Assessment of morbidity from complete axillary dissection

Effect of Intercostal Nerve Coaptation on Postoperative Pain in Implant-Based Breast Reconstruction: A Double-Blind, Randomized Controlled Pilot Study

PURPOSE

Patients undergoing breast surgery may experience chronic postoperative pain in the breasts, upper extremities, and axillary regions, and no established methods for preventing this pain are available at present. This study aimed to investigate whether coaptation of the transected intercostal nerve can prevent the development of neuropathic and chronic breast pain after mastectomy in implant-based breast reconstruction.

METHODS

A prospective, double-blind, randomized controlled trial was conducted by dividing patients who underwent implant-based breast reconstruction after mastectomy into a control group without nerve coaptation and an experimental group with nerve coaptation. Patient clinical information was collected, and a survey using the pain and quality of life scale was conducted at 6 and 12 months after surgery.

RESULTS

Fifteen patients completed the study, including seven in the control group and eight in the experimental group. The two groups showed no significant differences in terms of clinical factors. The experimental group exhibited lower Short-Form McGill Pain Questionnaire scores than the control group at 6 and 12 months postoperatively, with a statistically significant difference at 6 months. Numerical Rating Scale and Present Pain Intensity scores for both groups were in the "no to mild" range throughout the study period, with no statistically significant differences between the groups. Although the difference in the BREAST-Q™ results did not reach statistical significance, the experimental group showed an improvement in the quality of life.

CONCLUSION

Intercostal nerve coaptation after mastectomy in implant-based breast reconstruction may facilitate initial nerve recovery. Although trial results are needed to fully determine the clinical impact, our findings support the ongoing scientific and clinical efforts to use this technique.

Optimizing Axillary Management in Triple-Negative Breast Cancer Following Neoadjuvant Chemotherapy

INTRODUCTION

Triple-negative breast cancer (TNBC) often shows significant response to neoadjuvant chemotherapy (NACT), creating opportunities for axillary de-escalation. This study investigates axillary de-escalation and the factors influencing its use in TNBC.

METHODS

Patients with cT1-cT2, cN1 TNBC treated between 2012 and 2020 were identified from the National Cancer Database. Nodal response rates, including achievement of ypN0, were analyzed. Logistic regression identified clinical and sociodemographic factors associated with axillary management.

RESULTS

Among 12,742 patients undergoing axillary lymph node dissection (ALND), 31.7% achieved nodal pathologic complete response (pCR). These patients were more also likely to achieve breast tumor pCR. Treatment across multiple facilities was associated with a higher likelihood of attempted axillary de-escalation. ALND rates steadily declined between 2014 and 2020.

CONCLUSION

Despite achieving nodal pCR after NACT, many patients with TNBC underwent ALND. These findings underscore the need to refine criteria and increase adoption of axillary de-escalation strategies in TNBC.

The impact of axillary lymph node dissection on the prognosis of breast cancer patients undergoing up-front mastectomy with Sentinel lymph node micrometastases

Traditionally, completion axillary lymph node dissection (ALND) has been standard for breast cancer patients with positive sentinel lymph nodes (SLNs). However, ALND poses risks of morbidity. Recent trials suggest omission of ALND may be safe in selected cases. Controversy exists regarding ALND omission in mastectomy patients with micrometastases. We retrospectively analyzed data from 12 centers in China and the Surveillance, Epidemiology, and End Results (SEER) database. Patients with T1-2 breast cancer and SLN micrometastases who underwent up-front mastectomy were included. Patients were categorized into two groups: Non-ALND and ALND. Clinicopathological factors and survival outcomes were compared between the two groups. A total of 118 patients from 12 centers in China and 4,884 patients from the SEER database were included in the analysis. The Non-ALND group demonstrated non-inferiority in terms of recurrence-free survival (RFS), locoregional recurrence-free survival (LRFS), breast cancer-specific survival (BCSS), and overall survival (OS) when compared to the ALND group. Multivariable analysis identified significant predictors of survival outcomes. This study supports the omission of ALND in T1-2N1mi breast cancer patients undergoing mastectomy, demonstrating comparable survival outcomes to those undergoing ALND. Proper patient selection is essential for tailored treatment strategies.

Axillary lymph node metastasis in breast cancer: from historical axillary surgery to updated advances in the preoperative diagnosis and axillary management

Axillary lymph node status, which was routinely assessed by axillary lymph node dissection (ALND) until the 1990s, is a crucial factor in determining the stage, prognosis, and therapeutic strategy used for breast cancer patients. Axillary surgery for breast cancer patients has evolved from ALND to minimally invasive approaches. Over the decades, the application of noninvasive imaging techniques, machine learning approaches and emerging clinical prediction models for the detection of axillary lymph node metastasis greatly improves clinical diagnostic efficacy and provides optimal surgical selection. In this work, we summarize the historical axillary surgery and updated perspectives of axillary management for breast cancer patients.

Omitting axillary lymph node dissection is associated with an increased risk of regional recurrence in early stage breast cancer: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Breast cancer (BC) is a global problem, however, despite ALND is considered the standard treatment for early stage BC with node-positive, there is no sufficient data to determine which of these patients should undergo it. Thus, the aim of this systematic review was to clarify if there is any difference between NALND and ALND in terms of safety and prognosis of the patients.

METHODS

A shearch was carried in PubMed, Embase and Cochrane databases for studies that compared NALND and ALND. The statistics was performed in R software, in which a restricted maximum likelihood estimator random-effect model were employed to compute risk ratios and hazard ratios with 95% CI. Heterogeneity was accessed with I2 statistics.

RESULTS

There was 7 included studies, involving 7.338 patients, of whom 3.710 were randomized to omission of ALND. The follow-up period ranged from 5 to 10 years, with participant ages varying from 53 to 61 years. The analysis revealed significant increase in 10 years regional recurrence (RR 1.43; 95%CI 0.78 to 2.64; I²=0%) and a significant decrease in lymphedema (RR 0.35; 95% CI 0.23 to 0.53; I²=60%), however no significant result was found for last reported OS (HR 0.96; 95% CI 0.79 to 1.17; I2= 6%) or DFS (HR 1.002; 95% CI 0.960 to 1.045; I2=55%).

CONCLUSIONS

Our data suggest that while the NALND offers benefits in terms of preventing lymphedema, it was associated with a higher risk of 10 years regional recurrence. Thus, further studies are necessary to fully assess the role of these techniques in BC management.

Chronic post-surgical pain after total knee arthroplasty: a narrative review

Total knee arthroplasty (TKA) is an efficacious treatment for end-stage knee osteoarthritis, often accompanied by severe postoperative pain. In certain patients, this pain can persist for over 3 months and is referred to as chronic post-surgical pain (CPSP). Postoperative persistent pain has emerged as a significant and noteworthy issue impacting patient quality of life following TKA. The etiology of CPSP after TKA is multifaceted. Peripheral or central sensitizations resulting from inflammatory reactions, nerve injury, and neurobiological mechanisms are the primary mechanisms contributing to chronic persistent pain after TKA. Preoperative, intraoperative, and postoperative factors can induce pain sensitization. Once CPSP occurs after TKA, it significantly hampers patient recovery with challenging treatment options. Currently, among the preventive and therapeutic strategies for chronic pain after TKA, it is widely believed that early comprehensive preventive treatment to prevent acute to chronic pain transition can substantially reduce the incidence of CPSP following TKA. In recent years, studies have investigated perioperative strategies aimed at reducing the occurrence of persistent pain after TKA. This article provides an overview of advancements in understanding the pathogenesis, high-risk factors, and preventive measures for chronic pain following TKA. We hope that this review will guide future research directions on CPSP after TKA while contributing to clinical perioperative pain management.

Axillary de-escalation after neoadjuvant chemotherapy for advanced lymph node involvement in breast cancer

INTRODUCTION

Sentinel lymph node biopsy reduces morbidity in patients with clinically node-positive breast cancer who achieve axillary pathologic complete response following neoadjuvant therapy (NACT). De-escalation trials primarily addressed cN1 disease, with underrepresentation of cN2 disease. This study evaluates the role of de-escalation in patients with cN2 breast cancer.

METHODS

A retrospective analysis of the National Cancer Database (2013-2020) included women over 18 with T1-2 invasive breast cancer and clinical N2 disease who received NACT followed by ALND or SLNB then ALND. The primary outcome was pathologic nodal status post-NACT.

RESULTS

Of 5852 cN2 patients treated, 18.15 ​% achieved ypN0, 0.97 ​% had isolated tumor cells, 19.14 ​% were ypN1, 49.64 ​% were ypN2, and 12.20 ​% were ypN3 following NACT. Achieving ypN0 was associated with pCR in the breast, HER2-positive and triple-negative receptor status, cT2 tumors, and younger age.

CONCLUSION

Despite some patients with cN2 disease achieving ypN0, most exhibited residual axillary disease post-NACT. These findings indicate that axillary de-escalation may not be feasible for most patients with cN2 disease, underscoring the importance of meticulous patient selection and assessment.

Micrometastases in axillary lymph nodes in breast cancer, post-neoadjuvant systemic therapy

INTRODUCTION

The significance of minimal residual axillary disease, specifically micrometastases, following neoadjuvant systemic therapy (NST) remains largely unexplored. Our study aimed to elucidate the prognostic implications of micrometastases in axillary and sentinel lymph nodes following NST.

METHODS

This retrospective study analyzed primary breast cancer patients who underwent surgery after NST from September 2006 through February 2018. All patients received axillary lymph node dissection (ALND), either with or without sentinel lymph node biopsy. Recurrence-free survival (RFS)-associated variables were identified using a multivariate Cox proportional hazard model.

RESULTS

Of the 978 patients examined, 438 (44.8%) exhibited no pathologic lymph node involvement (ypN0) after NST, while 89 (9.1%) had micrometastases (ypN1mi) and 451 (46.7%) had macrometastases (ypN+). Notably, 51.1% of the patients with sentinel lymph node micrometastases (SLNmi) had additional metastases, nearly triple that of SLN-negative patients (P < 0.001), and 29.8% of SLNmi patients were upstaged with the ALND. Although ypN1mi was not associated with RFS in patients post-NST (HR, 1.02; 95% CI, 0.42-2.49; P = 0.958), SLNmi patients experienced significantly worse RFS compared to SLN-negative patients (hazard ratio [HR], 2.23; 95% confidence intervals [CI], 1.12-4.46; P = 0.023). Additional metastases in SLNmi were more prevalent in patients with larger residual breast disease greater than 20 mm, HR-positive/HER2-negative subtype, and low Ki-67 LI (< 14%).

CONCLUSIONS

SLNmi is a negative prognostic factor significantly associated with additional non-SLN metastases, while ypN1mi does not influence the prognosis compared to ypN0. Hence, additional ALND may be warranted to confirm axillary nodal status in patients with SLNmi.

Investigation of correlation between shear wave elastography and lymphangiogenesis in invasive breast cancer and diagnosis of axillary lymph node metastasis

BACKGROUND

Accurate evaluation of axillary lymph node metastasis (LNM) in breast cancer is very important. A large number of hyperplastic and dilated lymphangiogenesis cases can usually be found in the pericancerous tissue of breast cancer to promote the occurrence of tumor metastasis.Shear wave elastography (SWE) can be used as an important means for evaluating pericancerous stiffness. We determined the stiffness of the pericancerous by SWE to diagnose LNM and lymphangiogenesis in invasive breast cancer (IBC).

METHODS

Patients with clinical T1-T2 stage IBC who received surgical treatment in our hospital from June 2020 to December 2020 were retrospectively enrolled. A total of 299 patients were eventually included in the preliminary study, which included an investigation of clinicopathological features, ultrasonic characteristics, and SWE parameters. Multivariable logistic regression analysis was used to establish diagnostic model and evaluated its diagnostic performance of LNM. The correlation among SWE values, collagen volume fraction (CVF), and microlymphatic density (MLD) in primary breast cancer lesions was analyzed in another 97 patients.

RESULTS

The logistic regression model is Logit(P)=-1.878 + 0.992*LVI-2.010*posterior feature enhancement + 1.230*posterior feature shadowing + 0.102*posterior feature combined pattern + 0.009*Emax. The optimum cutoff value of the logistic regression model was 0.365, and the AUC (95% CI) was 0.697 (0.636-0.758); the sensitivity (70.7 vs. 54.3), positive predictive value (PPV) (54.0 vs. 50.8), negative predictive value (NPV) (76.9 vs. 69.7), and accuracy (65.2 vs. 61.9) were all higher than Emax. There was no correlation between the SWE parameters and MLD in primary breast cancer lesions.

CONCLUSIONS

The logistic regression model can help us to determine LNM, thus providing more imaging basis for the selection of preoperative treatment. The SWE parameter of the primary breast cancer lesion cannot reflect the peritumoral lymphangiogenesis, and we still need to find a new ultrasonic imaging method.

Patterns of completion axillary dissection for patients with cT1-2N0 breast cancer undergoing total mastectomy with positive sentinel lymph nodes

BACKGROUND AND OBJECTIVES

The ACOSOGZ0011 trial found that overall survival (OS) for patients with 1-2 positive nodes undergoing sentinel lymph node biopsy-alone (SLNB) was noninferior to completion axillary lymph node dissection (ALND), but excluded patients undergoing mastectomy. Our study examined patterns of ALND and its relationship with OS for SLNB-positive patients undergoing mastectomy.

METHODS

The National Cancer Database was queried (2010-2017) for patients with cT1-2N0 breast cancer undergoing mastectomy with positive sentinel lymph nodes. Clinical data were compared.

RESULTS

Of 20 001 patients, 11 574 (57.9%) underwent SLNB + ALND, and 8427 (42.1%) had SLNB-alone. The SLNB + ALND group had more positive nodes (mean 2.6 vs. 1.3, p < 0.001) and more frequently received nodal radiation (33.4% vs. 28.9%, p < 0.001). Patients diagnosed in later years were less likely to undergo ALND (2010: reference; 2017: odds ratio: 0.29, 95% confidence interval [CI]: 0.25-0.33, p < 0.001). ALND (hazard ratio [HR]: 0.97, 95% CI: 0.89-1.06, p = 0.49) and nodal radiation (HR: 0.92, 95% CI: 0.83-1.02, p = 1.06) were not independently associated with OS. Propensity-score matched 5-year OS was similar (SLNB + ALND: 90.9% vs. SLNB-alone: 90.3%, p = 0.65).

CONCLUSION

For patients undergoing mastectomy for cT1-2N0 breast cancer with positive SLNB, SLNB-alone was common and increased over time. Axillary radiation was not routinely delivered in the SLNB-alone group. Completion ALND and nodal radiation were not associated with improved survival.

Diagnostic performance of MRI for assessing axillary lymph node status after neoadjuvant chemotherapy in breast cancer: a systematic review and meta-analysis

OBJECTIVE

This systematic review examined the diagnostic performance of magnetic resonance imaging (MRI) for assessing axillary lymph node status (ALNS) after neoadjuvant chemotherapy (NAC) in breast cancer patients.

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science to identify relevant studies and used the QUADAS-2 tool to assess methodological quality of eligible studies. We used STATA version 12.0 to perform data pooling, heterogeneity testing, subgroup analysis, and sensitivity analysis.

RESULTS

For the 21 enrolled studies, including 2875 patients, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were respectively 0.63 (95% CI: 0.53-0.72), 0.75 (95% CI: 0.68-0.81), 2.52 (95% CI: 1.98-3.19), 0.50 (95% CI: 0.39-0.63), and 5.08 (95% CI: 3.38-7.63). The AUC was 0.76 (95% CI: 0.72-0.79). I2 values of sensitivity (I2 = 94.41%) and specificity (I2 = 88.97%) were both > 50%. For the initial positive ALN patients, the pooled sensitivity and specificity were 0.64 (95% CI: 0.53-0.75) and 0.74 (95% CI: 0.64-0.82), respectively. Sensitivity analyses by focusing on studies with MRI performed post-NAC, studies using DCE-MRI, or studies with low risk of bias showed similar results to the primary analyses.

CONCLUSION

MRI may have suboptimal diagnostic value in assessing ALNS after NAC for breast cancer patients. Due to the inconsistency of NAC regimens, the variability of axillary surgery, and the lack of time interval between MRI and surgery, further studies are needed to confirm our findings.

CLINICAL RELEVANCE STATEMENT

Our study provided the diagnostic value of MRI in assessing axillary lymph node status after neoadjuvant chemotherapy for breast cancer patients.

KEY POINTS

• MRI may have suboptimal diagnostic value in assessing axillary lymph node status after NAC for general breast cancer patients. • The initial axillary lymph node status has little impact on the diagnostic efficacy of MRI. • The substantial heterogeneity among studies highlights the need for further studies to provide more high-quality evidence in this field.

Omission of axillary lymph node dissection in breast cancer patients with micrometastasis or isolated tumor cells in sentinel lymph nodes: a 12-year experience in a tertiary breast unit

INTRODUCTION

After the IBCSG 23-01 trial, our breast center no longer performed axillary lymph node dissection (ALND) after detection of isolated tumor cells (ITC) or micrometastasis in the sentinel lymph nodes (SLN). A recent study suggested that up to half of the patients with micrometastasis in the SLN could benefit from ALND in terms of disease-free survival (DFS) and overall survival (OS).

METHODS

This retrospective, unicentric, study analyzed 261 consecutive cT1-3 cN0 breast cancer patients with ITC or micrometastasis in their SLN. Primary objective was comparison of ALND vs. SLN biopsy (SLNB) with regard to DFS and OS. Secondary objectives included analysis of factors associated with an increased rate of locoregional recurrence (LRR), distant metastasis (DM) and metachronous contralateral breast cancer (MCBC).

RESULTS

DFS events occurred in 19 patients (7.3%) and 14 patients died (5.4%). Median follow-up time was 78 months. 251 patients (96.2%) had micrometastasis in their SLN. There was no difference in the OS or DFS of ALND vs. SLNB patients. History of previous contralateral breast cancer and WBI were associated with an increased and decreased rate of LRR, respectively. Larger tumor size was associated with an increased rate of DM. Non-ductal histological types were associated with an increased rate of MCBC.

DISCUSSION

Avoiding ALND may be safe in pN1mi/pN0(i+) patients. Besides, we strongly encourage clinicians to develop their own follow-up protocols based on the best available evidence, to rapidly identify and treat breast cancer recurrence.

Surgical Management of the Axilla in HR+/HER2- Breast Cancer in the Z1071 Era: A Propensity Score-Matched Analysis of the National Cancer Database

BACKGROUND

Axillary management varies between sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) for patients with clinical N1 (cN1), hormone receptor-positive (HR+), human epidermal growth factor receptor 2 (HER2)/neu-negative (HER2-), infiltrative ductal carcinoma (IDC) who achieve a complete clinical response (cCR) to neoadjuvant systemic therapy (NAST). This study sought to evaluate clinical practice patterns and survival outcomes of SLNB versus ALND in this patient subset.

METHODS

Patients with cN1, HR+/HER2-, unilateral IDC demonstrating a cCR to NAST were identified from the 2012-2017 National Cancer Database (NCDB) and stratified based on final axillary surgery management (SLNB vs ALND). After propensity score-matching, overall survival (OS) was compared using a Kaplan-Meier analysis, and significant OS predictors were identified using Cox regression.

RESULTS

Of the 1676 patients selected for this study, 593 (35.4%) underwent SLNB and 1083 (64.6%) underwent ALND. Use of SLNB increased by 28 % between 2012 and 2017. Among a total of 584 matched patients, 461 matched ypN0 patients, and 108 matched ypN+ patients, mean OS did not differ between SLNB and ALND (all patients [92.1 ± 0.8 vs 90.2 ± 1.0 months; p = 0.157], ypN0 patients [92.4 ± 0.8 vs 89.9 ± 0.9 months; p = 0.105], ypN+ patients [83.5 ± 2.3 vs 91.7 ± 2.7 months; p ± 0.963). Cox regression identified age, Charlson score, clinical T stage, and pathologic nodal status as significant predictors of OS.

CONCLUSION

The final surgical management strategy used for cN1, HR+/HER2- IDC patients who achieved a cCR to NAST did not have a significant impact on survival outcomes in this analysis. Potential opportunities for de-escalation of axillary management among this patient subset exist, and validation studies are needed.

Analysis of the Risk Factors of Breast Cancer-Related Lymphedema and Construction and Evaluation of a Prediction Model

Objective: The occurrence of breast cancer-related lymphedema (BCRL) in postoperative breast cancer survivors is described and the independent risk factors of BCRL are analyzed. A BCRL nomogram prediction model is constructed, and its effectiveness is evaluated to screen out high-risk patients with BCRL. Methods: A univariate analysis was carried out to determine the risk factors possibly related to BCRL, and a logistic regression analysis was utilized to determine the independent risk factors related to BCRL. A BCRL nomogram prediction model was built, and a nomogram was drawn by R software v4.1.0. The area under the curve (AUC) of the receiver operating characteristic (ROC) and the Hosmer-Lemeshow test were used to evaluate the efficacy of the constructed model to assess its clinical application value. Results: The risk factors independently associated with BCRL were body mass index (BMI), handedness on the operation side, no BCRL-related rehabilitation plan, axillary lymph node dissection (ALND), taxane-based chemotherapy, and radiotherapy (all p < 0.05). The BCRL nomogram prediction model was built on this basis, and the results of the efficacy evaluation showed a good fit: AUC = 0.952 (95% confidence interval: 0.930-0.973) for the ROC and χ2 = 6.963, p = 0.540 for the Hosmer-Lemeshow test. Conclusions: The risk factors for BCRL included higher BMI, handedness on the operation side, no BCRL-related rehabilitation plan, ALND, taxane-based chemotherapy, and radiotherapy. In addition, the BCRL nomogram prediction model accurately calculated the risk of possible BCRL among breast cancer survivors and effectively screened for high-risk patients with BCRL. Therefore, this prediction model can provide a basis for rehabilitation physicians and therapists to formulate early and individualized prevention and treatment programs.

[Breast cancer radiation therapy: Current questions in 2023]

Radiation therapy is a corner stone of breast cancer treatment as it has been shown postoperatively that it improves local control and overall survival. In recent years, multidisciplinary therapeutic strategies have evolved considerably for early-stage breast cancer, both surgically and in terms of systemic treatments or radiation therapy. Each of these developments affects other treatment components and open up new questions allowing even more personalized treatments. Essentially normofractionated a few years ago, breast radiation therapy is today very largely moderately or even ultra hypofractionated. De-escalation of the surgery of the axilla has changed the indications for lymph node radiation therapy keeping similar efficacy with reduced toxicity. Indications for radiation therapy after neoadjuvant chemotherapy remain based on pre-chemotherapy staging pending the results of ongoing randomized studies. The addition of a boost to the tumor bed significantly reduces the risk of local recurrence, but the magnitude of this benefit decreases with increasing age. The main risk factors for local recurrence are young age, the associated extended ductal in situ component, hormone receptor negative and high-grade status. The results of the simultaneous integrated boost (SIB) seem similar with normo- or moderately hypofractionated radiation therapy regimen.

Comparison of survival outcomes between axillary conservation and axillary lymph node dissections in N1 early breast cancer: a propensity-matched SEER analysis

BACKGROUND

Sentinel lymph node dissection (SLND) is an alternative to axillary lymph node dissection (ALND) for breast cancer surgery. But the criteria of SLND only for patients with limited disease in the sentinel node is disputed.

METHODS

From the Surveillance, Epidemiology, and End Results (SEER) database, 2000-2015, we identified 97,296 early breast cancer females with 1-3 axillary lymph nodes macro-metastasis. Of them, 1-5 (axillary conservation group), 6-9, and ≥ 10 (ALND group) axillary lymph nodes were dissected in 28,639, 16,838, and 51,819 patients, respectively. According to the criteria of the ACOSOG Z0011 trial, two historical cohort studies of patients who underwent lumpectomy or mastectomy were conducted and the survival outcomes between ALND and axillary conservation were compared.

RESULTS

Overall, dissection of 6-9 regional lymph nodes resulted in the worst prognosis. After propensity-matched analysis, it was found that patients in the axillary conservation group had worse survival than the ALND group in overall survival. No significant difference in prognosis between the group undergoing lumpectomy was found both in OS and BCSS. Subgroup analysis revealed that Grade 3, T2, two lymph nodes positive, or Her2 positive were the main causes of worse survival in the axillary conservation group.

CONCLUSION

Not all patients with N1 early breast cancer suit axillary conservation. Axillary conservation was sufficient in patients who were treated with lumpectomy. ALND cannot be omitted in patients who were ineligible for the Z0011 and undergoing mastectomy with the following characteristics: T2, Grade 3, two positive lymph nodes, and Her2 positive, which may be better complemented to the Z0011 trial. Hence, under different surgical methods, the clinical precision treatment of ALND or axillary preservation is essential.

Abbreviated MRI for Comprehensive Regional Lymph Node Staging during Pre-Operative Breast MRI

Background: The detection of regional lymph node metastases (LNM), in particular significant LNM (≥N2), is important to guide treatment decisions in women with breast cancer. The purpose of this study was to determine whether a coronal pulse sequence as part of pre-operative breast MRI is useful to identify women without significant LNM. Material: Retrospective study between January 2017 and December 2019 on 414 consecutive women with breast cancer who underwent pre-operative breast MRI on a 1.5 T system. For lymph node (LN) staging, a coronal pre-contrast non-fat-suppressed T1-weighted TSE sequence was acquired with the system’s built-in body coil, covering the chest wall; acquisition time 3:12 min. Two radiologists rated the likelihood of LNM on a 3-point scale (absent/possible/present). Validation was obtained by histology from sentinel LN biopsy, axillary LN dissection, and/or PET/CT. Results: 368/414 women were staged to have no or non-significant LNM (pN0 in 282/414, pN1 in 86/414), and significant LNM (≥pN2) in 46/414. For identification of women with significant LNM, MRI was true-positive in 42/46, false-negative in 4/46, true-negative in 327/368, and false-positive in 41/83, the latter mostly caused by women with N1-disease (38/41), yielding an NPV and PPV for significant LNM of 98.8% [95%-CI: 97.0–100%] and 50.6% [43.1–58.1%], respectively. Conclusions: A 3 min coronal T1-weighted pulse sequence covering the chest wall as part of pre-operative breast MRI is useful to rule out significant LNM with high NPV. Where MRI staging is positive for significant LNM, additional work-up is indicated to improve the distinction of N1 and N2 disease.

Effect of the Paravertebral Block on Chronic Postsurgical Pain After Thoracic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

This study aimed to identify the benefits of thoracic paravertebral block (PVB) by focusing on its role in reducing chronic postsurgical pain (CPSP) after thoracic surgery.

DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

SETTING

Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies.

PARTICIPANTS

Patients undergoing thoracic surgeries.

INTERVENTION

Paravertebral block for postoperative analgesia.

MEASUREMENT AND MAIN RESULTS

A total of 1,028 adult patients from 10 RCTs were included in the final analysis. The incidence of CPSP at 3 months after surgery was not reduced in the PVB group compared with the no-block (odds ratio [OR] 0.59, 95% CI 0.34-1.04; p = 0.07; I² = 6.96%) and other-block (OR 1.39, 95% CI 0.30-6.42; p = 0.67; I² = 77.75%) groups. The PVB did not significantly reduce the incidence of CPSP after 6 months from surgery when compared with no block (OR 0.44, 95% CI 0.08-2.53; p = 0.36; I² = 87.53%) and other blocks (OR 1.17, 95% CI 0.71-1.95; p = 0.93; I² = 45.75%). The PVB significantly decreased postoperative pain at 24 and 48 hours at rest compared with the no- block group. The pain score was higher in the PVB group than in the other block groups 48 hours after surgery at rest.

CONCLUSIONS

Thoracic PVB does not prevent CPSP after thoracic surgery. Further large RCTs are required to confirm and validate the authors' results.

Use of LigaSure vessel sealing system versus conventional axillary dissection in breast cancer patients: a retrospective comparative study

BACKGROUND

In locally advanced breast cancer, axillary lymph node dissection remains a pivotal component of surgical therapy. Apart from this, it has been mostly replaced by sentinel node biopsy. Complications after axillary dissection include wound infection, neuropathy, lymphedema and-most frequently-seroma. In this retrospective multi-centre study, we compared the use of LigaSure^TM with monopolar electrocautery regarding perioperative outcome.

METHODS

A retrospective data analysis from female breast cancer patients who underwent axillary dissection at two breast centres in Austria that are using two different surgical techniques was performed for this study. We compared the rate of complications and re-operations, length of hospital stay, time to drain removal, total drain fluid, seroma formation after drain removal, number of seroma aspirations and total seroma fluid.

RESULTS

Seventy one female patients with a median age of 63 (30-83) were included in this study. In 35 patients LigaSure^TM and in 36 monopolar cautery was used for axillary dissection. There was no significant difference regarding intraoperative complications and rate of re-operations between the two groups (2.9 vs. 5.6%; p = 1 and 2.9 vs. 13.9%; p = 0.199). The time to drain removal and the length of hospital stay was similar in both groups. A significant difference in the occurence of postoperative wound infection could also not be shown. However, we found a significantly smaller total drain fluid in the LigaSure^TM-group compared to the cautery-group (364.6 ml vs. 643.4 ml; p = 0.004). Seroma formation after drain removal was more frequent in the LigaSure^TM-group (68.6 vs. 41.7%; p = 0.032) with a higher number of outpatient seroma aspirations (2.0 vs. 0.9; p = 0.005).

CONCLUSION

LigaSure^TM and monopolar cautery provide equivalent techniques in axillary lymph node dissection with comparable postoperative outcomes.

Total Tumor Load to assist in the decision for additional axillary surgery in the positive sentinel node breast cancer patients

The Total Tumor Load (TTL) concept has been demonstrated to accurately predict the status of the non-sentinel lymph nodes (NSLN) in breast cancer patients. In 2019, our center implemented the TTL cut-off of 30,000 CK19 mRNA copies/μL as sole criterion for deciding on performing ALND. This retrospective, unicentric, study analyzed 87 cT1-3N0 breast cancer patients treated consecutively in a period of two years and aimed to evaluate the performance of this criterion. Secondary objectives included the comparison of the criterion versus our previous Clinical Decision Rule (CDR) versus ACOSOG Z0011 criteria for avoiding an ALND in proportion of patients spared an ALND and in proportion of patients left with a surgically untreated metastasized axilla. An interim analysis revealed new TTL cut-offs for deciding on performing an ALND. The 30,000 CK19 mRNA copies/μL criterion yielded an area under the ROC Curve (AUC) of 0.849, a false positive (FP) rate of 30.1% and a positive predictive value (PPV) of 38.9%. The 30,000 CK19 mRNA copies/μL criterion spared 58.6% of the patients an ALND versus 41.4% with CDR versus 73.6% with Z0011 and left 0.0% patients with a surgically untreated metastasized axilla versus 21.4% with CDR versus 42.9% with Z0011. The new TTL cut-off of 260,000 CK19 mRNA copies/μL for deciding on an ALND yielded an AUC of 0.753, a FP rate of 13.7% and a PPV of 47.4%. This new criterion spared 78.2% of the study sample an ALND and left 35.7% of metastasized axillae surgically untreated. This study emphasizes the need to find a new balance between locoregional control and the morbidity associated with Berg levels I + II axillary lymph node dissection.

A novel nomogram containing efficacy indicators to predict axillary pathologic complete response after neoadjuvant systemic therapy in breast cancer

BACKGROUND

Neoadjuvant systemic therapy (NST) could make some clinically node-positive (cN+) breast cancer patients achieve axillary pathologic complete response (pCR). This study aimed to identify the patients who are likely to achieve axillary pCR and help surgeons make surgical decisions on the axilla.

METHODS

The cN+ breast cancer patients who received NST from 2015 to 2021 at The First Affiliated Hospital of Nanjing Medical University were enrolled. Univariate and multivariate logistic regression analyses were performed, and a nomogram was constructed based on the results of multivariate logistic regression analysis to predict the probability of axillary pCR and validated.

RESULTS

The axillary pCR was achieved in 208 (38.7%) patients. Patients who had a higher radiological response rate of breast tumor (P = 0.039), smaller longest diameter of positive node after NST (P = 0.028), ER-negative status (P = 0.006), HER2-positive status (P = 0.048) and breast pCR (P < 0.001) were more likely to achieve axillary pCR. The nomogram had an area under the receiver operating characteristic curve (AUC) of 0.795 (95% CI: 0.747-0.843), and the calibration curve showed good agreement.

CONCLUSION

A nomogram was constructed to predict the axillary pCR of cN+ patients receiving NST based on baseline and efficacy indicators to assist surgeons in making surgical decisions on the axilla.

Factors Associated with Axillary Lymph Node Status in Clinically Node-Negative Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy

Adequate axillary lymph node (ALN) staging is critical for patients with invasive breast cancer. However, neoadjuvant chemotherapy (NAC) was associated with a lower risk of ALN metastasis compared with those who underwent primary surgery among clinically node-negative (cN0) patients. This study aimed to investigate the factors associated with ALN status among patients with cN0 breast cancer undergoing NAC. A total of 222 consecutive patients with cN0 breast cancer undergoing NAC between January 2012 and December 2021 were reviewed. Univariate and multivariate analyses were performed to compare factors associated with positive ALN status. Seventeen patients (7.7%) had ALNs metastases. Here, 90 patients (40.5%) achieved pathologic complete response in the breast (breast-pCR), and all had negative ALN status. Lymphovascular invasion (odds ratio: 29.366, p < 0.0001) was an independent risk predictor of ALN metastasis in all study populations. Among patients without breast-pCR, mastectomies were performed more frequently in patients with ALN metastasis (52.9%) than in those without metastasis (20.9%) (p = 0.013). Our findings support the omission of axillary surgery in patients who achieve breast-pCR. Prospective studies are needed to confirm the feasibility of a future two-stage surgical plan for breast-conserving surgery in patients who are likely to achieve breast-pCR during clinical evaluation.

Different Imaging Modalities for the Diagnosis of Axillary Lymph Node Metastases in Breast Cancer: A Systematic Review and Network Meta-Analysis of Diagnostic Test Accuracy

BACKGROUND

Accurate diagnosis of axillary lymph node metastasis (ALNM) of breast cancer patients is important to guide local and systemic treatment.

PURPOSE

To evaluate the diagnostic performance of different imaging modalities for ALNM in patients with breast cancer.

STUDY TYPE

Systematic review and network meta-analysis (NMA).

SUBJECTS

Sixty-one original articles with 8011 participants.

FIELD STRENGTH

1.5 T and 3.0 T.

ASSESSMENT

We used the QUADAS-2 and QUADAS-C tools to assess the risk of bias in eligible studies. The identified articles assessed ultrasonography (US), MRI, mammography, ultrasound elastography (UE), PET, CT, PET/CT, scintimammography, and PET/MRI.

STATISTICAL ANALYSIS

We used random-effects conventional meta-analyses and Bayesian network meta-analyses for data analyses. We used sensitivity and specificity, relative sensitivity and specificity, superiority index, and summary receiver operating characteristic curve (SROC) analysis to compare the diagnostic value of different imaging modalities.

RESULTS

Sixty-one studies evaluated nine imaging modalities. At patient level, sensitivities of the nine imaging modalities ranged from 0.27 to 0.84 and specificities ranged from 0.84 to 0.95. Patient-based NMA showed that UE had the highest superiority index (5.95) with the highest relative sensitivity of 1.13 (95% confidence interval [CI]: 0.93-1.29) among all imaging methods when compared to US. At lymph node level, MRI had the highest superiority index (6.91) with highest relative sensitivity of 1.13 (95% CI: 1.01-1.23) and highest relative specificity of 1.11 (95% CI: 0.95-1.23) among all imaging methods when compared to US. SROCs also showed that UE and MRI had the largest area under the curve (AUC) at patient level and lymph node level of 0.92 and 0.94, respectively.

DATA CONCLUSION

UE and MRI may be superior to other imaging modalities in the diagnosis of ALNM in breast cancer patients at the patient level and the lymph node level, respectively. Further studies are needed to provide high-quality evidence to validate our findings.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

"Prevalence of chronic pain following resection of pelvic bone tumours: A single centre prospective observational survey"

Background

Hemipelvectomy is a major surgery most often performed for pelvic malignancy. These complex surgeries often involve dissection around major neurovascular bundle and resection of tumour being bone along with involved tissues. This may result in short and long term morbidities. There is very little literature about incidence of chronic pain after pelvic resections. We conducted a prospective study at a tertiary cancer hospital to assess the prevalence of chronic pain post hemipelvectomy.

Method

This is a single centre prospective observational study conducted over 30 months. Pain scores were recorded using Brief pain inventory (BPI) and pain detect questionnaire. The quality of life was assessed using musculoskeletal tumour society (MSTS) score. Intra-operative details like extent of surgical resection, nerves spared, details of intra-operative and post-operative analgesia were retrieved from the patient files. Data were analysed using SPSS 21 version.

Results

Neuropathic pain post hemipelvectomy was uncommon. The prevalence of mild to moderate somatic pain was around 30%. Functional limitation was minimal as assessed by BPI and MSTS score. A high incidence of numbness was seen to persist in and around the area of surgical incision (50%).

Conclusion

This is first study to report the incidence of chronic pain post hemipelvectomy done for pelvic tumour resections. Despite the extensive nature of resection involved, there is a low prevalence of neuropathic pain in this population. However, incidence of persistent somatic pain is high and there is a need for further studies for evaluating the causality.

Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer

Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.

Retrograde Manual Lymphatic Drainage following Vascularized Lymph Node Transfer to Distal Recipient Sites for Extremity Lymphedema: A Retrospective Study and Literature Review

BACKGROUND

Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites.

METHODS

Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared.

RESULTS

One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group.

CONCLUSION

Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Outcomes of Stage I and II Breast Cancer with Nodal Micrometastases Treated with Mastectomy without Axillary Therapy

PURPOSE

Studies that report equivalent oncologic outcomes of sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND) for T1-2N1mi breast cancers are heavily weighted with patients who received breast-conserving surgery (BCS). The impact of omitting ALND in N1mi patients treated with mastectomy is not well studied. It is also unknown if these patients would benefit from post-mastectomy radiotherapy (PMRT). This study reports the outcomes of patients with T1-2N1mi breast cancer treated by mastectomy without axillary therapy.

METHODS

Patients who had T1-2N1mi breast cancer and underwent mastectomy from January 1998 to December 2018 were identified from our multi-institutional prospective database. Axillary recurrence rate (ARR), disease-free survival (DFS), and overall survival (OS) are reported.

RESULTS

260 patients with pT1-2N1mi breast cancer who had mastectomy were identified. They had either SLNB (35.4%) or ALND (64.6%). Majority of these patients received adjuvant systemic therapy (93.8%). 77 (29.6%) patients received radiotherapy, 31 after SLNB and 46 after ALND. At median follow-up of 61 months, ARR was 1.1% (n = 1) in the SLNB only group, vs. 0.6% (n = 1) in the ALND group (p = 0.752). DFS and OS were not significantly different between patients with SLNB alone versus ALND (p = 0.40 and p = 0.27, respectively). Among 92 patients who had SLNB only, no DFS or OS difference was observed with the use of PMRT.

CONCLUSION

In T1-2N1mi patients with mastectomy and SLNB, axillary recurrences were rare. No statistically significant differences were noted between patients with SLNB, ALND, or PMRT. Our findings suggest that these patients may be safely treated without axillary therapy.

Patient-Reported Shoulder Morbidity and Fatigue among Breast Cancer Survivors: An Insight from a Tertiary Care Cancer Hospital

Context: Breast cancer is the most common cancer in Indian women with an annual mortality of around 87,000. Treatment for breast carcinoma may lead to swelling of the ipsilateral arm, shoulder stiffness, arm pain, and cancer-related fatigue. Very few centers in India have reported the arm and shoulder morbidity treated in their hospitals. Aims: The aim was to evaluate the predictive factors of arm and shoulder morbidity and fatigue among breast cancer survivors. Settings and Design: This was a retrospective analysis based on a prospectively maintained database. Materials and Methods: Early and locally advanced cases of breast cancer patients were screened for the study during 2015–2018. Eligible participants were invited to fill up the predetermined questionnaire, and their demographic and treatment-related information was accrued from a file archive. Follow-up period was estimated from the date of tissue diagnosis to last contact/time of interview. Results: Shoulder stiffness was the most common complaint followed by arm numbness. Obesity and diabetes played a crucial role in most of the morbidities and fatigue. The median fatigue score was 34, and the median time of appearance of lymphedema was 13 months. Modified radical mastectomy and radiotherapy to axilla were statistically significantly (P = 0.04 and 0.01, respectively) associated with greater shoulder stiffness and arm swelling. Conclusions: Obesity, diabetes, type of surgery, the extent of axillary dissection, and radiation plan are the major predictive factors of arm and shoulder morbidity. Further prospective validation is necessary for future breast cancer survivorship programs.

Is pre-operative axillary ultrasound alone sufficient to determine need for axillary dissection in early breast cancer patients?

Pre-operative status of axillary lymph node (ALN) in early breast cancer is usually initially assessed by pre-operative ultrasound, followed by ultrasound-guided needle biopsy (UNB) confirmation. Patients with positive nodal status will undergo axillary lymph node dissection (ALND), while those with negative nodal status will have sentinel lymph node biopsy. ALND is associated with higher morbidity than Sentinel lymph node biopsy. The objective of this study is to determine if axillary ultrasound alone without UNB is predictive enough to assign patients to ALND and to identify ultrasound features that are significantly associated with pathologically positive ALN.383 newly diagnosed primary breast cancer patients between 2012 and 2014, and who had undergone pre-operative axillary ultrasound in University Malaya Medical Centre with a complete histopathology report of the axillary surgery were retrospectively reviewed. ALN was considered positive if it had any of these features: cortical thickening > 3 mm, loss of fatty hilum, hypoechoic solid node, mass-like appearance, round shape and lymph node size > 5 mm. Post-operative histopathological reports were then analyzed for nodal involvement.The overall sensitivity, specificity, and accuracy of pre-operative axillary ultrasound in detecting diseased nodes were 45.5%, 80.7%, and 60.3% respectively. The positive (PPV) and negative predictive values were 76.5% and 51.8%. Round shape, loss of fatty hilum and mass-like appearance had the highest PPVs of 87%, 83% and 81.6% respectively and significant odds ratios (ORs) of 5.22 (95% confidence interval [CI]: 1.52 - 17.86), ORs of 4.77 (95% CI: 2.62 - 8.70) and ORs of 4.26 (95% CI: 2.37 - 7.67) respectively (P-value < .05). Cortical thickness of > 3 mm was identified to have low PPV at 69.1%, ORs of 1.71 (95% CI: 0.86 - 3.41, P = .126).There are features on axillary ultrasound that confer high PPV for axillary involvement i.e. round shape, loss of fatty hilum, and mass-like appearance. In a low resource setting, these features may benefit from ALND without further pre-operative biopsies. However, pre-operative UNB for features with low PPV that is, cortical thickness > 3 mm should be considered to obviate the unnecessary morbidity associated with ALND.

Prevention of Breast Cancer-Related Lymphedema

Tremendous progress has been made over the past several decades in the treatment of breast cancer. Mortality and recurrence rates continue to decline. Our ability to tailor patient- and tumor-specific treatments has rapidly advanced. The vast majority of our patients can safely have breast conservation. Unfortunately, for many patients, survivorship is burdened by ongoing quality-of-life issues. Most breast cancer patients are asymptomatic at presentation, and the onus is on us to preserve this. Surgery, radiation, and systemic therapy can result in long-term toxicities that can be amplified with multimodality approaches. We must strive to apply minimally effective therapies rather than a maximally tolerated approach. Breast cancer-related lymphedema (BCRL) is a particularly dreaded chronic complication. This review strives to give the reader a better understanding of BCRL and shed light on wisely choosing an integration of treatment modalities that minimizes BCRL risk. Key literature on emerging concepts is highlighted.

Impact of Breast Cancer Pretreatment Nodal Burden and Disease Subtype on Axillary Surgical Management

BACKGROUND

The management of clinically node-positive breast cancer after neoadjuvant chemotherapy (NAC) has progressed with the potential to avoid the morbidity of axillary lymph node dissection in patients with complete response to therapy. This study addresses the impact of pretreatment nodal burden and tumor subtype on axillary pathologic complete response (AXpCR) in patients treated with NAC to better inform axillary surgical management.

METHODS

A prospective database was reviewed to identify clinically node-positive patients who underwent NAC followed by axillary lymph node dissection. Patients were stratified in accordance with abnormal nodal burden on pretreatment axillary imaging defined as low (1-2 nodes) or high (≥3 nodes), and biologic subtype defined by hormone receptor (HR+, HR-) and HER2 (human epidermal growth factor receptor 2) status. The primary outcome was AXpCR.

RESULTS

AXpCR was 43% in the study population. There was no difference in AXpCR between low and high nodal burden groups (44% versus 42%, P = 0.87). Subtype correlated to AXpCR (P < 0.001) with the highest rate (78%) in the HR-/HER2+ group. Overall, HER2+ patients had a significantly higher AXpCR than HER2- subtypes (66% versus 28% P < 0.001). HR and HER2 status were also predictive of AXpCR when comparing patient, tumor, and treatment variables.

CONCLUSIONS

Biologic subtype better correlated with rates of AXpCR than nodal burden alone with the highest rates of AXpCR in HER2+ patients. Consideration of tumor biology is more informative than nodal burden when evaluating options for axillary management after NAC.

Axillary lymph node metastasis status prediction of early-stage breast cancer using convolutional neural networks

Deep learning (DL) algorithms have been proven to be very effective in a wide range of computer vision applications, such as segmentation, classification, and detection. DL models can automatically assess complex medical image scenes without human intervention and can be applied as a second reader to provide an additional opinion for the physician. To predict the axillary lymph node (ALN) metastatic status in patients with early-stage breast cancer, a deep learning-based computer-aided prediction system for ultrasound (US) images was proposed. A total of 153 women with breast tumor US images were involved in this study; there were 59 patients with metastasis and 94 patients without ALN metastasis. A deep learning-based computer-aided prediction (CAP) system using the tumor region and peritumoral tissue in ultrasound (US) images were employed to determine the ALN status in breast cancer. First, we adopted Mask R-CNN as our tumor detection and segmentation model to obtain the tumor localization and region. Second, the peritumoral tissue was extracted from the US image, which reflects metastatic progression. Third, we used the DL model to predict ALN metastasis. Finally, the simple linear iterative clustering (SLIC) superpixel segmentation method and the LIME explanation algorithm were employed to explain how the model makes decisions. The experimental results indicated that the DL model had the best prediction performance on tumor regions with 3 mm thick peritumoral tissue, and the accuracy, sensitivity, specificity, and AUC were 81.05% (124/153), 81.36% (48/59), 80.85% (76/94), and 0.8054, respectively. The results indicated that the proposed CAP system could help determine the ALN status in patients with early-stage breast cancer. The results reveal that the proposed CAP model, which combines primary tumor and peritumoral tissue, is an effective method to predict the ALN status in patients with early-stage breast cancer.

Diagnostic Performance of Quantitative and Qualitative Elastography for Axillary Lymph Node Metastasis in Breast Cancer: A Systematic Review and Meta-Analysis

Background: Studies have shown inconsistent results regarding the diagnostic performance of ultrasound elastography for axillary lymph node metastasis (ALNM) in breast cancer. This meta-analysis aimed to estimate the diagnostic performance of ultrasound elastography (divided into quantitative and qualitative elastography) for ALNM in patients with breast cancer. Methods: The PubMed and Embase databases were searched for eligible studies exploring the diagnostic performance of ultrasound elastography for ALNM in patients with breast cancer. The included studies were divided into quantitative and qualitative elastography groups to perform separate meta-analyses. The diagnostic performance was investigated with pooled sensitivity and specificity and diagnostic odds ratio (DOR) using a bivariate mixed-effects regression model. A summary receiver operating characteristic curve was constructed, and the area under the curve (AUC) was calculated. Results: Seven and 11 studies were included in the quantitative and qualitative elastography meta-analyses, respectively. The pooled sensitivity and specificity, DOR, and AUC with their corresponding 95% confidence intervals were 0.82 (0.75, 0.87), 0.88 (0.78, 0.93), 33 (13, 83), and 0.89 (0.86, 0.91), respectively, for quantitative elastography and 0.81 (0.69, 0.89), 0.92 (0.79, 0.97), 46 (12, 181), and 0.92 (0.89, 0.94), respectively, for qualitative elastography. No significant publication bias existed. Fagan plots demonstrated good clinical utility. However, substantial heterogeneity existed among studies. Study design, measurement, and reference standard served as potential sources of heterogeneity for quantitative studies, which were measurement and reference standard for qualitative studies. Conclusions: Both quantitative and qualitative elastography seem to be feasible, non-invasive diagnostic tools for ALNM in breast cancer. Nevertheless, the results must be interpreted carefully, paying attention to heterogeneity issues, especially for quantitative elastography studies.

Phylogenetic reconstruction of breast cancer reveals two routes of metastatic dissemination associated with distinct clinical outcome

Background

In breast cancer (BC), axillary lymph node (ALN) involvement is one of the strongest adverse prognostic factors. However, it is unclear whether loco-regional lymph node deposits are effectively the root of secondary metastases or only an indicator of competence of the primary tumour to spread to distant organs.

Methods

Here, we investigated the evolutionary trajectories of primary tumour, ALN and distant metastasis samples from 16 estrogen-receptor (ER)-positive lymph node-positive BC patients. Low-pass whole genome sequencing was performed to infer somatic copy number aberrations and the phylogenetic profiles for all patients were obtained.

Findings

We show that lymph nodes and distant metastases shared a common origin in only 25% of the cases highlighting that the predominant route of metastatic dissemination is the direct seeding of tumour cells from the primary tumour to distant organs, independently of lymph node metastasis. Noticeably, patients sharing a common origin significantly have worse prognosis.

Interpretation

Our results shed light on the routes on which tumour cells metastasize and their role in disease progression in ER-positive BC.

Funding

This work has received financial support from Les Amis de l'Institut Bordet, MEDIC, the Breast Cancer Research Foundation (BCRF), the Belgian Fonds National de la Recherche Scientifique (F.R.S-FNRS) and from a grant of the Région Wallonne.

An Update on Regional Nodal Irradiation: Indication, Target Volume Delineation, and Radiotherapy Techniques

Background

Tremendous changes have occurred in the treatment of breast cancer. This paper reviews and unifies the available data on modern axillary management of breast cancer patients with focus on the target volume delineation for regional nodal irradiation according to the most important contouring guidelines, the European Society for Radiotherapy and Oncology (ESTRO) and the Radiation Therapy and Oncology Group (RTOG).

Summary

The use of extensive radiotherapy target volumes (level I, II, III, IV) is probably not necessary for all patients to reproduce the clinical benefit shown in the available randomized trials (EORTC, MA.20, AMAROS, Z0011). Nevertheless, given the results in the MA.20 trial, where the patients received more modern systemic therapies and high irradiation doses in the medial paraclavicular region (level IV) and level II, it can be justified to include these regions completely in selected high-risk patients.

Key Messages

High-tangent irradiation results in a similar dose distribution in axillary levels I and II compared to the AMAROS treatment field design in some patients. This supports earlier assumptions that irradiation may have accounted for the good results after sentinel lymph node dissection alone in the Z0011 trial. The ESTRO and RTOG clinical target volume (CTV) definitions cover sufficiently the metastatic lymph node hotspots, with a better coverage for the ESTRO CTV. Further, contouring according to the ESTRO would spare a significantly larger part of the healthy lymphatic system, making it our preferred contouring atlas. Modern radiotherapy techniques, such as deep inspiration breath hold, should be cautiously employed in patients treated according to the inclusion criteria of the Z0011 as it will result in a lower dose to the axillary levels.

Surgical Management of Lymph Nodes in Melanoma

This article provides a comprehensive evaluation of surgical management of the lymph node basin in melanoma, with historical, anatomic, and evidence-based recommendations for practice.

Axillary Lymph Node Evaluation Utilizing Convolutional Neural Networks Using MRI Dataset

The aim of this study is to evaluate the role of convolutional neural network (CNN) in predicting axillary lymph node metastasis, using a breast MRI dataset. An institutional review board (IRB)-approved retrospective review of our database from 1/2013 to 6/2016 identified 275 axillary lymph nodes for this study. Biopsy-proven 133 metastatic axillary lymph nodes and 142 negative control lymph nodes were identified based on benign biopsies (100) and from healthy MRI screening patients (42) with at least 3 years of negative follow-up. For each breast MRI, axillary lymph node was identified on first T1 post contrast dynamic images and underwent 3D segmentation using an open source software platform 3D Slicer. A 32 × 32 patch was then extracted from the center slice of the segmented tumor data. A CNN was designed for lymph node prediction based on each of these cropped images. The CNN consisted of seven convolutional layers and max-pooling layers with 50% dropout applied in the linear layer. In addition, data augmentation and L2 regularization were performed to limit overfitting. Training was implemented using the Adam optimizer, an algorithm for first-order gradient-based optimization of stochastic objective functions, based on adaptive estimates of lower-order moments. Code for this study was written in Python using the TensorFlow module (1.0.0). Experiments and CNN training were done on a Linux workstation with NVIDIA GTX 1070 Pascal GPU. Two class axillary lymph node metastasis prediction models were evaluated. For each lymph node, a final softmax score threshold of 0.5 was used for classification. Based on this, CNN achieved a mean five-fold cross-validation accuracy of 84.3%. It is feasible for current deep CNN architectures to be trained to predict likelihood of axillary lymph node metastasis. Larger dataset will likely improve our prediction model and can potentially be a non-invasive alternative to core needle biopsy and even sentinel lymph node evaluation.

Regional Recurrence Rates With or Without Complete Axillary Dissection for Breast Cancer Patients with Node-Positive Disease on Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy

Purpose

Current standard of care for patients with breast cancer with a positive node on sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy is axillary dissection with irradiation of the regional nodes, but it is unknown whether axillary lymph node dissection (ALND) can be safely omitted if complete axillary radiation is delivered instead.

Methods and Materials

We identified 161 patients found to have a positive sentinel lymph node on SLNB after neoadjuvant chemotherapy for breast cancer between December 2006 and October 2017, who were treated with or without completion ALND. Local, regional, and distant recurrence and overall survival were analyzed using the Kaplan-Meier method. Patient, disease, and treatment factors potentially predictive of each outcome were entered into Cox regression analysis.

Results

Median follow-up was 28.8 months (range, 2.5-137.0). The 3-year regional control rate did not differ according to extent of axillary surgery (92.6% for SLNB alone vs 96.4% for SLNB with ALND, P = .616). Regional recurrence occurred as part of first recurrence in 9 patients (5.6%). Five patients failed in axillary levels 1 or 2, 6 failed in axillary level 3 or supraclavicular nodes, and 2 failed in internal mammary nodes, with some patients failing in multiple regional nodal areas. Extent of axillary dissection (SLNB only vs SLNB plus ALND) did not predict for disease control or survival. Patients who underwent ALND were significantly more likely to have lymphedema (25.0% vs 9.4%, P = .021).

Conclusions

Careful selection of patients with a positive sentinel node on SLNB after neoadjuvant chemotherapy for omission of completion ALND in favor of irradiation of the undissected axilla does not compromise local, regional, or distant control or overall survival and results in lower rates of lymphedema.

Management of the Axilla in T1-2 Breast Cancer Patients with Macrometastatic Sentinel Node Involvement Who Underwent Breast-Conserving Therapy

PURPOSE

The aims of our study were to determine the incidence of axillary recurrence and arm morbidity in T1-2 invasive breast cancer patients with macrometastases on the sentinel lymph node (SLN) who underwent breast-conserving therapy (BCT), with or without axillary lymph node dissection (ALND).

METHODS

One hundred and nine T1-2 invasive breast cancer patients with macrometastases on the SLN who underwent BCT in our institution were included in the study. Patients with 1-2 positive SLN and without extra nodal extension (ENE) on the SLN did not undergo ALND (SLN-only group) and patients with ENE or patients who had >2 metastatic nodes underwent level I, II ALND (ALND group). The SLN-only group received radiotherapy to three axillary levels, the supraclavicular fossa, and ± mammaria interna. ALND group received radiotherapy to axillary level III, the supraclavicular fossa, and ± mammaria interna. The incidence of axillary recurrence and arm morbidity were investigated.

RESULTS

Of the 109 patients, 18 patients with >2 metastatic SLNs and 10 with ENE on the SLN underwent ALND and 81 patients underwent SLN only. Median follow-up time was 37 months (3-77). There was no axillary recurrence in SLN-only group. However, in the ALND group 1 patient had developed axillary metastasis. There were 2 objective lymphoedema and 3 arm-shoulder restriction cases in the SLN-only group, and 2 and 3 in the ALND group, respectively.

CONCLUSIONS

Axillary dissection could safely be omitted in patients with 1-2 macrometastatic SLN and without ENE who undergo BCT and axillary radiotherapy.

Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial

BACKGROUND

We previously reported the 5-year results of the phase 3 IBCSG 23-01 trial comparing disease-free survival in patients with breast cancer with one or more micrometastatic (≤2 mm) sentinel nodes randomly assigned to either axillary dissection or no axillary dissection. The results showed no difference in disease-free survival between the groups and showed non-inferiority of no axillary dissection relative to axillary dissection. The current analysis presents the results of the study after a median follow-up of 9·7 years (IQR 7·8-12·7).

METHODS

In this multicentre, randomised, controlled, open-label, non-inferiority, phase 3 trial, participants were recruited from 27 hospitals and cancer centres in nine countries. Eligible women could be of any age with clinical, mammographic, ultrasonographic, or pathological diagnosis of breast cancer with largest lesion diameter of 5 cm or smaller, and one or more metastatic sentinel nodes, all of which were 2 mm or smaller and with no extracapsular extension. Patients were randomly assigned (1:1) before surgery (mastectomy or breast-conserving surgery) to no axillary dissection or axillary dissection using permuted blocks generated by a web-based congruence algorithm, with stratification by centre and menopausal status. The protocol-specified primary endpoint was disease-free survival, analysed in the intention-to-treat population (as randomly assigned). Safety was assessed in all randomly assigned patients who received their allocated treatment (as treated). We did a one-sided test for non-inferiority of no axillary dissection by comparing the observed hazard ratios (HRs) for disease-free survival with a margin of 1·25. This 10-year follow-up analysis was not prespecified in the trial's protocol and thus was not adjusted for multiple, sequential testing. This trial is registered with ClinicalTrials.gov, number NCT00072293.

FINDINGS

Between April 1, 2001, and Feb 8, 2010, 6681 patients were screened and 934 randomly assigned to no axillary dissection (n=469) or axillary dissection (n=465). Three patients were ineligible and were excluded from the trial after randomisation. Disease-free survival at 10 years was 76·8% (95% CI 72·5-81·0) in the no axillary dissection group, compared with 74·9% (70·5-79·3) in the axillary dissection group (HR 0·85, 95% CI 0·65-1·11; log-rank p=0·24; p=0·0024 for non-inferiority). Long-term surgical complications included lymphoedema of any grade in 16 (4%) of 453 patients in the no axillary dissection group and 60 (13%) of 447 in the axillary dissection group, sensory neuropathy of any grade in 57 (13%) in the no axillary dissection group versus 85 (19%) in the axillary dissection group, and motor neuropathy of any grade (14 [3%] in the no axillary dissection group vs 40 [9%] in the axillary dissection group). One serious adverse event (postoperative infection and inflamed axilla requiring hospital admission) was attributed to axillary dissection; the event resolved without sequelae.

INTERPRETATION

The findings of the IBCSG 23-01 trial after a median follow-up of 9·7 years (IQR 7·8-12·7) corroborate those obtained at 5 years and are consistent with those of the 10-year follow-up analysis of the Z0011 trial. Together, these findings support the current practice of not doing an axillary dissection when the tumour burden in the sentinel nodes is minimal or moderate in patients with early breast cancer.

FUNDING

International Breast Cancer Study Group.

Axillary Management in Breast Cancer Patients: A Comprehensive Review of the Key Trials

Optimal regional management in breast cancer patients has yet to be established. In patients who are clinically node-negative, but sentinel lymph node biopsy (SLNB)-positive, the treatment paradigm has shifted toward the de-escalation of further axillary management. In patients with 2 or fewer positive sentinel nodes, the standard of practice has shifted away from complete axillary lymph node dissection (ALND) as a result of the ACOSOG Z0011 trial. The role of regional nodal irradiation (RNI) to the axilla, supraclavicular and internal mammary regions has also been investigated in the setting of positive SLNB in trials such as the MA20 and EORTC 22922. Having shown evidence of benefit in locoregional control, efforts are now focused on comparing ALND with RNI in patients with limited nodal disease. Results of early trials such as AMAROS suggest noninferiority of radiotherapy. In patients with node-positive or locally advanced disease, neoadjuvant chemotherapy (NAC) is often used to downsize or downstage the disease. The utility of SLNB after NAC has been investigated, with discordant results reported from a number of trials. Current trials in progress seek to validate the noninferiority of RNI compared with ALND in patients with limited nodal disease, or in some trials, the complete omission of further axillary management. There is a global paradigm shift toward de-escalation of axillary management on the basis of recent evidence suggesting lack of benefit from overaggressive treatment. In this review we aim to summarize the seminal trials addressing regional management in breast cancer to illustrate this fact.

Application of Real-time Elastography Ultrasound in the Diagnosis of Axillary Lymph Node Metastasis in Breast Cancer Patients

The pathological status of axillary lymph nodes (ALN) plays a critical role in the staging and treatment of patients with breast cancer. Therefore, differential diagnosis of metastatic ALN is highly desirable in the clinic. We used real-time elastography (RTE) and gray-scale ultrasound to generate a new scoring system for determining ALN status and estimate their performance of this system. Ninety-seven ALNs were examined by both gray-scale ultrasound and RTE. The performance of gray-scale ultrasound was evaluated by the sum of scores according to its features. RTE images were determined by a modulated scoring system based on the percentage and distribution of hypoechoic cortex regions in the ALNs. Strain ratio was also calculated. Diagnostic performance was obtained by receiver operating characteristic curve analysis with pathologic findings used as the reference standard. The sensitivity, specificity and accuracy were 92%, 73% and 83%, respectively, for gray-scale ultrasound; 78%, 93%, 86%, respectively, for RTE; 88%, 96% and 92%, respectively, for the combined evaluation (AUC = 0.963), and 87%, 76% and 81%, respectively, for strain ratio. Gray-scale ultrasonography had a better sensitivity than RTE (92% vs 78%, P = 0.039), while the specificity for RTE was superior to that of gray-scale ultrasonography (93% vs 73%, P = 0.012). In conclusion, RTE showed a high specificity for evaluating the ALN status and may improve the diagnostic accuracy when combined with gray-scale ultrasound.

Is completion axillary lymph node dissection necessary in patients who are underrepresented in the ACOSOG Z0011 trial?

PURPOSE

The American College of Surgeons Oncology Group trial Z0011 demonstrated that axillary node dissection (ALND) can be omitted in patients managed with breast conserving surgery and 1 to 2 positive sentinel lymph nodes (SLNs) without adverse effects on locoregional recurrence or disease-free survival (DFS). We investigated patients with breast cancer for whom clinicopathologic features were underrepresented in the Z0011 trial and analyzed radiation therapy treatment patterns and clinical outcomes.

METHODS AND MATERIALS

We retrospectively reviewed records of patients who underwent a lumpectomy and SLN biopsy with positive SLNs but not an ALND and completed adjuvant radiation therapy. Eligible patients had T3 tumors, >2 positive SLNs, invasive lobular carcinoma, estrogen receptor negative status, extranodal extension, Nottingham Grade 3, or were age <50 years.

RESULTS

We identified 105 women treated between July 2011 and July 2016 with a median follow-up time of 48.5 months (Range, 11-83 months). There were 40 women with an extranodal extension (38.9%) and 42 women with grade 3 disease (40.0%). Nineteen patients received whole breast irradiation alone (18.1%) and 86 patients were treated with modified tangent fields including the superior axilla level I/II (81.9%). Thirty-three patients (31.4%) also received a 3rd supraclavicular, nodal-directed field. Among the 86 patients who received axillary nodal irradiation, nodal volume contouring was performed in 77 patients (89.5%). Fifty-one patients (48.6%) also received adjuvant chemotherapy. The overall rates of 4-year DFS and locoregional control (LRC) were 94.3% and 98.1%, respectively. Off all patients, 1 patient experienced an internal mammary nodal recurrence, another patient a contralateral breast tumor, and two patients distant metastases. There were no axillary or ipsilateral breast tumor recurrences.

CONCLUSIONS

This retrospective analysis of women who were underrepresented or excluded from the Z11 trial and underwent a lumpectomy and SLN biopsy with positive SLNs demonstrated comparable rates of LRC and DFS. The high rates of LRC and DFS suggest that completion ALND may be safely omitted in this patient population but larger data sets and longer follow-up times are needed to confirm this finding.

Impact of sentinel lymph node biopsy in newly diagnosed invasive breast cancer patients with suspicious node: a comparative accuracy survey of fine-needle aspiration biopsy versus core-needle biopsy

Comparing diagnostic accuracy study between ultrasonography (US) guided fine-needle aspiration biopsy (FNAB) and core-needle biopsy (CNB) of the Sentinel lymph nodes (SLNs) in newly diagnosed invasive breast cancer patients. We selected 289 newly diagnosed invasive breast cancer patients from June 2015 to July 2017. Ultrasound (US) guided fine-needle aspiration cytology (FNA) and core-needle biopsy (CNB) was performed to identify patients with suspicious sentinel lymph node (SLN). Patients with a cortical thickness > 2 mm or atypical morphological characteristics were recommended FNA and CNB. Axillary lymph node dissection (ALND) was applied to patients with biopsy-proven metastasis, and sentinel lymph node biopsy (SLNB) was applied to FNA or CNB negative patients. ALND was also performed when SNB is positive. Out of 289 patients, only 131 patients met final study criteria. Lymph node status was evaluated by FNA, CNB, SLND, and ALND. Among 131 patients, 45 were deemed positive for metastasis and 86 were determined to be negative with CNB, whereas 38 were deemed positive for metastasis and 93 were determined to be negative by using FNAB. CNB was used to correctly identify seven axillae as positive for metastasis that were deemed negative by using FNAB. There were no positive FNAB results in axillae that were negative for metastasis with CNB. All patients underwent SLNB and those with biopsy-proved axillary metastases were assigned directly to ALND as the primary staging procedure. The final histopathologic assessment indicated that 50 (38.2%) of the 131 axillae studied had axillary LN metastases. Axillary US-guided CNB was used to correctly identify 45 (90.0%) of the 50 LN-positive axillae, whereas axillary US-guided FNAB was used to correctly identify 38 (76.0%, P < 0. 001). There were no false-positive results. CNB netted 5 false-negative results, and FNAB resulted in 12. There was significantly different accuracy between different diagnostic tools. In our study, we demonstrated that CNB is a more reliable approach than FNA for the preoperative diagnosis of SLN metastasis.

Lymph Node Radiotherapy Instead of Extended Axillary Surgery - the New Standard?

Breast cancer treatment has undergone major changes in the last 20 years. Specifically, the role of axillary lymph node dissection has changed from radical axillary dissection with excision of a high number of lymph nodes to sentinel lymph node biopsy (SLNB). This paradigm shift is associated with a controversial debate regarding the significance of axillary staging, the need for surgery, and the role of radiotherapy. Looking ahead, lymph node staging and axillary treatment might shift from SLNB and/or axillary dissection to ultrasound-guided needle biopsy and irradiation of regional lymph nodes in order to reduce treatment-related sequelae in early-stage breast cancer.

Localization of the Sentinel Lymph Node in Breast Cancer by Combined Lymphoscintigraphy, Blue DYE and Intraoperative Gamma Probe

Axillary lymph node status represents the most important prognostic factor in patients with operable breast cancer. A severe limitation of this technique is the relatively high rate of false negative sentinel lymph nodes (>5%). We studied 284 patients suffering from breast cancer; 264 had T1 tumors (16 T1a, 37 T1b and 211 T1c), while 20 had T2 tumors. All patients underwent lymphoscintigraphy 18-h before surgery. At surgery, 0.5 mL of patent blue violet was injected subdermally, and the sentinel lymph node (SN) was searched by gamma probe and by the dye method. The surgically isolated SN was processed for intraoperative and delayed examinations.

The SN was successfully identified by the combined radioisotopic procedure and patent blue dye technique in 278/284 cases (97.9%). Analysis of the predictive value of the SN in relation to the status of the axillary lymph nodes was limited to 191 patients undergoing standard axillary dissection irrespective of the SN status. Overall, 63/191 (33%) identified SNs were metastatic, the SN alone being involved in 37/63 (58.7%) patients; a positive axillary status with negative SN was found in 10/73 (13.7%) patients with metastatic involvement. In T1a-T1b patients the SN turned out to be metastatic in 9/53 patients (17.0%). In 7/9 patients the SN was the only site of metastasis, while in 2/9 patients other axillary lymph nodes were found to be metastatic in addition to the SN. None of the 44 patients in whom the SN proved to be non-metastatic showed any metastatic involvement of other axillary lymph nodes.

Our results demonstrate a good predictive value of SN biopsy in patients with breast cancer; the predictive value was excellent in those subjects with nodules smaller than 1 cm.