Is axillary lymph node clearance required in node-positive breast cancer?

Development of predictive models for pathological response status in breast cancer after neoadjuvant therapy based on peripheral blood inflammatory indexes

BACKGROUND

Achieving a pathological complete response (pCR) after neoadjuvant therapy (NAT) is considered to be a critical factor for a favourable prognosis in breast cancer. However, discordant pathological complete response (DpCR), characterised by isolated responses in the breast or axillary, represents an intermediate pathological response category between no response and complete response. This study aims to investigate predictive factors and develop models based on peripheral blood inflammatory indexes to more accurately predict NAT outcomes.

METHOD

A total of 789 eligible patients were enrolled in this retrospective study. The patients were randomized into training and validation cohort according to a 7:3 ratio. Lasso and uni/multivariable logistic regression analysis were applied to identify the predictor variables. Two Nomograms combining clinico-pathologic features and peripheral blood inflammatory indexes were developed.

RESULT

Molecular Subtype, HALP, P53, and FAR were used to construct the predictive models for traditional non pCR (T-NpCR) and total-pCR (TpCR). The T-NpCR group was divided into DpCR and non pCR (NpCR) subgroups to construct a new model to more accurately predict NAT outcomes. cN, HALP, FAR, Molecular Subtype, and RMC were used to construct the predictive models for NpCR and DpCR. The receiver operating characteristic (ROC) curves indicate that the model exhibits robust predictive capacity. Clinical Impact Curves (CIC) and Decision Curve Analysis (DCA) indicate that the models present a superior clinical utility.

CONCLUSION

HALP and FAR were identified as peripheral blood inflammatory index predictors for accurately predicting NAT outcomes.

An unsupervised learning model based on CT radiomics features accurately predicts axillary lymph node metastasis in breast cancer patients: diagnostic study

BACKGROUND

The accuracy of traditional clinical methods for assessing the metastatic status of axillary lymph nodes (ALNs) is unsatisfactory. In this study, the authors propose the use of radiomic technology and three-dimensional (3D) visualization technology to develop an unsupervised learning model for predicting axillary lymph node metastasis in patients with breast cancer (BC), aiming to provide a new method for clinical axillary lymph node assessment in patients with this disease.

METHODS

In this study, we retrospectively analyzed the data of 350 patients with invasive BC who underwent lung-enhanced computed tomography (CT) and axillary lymph node dissection surgery at the Department of Breast Surgery of the Second Xiangya Hospital of Central South University. The authors used 3D visualization technology to create a 3D atlas of ALNs and identified the region of interest for the lymph nodes. Radiomic features were subsequently extracted and selected, and a prediction model for ALNs was constructed using the K-means unsupervised algorithm. To validate the model, the authors prospectively collected data from 128 BC patients who were clinically evaluated as negative at our center.

RESULTS

Using 3D visualization technology, we extracted and selected a total of 36 CT radiomics features. The unsupervised learning model categorized 1737 unlabeled lymph nodes into two groups, and the analysis of the radiomic features between these groups indicated potential differences in lymph node status. Further validation with 1397 labeled lymph nodes demonstrated that the model had good predictive ability for axillary lymph node status, with an area under the curve of 0.847 (0.825-0.869). Additionally, the model's excellent predictive performance was confirmed in the 128 axillary clinical assessment negative cohort (cN0) and the 350 clinical assessment positive (cN+) cohort, for which the correct classification rates were 86.72 and 87.43%, respectively, which were significantly greater than those of clinical assessment methods.

CONCLUSIONS

The authors created an unsupervised learning model that accurately predicts the status of ALNs. This approach offers a novel solution for the precise assessment of ALNs in patients with BC.

A Tumor-Activatable Liposomal Nanoprobe for Selective Visualization of Metastatic Lymph Nodes

The precise identification of sentinel lymph nodes (SLNs) during surgery and assessment of their benign status is crucial for accurate tumor staging and optimal treatment strategizing. Currently, a deficiency exists in non-invasive in vivo diagnostic techniques that can accurately pinpoint SLNs during surgery while simultaneously evaluating their benign status. Here, a tumor-activatable liposomal nanoprobe (nTAL) is developed, remotely loaded with clinically approved photosensitizer, methyl aminolevulinate (MAL), to noninvasively visualize the tumor metastasis lymph nodes (LNs) with precision. Benefited from the highly efficient LNs draining of nanosized liposome and tumor cell-specific transformation of the non-fluorescent MAL to fluorescent protoporphyrin IX (PPIX), nTAL succeeded in targeting the SLNs and differentiated the metastatic from the benign ones with a positive correlation between PPIX generation and tumor cell infiltration in LNs. Moreover, the nTAL technology is capable of probing the early metastatic stage with a primary tumor size of 50 mm3. This study provides a new strategy for intraoperative visualization of real-time sentinel node dissection.

Breast conservation and axillary management after primary systemic therapy in patients with early-stage breast cancer: the Lucerne toolbox

Primary systemic therapy is increasingly used in the treatment of patients with early-stage breast cancer, but few guidelines specifically address optimal locoregional therapies. Therefore, we established an international consortium to discuss clinical evidence and to provide expert advice on technical management of patients with early-stage breast cancer. The steering committee prepared six working packages to address all major clinical questions from diagnosis to surgery. During a consensus meeting that included members from European scientific oncology societies, clinical trial groups, and patient advocates, statements were discussed and voted on. A consensus was reached in 42% of statements, a majority in 38%, and no decision in 21%. Based on these findings, the panel developed clinical guidance recommendations and a toolbox to overcome many clinical and technical requirements associated with the diagnosis, response assessment, surgical planning, and surgery of patients with early-stage breast cancer. This guidance could convince clinicians and patients of the major clinical advancements purported by primary systemic therapy, the use of less extensive and more targeted surgery to improve the lives of patients with breast cancer.

The necessity of IIb dissection in T1-T2N0M0 oral squamous cell carcinoma: protocol for a randomized controlled trial

Background

There is a growing debate on the relationship between health-related quality of life (HRQoL) and patient survival which has been going on for the last few decades. The greatest wish of clinicians is to extend the latter while improving the former. Following neck dissection of early-stage oral carcinoma, “shoulder syndrome” appears due to traction of the accessory nerve during removal of level IIb, which greatly affects patient quality of life. Since occult metastasis in level IIb of early-stage oral carcinoma is extremely low, some surgeons suggest that level IIb can be exempt from dissection to improve the HRQoL. However, other surgeons take the opposite view, and thus there is no consensus on the necessity of IIb dissection in T1–2N0M0 oral squamous cell carcinoma (OSCC).

Methods

We designed a parallel-group, randomized, non-inferiority trial that is supported by Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China. We will enroll 522 patients with early oral carcinoma who match the inclusion criteria, and compare differences in 3-year overall survival, progression–free survival (PFS) and HRQoL under different interventions (retention or dissection of level IIb). The primary endpoints will be tested by means of two-sided log-rank tests. Analysis of overall and progression-free survival will be performed in subgroups that were defined according to stratification factors with the use of univariate Cox analysis. In addition, we will use post-hoc subgroup analyses on the basis of histological factors that were known to have effects on survival, such as death of invasion of the primary tumor. To evaluate HRQoL, we will choose the Constant–Murley scale to measure shoulder function.

Discussion

Currently, there are no randomized controlled trials with large sample sizes on the necessity of IIB dissection in T1–T2N0M0 OSCC. We designed this noninferiority RCT that combines survival rate and HRQoL to assess the feasibility of IIb neck dissection. The result of this trial may guide clinical practice and change the criteria of how early-stage oral cancer is managed. The balance between survival and HRQoL in this trial is based on early-stage breast cancer treatment and may provide new ideas for other malignancies.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800019128. Registered on 26 October 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3683-y) contains supplementary material, which is available to authorized users.

Serum Trace Elements and Their Associations with Breast Cancer Subgroups in Korean Breast Cancer Patients

The relationships between serum levels of trace elements and breast cancer remain relatively unknown. In this study, we investigate serum levels of seven trace elements in Korean breast cancer patients compared to controls without breast cancer. Serum trace element levels were determined using inductively coupled plasma mass spectrometry in Korean breast cancer patients before initiation of breast cancer treatment. Korean females without breast cancer served as a control group. Trace element levels were measured in the discovery cohort (n = 287) and were validated in an independent cohort (n = 142). We further investigated possible associations between trace element levels and the presence of lymph node metastasis, distant metastasis, or triple-negative breast cancer among breast cancer patients in subgroup analyses. Serum manganese and molybdenum levels were significantly higher (p < 0.05) in breast cancer patients than in controls. Serum copper levels were significantly higher in breast cancer patients with distant metastasis, while selenium levels were significantly lower. Other trace elements were neither significantly different between breast cancer patients and controls nor between subgroups of breast cancer patients. Our study provides insights about the potential roles and impacts of trace elements through an assessment of the associations between trace elements and breast cancer.

Ten-year report on axillary recurrence after negative sentinel node biopsy for breast cancer from the Swedish Multicentre Cohort Study

BACKGROUND

The omission of axillary lymph node dissection (ALND) in patients with breast cancer with a negative finding on sentinel node biopsy (SNB) has reduced arm morbidity substantially. Early follow-up reports have shown the rate of axillary recurrence to be significantly lower than expected, with a median false-negative rate of 7 per cent for SNB. Long-term follow-up is needed as recurrences may develop late.

METHODS

The Swedish Multicentre Cohort Study included 3518 women with breast cancer and a clinically negative axilla, in whom SNB was planned. ALND was performed only in patients with sentinel node metastasis. Twenty-six centres contributed to enrolment between September 2000 and January 2004. The primary endpoint was the axillary recurrence rate and the secondary endpoint was breast cancer-specific survival, calculated using Kaplan-Meier survival estimates.

RESULTS

Some 2216 sentinel node-negative patients with 2237 breast cancers were analysed. The median follow-up time was 126 (range 0-174) months. Isolated axillary recurrence was found in 35 patients (1·6 per cent). High histological grade and multifocal tumours were risk factors for axillary recurrence, whereas the removal of more than two sentinel nodes decreased the risk. Fourteen (40 per cent) of 35 patients died as a consequence of axillary recurrence.

CONCLUSION

The risk of axillary recurrence remains lower than expected after a negative finding on SNB at 10-year follow-up. Axillary recurrences may occur long after primary surgery, and lead to a significant risk of breast cancer death.

The significance of sentinel lymph node micrometastasis in breast cancer: Comparing outcomes with and without axillary clearance

BACKGROUND

Management of micrometastasis in the sentinel node is a controversial topic. Most of the guidelines don't recommend further axillary treatment if micrometastasis are the only finding in the sentinel node. However, some evidence suggests that micrometastasis have significant effect on long term outcomes and therefore indicate systemic treatment.

METHOD

Retrospective cohort study reviewing the management of patients with micrometastasis in the sentinel nodes. Two groups were compared, those who had further axillary clearance and those who had not. The primary endpoints were loco-regional recurrence and lymphedema rate. The secondary endpoints were distant metastasis rate, OS and DFS.

RESULTS

95 patients were found to have micrometastasis or ITC in the axillary SNB over a period of 10 years. Of those, 38 patients had axillary clearance after SNB, while 57 did not. Lymphedema rate was 18.4% in the axillary clearance group versus 0% in the no axillary clearance group (p < 0.001). The LRR event was rare therefore not compared. Distant metastasis rate was 7.01% in the SNB group versus 2.6% in the axillary clearance group. There were no mortalities in the axillary clearance group. This compares to 7.01% among the patients who didn't have axillary clearance. All the patients who died had developed distant metastasis as a cause of death. There was a difference in OS between the two groups in favor of the axillary clearance group (p = 0.004).

DISCUSSION

Although not an indication for axillary clearance recent guidelines, micrometastasis and ITC found in the SNB are a sign of a biologically different disease. This important information should be taken in consideration when planning the adjuvant treatment in those patients among other factors considered.