Science, Anglia Ruskin University, East Road, Cambridge, CB1 1PT, United Kingdom
| | - John R Benson
- Cambridge Breast Unit, Addenbrookes Hospital, Cambridge, CB2 0QQ, United Kingdom; Faculty of Medical Science, Anglia Ruskin University, East Road, Cambridge, CB1 1PT, United Kingdom.
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19
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Grischke EM, Röhm C, Hahn M, Helms G, Brucker S, Wallwiener D. ICG Fluorescence Technique for the Detection of Sentinel Lymph Nodes in Breast Cancer: Results of a Prospective Open-label Clinical Trial. Geburtshilfe Frauenheilkd 2015; 75:935-940. [PMID: 26500370 PMCID: PMC4596694 DOI: 10.1055/s-0035-1557905] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 06/25/2015] [Accepted: 06/25/2015] [Indexed: 10/23/2022] Open
Abstract
Introduction: Detection of sentinel lymph nodes (SLN) is the standard procedure to evaluate axillary lymph node status in breast cancer. In addition to known and established procedures such as the blue dye method and scintigraphy, this study investigated the efficacy of a method based on use of the fluorescent dye indocyanine green (ICG). Patients and Method: A total of 126 women with breast cancer histologically verified by punch biopsy were studied during surgical removal of SLN. In addition to SLN marking with technetium and scintigraphy, intra-individual comparison was done using indocyanine green (ICG) for marking instead of the standard blue dye. Results: Scintigraphy had a detection rate of 96 %; the detection rate with ICG was just under 89 %. A body mass index (BMI) > 40 was found to be a limiting factor for the fluorescent method. Investigation into potential toxicities associated with the use of the fluorescent dye ICG revealed no systemic or even local side effects. The fluorescent method was found to be significantly less expensive than the scintigraphy method. Conclusion: The ICG fluorescence technique for the detection of SLN was found to be a valid and feasible method in clinical practice when compared directly with the blue dye method and scintigraphy.
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Affiliation(s)
| | - C. Röhm
- Universitäts-Frauenklinik Tübingen, Tübingen
| | - M. Hahn
- Universitäts-Frauenklinik Tübingen, Tübingen
| | - G. Helms
- Universitäts-Frauenklinik Tübingen, Tübingen
| | - S. Brucker
- Universitäts-Frauenklinik Tübingen, Tübingen
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Sato Y, Kinoshita T, Suzuki J, Jimbo K, Asaga S, Hojo T, Yoshida M, Tsuda H. Preoperatively diagnosed ductal carcinoma in situ: risk prediction of invasion and effects on axillary management. Breast Cancer 2015; 23:761-70. [PMID: 26324092 DOI: 10.1007/s12282-015-0636-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 08/15/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preoperatively diagnosed ductal carcinoma in situ (DCIS) has the potential to have occult invasion. The predictors of invasive carcinoma underestimation in patients with DCIS diagnosed by preoperative percutaneous biopsy were identified and the effects of underestimation on axillary management were evaluated. METHODS Medical records of 280 patients preoperatively diagnosed as DCIS who underwent surgery were retrospectively analyzed. The patients were divided into non-invasive and invasive carcinoma groups according to the final pathological diagnosis. Risk predictors of invasive carcinoma underestimation and axillary lymph node (ALN) metastasis were analyzed. The axillary status estimated by pathological diagnosis and one-step nucleic acid amplification (OSNA) assay was evaluated. RESULTS The presence of an invasive carcinoma was overlooked in 104 (37.1 %) patients. A clinically palpable mass was an independent risk predictor of invasive carcinoma underestimation by multivariate analysis. There was no risk predictor of ALN metastasis. No ALN metastasis was seen in non-invasive carcinoma group. Six (6.2 %) patients in invasive carcinoma group had macro- or micrometastasis in sentinel lymph nodes (SLNs). Non-SLN metastasis was observed in 3 patients of them. Fourteen patients with only isolated tumor cells (ITCs) or only OSNA-positive SLNs had no metastasis in non-SLNs. CONCLUSIONS SLN biopsy and, if necessary, subsequent ALN dissection (ALND) should be performed in patients with DCIS who have a risk predictor of underestimation. ALND can be avoided in patients who have histologically negative or ITC-positive SLNs, regardless of the presence of invasion on final pathological diagnosis.
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Affiliation(s)
- Yuya Sato
- Breast Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Takayuki Kinoshita
- Breast Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
| | - Junko Suzuki
- Breast Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Kenjiro Jimbo
- Breast Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Sota Asaga
- Breast Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Takashi Hojo
- Breast Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Masayuki Yoshida
- Department of Pathology and Clinical Laboratories, National Cancer Center Hospital, Tokyo, Japan
| | - Hitoshi Tsuda
- Department of Pathology and Clinical Laboratories, National Cancer Center Hospital, Tokyo, Japan
- Department of Basic Pathology, National Defence Medical College, Tokorozawa, Japan
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21
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Deambrogio C, Castellano I, Paganotti A, Zorini EO, Corsi F, Bussone R, Franchini R, Antona J, Miglio U, Sapino A, Antonacci C, Boldorini R. A new clinical cut-off of cytokeratin 19 mRNA copy number in sentinel lymph node better identifies patients eligible for axillary lymph node dissection in breast cancer. J Clin Pathol 2014; 67:702-6. [PMID: 24906358 DOI: 10.1136/jclinpath-2014-202384] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS Cytokeratin 19 (CK19) mRNA copy number predicts the probability of tumour load in axillary lymph nodes (ALN) and can help in decision-making regarding the axillary dissection. The purpose of this study was to define a new cut-off of CK19 mRNA copy number using the one-step nucleic acid amplification (OSNA) assay on metastatic sentinel lymph nodes (SLN) in order to identify cases at risk of having one or more positive ALN. METHODS 1296 SLN from 1080 patients were analysed with the OSNA assay. 194 patients with positive SLN underwent ALN dissection and the mean value of CK19 copy number (320 000) of their SLN was set as initial cut-off. Receiver operative characteristics curve identify a best cut-off of 7700 (sensitivity 78%, specificity 57%). A comparison between our and the traditional cut-off (5000) was performed. RESULTS The cut-off of 7700 successfully identifies patients with positive ALN (p=0.001, false- negative cases: 17%). In the range between 5000 and 7700, one patient with positive ALN would not undergo axillary dissection, whereas eight patients with negative ALN would be correctly identified. CONCLUSIONS We suggest that the level of CK19 mRNA copy number could be the only parameter to consider in the intraoperative management of the axilla.
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Affiliation(s)
- Cristina Deambrogio
- Department of Health Science, School of Medicine, University of Eastern Piedmont "Amedeo Avogadro", Novara, Italy
| | | | | | | | - Fabio Corsi
- Department of Surgery, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Riccardo Bussone
- Breast Unit, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Jlenia Antona
- Department of Health Science, School of Medicine, University of Eastern Piedmont "Amedeo Avogadro", Novara, Italy
| | - Umberto Miglio
- Department of Health Science, School of Medicine, University of Eastern Piedmont "Amedeo Avogadro", Novara, Italy
| | - Anna Sapino
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Renzo Boldorini
- Department of Health Science, School of Medicine, University of Eastern Piedmont "Amedeo Avogadro", Novara, Italy
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Giammarile F, Bozkurt MF, Cibula D, Pahisa J, Oyen WJ, Paredes P, Olmos RV, Sicart SV. The EANM clinical and technical guidelines for lymphoscintigraphy and sentinel node localization in gynaecological cancers. Eur J Nucl Med Mol Imaging 2014; 41:1463-77. [PMID: 24609929 DOI: 10.1007/s00259-014-2732-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 02/14/2014] [Indexed: 02/06/2023]
Abstract
The accurate harvesting of a sentinel node in gynaecological cancer (i.e. vaginal, vulvar, cervical, endometrial or ovarian cancer) includes a sequence of procedures with components from different medical specialities (nuclear medicine, radiology, surgical oncology and pathology). These guidelines are divided into sectione entitled: Purpose, Background information and definitions, Clinical indications and contraindications for SLN detection, Procedures (in the nuclear medicine department, in the surgical suite, and for radiation dosimetry), and Issues requiring further clarification. The guidelines were prepared for nuclear medicine physicians. The intention is to offer assistance in optimizing the diagnostic information that can currently be obtained from sentinel lymph node procedures. If specific recommendations given cannot be based on evidence from original scientific studies, referral is made to "general consensus" and similar expressions. The recommendations are designed to assist in the practice of referral to, and the performance, interpretation and reporting of all steps of the sentinel node procedure in the hope of setting state-of-the-art standards for high-quality evaluation of possible metastatic spread to the lymphatic system in gynaecological cancer. The final result has been discussed by a group of distinguished experts from the EANM Oncology Committee and the European Society of Gynaecological Oncology (ESGO). The document has been endorsed by the SNMMI Board.
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Affiliation(s)
- Francesco Giammarile
- Médecine Nucléaire, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon and EMR HCL/UCBL, Faculté de Médecine, Université Claude Bernard, Lyon 1, Villeurbanne, France,
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23
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Benson JR, Jatoi I. Sentinel lymph node biopsy and neoadjuvant chemotherapy in breast cancer patients. Future Oncol 2014; 10:577-86. [DOI: 10.2217/fon.13.231] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
ABSTRACT: Patient selection and timing of sentinel lymph node (SLN) in the context of primary chemotherapy continues to evolve; there is some evidence that primary chemotherapy may modify lymphatic drainage patterns and cause differential downstaging between SLNs and non-SLNs. SLN biopsy undertaken prior to chemotherapy will minimize the risk of a false-negative result, may allow more accurate initial staging and provides important information on prognostication which can guide decisions about adjuvant radiotherapy. However, quantification of regional metastatic load is incomplete and some advocate SLN biopsy after primary chemotherapy to take advantage of nodal downstaging and avoidance of axillary dissection in up to 40% of patients. Initial reports on false-negative rates for SLN biopsy after primary chemotherapy in patients who had proven axillary node metastases at presentation based on needle core biopsy were relatively high and a cause for clinical concern. However, more recent data suggest that SLN biopsy is as accurate when performed post- as pre-neochemotherapy and current practice incorporates both approaches.
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Affiliation(s)
- John R Benson
- Cambridge Breast Unit, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Ismail Jatoi
- Division of Surgical Oncology, University of Texas Health Science Centre, San Antonio, Texas, USA
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24
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Giammarile F, Alazraki N, Aarsvold JN, Audisio RA, Glass E, Grant SF, Kunikowska J, Leidenius M, Moncayo VM, Uren RF, Oyen WJG, Valdés Olmos RA, Vidal Sicart S. The EANM and SNMMI practice guideline for lymphoscintigraphy and sentinel node localization in breast cancer. Eur J Nucl Med Mol Imaging 2013; 40:1932-47. [DOI: 10.1007/s00259-013-2544-2] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/13/2013] [Indexed: 02/06/2023]
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26
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Takeuchi M, Sugie T, Abdelazeem K, Kato H, Shinkura N, Takada M, Yamashiro H, Ueno T, Toi M. Lymphatic mapping with fluorescence navigation using indocyanine green and axillary surgery in patients with primary breast cancer. Breast J 2012; 18:535-41. [PMID: 23009222 DOI: 10.1111/tbj.12004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The indocyanine green fluorescence (ICGf) navigation method provides real-time lymphatic mapping and sentinel lymph node (SLN) visualization, which enables the removal of SLNs and their associated lymphatic networks. In this study, we investigated the features of the drainage pathways detected with the ICGf navigation system and the order of metastasis in axillary nodes. From April 2008 to February 2010, 145 patients with clinically node-negative breast cancer underwent SLN surgery with ICGf navigation. The video-recorded data from 79 patients were used for lymphatic mapping analysis. We analyzed 145 patients with clinically node-negative breast cancer who underwent SLN surgery with the ICGf navigation system. Fluorescence-positive SLNs were identified in 144 (99%) of 145 patients. Both single and multiple routes to the axilla were identified in 47% of cases using video-recorded lymphatic mapping data. An internal mammary route was detected in 6% of the cases. Skip metastasis to the second or third SLNs was observed in 6 of the 28 node-positive patients. We also examined the strategy of axillary surgery using the ICGf navigation system. We found that, based on the features of nodal involvement, 4-node resection could provide precise information on the nodal status. The ICGf navigation system may provide a different lymphatic mapping result than computed tomography lymphography in clinically node-negative breast cancer patients. Furthermore, it enables the identification of lymph nodes that do not accumulate indocyanine green or dye adjacent to the SLNs in the sequence of drainage. Knowledge of the order of nodal metastasis as revealed by the ICGf system may help to personalize the surgical treatment of axilla in SLN-positive cases, although additional studies are required.
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Affiliation(s)
- Megumi Takeuchi
- Department of Breast Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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Abstract
Our understanding of the role of lymph nodes (LN) in the metastasization process (MET) is marginal. Positive LNs (pLN) are the most important prognostic factor and lymph node dissection (LND) is still standard practice in primary treatment. However, up to now, there is almost no evidence that elective LND has a survival benefit. Based on many clinical and experimental findings, we propose that tumor foci in regional LN are incapable of metastasization and can therefore not infiltrate further LN and organs. Available data demonstrate a very early infiltration of MET capable tumor cells from the primary tumor into regional LN, and thereafter an increased probability of subsequent LN infiltrations. Disparate growth rates of the first versus subsequent infiltrating tumors as well as the asymptotic growth and prognosis of large tumor foci in LN explain many clinical observations for solid tumors. The consequence of the hypothesis "pLN do not metastasize" would impact clinical treatment and research and contribute to understanding the mounting evidence against LND.
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Affiliation(s)
- Jutta Engel
- Ludwig-Maximilians-University, Clinic Großhadern, Munich, Germany
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28
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King B, Shortis A. Functional axillary anatomy: time for a new look at the clavipectoral fascia? ANZ J Surg 2012; 82:576-7. [DOI: 10.1111/j.1445-2197.2012.06162.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wishart GC, Loh SW, Jones L, Benson JR. A feasibility study (ICG-10) of indocyanine green (ICG) fluorescence mapping for sentinel lymph node detection in early breast cancer. Eur J Surg Oncol 2012; 38:651-6. [PMID: 22704050 DOI: 10.1016/j.ejso.2012.05.007] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 04/12/2012] [Accepted: 05/17/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is now increasing evidence to support the use of indocyanine green (ICG) for sentinel lymph node (SLN) detection in early breast cancer. The primary objective of this feasibility study (ICG-10) was to determine the sensitivity and safety of ICG fluorescence imaging in sentinel lymph node identification when combined with blue dye and radiocolloid. METHODS One hundred women with clinically node negative breast cancer (95 unilateral; 5 bilateral) had sentinel lymph node (SLN) biopsy using blue dye, radioisotope and ICG. One patient was excluded from analysis and sensitivity, or detection rate, of ICG alone, and in combination with blue dye and/or radioisotope, was calculated for the remaining 104 procedures in 99 patients. RESULTS Transcutaneous fluorescent lymphography was visible in all 104 procedures. All 202 true SLNs, defined as blue and/or radioactive, were also fluorescent with ICG. Detection rates were: ICG alone 100%, ICG & blue dye 95.0%, ICG & radioisotope 77.2%, ICG & blue dye & radioisotope 73.1%. Metastases were found in 25 of 201 SLNs (12.4%) and all positive nodes were fluorescent, blue and radioactive. The procedural node positivity rate was 17.3%. CONCLUSION The results of this study confirm the high sensitivity of ICG fluorescence for SLN detection in early breast cancer. The combination of ICG and blue dye had the highest nodal sensitivity at 95.0% defining a dual approach to SLN biopsy that avoids the need for radioisotope.
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Affiliation(s)
- G C Wishart
- Cambridge Breast Unit, Box 97, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 2QQ, UK
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Classe JM, Baffert S, Sigal-Zafrani B, Fall M, Rousseau C, Alran S, Rouanet P, Belichard C, Mignotte H, Ferron G, Marchal F, Giard S, Tunon de Lara C, Le Bouedec G, Cuisenier J, Werner R, Raoust I, Rodier JF, Laki F, Colombo PE, Lasry S, Faure C, Charitansky H, Olivier JB, Chauvet MP, Bussières E, Gimbergues P, Flipo B, Houvenaeghel G, Dravet F, Livartowski A. Cost comparison of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. A national study based on a prospective multi-institutional series of 985 patients 'on behalf of the Group of Surgeons from the French Unicancer Federation'. Ann Oncol 2012; 23:1170-1177. [PMID: 21896543 PMCID: PMC3335244 DOI: 10.1093/annonc/mdr355] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 05/11/2011] [Accepted: 06/20/2011] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients. PATIENTS AND METHODS We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery. RESULTS Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001]. CONCLUSION ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.
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Affiliation(s)
- J M Classe
- Surgical Department, Institut de Cancérologie de l'Ouest-Center Gauducheau, Nantes.
| | - S Baffert
- Medico economic unit, Institut Curie, Paris
| | | | - M Fall
- Medico economic unit, Institut Curie, Paris
| | - C Rousseau
- Nuclear medicine Department, Institut de Cancérologie de l'Ouest-Center Gauducheau, Nantes
| | - S Alran
- Surgical Department, Institut Curie, Paris
| | - P Rouanet
- Surgical Department, Center Val d'Aurel Montpellier
| | - C Belichard
- Surgical Department, Center René Huguenin, Saint Cloud
| | - H Mignotte
- Surgical Department, Center Léon Bérard, Lyon
| | - G Ferron
- Surgical Department, Institut Claudius Regaud, Toulouse
| | - F Marchal
- Surgical Department, Center Alexis Vautrin, Nancy
| | - S Giard
- Surgical Department, Center Oscar Lambret, Lille
| | | | - G Le Bouedec
- Surgical Department, Center Jean Perrin, Clermont Ferrand
| | - J Cuisenier
- Surgical Department, Center Georges François Leclerc, Dijon
| | - R Werner
- Surgical Department, Center Jean Godinot, Reims
| | - I Raoust
- Surgical Department, Center Georges Lacassagne, Nice
| | - J-F Rodier
- Surgical Department, Center Paul Strauss, Strasbourg
| | - F Laki
- Medico economic unit, Institut Curie, Paris; Surgical Department, Institut Curie, Paris
| | - P-E Colombo
- Surgical Department, Center Val d'Aurel Montpellier
| | - S Lasry
- Surgical Department, Center René Huguenin, Saint Cloud
| | - C Faure
- Surgical Department, Center Léon Bérard, Lyon
| | - H Charitansky
- Surgical Department, Institut Claudius Regaud, Toulouse
| | - J-B Olivier
- Surgical Department, Center Alexis Vautrin, Nancy
| | - M-P Chauvet
- Surgical Department, Center Oscar Lambret, Lille
| | - E Bussières
- Surgical Department, Center Bergonié, Bordeaux
| | - P Gimbergues
- Surgical Department, Center Jean Perrin, Clermont Ferrand
| | - B Flipo
- Surgical Department, Center Georges Lacassagne, Nice
| | - G Houvenaeghel
- Surgical Department, Institut Paoli Calmette Marseille, France
| | - F Dravet
- Surgical Department, Institut de Cancérologie de l'Ouest-Center Gauducheau, Nantes
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Farooq A, Chandrshekar M, Horgan K. Role of sentinel lymph node biopsy in patients with ductal carcinoma in situ and microinvasion. SURGICAL PRACTICE 2012. [DOI: 10.1111/j.1744-1633.2012.00588.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reliability of whole sentinel lymph node analysis by one-step nucleic acid amplification for intraoperative diagnosis of breast cancer metastases. Ann Surg 2012; 255:334-42. [PMID: 21975319 DOI: 10.1097/sla.0b013e31823000ed] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the reliability of using the One-Step Nucleic Acid Amplification (OSNA) assay as a single test on whole sentinel lymph nodes (SLN) as a method of intraoperative diagnosis and staging of SLNs in breast cancer. BACKGROUND Combining histological and molecular assessment of metastasis on the same SLN may not fully reproduce the actual load of cancer cells present in the SLN and create problems in decisions regarding axillary dissection. METHODS Selection criteria for the whole SLN OSNA test required that the primary tumor expressed CK19 in more than 80% of tumor cells. Imprint cytology analysis of SLNs was performed together with the OSNA. RESULTS Of the 279 patients enrolled for SLN evaluation, 123 gave consent to the OSNA protocol and 156 to the standard histology. Thirteen patients were excluded from OSNA evaluation because of low CK19 gene expression in the primary tumor; only 2.3% were truly negative. The kappa of concordance between the imprint cytology and OSNA results was 0.52. The rate of macrometastases determined by OSNA was 11% versus 20% determined by histology, whereas the rate of OSNA-micrometastases (18%) was significantly higher than that determined by histology (8%). The rate of SLN-negative cases was similar between the 2 protocols. Macrometastases correlated with the presence of vascular invasion in both protocols. The rate of axillary lymph node metastases was consistent with SLN tumor load. CONCLUSIONS Intraoperative OSNA assay performed on the whole SLN gave objective and reproducible results that were useful for directing decisions regarding axillary dissection and for accurately defining the SLN stage.
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Rattay T, Muttalib M, Khalifa E, Duncan A, Parker SJ. Clinical utility of routine pre-operative axillary ultrasound and fine needle aspiration cytology in patient selection for sentinel lymph node biopsy. Breast 2011; 21:210-4. [PMID: 21981897 DOI: 10.1016/j.breast.2011.09.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 09/13/2011] [Accepted: 09/18/2011] [Indexed: 11/15/2022] Open
Abstract
In patients with operable breast cancer, pre-operative evaluation of the axilla may be of use in the selection of appropriate axillary surgery. Pre-operative axillary ultrasound (US) and fine needle aspiration cytology (FNAC) assessments have become routine practice in many breast units, although the evidence base is still gathering. This study assessed the clinical utility of US+/-FNAC in patient selection for either axillary node clearance (ANC) or sentinel lymph node biopsy (SLNB) in patients undergoing surgery for operable breast cancer. Over a two-year period, 348 patients with a clinically negative axilla underwent axillary US. 67 patients with suspicious nodes on US also underwent FNAC. The sensitivity and specificity of axillary investigations to determine nodal involvement were 56% (confidence interval: 47-64%) and 90% (84-93%) for US alone, and 76% (61-87%) and 100% (65-100%) for FNAC combined with US, respectively. With a positive US, the post-test probability was 78%. A negative US carried a post-test probability of 25%. When FNAC was positive, the post-test probability was greater than unity. A negative FNAC yielded a post-test probability of 52%. All patients with positive FNAC and most patients with suspicious US were listed for axillary node clearance (ANC) after consideration at the multi-disciplinary team (MDT) meeting. With pre-operative axillary US+/-FNAC, 20% of patients were saved a potential second axillary procedure, facilitating a reduction in the overall re-operation rate to 12%. In this study, a positive pre-operative US+/-FNAC directs patients towards ANC. When the result is negative, other clinico-pathological factors need to be taken into account in the selection of the appropriate axillary procedure.
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Affiliation(s)
- T Rattay
- Breast Surgery, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
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Wang L, Su D, Yan HJ, Xu JH, Zheng ZG, Hu YJ, Pan XD, Ding XW, Chen C, Chen B, Mao WM, Meng XL. Primary Study of Lymph Node Metastasis-Related Serum Biomarkers in Breast Cancer. Anat Rec (Hoboken) 2011; 294:1818-24. [DOI: 10.1002/ar.21455] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 06/22/2011] [Indexed: 01/22/2023]
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Predicting lymphatic drainage patterns and primary tumour location in patients with breast cancer. Breast Cancer Res Treat 2011; 130:699-705. [PMID: 21850393 DOI: 10.1007/s10549-011-1737-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 08/09/2011] [Indexed: 10/17/2022]
Abstract
Detailed knowledge of the lymphatic drainage of the breast is limited. Lymphoscintigraphy is a technique used during breast cancer treatment to accurately map patterns of lymphatic drainage from the primary tumour to the draining lymph nodes. This study aimed to create a statistical model to analyse the spread of breast cancer and primary tumour location using a large lymphoscintigraphy database, and visualise the results with a novel computational model. This study was based on lymphoscintigraphy data from 2,304 breast cancer patients treated at the Royal Prince Alfred Hospital Medical Centre in Sydney, Australia. Bayesian inferential techniques were implemented to estimate the probabilities of lymphatic drainage from each region of the breast to each draining node field, to multiple node fields, and to determine probabilities of tumour prevalence in each breast region. A finite element model of the torso and discrete model of the draining node fields were created to visualise these data and a software tool was developed to display the results ( www.abi.auckland.ac.nz/breast-cancer ). Results confirmed that lymphatic drainage is most likely to occur to the axillary node field, and that there is significant likelihood of drainage to the internal mammary node field. The likelihood of lymphatic drainage from the whole breast to the axillary, internal mammary, infraclavicular, supraclavicular and interpectoral node fields were 98.2, 35.3, 1.7, 3.1, and 0.7%, respectively; whilst the probability of lymphatic drainage to multiple node fields was estimated to be 36.4%. Additionally, primary tumours are most likely to develop in the upper regions of the breast. The models developed provide quantitative estimates of lymphatic drainage of the breast, giving important insights into understanding breast cancer metastasis and have the potential to benefit both clinicians and patients during breast cancer diagnosis and treatment.
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Avril A, Le Bouëdec G, Lorimier G, Classe JM, Tunon-de-Lara C, Giard S, MacGrogan G, Debled M, Mathoulin-Pélissier S, Mauriac L. Phase III randomized equivalence trial of early breast cancer treatments with or without axillary clearance in post-menopausal patients results after 5 years of follow-up. Eur J Surg Oncol 2011; 37:563-70. [PMID: 21665421 DOI: 10.1016/j.ejso.2011.04.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 04/20/2011] [Accepted: 04/21/2011] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Axillary lymph node clearance (ALNC) improves locoregional control and provides prognostic information for early breast cancer treatment, but effects on survival are controversial. This multicentre, randomized pragmatic equivalence trial compares outcomes for post-menopausal early invasive breast cancer patients after locoregional treatment with ALNC and adjuvant therapies to outcomes after locoregional treatment without ALNC and adjuvant therapies. METHODS From 1995-2005, women aged ≥ 50 years with early breast cancer (tumor ≤ 10 mm) and clinically-negative axillary nodes were randomized to receive treatment with ALNC (Ax) or without (no-Ax). Adjuvant therapies were prescribed according to hormonal receptor status and individual histological results. The primary endpoint was overall survival (OS); secondary endpoints were event-free survival (EFS) and functional outcomes. The trial was terminated due to lack of equivalence and low accrual after first interim analyses. TRIAL REGISTRATION NCT00210236. RESULTS Of 625 patients, 297 no-Ax and 310 Ax patients were maintained for final per-protocol analyses. OS and EFS at five years were not equivalent (Ax vs. no-Ax: 98% vs. 94% and 96% vs. 90% respectively). Recurrence was higher for no-Ax, particularly in the first five years after surgery. Axillary nodes were positive for 14% Ax patients but only 2% no-Ax patients experienced axillary node recurrence. Functional impairments were greater after ALNC. CONCLUSION Our results fail to demonstrate equivalence of outcomes when ALNC is omitted from post-menopausal early breast cancer patient treatment. However the low locoregional recurrence rates warrant further examination over a longer duration, in particular to consider whether these would impact on survival.
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Affiliation(s)
- A Avril
- Department of Surgery, Institut Bergonié, 229 cours de l'Argonne, 33076 Bordeaux Cedex, France.
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Blumgart EI, Uren RF, Nielsen PMF, Nash MP, Reynolds HM. Lymphatic drainage and tumour prevalence in the breast: a statistical analysis of symmetry, gender and node field independence. J Anat 2011; 218:652-9. [PMID: 21453408 DOI: 10.1111/j.1469-7580.2011.01362.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Current understanding of the lymphatics draining the breast is controversial, despite its known importance in the spread of breast cancer. Similarly, knowledge regarding the spatial distribution of primary tumours in the breast is limited. This study sought to test commonly held assumptions in this field, including: (i) that breast lymphatic drainage and tumour prevalence are symmetric between the left and right sides of the body, (ii) that males and females have the same drainage patterns and tumour prevalences, and (iii) that lymphatic drainage in the breast occurs independently to different node fields. This study has used lymphoscintigraphy data from 2304 breast cancer patients treated at the RPAH Medical Centre, Sydney, Australia. Symmetry of lymphatic drainage and tumour distribution as well as gender differences were tested using Fisher's exact test. Drainage independence was assessed using Fisher's exact test, and a multivariate probit model was used to test for drainage correlations. Results showed that the breasts are likely to have symmetric lymphatic drainage and tumour prevalence, and that there is no significant difference between males and females. Furthermore, results showed that direct lymphatic drainage of the breasts is likely to be independent between node fields. Collectively, these results serve to further our understanding of lymphatic anatomy and the distribution of tumours in the breast.
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Affiliation(s)
- Evan I Blumgart
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.
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Toi M, Winer EP, Inamoto T, Benson JR, Forbes JF, Mitsumori M, Robertson JFR, Sasano H, von Minckwitz G, Yamauchi A, Klimberg VS. Identifying gaps in the locoregional management of early breast cancer: highlights from the Kyoto Consensus Conference. Ann Surg Oncol 2011; 18:2885-92. [PMID: 21431404 DOI: 10.1245/s10434-011-1666-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Indexed: 02/05/2023]
Abstract
A consensus conference was held to investigate issues related to the local management of early breast cancer. Here, we highlight the major topics discussed at the conference and propose ideas for future studies. Regarding axillary management, we examined three major issues. First, we discussed whether the use of axillary reverse mapping could clarify the lymphatic system of breast and whether the ipsilateral arm might help avoid lymphedema. Second, the use of an indocyanine green fluorescent navigation system was discussed for intraoperative lymphatic mapping. These new issues should be examined further in practice. Finally, some agreement was reached on the importance of "four-node diagnosis" to aid in the diagnostic accuracy of sentinel nodes. Regarding breast treatment, there was general agreement that the clinical value of surgical margins in predicting local failure was dependent on the tumor's intrinsic biology and subtypes. For patients treated with preoperative chemotherapy, less extensive excision may be feasible in those who respond to systemic therapy in an acceptable manner. Most trials of preoperative chemotherapy lack outcome data on local recurrence. Therefore, there is a need for such data for overview analysis. We also agreed that radiation after mastectomy may be beneficial in node-positive cases where more than four nodes are involved. Throughout the discussions for both invasive and noninvasive disease, the investigation of nomograms was justified for major issues in the decision-making process, such as the presence or absence of microinvasion and the involvement of nonsentinel nodes in sentinel node-positive patients.
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Affiliation(s)
- Masakazu Toi
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawara-cho, Sakyo-ku, Kyoto, Japan.
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Abstract
Distant metastases (MET) are for most solid cancers decisive life-threatening events. Data about MET-free survival and survival after MET show a strong dependency on the kind of cancer and the prognostic features. Nonetheless, within biological subgroups, the MET process is very homogenous. Therefore, the growth rate can be estimated from initiation of MET to MET diagnosis and to time of death. Based on the known volume doubling time of breast cancer, the time of the first possible dissemination can also be estimated. Important consequences of these MET-initiation estimates are the hypotheses that almost all MET are initiated before removal of the primary tumor and that MET do not metastasize in a clinically relevant magnitude. Although breast cancer data were primarily used to form these hypotheses, the discussed MET process can be generalized to all solid cancers. The impact of these hypotheses on diagnostic, curative and palliative treatment, aftercare, and especially on clinical research would be important.
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Van Belle V, Decock J, Hendrickx W, Brouckaert O, Pintens S, Moerman P, Wildiers H, Paridaens R, Christiaens MR, Van Huffel S, Neven P. Short-Term Prognostic Index for Breast Cancer: NPI or Lpi. PATHOLOGY RESEARCH INTERNATIONAL 2010; 2011:918408. [PMID: 21253502 PMCID: PMC3021876 DOI: 10.4061/2011/918408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 12/02/2010] [Indexed: 12/02/2022]
Abstract
Axillary lymph node involvement is an important prognostic factor for breast cancer survival but is confounded by the number of nodes examined. We compare the performance of the log odds prognostic index (Lpi), using a ratio of the positive versus negative lymph nodes, with the Nottingham Prognostic Index (NPI) for short-term breast cancer specific disease free survival. A total of 1818 operable breast cancer patients treated in the University Hospital of Leuven between 2000 and 2005 were included. The performance of the NPI and Lpi were compared on two levels: calibration and discrimination. The latter was evaluated using the concordance index (cindex), the number of patients in the extreme groups, and difference in event rates between these. The NPI had a significant higher cindex, but a significant lower percentage of patients in the extreme risk groups. After updating both indices, no significant differences between NPI and Lpi were noted.
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Affiliation(s)
- V. Van Belle
- Division SCD, Department of Electrical Engineering (ESAT), K.U.Leuven, Kasteelpark Arenberg 10/2446, 3000 Leuven, Belgium
| | - J. Decock
- School of Biological Sciences, University of East Anglia (UEA), NR4 7TJ Norwich, UK
| | - W. Hendrickx
- School of Medicine, Health Policy and Practice, University of East Anglia, NR4 7TJ Norwich, UK
| | - O. Brouckaert
- Multidisciplinary Breast Centre (MBC), University Hospitals Leuven, Leuven, Belgium
| | - S. Pintens
- Multidisciplinary Breast Centre (MBC), University Hospitals Leuven, Leuven, Belgium
| | - P. Moerman
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - H. Wildiers
- Multidisciplinary Breast Centre (MBC), University Hospitals Leuven, Leuven, Belgium
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - R. Paridaens
- Multidisciplinary Breast Centre (MBC), University Hospitals Leuven, Leuven, Belgium
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - M. R. Christiaens
- Multidisciplinary Breast Centre (MBC), University Hospitals Leuven, Leuven, Belgium
| | - S. Van Huffel
- Division SCD, Department of Electrical Engineering (ESAT), K.U.Leuven, Kasteelpark Arenberg 10/2446, 3000 Leuven, Belgium
| | - P. Neven
- Multidisciplinary Breast Centre (MBC), University Hospitals Leuven, Leuven, Belgium
- Department of Gynaecological Oncology, University Hospitals Leuven, Leuven, Belgium
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Moon HG, Han W, Noh DY. Comparable Survival Between pN0 Breast Cancer Patients Undergoing Sentinel Node Biopsy and Extensive Axillary Dissection: A Report From the Korean Breast Cancer Society. J Clin Oncol 2010; 28:1692-9. [DOI: 10.1200/jco.2009.25.9226] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose Recent studies showing survival benefit of extensive axillary lymph node dissection (ALND) in pN0 breast cancer have challenged the concept of sentinel node biopsy (SNB). In this study, the survival and recurrence after SNB alone and ALND in pN0 Korean breast cancer patients were investigated. Patients and Methods Using information from two large databases, including a Korean nationwide registry, we assessed survival relative to the extent of ALND in pN0 breast cancer patients. We also compared the survival of pN0 patients who underwent SNB alone with survival in those who underwent varying degrees of ALND. Results In an analysis of 1,607 pN0 patients from a single institution, less extensive ALND significantly increased the risks of breast cancer death and systemic recurrence but not of locoregional recurrence. These findings were validated by an analysis of nationwide registry data on 17,672 pN0 patients; patients with > 20 dissected lymph nodes had significantly better overall survival (OS) and breast cancer–specific survival (BCSS) than those with 10 to 20 or < 10 dissected lymph nodes. Patients who underwent SNB alone showed OS (hazard ratio [HR], 1.03; 9% CI, 0.08 to 1.56) and BCSS (HR, 1.15; 95% CI, 0.75 to 1.78) similar to those of patients who underwent extensive ALND (> 20 dissected lymph nodes), despite the small number of lymph nodes removed. Conclusion Extensive ALND is associated with better survival and less systemic recurrence than less extensive ALND in patients with pN0 breast cancer. However, SNB alone showed excellent survival results, similar to those of extensive ALND, supporting the long-term oncologic safety of SNB.
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Affiliation(s)
- Hyeong-Gon Moon
- From the Department of Surgery, Gyeongsang National University Hospital, Gyeongsang Institute of Health Science, Jinju; Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wonshik Han
- From the Department of Surgery, Gyeongsang National University Hospital, Gyeongsang Institute of Health Science, Jinju; Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Young Noh
- From the Department of Surgery, Gyeongsang National University Hospital, Gyeongsang Institute of Health Science, Jinju; Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Sentinel node biopsy in breast cancer: time has come to systematically perform it before planned axillary clearance. Breast 2009; 19:65-6. [PMID: 19896849 DOI: 10.1016/j.breast.2009.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 10/14/2009] [Indexed: 11/21/2022] Open
Abstract
Sentinel lymph node biopsy is a simple and relatively safe technique that emerged as a standard in the management of early breast cancer. Indications are becoming larger and because this particular node provides significant epidemiological, clinical, pathological, educational and prognostic information efforts must be done to identify it even when a a complete axillary clearance is planned.
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Abstract
Adoption of urbanised lifestyles together with changes in reproductive behaviour might partly underlie the continued rise in worldwide incidence of breast cancer. Widespread mammographic screening and effective systemic therapies have led to a stage shift at presentation and mortality reductions in the past two decades. Loco-regional control of the disease seems to affect long-term survival, and attention to surgical margins together with improved radiotherapy techniques could further contribute to mortality gains. Developments in oncoplastic surgery and partial-breast reconstruction have improved cosmetic outcomes after breast-conservation surgery. Optimum approaches for delivering chest-wall radiotherapy in the context of immediate breast reconstruction present special challenges. Accurate methods for intraoperative assessment of sentinel lymph nodes remain a clinical priority. Clinical trials are investigating combinatorial therapies that use novel agents targeting growth factor receptors, signal transduction pathways, and tumour angiogenesis. Gene-expression profiling offers the potential to provide accurate prognostic and predictive information, with selection of best possible therapy for individuals and avoidance of overtreatment and undertreatment of patients with conventional chemotherapy. Short-term presurgical studies in the neoadjuvant setting allow monitoring of proliferative indices, and changes in gene-expression patterns can be predictive of response to therapies and long-term outcome.
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Affiliation(s)
- John R Benson
- Cambridge Breast Unit, Addenbrookes Hospital and University of Cambridge, Cambridge, UK
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Volume-controlled vs no/short-term drainage after axillary lymph node dissection in breast cancer surgery: A meta-analysis. Breast 2009; 18:109-14. [DOI: 10.1016/j.breast.2009.02.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 12/24/2008] [Accepted: 02/12/2009] [Indexed: 11/18/2022] Open
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Spanheimer PM, Graham MM, Sugg SL, Scott-Conner CEH, Weigel RJ. Measurement of Uterine Radiation Exposure from Lymphoscintigraphy Indicates Safety of Sentinel Lymph Node Biopsy during Pregnancy. Ann Surg Oncol 2009; 16:1143-7. [DOI: 10.1245/s10434-009-0390-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 02/02/2009] [Accepted: 02/03/2009] [Indexed: 11/18/2022]
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Samphao S, Eremin O. In reply: In favor of axillary lymph node dissection: need for a pragmatic view. Ann Surg Oncol 2009; 16:1066-7. [PMID: 19169755 DOI: 10.1245/s10434-008-0311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 11/12/2008] [Indexed: 11/18/2022]
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Yun M, Cho A. Radiation Safety Issues Related to Sentinel Lymph Node Biopsy using Radioactive Colloid: Commentary on "Exposure of Surgical Staff to Radiation". J Breast Cancer 2009. [DOI: 10.4048/jbc.2009.12.2.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Mijin Yun
- Division of Nuclear Medicine, Department of Diagnostic Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Arthur Cho
- Division of Nuclear Medicine, Department of Diagnostic Radiology, Yonsei University College of Medicine, Seoul, Korea
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Axelsson CK, Düring M, Christiansen PM, Wamberg PA, Søe KL, Møller S. Impact on regional recurrence and survival of axillary surgery in women with node-negative primary breast cancer. Br J Surg 2008; 96:40-6. [DOI: 10.1002/bjs.6350] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Abstract
Background
This study examined whether axillary lymph node dissection (ALND) with removal of many normal lymph nodes resulted in a reduced rate of axillary recurrence and better survival, as reported in recent studies.
Methods
The follow-up analyses were based on 8657 patients with node-negative primary breast cancer treated solely by surgery. Median follow-up was 9 years.
Results
The number of lymph nodes removed correlated with a reduction in the rate of subsequent axillary recurrence (from 2·1 to 0·4 per cent; P = 0·037), local recurrence (from 7·4 to 3·8 per cent; P < 0·001) distant metastases (from 15·0 to 10·3 per cent; P < 0·001) and death as first event (from 7·5 to 5·5 per cent; P = 0·012).
Conclusion
When ALND is indicated, at least ten axillary lymph nodes should be retrieved. The role of ALND as primary treatment has decreased significantly during the past decade. The findings leave the concept of the sentinel node biopsy intact, as a highly specific procedure compared to ALND.
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Affiliation(s)
- C K Axelsson
- Department F of Breast Surgery, Herlev University Hospital, Copenhagen, Denmark
| | - M Düring
- DBCG Secretariat, Rigshospitalet, Copenhagen, Denmark
| | - P M Christiansen
- Surgical Department P, Aarhus University Hospital, Aarhus, Denmark
| | - P A Wamberg
- Surgical Department K, Vejle Hospital, Vejle, Denmark
| | - K L Søe
- Surgical Department A, Odense University Hospital, Odense, Denmark
| | - S Møller
- DBCG Secretariat, Rigshospitalet, Copenhagen, Denmark
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Gill G. Sentinel-Lymph-Node-Based Management or Routine Axillary Clearance? One-Year Outcomes of Sentinel Node Biopsy Versus Axillary Clearance (SNAC): A Randomized Controlled Surgical Trial. Ann Surg Oncol 2008; 16:266-75. [DOI: 10.1245/s10434-008-0229-z] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Revised: 10/06/2008] [Accepted: 10/08/2008] [Indexed: 11/18/2022]
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Langbecker D, Hayes SC, Newman B, Janda M. Treatment for upper-limb and lower-limb lymphedema by professionals specializing in lymphedema care. Eur J Cancer Care (Engl) 2008; 17:557-64. [PMID: 18771539 DOI: 10.1111/j.1365-2354.2007.00878.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Up to 60% of patients with cancer of the vulva, and between 20 and 30% of patients with breast or abdominal cancers may develop lymphedema following treatment. The aims of this study were to assess health professionals' knowledge about treatment, diagnostic procedures, advice and confidence in treatment of patients with either upper-limb (ULL) or lower-limb lymphoedema (LLL), and whether these differed by health professionals' background or for patients with ULL compared with LLL. A cross-sectional telephone interview was undertaken in 2006, of 63 health professionals (response rate 92.6%) known to treat lymphedema. Sixty-three per cent of the health professionals were physiotherapists; the majority were university-trained, with 20 years' experience or more. Ninety-five per cent of health professionals used circumferential measurements to establish lymphedema status, and most health professionals advised avoiding scratches and cuts (100%), insect bites (98.4%), sunburn (98.4%) and excessive exercise (65.1%) on the affected limb. Health professionals reported that compared with patients with LLL, patients with ULL were more likely to present within the first 3 months of being symptomatic (P < 0.01). Patients with LLL were more likely to present with swelling (P = 0.001), heaviness (P = 0.003), tightness (P = 0.007) and skin problems (P < 0.001) compared with patients with ULL. Treatment and advice differed according to health professionals' background, but not location of lymphedema (ULL vs. LLL). Assessment, treatment and advice for lymphedema vary across professional groups. Our results suggest that improvements should be attempted in the early detection of lymphedema, in particular of LLL among cancer patients.
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Affiliation(s)
- D Langbecker
- School of Public Health and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
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