Sentinel node skills verification and surgeon performance: data from a multicenter clinical trial for early-stage breast cancer

Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist

BACKGROUND

Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist.

METHODS

A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis.

RESULTS

A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies).

CONCLUSIONS

On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.

Long-term results of fluorescence and indigo carmine blue dye-navigated sentinel lymph node biopsy

BACKGROUND

Sentinel lymph node biopsy is widely applied for the management of clinically node-negative breast cancer, and a radioisotope with a blue dye are most often used as tracers. Fluorescence of indocyanine green could also potentially be used as tracer. This study aimed to demonstrate the long-term survival results of fluorescence-guided sentinel lymph node biopsy.

PATIENTS AND METHODS

Patients with clinically node-negative breast cancer who underwent surgery as initial treatment were included in this study. Both fluorescence of indocyanine green and indigo carmine blue dye were used as tracers. Axillary lymph node dissection was omitted unless metastasis was pathologically proven in sentinel nodes. Breast cancer recurrence and death were recorded and prognostic factors were identified using disease-free survival and overall survival data.

RESULTS

A total of 565 patients were analyzed. There were 14 (2.5%) patients whose sentinel nodes could not be identified, yielding an identification rate of 97.5%. Axillary dissection was performed in 90 patients. Forty-three recurrences including 6 ipsilateral axilla recurrence and 13 deaths were observed during the median 83 months of follow-up period. Seven-year disease-free and overall survival were 92.4% and 97.3%, respectively. Multivariate analyses demonstrated that pre-menopausal status and invasive lobular carcinoma were significant unfavorable prognostic factors of disease-free survival. Half of ipsilateral axilla recurrences occurred within 5 years after surgery and these recurrences were correlated with inappropriate adjuvant therapy.

CONCLUSION

Fluorescence-guided sentinel lymph node biopsy demonstrated favorable prognostic results and could be alternative to the radioisotope for clinically node-negative breast cancer.

Decreasing rates of axillary lymph node dissections over time: Implications for surgical resident exposure and operative skills development

BACKGROUND

Sentinel lymph node biopsy has supplanted axillary lymph node dissection (ALND) in clinically node-negative breast cancer and select node-positive disease. We hypothesized a decreasing rate of both ALND and resident exposure over time.

METHODS

We identified women with clinical Stage I-III breast cancer in the National Cancer Data Base (2004-2014). Adjusted multivariate logistic regression was used to estimate the effect of various factors on receipt of ALND. Yearly procedural rates for residents were extracted from surgical case log reports for comparison against procedural rates.

RESULTS

1,131,363 patients were identified; 255,306 received ALND, 876,057 underwent non-ALND management. ALND rates declined from 2004 (32%) to 2014 (16%, p < 0.001), with the largest decline occurring between 2010 and 2011 (24%-20%). After adjustment, this effect was maintained, with ALND rates decreasing with each additional year (OR = 0.90, 95% CI 0.89-0.90). Resident procedure volumes similarly declined from 1999 to 2017 (p < 0.001).

CONCLUSIONS

Significant declines in both ALND rates and procedural volume in residency may impact outcomes, as ALNDs are being performed in ever more challenging oncologic scenarios by potentially less-experienced surgeons.

Can Complete Axillary Node Dissection Be Safely Omitted in Patients with Early Breast Cancer When the Sentinel Node Biopsy Is Positive for Malignancy? An Update for Clinical Practice

The sentinel lymph node biopsy (SLNB) has become the new standard-of-care for patients with clinically node-negative invasive breast cancer. The focused examination of fewer lymph nodes in addition to improvements in histopathological and molecular analysis have increased the rate at which micrometastases and isolated tumor cells are identified. We reviewed the literature and summarized the evidence regarding the need for complete axillary lymph node dissection (ALND) following the finding of a positive sentinel node biopsy through the identification of the most important outcomes and evaluation of quality of evidence. The article focuses on the safe omission of complete ALND when the axillary lymph nodes contain macrometastases and provides an overview of the topic primarily based on level 1 evidence derived from randomized clinical trials with a critical appraisal of the ACOSOG Z0011 trial.

Could axillary clearance be avoided in clinically node-negative breast cancer patients with positive nodes diagnosed by ultrasound guided biopsy in the post-ACOSOG Z0011 era?

BACKGROUND AND OBJECTIVES

The role of ultrasound (US) guided biopsy in selecting patients for an upfront lymph node dissection (ALND) has been controversial following the publication of the American College of Surgeons (ACOSOG) Z0011 data. The purpose of this study was to investigate if patients with positive axillary lymph nodes (LNs) proven by US guided biopsy should be recommended for ALND and to analyze the utility of preoperative US and US guided biopsy in planning axillary surgery to avoid both unnecessary ALND and unnecessary SLNB.

METHODS

Patients with a positive preoperative LN biopsy were identified and evaluated to determine their suitability for inclusion according to the criteria proposed in the Z0011 data. The correlation of the number of suspicious nodes found using US with the number of positive nodes on ALND was studied.

RESULTS

A total of 261 breast cancer patients who had a positive preoperative LN needle biopsy were identified, among them, 79 patients with cT1-2N0 breast cancer and ALND were enrolled in the study. Thirty-one patients (39.2%) had ≤2 positive nodes identified in pathology and 10 patients (12.7%) met all of the Z0011 criteria and might have been spared ALND. A significantly greater proportion of women with ≥3 positive nodes during ALND had >1 abnormal LN identified using US compared to women with ≤2 positive LNs found using ALND (66.7% vs. 6.5%, p<0.0001).

CONCLUSION

US with needle biopsy is valuable to patients with multiple suspicious nodes found using US while SLND without US guided needle biopsy is suggested if only one abnormal LN is detected on US in the post-Z0011 era.

Breast sentinel lymph node biopsy with imaging towards minimally invasive surgery

Breast sentinel lymph nodes are still commonly assessed through complete lymph node dissections, which is a time-consuming and radical approach because the nodes are difficult to identify. To prevent false diagnosis and achieve accurate results, minimally invasive, image-guided procedures are applied and constantly improved. The purpose of this paper is to present the currently used imaging modalities ultrasound, fluorescence, single-photon emission computed tomography (SPECT), magnetic resonance imaging (MRI) and hybrid imaging methods and comparing their effectiveness for breast sentinel lymph node biopsy. A definition for an ideal imaging system combining efficient minimally invasive techniques with workflow considerations is also discussed. As a conclusion, upcoming imaging methods and their future outlook with areas of advancement are presented.

Fifteen-Year Decrease in General Surgery Resident Breast Operative Experience: Are We Training Proficient Breast Surgeons?

OBJECTIVE

The goal of the study was to evaluate trends in general surgery resident breast cases over the past 15 years.

STUDY DESIGN

The Accreditation Council for Graduate Medical Education (ACGME) Case Logs Statistics Reports from 2000 to 2015 were reviewed for average breast-specific case numbers and trends over time. ACGME data were available for all cases and breast-specific cases including the following: excisional biopsy/lumpectomy, simple mastectomy, modified radical mastectomy, and sentinel lymph node excision.

SETTING

The study evaluation was conducted at Cleveland Clinic, Cleveland, Ohio.

PARTICIPANTS

No individuals directly participated in this project. However, all general surgery residents at ACGME-accredited programs are represented in this analysis by virtue of the ACGME Case Logs Statistics Reports.

RESULTS

Total residency case volume increased by 2% (2000-2015, p = 0.0159), with 2015 graduates logging 985.5 cases. In contrast, breast cases decreased by 17.1%. The largest drops were in modified radical mastectomy (61.5% decrease, p = 0.0001) and excisional biopsy/lumpectomy (25.8% decrease). Simple mastectomy increased from 6.0 to 10.8 cases (p = 0.0001). Sentinel lymph node excision fluctuated, but has been down-trending recently (67.3% decrease from 2010 to 2015, p = 0.0001). Decreased experience is occurring at both junior and senior resident levels.

CONCLUSIONS

Breast case operative experience for general surgery residents decreased by 17% between 2000 and 2015, despite increase in overall operative volume. Residents have less experience in more advanced cases including axillary management, raising concern about the proficiency of graduating surgeons with respect to these procedures. It is reasonable to set national minimums for resident breast operative experience to ensure that individuals are appropriately trained to perform these cases in practice.

Prevalence and Consequences of Axillary Lymph Node Dissection in the Era of Sentinel Lymph Node Biopsy for Breast Cancer

BACKGROUND

Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity.

OBJECTIVE

Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND.

RESEARCH DESIGN/SUBJECTS

Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009.

MEASURES

Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated.

RESULTS

Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases.

CONCLUSIONS

In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.

Quantitative investigation of a novel small field of view hybrid gamma camera (HGC) capability for sentinel lymph node detection

Objective:

The hybrid gamma camera (HGC) has been developed to enhance the localization of radiopharmaceutical uptake in targeted tissues during surgical procedures such as sentinel lymph node (SLN) biopsy. To assess the capability of the HGC, a lymph node contrast (LNC) phantom was constructed to simulate medical scenarios of varying radioactivity concentrations and SLN size.

Methods:

The phantom was constructed using two clear acrylic glass plates. The SLNs were simulated by circular wells of diameters ranging from 10 to 2.5 mm (16 wells in total) in 1 plate. The second plate contains four larger rectangular wells to simulate tissue background activity surrounding the SLNs. The activity used to simulate each SLN ranged between 4 and 0.025 MBq. The activity concentration ratio between the background and the activity injected in the SLNs was 1 : 10. The LNC phantom was placed at different depths of scattering material ranging between 5 and 40 mm. The collimator-to-source distance was 120 mm. Image acquisition times ranged from 60 to 240 s.

Results:

Contrast-to-noise ratio analysis and full-width-at-half-maximum (FWHM) measurements of the simulated SLNs were carried out for the images obtained. Over the range of activities used, the HGC detected between 87.5 and 100% of the SLNs through 20 mm of scattering material and 75–93.75% of the SLNs through 40 mm of scattering material. The FWHM of the detected SLNs ranged between 11.93 and 14.70 mm.

Conclusion:

The HGC is capable of detecting low accumulation of activity in small SLNs, indicating its usefulness as an intraoperative imaging system during surgical SLN procedures.

Advances in knowledge:

This study investigates the capability of a novel small-field-of-view (SFOV) HGC to detect low activity uptake in small SLNs. The phantom and procedure described are inexpensive and could be easily replicated and applied to any SFOV camera, to provide a comparison between systems with clinically relevant results.

Troubleshooting Sentinel Lymph Node Biopsy in Breast Cancer Surgery

BACKGROUND

Performing a sentinel lymph node biopsy (SLNB) is the standard of care for axillary nodal staging in patients with invasive breast cancer and clinically negative nodes. The procedure provides valuable staging information with few complications when performed by experienced surgeons. However, variation in proficiency exists for this procedure, and a great amount of experience is required to master the technique, especially when faced with challenging cases. The purpose of this paper was to provide a troubleshooting guide for commonly encountered technical difficulties in SLNB, and offer potential solutions so that surgeons can improve their own technical performance from the collective knowledge of experienced specialists in the field.

METHODS

Information was obtained from a convenience sample of six experienced breast cancer specialists, each actively involved in training surgeons and residents/fellows in SLNB. Each surgeon responded to a structured interview in order to provide salient points of the SLNB procedure.

RESULTS

Four of the key opinion surgical specialists provided their perspective using technetium-99 m sulfur colloid, and two shared their experience using blue dye only. Distinct categories of commonly encountered problem scenarios were presented and agreed upon by the panel of surgeons. The responses to each of these scenarios were collected and organized into a troubleshooting guide.

DISCUSSION

We present a compilation of 'tips' organized as a troubleshooting guide to be used to guide surgeons of varying levels of experience when encountering technical difficulties with SLNB.

Breast cancer recurrence after sentinel lymph node biopsy

OBJECTIVE

To look into the pattern of breast cancer recurrence following mastectomy, breast conservative surgery and radiotherapy or chemotherapy after SLNB at our institution.

METHODS

Between January 2005 and December 2014, all patients diagnosed with breast cancer with clinically negative axilla, underwent SLNB. We reviewed their medical records to identify pattern of cancer recurrence.

RESULTS

The median follow-up was 35.5 months. Eighty five patients (70.8%) had a negative sentinel lymph node (SLN) and subsequently had no further axillary treatment, one of them (1.2%) developed axillary recurrence 25 months postoperatively. Twenty five patients (20.8%) had a positive SLN (macrometastases) and subsequently had immediate axillary lymph node dissection (ALND). Ten patients (8.3%) had a positive SLN (micrometastases). In the positive SLN patients (macrometastases and micrometastases), there were two ipsilateral breast recurrences (5.7%), seen three and four years postoperatively. Also in this group, there was one (2.9%) distant metastasis to bone three years postoperatively.

CONCLUSION

In this series, the clinical axillary false negative rate for SLNB was 1.2% which is in accordance with the published literature. This supports the use of SLNB as the sole axillary staging procedure in breast cancer patients with negative SLNB. Axillary lymph node dissection can be safely omitted in patients with micrometastases in their sentinel lymph node(s).

Two decades of axillary management in breast cancer

Background

Axillary lymph node dissection (ALND) in patients with breast cancer provides prognostic information. For many years, positive nodes were the most important indication for adjuvant systemic therapy. It was also believed that regional control could not be achieved without axillary clearance in a positive axilla. However, during the past 20 years the treatment and staging of the axilla has undergone many changes. This large population-based study was conducted in the south-east of the Netherlands to evaluate the changing patterns of care regarding the axilla, including the introduction of sentinel lymph node biopsy (SLNB) in the late 1990s, implementation of the results of the American College of Surgeons Oncology Group Z0011 study, and the initial effects of the European Organization for Research and Treatment of Cancer AMAROS study.

Methods

Data from the population-based Eindhoven Cancer Registry of all women diagnosed with invasive breast cancer in the south of the Netherlands between January 1993 and July 2014 were used.

Results

The proportion of 34 037 women staged by SLNB without completion ALND increased from 0 per cent in 1993–1994 to 69·0 per cent in 2013–2014. In the same period the proportion undergoing ALND decreased from 88·8 to 18·7 per cent. Among women with one to three positive lymph nodes, the proportion undergoing SLNB alone increased from 10·6 per cent in 2011–2012 to 37·6 per cent in 2013–2014.

Conclusion

This population-based study demonstrated the radical transformation in management of the axilla since the introduction of SLNB and following the recent publication of trials on management of the axilla with a low metastatic burden.

The feasibility of the ACOSOG Z0011 Criteria to Chinese Breast Cancer Patients: A Multicenter Study

The aim of this study was to determine the feasibility of the Z0011 criteria to Chinese breast cancer patients. An survey about the Z0011 trial was distributed and we collected 658 consecutive patients with axillary lymph node dissection (ALND) after positive sentinel lymph node (SLN) biopsy from five centers’ databases and grouped them as eligible or ineligible for omitting ALND according to the Z0011 criteria. The eligible group was compared with the cohort included in the Z0011 trial and with the ineligible group. Of the 427 respondants, 106 (24.8%) and 130 (30.4%)would not routinely perform ALND in patients meeting Z0011 criteria before and after learning of the trial results, respectively. Among the 658 patients, 151 (22.9%) were eligible and 507 were ineligible for omitting ALND. The clinicopathologic factors were not statistically different between the eligible group and the Z0011 cohort. Compared with the eligible Group, the ineligible group had significantly more T2 and T3 stage tumors, positive lymph nodes(LNs) and positive non-sentinel lymph nodes (NSLNs) (P < 0.01). The findings suggest good exportability of the Z0011 criteria to Chinese patients omitting ALND, but application of Z0011 as national treatment guideline still needs additional time and effort.

Current Status of Radiotherapy for the Management of Regional Nodes in Breast Cancer

Worldwide, breast cancer is the most common invasive cancer in women. Breast cancer constitutes about 23% of invasive cancers in women. The management of breast cancer depends on various factors, including the cancer stage and patient age. Breast cancer is usually treated with surgery, which can be followed by chemotherapy or radiation therapy, or both. Until recently, the standard procedure for axillary study was axillary dissection. Sentinel lymph node biopsy has been validated as a less-aggressive axillary treatment without an impact on survival. In the present report, we review the current management of the axillary lymph nodes, especially from the viewpoint of an oncology radiotherapist.

Sentinel lymph node biopsy and nodal ultrastaging in colorectal cancer

The tumor status of the regional lymph nodes is the most important prognostic indicator in colorectal cancer (CRC), as it is in other solid tumors. Sentinel lymph node biopsy (SLNB), which has profoundly impacted the treatment of melanoma and breast cancer, has been applied in CRC in an attempt to improve nodal staging accuracy. The challenge lies in identifying patients who have tumor-negative nodes but are at high risk of regional or distant failure and therefore may benefit from adjuvant chemotherapy. Because standard pathological analysis of lymph nodes may incorrectly stage colon cancer, multiple studies have investigated nodal ultrastaging based on identification and immunohistochemical and/or molecular assessment of the sentinel node. This review focuses on the technique of SNLB, its feasibility and validity, and the controversies that remain regarding the clinical significance of nodal ultrastaging in CRC.

Robotic blue-dye sentinel lymph node detection for endometrial cancer - Factors predicting successful mapping

OBJECTIVE

Sentinel lymph node (SLN) mapping has emerged as a viable option for the treatment of patients with endometrial cancer. We report our initial experience with SLN mapping algorithm, and examine the factors predicting successful SLN mapping.

METHODS

We analyzed all data recorded in our institute on robotic blue-dye SLN detection mapping from the time it was first introduced to our department in January 2012-December 2014. Data included patient demographics, SLN allocation, operating room times, and pathology results.

RESULTS

During the study period, 74 patients had robotic assisted surgery for endometrial cancer with attempted SLN mapping. SLN was found overall in 46 patients (62.1%). At first, SLN was detected in only 50% of cases, but after performing 30 cases, detection rates rose to 84.6% (OR = 3.34, CI 1.28-8.71; p = 0.003). Univariate analysis showed a higher detection rate with methylene blue than patent blue dye, 74.3% vs. 52.3% (OR = 2.744, 95% CI 1.026-7.344; p = 0.042). In multivariate analysis, high body mass index (BMI) was associated with failed mapping (OR = 0.899; 95% CI 0.808-1.00), as was the presence of lymph-vascular space invasion (LVSI) (OR = 0.126; 95% CI 0.24-0.658) and few cases per surgeon (OR = 1.083, 95% CI 1.032-1.118). Factors related to uterine pathology itself, including tumor histology, grade, method of diagnosis, the presence of an endometrial polyp, and lower uterine segment involvement were not found to be associated with successful mapping.

CONCLUSIONS

Surgeon experience, BMI and LVSI may affect the success rate of SLN mapping for endometrial cancer. These factors should be investigated further in future studies.

Towards optimal management of the axilla in the context of a positive sentinel node biopsy in early breast cancer

The sentinel lymph node biopsy (SLNB) was initially pioneered for staging melanoma in 1994 and it has been subsequently validated by several trials, and has become the new standard of care for patients with clinically node negative invasive breast cancer. The focussed examination of fewer lymph nodes in addition to improvements in histopathological and molecular analysis has increased the rate at which micrometastases and isolated tumour cells are identified. In this article we review the literature regarding the optimal management of the axilla when the SLNB is positive for metastatic disease based on level 1 evidence derived from randomised clinical trials.

Impact of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial on clinical management of the axilla in older breast cancer patients: a SEER-medicare analysis

BACKGROUND

American College of Surgeons Oncology Group (ACOSOG) Z0011 demonstrated that eligible breast cancer patients with positive sentinel lymph nodes (SLN) could be spared an axillary lymph node dissection (ALND) without sacrificing survival or local control. Although heralded as a ‘‘practice-changing trial,’’ some argue that the stringent inclusion criteria limit the trial’s clinical significance. The objective was to assess the potential impact of ACOSOG Z0011 on axillary surgical management of Medicare patients and examine current practice patterns.

METHODS

Medicare beneficiaries aged C66 years with nonmetastatic invasive breast cancer diagnosed from 2001 to 2007 were identified from the Surveillance, Epidemiology and End Results-Medicare database (n = 59,431). Eligibility for ACOSOG Z0011 was determined: SLN mapping, tumor\5 cm, no neoadjuvant treatment, breast conservation; number of positive nodes was determined. Actual surgical axillary management for eligible patients was assessed.

RESULTS

Twelve percent (6,942/59,431) underwent SLN mapping and were node positive. Overall, 2,637 patients (4.4 % (2,637/59,431) of the total cohort, but 38 % (2,637/6,942) of patients with SLN mapping and positive nodes) met inclusion criteria for ACOSOG Z0011, had 1 or 2 positive lymph nodes, and could have been spared an ALND. Of these 2,637 patients, 46 % received a completion ALND and 54 % received only SLN biopsy.

CONCLUSIONS

Widespread implementation of ACOSOG Z0011 trial results could potentially spare 38 % of older breast cancer patients who undergo SLN mapping with positive lymph nodes an ALND. However, 54 % of these patients are already managed with SLN biopsy alone, lessening the impact of this trial on clinical practice in older breast cancer patients.

Omission of axillary lymph node dissection for clinically node negative early-stage breast cancer patients

BACKGROUND

For clinically node negative (N0) breast cancer patients, sentinel node (SN) biopsy (SNB) is a standard technique and complete axillary lymph node dissection (ALND) remains the standard treatment when the SN is positive. However, the American College of Surgeons Oncology Group Z0011 trial and the International Breast Cancer Study Group 23-01 trial showed that SNB without ALND can offer excellent regional control and equal survival compared with ALND for limited macrometastatic and micrometastatic SN involvement, respectively. We retrospectively evaluated axillary control rates in clinically N0 patients who had no axillary surgical treatment.

METHODS

Data on 158 patients who underwent breast-conserving therapy without any axillary surgical procedure between 1994 and 2010 were extracted. The last follow-up was on May 2013, and the overall median follow-up period was 119.0 months.

RESULTS

Of all 158 patients, 10 (6.3 %) and 3 (1.9 %) developed locoregional and axillary recurrences, respectively. The 10-year locoregional and axillary recurrence rates were 5.8 and 2.1 %, respectively. The 5- and 10-year overall survival rates were 94.0 and 84.8 %, respectively. Cases with axillary recurrence tended to have common risk factors for recurrence.

CONCLUSION

Even if SNB and ALND were omitted, local and regional recurrence rates were very low among clinically N0 patients and were at the same levels shown in recent trials. This suggests that at least ALND might be safely avoided in clinically N0 patients without any obvious risk factors regardless of axillary nodal status after SNB.

Factors associated with local-regional recurrence after a negative sentinel node dissection: results of the ACOSOG Z0010 trial

OBJECTIVE

To determine factors important in local-regional recurrence (LRR) in patients with negative sentinel lymph nodes (SLNs) by hematoxylin and eosin (H&E) staining.

BACKGROUND

Z0010 was a prospective multicenter trial initiated in 1999 by the American College of Surgeons Oncology Group to evaluate occult disease in SLNs and bone marrow of early-stage breast cancer patients. Participants included women with biopsy-proven T1-2 breast cancer with clinically negative nodes, planned for lumpectomy and whole breast irradiation.

METHODS

Women with clinical T1-2,N0,M0 disease underwent lumpectomy and SLN dissection. There was no axillary-specific treatment for H&E-negative SLNs, and clinicians were blinded to immunohistochemistry results. Systemic therapy was based on primary tumor factors. Univariable and multivariable analyses were performed to determine clinicopathologic factors associated with LRR.

RESULTS

Of 5119 patients, 3904 (76.3%) had H&E-negative SLNs. Median age was 57 years (range 23-95). At median follow-up of 8.4 years, there were 127 local, 20 regional, and 134 distant recurrences. Factors associated with local-regional recurrence were hormone receptor-negative disease (P = 0.0004) and younger age (P = 0.047). In competing risk-regression models, hormone receptor-positive disease and use of chemotherapy were associated with reduction in local-regional recurrence. When local recurrence was included in the model as a time-dependent variable, older age, T2 disease, high tumor grade, and local recurrence were associated with reduced overall survival.

CONCLUSIONS

Local-regional recurrences are rare in early-stage breast cancer patients with H&E-negative SLNs. Younger age and hormone receptor-negative disease are associated with higher event rates, and local recurrence is associated with reduced overall survival.

When is a lymph node dissection a lymph node dissection? The number of lymph nodes resected in sentinel and axillary lymph node dissections

PURPOSE

We sought to compare the number of lymph nodes (LN) resected in axillary lymph node dissections (ALND) and sentinel lymph node dissections (SLND), and to assess the validity of registry reporting for axillary staging in breast cancer.

METHODS

Women in the California Cancer Registry who underwent surgical axillary staging for T1/T2, M0 breast cancer between 2004 and 2008 were evaluated. The number of LN resected in patients reported as having SLND+ALND and ALND were assessed for compliance with 6 and 10 LN threshold definitions for ALND. The proportion of patients with ≤3 LN removed was assessed for patients receiving SLND only.

RESULTS

Of 71,907 patients, 45.5 % had SLND, 24.0 %, SLND+ALND, and 30.5 %, ALND. The median number of LN resected with SLND cases was 2 (range 1-41); SLND+ALND, 9 (range 1-63); and ALND, 11 (range 1-81) (p < 0.0001). Of patients undergoing ALND, 56.7 % had ≥10 LN removed; 46.2 % of patients with SLND+ALND had ≥10 LN removed (p < 0.0001). Overall, 75.5 % of patients with ALND had ≥6 LN removed and 67.8 % of patients with SLND+ALND had ≥6 LN removed (p < 0.0001). Of those receiving only SLND, 83.4 % had ≤3 LN removed.

CONCLUSIONS

A significant proportion of patients did not meet the minimum LN count thresholds for full ALND or had excess LN removed in a SLND. Further investigation is required to determine whether absolute LN number or reported operative procedure and implied surgical technique better defines axillary staging in a registry database.

Who should have or not have an axillary node dissection with breast cancer?

There have been dramatic changes in the approach to the axilla in women with breast cancer over the last 100 years, reflecting the evolution in our understanding of the underlying tumor biology, reduced disease burden because of early detection, and advances in all breast cancer treatment modalities. The approach to the axilla needs to be individualized, much like the extent of surgery for the primary tumor. Axillary dissection remains an important intervention for patients with more locally advanced disease. However, in patients with early-stage breast cancer, in whom regional recurrence is extremely low, the added benefit of an ALND has yet to be confirmed.

Paradigm shift in axilla surgery for breast cancer patients treated with sentinel node biopsy

BACKGROUND

Sentinel node biopsy (SNB) is a standard technique for the diagnosis of regional lymph node metastases in clinically node-negative breast cancer patients. In the case of pathologically negative sentinel lymph nodes (SLN), axillary lymph node dissection (ALND) can be avoided.

METHODS

Recent clinical studies on SNB in breast cancer were reviewed regarding the pathological and molecular diagnosis of SLN, the tools used to predict non-SLN metastases, the prognostic significance of isolated tumor cells (ITC) and micrometastases (MIC), and axilla surgery.

RESULTS

ITC or MIC in SLN was associated with worse survival in patients treated with SNB alone or SNB followed by ALND. However, this effect was limited and adjuvant therapy improved survival. If T1 and one SLN-positive breast cancer patients are treated with whole-breast irradiation and adjuvant therapy, additional ALND may not be necessary.

CONCLUSIONS

SNB without ALND can be adopted for patients with a small number of SLN metastases. Although the lack of apparent regional lymph node recurrence, similar to tumor dormancy, cannot be fully explained, ALND should be performed in cases that are highly suspected to be non-SLN metastases.

Local and regional control in breast cancer: role of sentinel node biopsy

The development and acceptance of the SLND has profoundly affected the management of breast cancer. SLND has supplanted ALND as a highly accurate and less-morbid axillary staging procedure in patients with clinically node-negative early-stage breast cancer. SLND alone is associated with less than 1% isolated axillary recurrence in patients with node-negative disease and provides excellent regional nodal control. Historically, ALND has been the recommended treatment for patients with SLN metastases. ALND was thought to offer prognostic information, prevent axillary local recurrence, and possibly render a small survival benefit. However, resection of nonsentinel nodes with metastases may not affect survival, and not all axillary metastases progress to become clinically evident. Furthermore, with increased understanding of tumor biology, nodal status and number of involved lymph nodes are no longer the only determinants of systemic therapy. As improved breast cancer screening allows identification of early-stage disease localized to the breast, and because treatment plans are more often made on the basis of tumor biology, the role of completion ALND may be less critical. The low LRR rates seen in the ACOSOG Z0011 trial, several other randomized trials, and retrospective reviews suggest that SLND alone may provide adequate locoregional control and provide adequate information to guide adjuvant systemic therapy in selected women with clinically node-negative early-stage breast cancer.

The evolution of the locoregional therapy of breast cancer

Breast-conserving therapy (BCT) and mastectomy have equal survival outcomes. Rates of local recurrence after BCT have declined steadily, largely as a result of the widespread use of systemic therapy. Sentinel node biopsy has replaced axillary dissection for staging the axilla, and in women undergoing BCT with whole-breast irradiation (WBI), axillary dissection is not needed for local control or survival in those with fewer than three involved sentinel nodes. Alternatives to 6 weeks of WBI have been shown to be safe and effective for subsets of breast cancer patients, and the use of preoperative chemotherapy allows BCT in some women who require mastectomy if surgery is the initial step in treatment. The combination of the smaller cancers detected with screening and the routine use of multimodality therapy has resulted in a decrease in the morbidity of local therapy and improved cancer treatment outcomes.

Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage invasive breast cancer

CONTEXT

Immunochemical staining of sentinel lymph nodes (SLNs) and bone marrow identifies breast cancer metastases not seen with routine pathological or clinical examination.

OBJECTIVE

To determine the association between survival and metastases detected by immunochemical staining of SLNs and bone marrow specimens from patients with early-stage breast cancer.

DESIGN, SETTING, AND PATIENTS

From May 1999 to May 2003, 126 sites in the American College of Surgeons Oncology Group Z0010 trial enrolled women with clinical T1 to T2N0M0 invasive breast carcinoma in a prospective observational study.

INTERVENTIONS

All 5210 patients underwent breast-conserving surgery and SLN dissection. Bone marrow aspiration at the time of operation was initially optional and subsequently mandatory (March 2001). Sentinel lymph node specimens (hematoxylin-eosin negative) and bone marrow specimens were sent to a central laboratory for immunochemical staining; treating clinicians were blinded to results.

MAIN OUTCOME MEASURES

Overall survival (primary end point) and disease-free survival (a secondary end point).

RESULTS

Of 5119 SLN specimens (98.3%), 3904 (76.3%) were tumor-negative by hematoxylin-eosin staining. Of 3326 SLN specimens examined by immunohistochemistry, 349 (10.5%) were positive for tumor. Of 3413 bone marrow specimens examined by immunocytochemistry, 104 (3.0%) were positive for tumors. At a median follow-up of 6.3 years (through April 2010), 435 patients had died and 376 had disease recurrence. Immunohistochemical evidence of SLN metastases was not significantly associated with overall survival (5-year rates: 95.7%; 95% confidence interval [CI], 95.0%-96.5% for immunohistochemical negative and 95.1%; 95% CI, 92.7%-97.5% for immunohistochemical positive disease; P = .64; unadjusted hazard ratio [HR], 0.90; 95% CI, 0.59-1.39; P = .64). Bone marrow metastases were associated with decreased overall survival (unadjusted HR for mortality, 1.94; 95% CI, 1.02-3.67; P = .04), but neither immunohistochemical evidence of tumor in SLNs (adjusted HR, 0.88; 95% CI, 0.45-1.71; P = .70) nor immunocytochemical evidence of tumor in bone marrow (adjusted HR, 1.83; 95% CI, 0.79-4.26; P = .15) was statistically significant on multivariable analysis.

CONCLUSION

Among women receiving breast-conserving therapy and SLN dissection, immunohistochemical evidence of SLN metastasis was not associated with overall survival over a median of 6.3 years, whereas occult bone marrow metastasis, although rare, was associated with decreased survival.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00003854.

Sentinel node biopsy in colorectal cancer: Must we believe it?

Lymph node metastasis predicts survival and recurrence in colon cancer (CC), so decisions regarding adjuvant therapy are largely based on nodal status. Chemotherapy is not a routine treatment for node-negative CC because its toxicity and expense exceed its limited benefit in patients without evidence of nodal involvement. The sentinel lymph node (SLN) procedure is a selective sampling technique that can be used to ultrastage regional nodes. The real problem of SLN biopsy in CC is the procedure sensitivity rate. In future, studies concerning SLNs will have to consider issues such as the role of laparoscopy in colorectal resection (which cause technical difficulties in identification of SLNs) and the risk of overstaging of illness as well as the need to exclude T4 CC and, probably, rectal cancer from the studies. Is this the future of correct staging of colorectal cancer? Lymphadenectomy is at the present an integral part of colorectal surgery and surgeons must perform it correctly to improve their results. Nevertheless, for the future another "staging system" is necessary in colorectal cancer which takes into account biologic aspects of the tumor to identify patients with aggresive illness in order to treat them with more effective and less toxic therapies.

Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients

OBJECTIVE

Sentinel lymph node (SLN) surgery is widely used for nodal staging in early-stage breast cancer. This study was performed to evaluate the accuracy of SLN surgery for patients undergoing neoadjuvant chemotherapy versus patients undergoing surgery first.

SUMMARY BACKGROUND DATA

Controversy exists regarding the timing of SLN surgery in patients planned for neoadjuvant chemotherapy. Proponents of SLN surgery after chemotherapy prefer a single surgical procedure with potential for fewer axillary dissections. Opponents cite early studies with low identification rates and high false-negative rates after chemotherapy.

METHODS

A total of 3746 patients with clinically node negative T1-T3 breast cancer underwent SLN surgery from 1994 to 2007. Clinicopathologic data were reviewed and comparisons made between patients receiving neoadjuvant chemotherapy and those undergoing surgery first.

RESULTS

Of the patients, 575 (15.3%) underwent SLN surgery after chemotherapy and 3171 (84.7%) underwent surgery first. Neoadjuvant patients were younger (51 vs. 57 years, P < 0.0001) and had more clinical T2-T3 tumors (87.3% vs. 18.8%, P < 0.0001) at diagnosis. SLN identification rates were 97.4% in the neoadjuvant group and 98.7% in the surgery first group (P = 0.017). False-negative rates were similar between groups (5/84 [5.9%] in neoadjuvant vs. 22/542 [4.1%] in the surgery first group, P = 0.39). Analyzed by presenting T stage, there were fewer positive SLNs in the neoadjuvant group (T1: 12.7% vs. 19.0%, P = 0.2; T2: 20.5% vs. 36.5%, P < 0.0001; T3: 30.4% vs. 51.4%, P = 0.04). Adjusting for clinical stage revealed no differences in local-regional recurrences, disease-free or overall survival between groups.

CONCLUSIONS

SLN surgery after chemotherapy is as accurate for axillary staging as SLN surgery prior to chemotherapy. SLN surgery after chemotherapy results in fewer positive SLNs and decreases unnecessary axillary dissections.

Predictors of arm morbidity following breast cancer surgery

OBJECTIVE

Arm morbidity post-breast cancer surgery is increasingly being recognized as a chronic problem for some women following breast cancer surgery. The purpose of this study was to examine demographic, disease, and treatment-related predictors of a comprehensive array of chronic arm morbidity (pain, lymphedema, functional disability, and range of motion) post-breast cancer surgery.

METHODS

Women (n=316) with a non-metastatic primary diagnosis of breast cancer were accrued from cancer centers in four Canadian cities. Patients completed a clinical assessment and measures of arm morbidity at 6-12 months post-breast cancer surgery. The independent variables in the MANOVA to predict arm morbidity included: Lymph node management type, number of axillary nodes dissected, type of surgery, disease stage, presence of post-operative infection, radiation to the axilla, body mass index (BMI), assessment time post-surgery, education, and partner status.

RESULTS

Pain was significantly predicted by axillary lymph node management, lack of a partner, and post-operative infection; lymphedema by axillary lymph node management, number of axillary nodes dissected, radiation to the axilla, and having a modified radical mastectomy; functional disability by post-operative infection and high BMI; and restricted external rotation by axillary lymph node management, low educational attainment, and advanced disease.

CONCLUSION

Comprehensive behavioral management and rehabilitation programs are needed to treat arm morbidity following breast cancer surgery. These programs should address the full scope of symptoms and associated psychosocial and functional sequelae.

Sentinel lymph node dissection is technically feasible in older breast cancer patients

BACKGROUND

Previous studies suggested that sentinel lymph node (SLN) identification rates are lower in older breast cancer patients. This study was undertaken to compare identification rates in patients 70 years of age and older versus those younger than 70 years in a large cohort undergoing sentinel lymph node dissection (SLND).

STUDY DESIGN

Patients undergoing SLND between August 1993 and December 2006 were identified and grouped by age. Clinicopathologic data and details regarding the procedure were reviewed.

RESULTS

Of the 3995 patients undergoing SLND, 3406 (85.3%) were under 70 years of age, and 589 (14.7%) were 70 years or older. Age was significantly associated with clinical stage (P = .001) and tumor grade (P < .0001). A greater proportion in the older group had clinical stage I disease (74.7% vs. 66.8%), and a lower proportion had grade 3 tumors (24.0% vs. 36.1%). There were no significant differences by age in the mapping method or site of injection. Overall SLN identification rate was 97.2% and did not differ significantly by age. The SLN was positive in 23.1% of younger patients and 18.2% of older patients (P = .01).

CONCLUSION

Sentinel lymph node dissection can be performed with high identification rates regardless of patient age. Breast cancer patients 70 years and older with clinically negative axillary lymph nodes should be offered SLND, as the presence of lymph node metastasis may alter adjuvant therapy recommendations.

Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial

BACKGROUND AND OBJECTIVE

Sentinel lymph node dissection (SLND) has eliminated the need for axillary dissection (ALND) in patients whose sentinel node (SN) is tumor-free. However, completion ALND for patients with tumor-involved SNs remains the standard to achieve locoregional control. Few studies have examined the outcome of patients who do not undergo ALND for positive SNs. We now report local and regional recurrence information from the American College of Surgeons Oncology Group Z0011 trial.

METHODS

American College of Surgeons Oncology Group Z0011 was a prospective trial examining survival of patients with SN metastases detected by standard H and E, who were randomized to undergo ALND after SLND versus SLND alone without specific axillary treatment. Locoregional recurrence was evaluated.

RESULTS

There were 446 patients randomized to SLND alone and 445 to SLND + ALND. Patients in the 2 groups were similar with respect to age, Bloom-Richardson score, estrogen receptor status, use of adjuvant systemic therapy, tumor type, T stage, and tumor size. Patients randomized to SLND + ALND had a median of 17 axillary nodes removed compared with a median of only 2 SN removed with SLND alone (P < 0.001). ALND also removed more positive lymph nodes (P < 0.001). At a median follow-up time of 6.3 years, there were no statistically significant differences in local recurrence (P = 0.11) or regional recurrence (P = 0.45) between the 2 groups.

CONCLUSIONS

Despite the potential for residual axillary disease after SLND, SLND without ALND can offer excellent regional control and may be reasonable management for selected patients with early-stage breast cancer treated with breast-conserving therapy and adjuvant systemic therapy.

Accuracy of sentinel node biopsy for breast cancer using blue dye alone

Blue dye alone (BDA), lymphoscintigraphy alone, or, a combination of the two techniques are used for sentinel node biopsy (SNB) in breast cancer. This study reviews the effectiveness of the SNB technique using BDA by measuring the node identification rate and comparing the cohort node positivity with expected rates from established nomograms. A consecutive case series was examined from the database. This included the learning experience of six surgeons. Patients with unifocal tumors estimated at less than 31 mm were eligible. The tumor and axillary nodal histology was recorded. Published data were then used to calculate and predict node positivity rates in the study according to the size and grade of the tumors. There were 332 SNB procedures from 2001 to 2008. BDA successfully identified nodes in 94.6% (314/332) of the cases. The identification rate improved with experience. In patients with invasive cancer, 28.4% (85/299) of SNB were found to be positive for metastases or micrometastases. The node identification rate and the node positivity rate were found to be within published predicted ranges for the size and grade of the study tumors. The SNB with BDA was found to be effective in identifying sentinel nodes (SLN) in breast cancer. Surgeon experience was a factor in the success of the technique. Rates of detecting metastases were consistent with internationally published data, suggesting that BDA may perform as well as other techniques in experienced hands.

Adherence to the National Quality Forum (NQF) breast cancer measures within cancer clinical trials: a review from ACOSOG Z0010

BACKGROUND

In 2007, the National Quality Forum (NQF) released four performance measures for the treatment of breast cancer. We proposed to study the degree of adherence with these measures among participating institutions in a multi-institutional trial.

METHODS

American College of Surgeons Oncology Group (ACOSOG) Z0010 enrolled breast cancer patients onto a phase II trial studying the prognostic significance of bone marrow and sentinel node micrometastases. The current study used chi(2) analyses to determine the degree of adherence with four NQF measures among three institution types: academic, community, and teaching affiliate.

RESULTS

The study revealed small but important differences in two measures. Ninety-five percent of patients from teaching affiliated institutions received whole-breast radiation compared to 92% at academic and 91% at community hospitals. Among patients who were underinsured or uninsured, a marked decrease in radiation use was noted in comparison to patients with insurance-85 versus 93%, respectively. The study also revealed a difference among institutional types in patients undergoing excisional biopsy for diagnosis. In teaching-affiliated hospitals, 28.6% underwent excisional biopsy as compared to 36.8 and 37.4% in academic and community hospitals, respectively. There was no statistically significant difference between adherence rates with the remaining two measures. Adjuvant chemotherapy was administered to patients with hormone receptor negative tumors > or =1 cm in size in 79-85% of institutions. Tamoxifen was administered to 79-82% of those patients with hormone receptor-positive cancers.

CONCLUSIONS

Among breast cancer patients enrolled onto a multi-institutional clinical trial, we found a high degree of adherence with current consensus standards for adjuvant treatment, despite varied practice environments.

Sentinel node identification rate and nodal involvement in the EORTC 10981-22023 AMAROS trial

Background

The randomized EORTC 10981-22023 AMAROS trial investigates whether breast cancer patients with a tumor-positive sentinel node biopsy (SNB) are best treated with an axillary lymph node dissection (ALND) or axillary radiotherapy (ART). The aim of the current substudy was to evaluate the identification rate and the nodal involvement.

Methods

The first 2,000 patients participating in the AMAROS trial were evaluated. Associations between the identification rate and technical, patient-, and tumor-related factors were evaluated. The outcome of the SNB procedure and potential further nodal involvement was assessed.

Results

In 65 patients, the sentinel node could not be identified. As a result, the sentinel node identification rate was 97% (1,888 of 1,953). Variables affecting the success rate were age, pathological tumor size, histology, year of accrual, and method of detection. The SNB results of 65% of the patients (n = 1,220) were negative and the patients underwent no further axillary treatment. The SNB results were positive in 34% of the patients (n = 647), including macrometastases (n = 409, 63%), micrometastases (n = 161, 25%), and isolated tumor cells (n = 77, 12%). Further nodal involvement in patients with macrometastases, micrometastases, and isolated tumor cells undergoing an ALND was 41, 18, and 18%, respectively.

Conclusions

With a 97% detection rate in this prospective international multicenter study, the SNB procedure is highly effective, especially when the combined method is used. Further nodal involvement in patients with micrometastases and isolated tumor cells in the sentinel node was similar—both were 18%.

Sentinel node biopsy in colorectal cancer: Must we believe it?

April 22, 2013

As Editor-in-Chief of the World Journal of Gastrointestinal Surgery, it has come to my attention that two articles that have published in our journal are very similar to the content of previously published papers.

Specifically, the two articles:

Scabini S, Rimini E, Massobrio A, Romairone E, Linari C, Scordamaglia R, Marini LD, Ferrando V. Primary omental torsion: A case report. World J Gastrointest Surg 2011 Oct 27; 3(10): 153-5. DOI: 10.4240/wjgs.v3.i10.153. PubMed PMID: 22110847; PMCID: PMC3220728 has a number of very common features to the previously published paper Efthimiou M, Kouritas VK, Fafoulakis F, Fotakakis K, Chatzitheofilou K. Primary omental torsion: report of two cases. Surg Today 2009; 39(1): 64-7. DOI: 10.1007/s00595-008-3794-7. Epub 2009 Jan 8. PMID: 19132472.

Scabini S. Sentinel node biopsy in colorectal cancer: Must we believe it World J Gastrointest Surg 2010 Jan 27; 2(1): 6-8. DOI: 10.4240/wjgs.v2.i1.6 PMID: 21160827; PMCID: PMC2999193 has copied entire paragraphs from two papers by Nicholl M, Bilchik AJ. Is routine use of sentinel node biopsy justified in colon cancer Ann Surg Oncol 2008 Jan; 15(1): 1-3. Epub 2007 Oct 11. PubMed PMID: 17929100 and Bilchik AJ, Compton C. Close collaboration between surgeon and pathologist is essential for accurate staging of early colon cancer. Ann Surg. 2007 Jun; 245(6): 864-6. PMID: 17522510; PMCID: PMC1876950.

Based on my review of the aforementioned articles, these two articles are being retracted.

I have also asked the office of the World Journal of Gastrointestinal Surgery to make it a matter of policy to use routinely anti-plagiarism software to screen all submissions to the journal in the future.

Sincerely,

Timothy M. Pawlik, MD, MPH, PhD

Editor-in-Chief World Journal of Gastrointestinal Surgery

Randomized clinical trials in breast cancer

Breast cancer remains the most common cancer diagnosed in women and the second leading cause of cancer-related deaths in this group. Significant advances in the treatment of breast cancer and in the ability to screen for the disease mean that it is also one of the most curable forms of cancer. Long-term updates of the trials reviewed in the previous edition of this article have demonstrated that breast-conserving therapy remains a viable option for most patients, and that local control is related to overall survival. New chemotherapeutic options and endocrine therapies are available to select subsets of patients, and the use of endocrine therapy in breast cancer prevention has been shown to be of clear benefit. The sheer number of breast cancer-related randomized, controlled trials makes it impossible to review all level Ia evidence in this article but, where possible, extensive referencing and tabular review of related trials are used to provide the reader with a clear outline of the central data dictating current standard of care.