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Liu Q, Yang R, Wang D, Liu Q. Role of low-density cholesterol and Interleukin-17 interaction in breast cancer pathogenesis and treatment. Cell Biol Int 2024. [PMID: 39318044 DOI: 10.1002/cbin.12250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 09/02/2024] [Accepted: 09/17/2024] [Indexed: 09/26/2024]
Abstract
Breast cancer (BC) has become the most prevalent cancer worldwide, and further research is being conducted to deepen our understanding of its pathogenesis and treatment. Lipid metabolism disorder is a significant alteration in cancer cells, and the investigation into the role of Interleukin-17 (IL-17) in malignant tumors has emerged as a research focus in recent years. Thus, exploring changes in lipid metabolism and inflammatory factors in BC cells is crucial in identifying potential therapeutic targets. This article summarizes the progress made in the research on the main low-density cholesterol (LDL) transporter and IL-17 in lipid metabolism, and their potential involvement in the development of BC. The article aims to establish a theoretical foundation for the development of BC-related therapies.
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Affiliation(s)
- Qingqing Liu
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine-Zhuhai Hospital, The 2nd Clinical School of Medicine, Guangzhou University of Chinese Medicine, Guangdong, 510120, China
| | - Rongyuan Yang
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine-Zhuhai Hospital, The 2nd Clinical School of Medicine, Guangzhou University of Chinese Medicine, Guangdong, 510120, China
| | - Dawei Wang
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine-Zhuhai Hospital, The 2nd Clinical School of Medicine, Guangzhou University of Chinese Medicine, Guangdong, 510120, China
- The 1st Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangdong, 510405, China
| | - Qing Liu
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine-Zhuhai Hospital, The 2nd Clinical School of Medicine, Guangzhou University of Chinese Medicine, Guangdong, 510120, China
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2
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Sun Z, Liu K, Guo Y, Jiang N, Ye M. Surgery paradigm for locally advanced breast cancer following neoadjuvant systemic therapy. Front Surg 2024; 11:1410127. [PMID: 39308852 PMCID: PMC11412956 DOI: 10.3389/fsurg.2024.1410127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 08/27/2024] [Indexed: 09/25/2024] Open
Abstract
Locally advanced breast cancer (LABC) remains a significant clinical challenge, particularly in developing countries. While neoadjuvant systemic therapy (NST) has improved the pathological complete response (pCR) rates, particularly in HER2-positive and triple-negative breast cancer patients, surgical management post-NST continues to evolve. The feasibility of omitting surgery and the increasing consideration of breast-conserving surgery, immediate reconstruction in LABC patients are important areas of exploration. Accurate assessment of tumor response to NST through advanced imaging and minimally invasive biopsies remains pivotal, though challenges persist in reliably predicting pCR. Additionally, axillary lymph node management continues to evolve, with emerging strategies aiming to minimize the extent of surgery in patients who achieve nodal downstaging post-NST. Minimizing axillary lymph node dissection in favor of less invasive approaches is gaining attention, though further evidence is needed to establish its oncological safety. The potential for personalized treatment approaches, reducing surgical morbidity, and improving quality of life are key goals in managing LABC, while maintaining the priority of achieving favorable long-term outcomes.
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Affiliation(s)
| | | | | | | | - Meina Ye
- Department of Breast Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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3
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Sisó C, Rubio IT. Two step procedures: sequels are never any good. Gland Surg 2024; 13:1336-1340. [PMID: 39282033 PMCID: PMC11399001 DOI: 10.21037/gs-24-229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 08/07/2024] [Indexed: 09/18/2024]
Affiliation(s)
- Christian Sisó
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Isabel T Rubio
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Madrid, Spain
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4
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Cabıoğlu N, Karanlık H, Yılmaz R, Emiroğlu S, Tükenmez M, Bademler S, Şimşek DH, Kantarcı TR, Yirgin İK, Bayram A, Dursun M. Targeted axillary dissection reduces residual nodal disease in clinically node- positive breast cancer after neoadjuvant chemotherapy. World J Surg Oncol 2024; 22:178. [PMID: 38971793 PMCID: PMC11227135 DOI: 10.1186/s12957-024-03413-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/14/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Any advantage of performing targeted axillary dissection (TAD) compared to sentinel lymph node (SLN) biopsy (SLNB) is under debate in clinically node-positive (cN+) patients diagnosed with breast cancer. Our objective was to assess the feasibility of the removal of the clipped node (RCN) with TAD or without imaging-guided localisation by SLNB to reduce the residual axillary disease in completion axillary lymph node dissection (cALND) in cN+ breast cancer. METHODS A combined analysis of two prospective cohorts, including 253 patients who underwent SLNB with/without TAD and with/without ALND following NAC, was performed. Finally, 222 patients (cT1-3N1/ycN0M0) with a clipped lymph node that was radiologically visible were analyzed. RESULTS Overall, the clipped node was successfully identified in 246 patients (97.2%) by imaging. Of 222 patients, the clipped lymph nodes were non-SLNs in 44 patients (19.8%). Of patients in cohort B (n=129) with TAD, the clipped node was successfully removed by preoperative image-guided localisation, or the clipped lymph node was removed as the SLN as detected on preoperative SPECT-CT. Among patients with ypSLN(+) (n=109), no significant difference was found in non-SLN positivity at cALND between patients with TAD and RCN (41.7% vs. 46.9%, p=0.581). In the subgroup with TAD with axillary lymph node dissection (ALND; n=60), however, patients with a lymph node (LN) ratio (LNR) less than 50% and one metastatic LN in the TAD specimen were found to have significantly decreased non-SLN positivity compared to others (27.6% vs. 54.8%, p=0.032, and 22.2% vs. 50%, p=0.046). CONCLUSIONS TAD by imaging-guided localisation is feasible with excellent identification rates of the clipped node. This approach has also been found to reduce the additional non-SLN positivity rate to encourage omitting ALND in patients with a low metastatic burden undergoing TAD.
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Affiliation(s)
- Neslihan Cabıoğlu
- Department of Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye.
| | - Hasan Karanlık
- Department of Surgical Oncology, Istanbul University, Institute of Oncology, Istanbul, Türkiye
| | - Ravza Yılmaz
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Selman Emiroğlu
- Department of Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Mustafa Tükenmez
- Department of Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Süleyman Bademler
- Department of Surgical Oncology, Istanbul University, Institute of Oncology, Istanbul, Türkiye
| | - Duygu Has Şimşek
- Department of Nuclear Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Tarık Recep Kantarcı
- Department of Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - İnci Kızıldağ Yirgin
- Department of Radiology, Istanbul University, Institute of Oncology, Istanbul, Türkiye
| | - Aysel Bayram
- Department of Pathology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Memduh Dursun
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
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5
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Pfob A, Kokh DB, Surovtsova I, Riedel F, Morakis P, Heil J. Oncologic Outcomes for Different Axillary Staging Techniques in Patients with Nodal-Positive Breast Cancer Undergoing Neoadjuvant Systematic Treatment: A Cancer Registry Study. Ann Surg Oncol 2024; 31:4381-4392. [PMID: 38710911 PMCID: PMC11164833 DOI: 10.1245/s10434-024-15292-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/28/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Targeted approaches such as targeted axillary dissection (TAD) or sentinel lymph node biopsy (SLNB) showed false-negative rates of < 10% compared with axillary lymph node dissection (ALND) in patients with nodal-positive breast cancer undergoing neoadjuvant systemic treatment (NAST). We aimed to evaluate real-world oncologic outcomes for different axillary staging techniques. METHODS We identified nodal-positive breast cancer patients undergoing NAST from 2016 to 2021 from the state cancer registry of Baden-Wuerttemberg, Germany. Invasive disease-free survival (iDFS) was assessed using Kaplan-Meier statistics and multivariate Cox regression models (adjusted for age, ypN stage, ypT stage, and tumor biologic subtype). RESULTS A total of 2698 patients with a median follow-up of 24.7 months were identified: 2204 underwent ALND, 460 underwent SLNB (255 with ≥ 3 sentinel lymph nodes [SLNs] removed, 205 with 1-2 SLNs removed), and 34 underwent TAD. iDFS 3 years after surgery was 69.7% (ALND), 76.6% (SLNB with ≥ 3 SLNs removed), 76.7% (SLNB with < 3 SLNs removed), and 78.7% (TAD). Multivariate Cox regression analysis showed no significant influence of different axillary staging techniques on iDFS (hazard ratio [HR] for SLNB with < 3 SLNs removed 0.96, 95% confidence interval [CI] 0.62-1.50; HR for SLNB with ≥ 3 SLNs removed 0.86, 95% CI 0.56-1.3; HR for TAD 0.23, 95% CI 0.03-1.64; ALND reference), and for ypN+ (HR 1.92, 95% CI 1.49-2.49), triple-negative breast cancer (HR 2.35, 95% CI 1.80-3.06), and ypT3-4 (HR 2.93, 95% CI 2.02-4.24). CONCLUSION These real-world data provide evidence that patient selection for de-escalated axillary surgery for patients with nodal-positive breast cancer undergoing NAST was successfully adopted and no early alarm signals of iDFS detriment were detected.
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Affiliation(s)
- André Pfob
- Department of Obstetrics and Gynecology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daria B Kokh
- Klinische Landesregisterstelle, Krebsregister Baden-Württemberg, Stuttgart, Germany
| | - Irina Surovtsova
- Klinische Landesregisterstelle, Krebsregister Baden-Württemberg, Stuttgart, Germany
| | - Fabian Riedel
- Department of Obstetrics and Gynecology, Heidelberg University Hospital, Heidelberg, Germany
| | - Philipp Morakis
- Klinische Landesregisterstelle, Krebsregister Baden-Württemberg, Stuttgart, Germany.
| | - Joerg Heil
- Department of Obstetrics and Gynecology, Heidelberg University Hospital, Heidelberg, Germany.
- Breast Centre Heidelberg, Klinik St. Elisabeth, Heidelberg, Germany.
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6
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Connors C, Al-Hilli Z. De-escalation of Axillary Surgery After Neoadjuvant Therapy. Clin Breast Cancer 2024; 24:385-391. [PMID: 38735808 DOI: 10.1016/j.clbc.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/25/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024]
Abstract
Surgical de-escalation of the axilla has evolved over the past 28 years since the emergence of sentinel lymph node surgery. Well-documented complications of the once standard of care axillary lymph node dissection (ALND), including lymphedema, led physician scientists towards a progressive push to study and incorporate less invasive techniques in the axilla. Many trials have justified oncologic safety of axillary de-escalation in patients who are spared neoadjuvant treatment. The applicability in the neoadjuvant setting, however, is less clear and axillary surgical approaches in this patient population have evolved at a slower pace. This review aims to analyze current data in axillary management for patients undergoing neoadjuvant treatment and to discuss current surgical approaches based on nodal pathologic response.
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Affiliation(s)
- Casey Connors
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Zahraa Al-Hilli
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH.
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7
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Boland MR. Modern management of the axilla. J Surg Oncol 2024; 130:23-28. [PMID: 38643485 DOI: 10.1002/jso.27649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/11/2024] [Indexed: 04/23/2024]
Abstract
Surgical management of the axilla has evolved considerably in recent years, with a strong focus on de-escalation to minimise morbidity whilst maintaining oncological outcomes. Current trials will focus on the omission of Sentinel node biopsy in select groups of patients, while axillary lymph node dissection will be reserved for those with more aggressive disease.
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Affiliation(s)
- Michael R Boland
- Department of Breast Surgery, St Vincent's University Hospital, Dublin, Ireland
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8
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Nijveldt JJ, Rajan KK, Boersma K, Noorda EM, van der Starre-Gaal J, Kate MV'VT, Roeloffzen EMA, Vendel BN, Beek MA, Francken AB. Implementation of the Targeted Axillary Dissection Procedure in Clinically Node-Positive Breast Cancer: A Retrospective Analysis. Ann Surg Oncol 2024; 31:4477-4486. [PMID: 38523225 DOI: 10.1245/s10434-024-15182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/03/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The targeted axillary dissection (TAD) procedure is used in clinically positive lymph node (cN+) breast cancer to assess whether pathological complete response (pCR) is achieved after neoadjuvant systemic therapy (NST) to decide on de-escalation of axillary lymph node dissection (ALND). In this study, we review the implementation of the TAD procedure in a large regional breast cancer center. METHODS All TAD procedures between 2016 and 2022 were reviewed. The TAD procedure consists of marking pre-NST the largest suspected metastatic lymph node(s) using a radioactive I-125 seed. During surgery, the marked node was excised together with a sentinel node procedure. Axillary therapy (ALND, axillary radiotherapy, or nothing) recommendations were based on the amount of suspected positive axillary lymph nodes (ALNs < 4 or ≥ 4) pre-NST and if pCR was achieved after NST. RESULTS A total of 312 TAD procedures were successfully performed in 309 patients. In 134 (43%) cases, pCR of the TAD lymph nodes were achieved. Per treatment protocol, 43 cases (14%) did not receive any axillary treatment, 218 cases (70%) received adjuvant axillary radiotherapy, and 51 cases (16%) underwent an ALND. During a median follow-up of 2.8 years, 46 patients (14%) developed recurrence, of which 11 patients (3.5%) had axillary recurrence. CONCLUSIONS Introduction of the TAD procedure has resulted in a reduction of 84% of previously indicated ALNDs. Moreover, 18% of cases did not receive adjuvant axillary radiotherapy. These data show that implementation of de-escalation axillary treatment with the TAD procedure appeared to be successful.
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Affiliation(s)
- Joni J Nijveldt
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands
| | - Kiran K Rajan
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands.
| | - Karina Boersma
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands
| | - Eva M Noorda
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands
| | | | | | | | - Brian N Vendel
- Department of Nuclear Medicine, Isala Zwolle, Zwolle, The Netherlands
| | - Maarten A Beek
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands
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9
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Varghese J, Patani N, Wazir U, Novintan S, Michell MJ, Malhotra A, Mokbel K, Mokbel K. Wire-Free Targeted Axillary Dissection: A Pooled Analysis of 1300+ Cases Post-Neoadjuvant Systemic Therapy in Node-Positive Early Breast Cancer. Cancers (Basel) 2024; 16:2172. [PMID: 38927878 PMCID: PMC11201777 DOI: 10.3390/cancers16122172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Recent advances in neoadjuvant systemic therapy (NST) have significantly improved pathologic complete response rates in early breast cancer, challenging the role of axillary lymph node dissection in nose-positive patients. Targeted axillary dissection (TAD) integrates marked lymph node biopsy (MLNB) and tracer-guided sentinel lymph node biopsy (SLNB). The introduction of new wire-free localisation markers (LMs) has streamlined TAD and increased its adoption. The primary endpoints include the successful localisation and retrieval rates of LMs. The secondary endpoints include the pathological complete response (pCR), SLNB, and MLNB concordance, as well as false-negative rates. Seventeen studies encompassing 1358 TAD procedures in 1355 met the inclusion criteria. The localisation and retrieval rate of LMs were 97% and 99%. A concordance rate of 67% (95% CI: 64-70) between SLNB and MLNB was demonstrated. Notably, 49 days (range: 0-272) was the average LM deployment time to surgery. pCR was observed in 46% (95% CI: 43-49) of cases, with no significant procedure-related complications. Omitting MLNB or SLNB would have under-staged the axilla in 15.2% or 5.4% (p = 0.0001) of cases, respectively. MLNB inclusion in axillary staging post-NST for initially node-positive patients is crucial. The radiation-free Savi Scout, with its minimal MRI artefacts, is the preferred technology for TAD.
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Affiliation(s)
- Jajini Varghese
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Royal Free London NHS Trust, Pond Street, London NW3 2QG, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Neill Patani
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Umar Wazir
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
| | - Shonnelly Novintan
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- East Suffolk North Essex NHS Foundation Trust, Turner Road, Colchester CO4 5JL, UK
| | - Michael J. Michell
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Kings College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Anmol Malhotra
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Royal Free London NHS Trust, Pond Street, London NW3 2QG, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Kinan Mokbel
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Health and Care Profession Department, Faculty of Health and Life Sciences, University of Exeter Medical School, Exeter EX1 2HZ, UK
| | - Kefah Mokbel
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
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10
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Alamoodi M, Wazir U, Venkataraman J, Almukbel R, Mokbel K. Assessing the Efficacy of Radioactive Iodine Seed Localisation in Targeted Axillary Dissection for Node-Positive Early Breast Cancer Patients Undergoing Neoadjuvant Systemic Therapy: A Systematic Review and Pooled Analysis. Diagnostics (Basel) 2024; 14:1175. [PMID: 38893701 PMCID: PMC11172271 DOI: 10.3390/diagnostics14111175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/24/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Targeted axillary dissection (TAD), employing marked lymph node biopsy (MLNB) alongside sentinel lymph node biopsy (SLNB), is increasingly recognised for its efficacy in reducing false negative rates (FNRs) in node-positive early breast cancer patients receiving neoadjuvant systemic therapy (NST). One such method, 125I radioactive seed localisation (RSL), involves implanting a seed into a biopsy-proven lymph node either pre- or post-NST. This systematic review and pooled analysis aimed to assess the performance of RSL in TAD among node-positive patients undergoing NST. Six studies, encompassing 574 TAD procedures, met the inclusion criteria. Results showed a 100% successful deployment rate, with a 97.6% successful localisation rate and a 99.8% retrieval rate. Additionally, there was a 60.0% concordance rate between SLNB and MLNB. The FNR of SLNB alone was significantly higher than it was for MLNB (18.8% versus 5.3%, respectively; p = 0.001). Pathological complete response (pCR) was observed in 44% of cases (248/564). On average, the interval from 125I seed deployment to surgery was 75.8 days (range: 0-272). These findings underscore the efficacy of RSL in TAD for node-positive patients undergoing NST, enabling precise axillary pCR identification and facilitating the safe omission of axillary lymph node dissection.
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Affiliation(s)
| | | | | | | | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK; (M.A.); (U.W.); (J.V.); (R.A.)
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11
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Tasoulis MK, Lee HB, Kuerer HM. Omission of Breast Surgery in Exceptional Responders. Clin Breast Cancer 2024; 24:310-318. [PMID: 38365541 DOI: 10.1016/j.clbc.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/22/2024] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
Breast cancer management has transformed significantly over the last decades, primarily through the integration of neoadjuvant systemic therapy (NST) and the evolving understanding of tumor biology, enabling more tailored treatment strategies. The aim of this review is to critically present the historical context and contemporary evidence surrounding the potential of omission of surgery post-NST, focusing on exceptional responders who have achieved a pathologic complete response (pCR). Identifying these exceptional responders before surgery remains a challenge, however standardized image-guided biopsy may allow optimized patient selection. The safety and feasibility of omitting breast and axillary surgeries in these exceptional responders are explored in ongoing clinical trials and the reported preliminary results appear promising. Moreover, understanding patient and physician perspectives regarding the potential elimination of surgery post-NST is integral. While some patients express a preference to omit or minimize surgery, the majority of healthcare providers are intrigued by the prospect of avoiding surgical interventions and endorse further research in this field.
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Affiliation(s)
- Marios-Konstantinos Tasoulis
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Breast Cancer Research, The Institute of Cancer Research, London, UK.
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Henry Mark Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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12
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Qiu J, Cheng Z, Jiang Z, Gan L, Zhang Z, Xie Z. Immunomodulatory Precision: A Narrative Review Exploring the Critical Role of Immune Checkpoint Inhibitors in Cancer Treatment. Int J Mol Sci 2024; 25:5490. [PMID: 38791528 PMCID: PMC11122264 DOI: 10.3390/ijms25105490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/11/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
An immune checkpoint is a signaling pathway that regulates the recognition of antigens by T-cell receptors (TCRs) during an immune response. These checkpoints play a pivotal role in suppressing excessive immune responses and maintaining immune homeostasis against viral or microbial infections. There are several FDA-approved immune checkpoint inhibitors (ICIs), including ipilimumab, pembrolizumab, and avelumab. These ICIs target cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed death ligand 1 (PD-L1). Furthermore, ongoing efforts are focused on developing new ICIs with emerging potential. In comparison to conventional treatments, ICIs offer the advantages of reduced side effects and durable responses. There is growing interest in the potential of combining different ICIs with chemotherapy, radiation therapy, or targeted therapies. This article comprehensively reviews the classification, mechanism of action, application, and combination strategies of ICIs in various cancers and discusses their current limitations. Our objective is to contribute to the future development of more effective anticancer drugs targeting immune checkpoints.
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Affiliation(s)
- Junyu Qiu
- College of Basic Medical, Nanchang University, Nanchang 330006, China; (J.Q.); (Z.C.); (Z.J.); (L.G.); (Z.Z.)
- Queen Mary School, Medical Department, Nanchang University, Nanchang 330031, China
| | - Zilin Cheng
- College of Basic Medical, Nanchang University, Nanchang 330006, China; (J.Q.); (Z.C.); (Z.J.); (L.G.); (Z.Z.)
- Queen Mary School, Medical Department, Nanchang University, Nanchang 330031, China
| | - Zheng Jiang
- College of Basic Medical, Nanchang University, Nanchang 330006, China; (J.Q.); (Z.C.); (Z.J.); (L.G.); (Z.Z.)
- Queen Mary School, Medical Department, Nanchang University, Nanchang 330031, China
| | - Luhan Gan
- College of Basic Medical, Nanchang University, Nanchang 330006, China; (J.Q.); (Z.C.); (Z.J.); (L.G.); (Z.Z.)
- Huan Kui School, Medical Department, Nanchang University, Nanchang 330031, China
| | - Zixuan Zhang
- College of Basic Medical, Nanchang University, Nanchang 330006, China; (J.Q.); (Z.C.); (Z.J.); (L.G.); (Z.Z.)
- Queen Mary School, Medical Department, Nanchang University, Nanchang 330031, China
| | - Zhenzhen Xie
- College of Basic Medical, Nanchang University, Nanchang 330006, China; (J.Q.); (Z.C.); (Z.J.); (L.G.); (Z.Z.)
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Wang J, Tian C, Zheng BJ, Zhang J, Jiao DC, Qu JR, Liu ZZ. The use of longitudinal CT-based radiomics and clinicopathological features predicts the pathological complete response of metastasized axillary lymph nodes in breast cancer. BMC Cancer 2024; 24:549. [PMID: 38693523 PMCID: PMC11062000 DOI: 10.1186/s12885-024-12257-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/12/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Accurate assessment of axillary status after neoadjuvant therapy for breast cancer patients with axillary lymph node metastasis is important for the selection of appropriate subsequent axillary treatment decisions. Our objectives were to accurately predict whether the breast cancer patients with axillary lymph node metastases could achieve axillary pathological complete response (pCR). METHODS We collected imaging data to extract longitudinal CT image features before and after neoadjuvant chemotherapy (NAC), analyzed the correlation between radiomics and clinicopathological features, and developed models to predict whether patients with axillary lymph node metastasis can achieve axillary pCR after NAC. The clinical utility of the models was determined via decision curve analysis (DCA). Subgroup analyses were also performed. Then, a nomogram was developed based on the model with the best predictive efficiency and clinical utility and was validated using the calibration plots. RESULTS A total of 549 breast cancer patients with metastasized axillary lymph nodes were enrolled in this study. 42 independent radiomics features were selected from LASSO regression to construct a logistic regression model with clinicopathological features (LR radiomics-clinical combined model). The AUC of the LR radiomics-clinical combined model prediction performance was 0.861 in the training set and 0.891 in the testing set. For the HR + /HER2 - , HER2 + , and Triple negative subtype, the LR radiomics-clinical combined model yields the best prediction AUCs of 0.756, 0.812, and 0.928 in training sets, and AUCs of 0.757, 0.777 and 0.838 in testing sets, respectively. CONCLUSIONS The combination of radiomics features and clinicopathological characteristics can effectively predict axillary pCR status in NAC breast cancer patients.
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Affiliation(s)
- Jia Wang
- Department of Breast Disease, Henan Breast Cancer Center, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, Henan, 450008, China
| | - Cong Tian
- Department of Breast Disease, Henan Breast Cancer Center, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, Henan, 450008, China
| | - Bing-Jie Zheng
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, Henan, 450008, China
| | - Jiao Zhang
- Department of Breast Disease, Henan Breast Cancer Center, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, Henan, 450008, China
| | - De-Chuang Jiao
- Department of Breast Disease, Henan Breast Cancer Center, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, Henan, 450008, China
| | - Jin-Rong Qu
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, Henan, 450008, China.
| | - Zhen-Zhen Liu
- Department of Breast Disease, Henan Breast Cancer Center, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, Henan, 450008, China.
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14
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Wickberg Å, Prag C, Valachis A, Karlsson L, Johansson B. Intraoperative Radiation Therapy Delivered by Brachytherapy in Breast Cancer: An Interim Analysis of a Phase 2 Trial. Clin Breast Cancer 2024; 24:243-252. [PMID: 38185607 DOI: 10.1016/j.clbc.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 12/12/2023] [Accepted: 12/17/2023] [Indexed: 01/09/2024]
Abstract
PURPOSE Intraoperative breast cancer radiotherapy (IORT) offers an alternative to external beam radiotherapy (EBRT) after breast-conserving surgery (BCS). The Intraoperative brachytherapy (IOBT) trial applies high dose rate (HDR) brachytherapy with a new applicator prototype as IORT after BCS. In this interim analysis of the IOBT trial, we present the oncological safety and toxicity of the method METHODS: Eligible patients were women, ≥ 50 years old with an unifocal nonlobular, estrogen-receptor-positive, HER2-negative breast cancer, cN0, ≤ 3 cm, treated with BCS and sentinel node biopsy (SNB). Toxicity was registered according to the LENT-SOMA scale. Cumulative incidence of local (LR) and regional recurrence (RR) were calculated through cumulative incidence function whereas overall survival (OS) was illustrated through Kaplan-Meier curve. RESULTS Until February 2023, 155 women (median age 68 years) were included in the trial. Twenty-nine women (18.7%) received supplemental EBRT, mostly due to positive SNB. Three-year cumulative incidence of LR and RR were 1.0% (CI 95 % 0.1%-2.3%) and 2.1% (CI 95% 0.8%-4.2%) respectively. Five- year cumulative incidence of LR and RR were 3.9% (CI 95% 1.8%-6.4%) and 2.1% (CI 95% 0.8%-4.2%) respectively. Five-year OS was 96.3% (CI 95% 93.6%-98.4%). Side effects were limited, low grade, and transient. CONCLUSION Acknowledging the short median follow-up time at interim analysis, our initial results indicate that delivering IORT through HDR brachytherapy in carefully selected breast cancer patients is feasible and oncological safe so far. A long-term follow-up is essential to confirm the initial results.
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Affiliation(s)
- Åsa Wickberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Örebro, Sweden.
| | - Clara Prag
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Örebro, Sweden
| | - Antonis Valachis
- Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Örebro, Sweden
| | - Leif Karlsson
- Department of medical Physics, Örebro University Hospital, Örebro, Sweden
| | - Bengt Johansson
- Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Örebro, Sweden
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15
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Kontos M, Kanavidis P, Kühn T, Masannat Y, Gulluoglu B. Targeted axillary dissection: worldwide variations in clinical practice. Breast Cancer Res Treat 2024; 204:389-396. [PMID: 38175449 DOI: 10.1007/s10549-023-07204-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Targeted axillary dissection (TAD) for the axillary staging of clinically node-positive (cN +) breast cancer patients converting to clinically node negative post neoadjuvant chemotherapy (NAC), has gained popularity due to its minimal false negative rate and low arm morbidity. The aim of this study is to shed more light on the variation in the clinical practice globally in terms of indications and perceived limitations of TAD. METHODS A panel of expert breast surgeons constructed a structured questionnaire comprising of 18 questions and asked surgeons worldwide for their opinions and routine practice on TAD. The questionnaire was electronically distributed and answers were collected between May 1st and August 1st 2022. RESULTS Responses included 137 entries from 36 countries. Of them, 73.7% consider TAD for cN + patients planned to receive NAC. Among them, the greatest number of respondents (45%) perform the procedure for tumours up to T3, whereas 27% regardless of T-stage. The majority (42%) perform TAD on patients with 1-3 positive nodes and only 30% consider TAD when matted nodes are present. HER2 positive and Triple Negative subtypes are more likely to undergo TAD than Luminal A and B (86%, 79.1%, 39.5%, and 62.8%, respectively). Maximum acceptable lymph node burden is median 3 nodes for any subtype with a tendency to accept more positive nodes for Triple Negative. CONCLUSION This study demonstrates the differences in current practice regarding TAD as well as the fact that the biology of the tumour heavily affects the method of axillary staging.
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Affiliation(s)
- Michalis Kontos
- National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Yazan Masannat
- Broomfield Hospital, Mid and South Essex NHS Trust, Chelmsford, UK, Broomfield, UK
- University of Aberdeen, School of Medicine, Medical Science and Nutrition, Aberdeen, UK
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16
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de Wild SR, Koppert LB, de Munck L, Vrancken Peeters MJTFD, Siesling S, Smidt ML, Simons JM. Prognostic effect of nodal status before and after neoadjuvant chemotherapy in breast cancer: a Dutch population-based study. Breast Cancer Res Treat 2024; 204:277-288. [PMID: 38133707 DOI: 10.1007/s10549-023-07178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/04/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE In breast cancer, neoadjuvant chemotherapy (NAC) can downstage the nodal status, and can even result in a pathological complete response, which is associated with improved prognosis. This study aimed to determine the prognostic effect of nodal status before and after NAC. METHODS Women with breast cancer treated with NAC were selected from the Netherlands Cancer Registry if diagnosed between 2005 and 2019, and classified based on nodal status before NAC: node-negative (cN0), or node-positive based on fine needle aspiration cytology or core needle biopsy (cN+). Subgroups were based on nodal status after NAC: absence (ypN0) or presence (ypN+) of nodal disease. Five-year overall survival (OS) was assessed with Kaplan-Meier survival analyses, also per breast cancer molecular subtype. To adjust for potential confounders, multivariable analyses were performed. RESULTS A total of 6,580 patients were included in the cN0 group, and 11,878 in the cN+ group. The 5-year OS of the cN0ypN0-subgroup was statistically significant better than that of the cN+ypN0-subgroup (94.4% versus 90.1%, p < 0.0001). In cN0 as well as cN+ disease, ypN+ had a statistically significant worse 5-year OS compared to ypN0. For hormone receptor (HR)+ human epidermal growth factor receptor 2 (HER2)-, HR+ HER2+, HR-HER2+, and triple negative disease, respectively, 5-year OS in the cN0ypN+-subgroup was 89.7%, 90.4%, 73.7%, and 53.6%, and in the cN+ypN+-subgroup 84.7%, 83.2%, 61.4%, and 48.8%. In multivariable analyses, cN+ and ypN+ disease were both associated with worse OS. CONCLUSION This study suggests that both cN-status and ypN-status, and molecular subtype should be considered to further improve prognostication.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Center+, GROW School for Oncology and Reproduction, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands.
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Center, University of Twente, Enschede, The Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Center+, GROW School for Oncology and Reproduction, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands
| | - Janine M Simons
- Department of Surgery, Maastricht University Medical Center+, GROW School for Oncology and Reproduction, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands
- Department of Radiotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
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17
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Grašič Kuhar C, Geiger J, Schwab FD, Heinzelmann-Schwartz V, Vetter M, Weber WP, Kurzeder C. Prognostic Importance of Axillary Lymph Node Response to Neoadjuvant Systemic Therapy on Axillary Surgery in Breast Cancer-A Single Center Experience. Cancers (Basel) 2024; 16:1306. [PMID: 38610984 PMCID: PMC11010874 DOI: 10.3390/cancers16071306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Neoadjuvant systemic treatment (NST) is the standard treatment for HER2+, triple-negative (TN), and highly proliferative luminal HER2- early breast cancer. Pathologic complete response (pCR) after NST is associated with improved outcomes. We evaluated the predictive factors for axillary-pCR (AXpCR) and its impact on the extent of axillary node surgery. This retrospective study included 92 patients (median age of 50.4 years) with an initially node-positive disease. Patients were treated with molecular subtype-specific NST (4.3% were luminal A-like, 28.3% luminal HER2-, 26.1% luminal HER2+, 18.5% HER2+ non-luminal, and 22.8% TN). Axillary-, breast- and total-pCR were achieved in 52.2%, 48.9%, and 38% of patients, respectively. In a binary logistic regression model for the whole population, the only independent factor significantly associated with AXpCR was breast-pCR (OR 7.4; 95% CI 2.6-20.9; p < 0.001). In patients who achieved breast-pCR, aggressive subtypes (HER2+ and TN; OR 11.24) and clinical tumor stage (OR 0.10) had a significant impact on achieving AXpCR. Axillary lymph node dissection was avoided in 53.3% of patients. In conclusion, in node-positive patients with HER2+ and TN subtypes, who achieved breast-pCR after NST, de-escalation of axillary surgery could be considered in most cases.
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Affiliation(s)
- Cvetka Grašič Kuhar
- Department of Medical Oncology, Institute of Oncology, 1000 Ljubljana, Slovenia
- Faculty of Medicine Ljubljana, University of Ljubljana, 1000 Ljubljana, Slovenia
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
| | - James Geiger
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
| | - Fabienne Dominique Schwab
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
- Department of Gynecologic Oncology, University Hospital Basel, 4031 Basel, Switzerland;
| | | | - Marcus Vetter
- Medical Faculty, University of Basel, 4001 Basel, Switzerland;
- Department of Hematology and Oncology, Cantonal Hospital Basel-Land, 4410 Liestal, Switzerland
| | - Walter Paul Weber
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
| | - Christian Kurzeder
- Breast Cancer Center, University Hospital Basel, University of Basel, 4001 Basel, Switzerland; (J.G.); (F.D.S.); (W.P.W.); (C.K.)
- Department of Gynecologic Oncology, University Hospital Basel, 4031 Basel, Switzerland;
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18
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de Wild SR, Koppert LB, van Nijnatten TJA, Kooreman LFS, Vrancken Peeters MJTFD, Smidt ML, Simons JM. Systematic review of targeted axillary dissection in node-positive breast cancer treated with neoadjuvant systemic therapy: variation in type of marker and timing of placement. Br J Surg 2024; 111:znae071. [PMID: 38531689 PMCID: PMC10965400 DOI: 10.1093/bjs/znae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/15/2024] [Accepted: 03/02/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND In node-positive (cN+) breast cancer treated with neoadjuvant systemic therapy, combining sentinel lymph node biopsy and targeted lymph node excision, that is targeted axillary dissection, increases accuracy. Targeted axillary dissection procedures differ in terms of the targeted lymph node excision technique. This systematic review aimed to provide an overview of targeted axillary dissection procedures regarding definitive marker type and timing of placement: before neoadjuvant systemic therapy (1-step procedure) or after neoadjuvant systemic therapy adjacent to a clip placed before the neoadjuvant therapy (2-step procedure). METHODS PubMed and Embase were searched, to 4 July 2023, for RCTs, cohort studies, and case-control studies with at least 25 patients. Studies of targeted lymph node excision only (without sentinel lymph node biopsy), or where intraoperative localization of the targeted lymph node was not attempted, were excluded. For qualitative synthesis, studies were grouped by definitive marker and timing of placement. The targeted lymph node identification rate was reported. Study quality was assessed using a National Institutes of Health quality assessment tool. RESULTS Of 277 unique records, 51 studies with a total of 4512 patients were included. Six definitive markers were identified: wire, 125I-labelled seed, 99mTc, (electro)magnetic/radiofrequency markers, black ink, and a clip. Fifteen studies evaluated one-step procedures, with the identification rate of the targeted lymph node at surgery varying from 8 of 13 to 47 of 47. Forty-one studies evaluated two-step procedures, with the identification rate of the clipped targeted lymph node on imaging after neoadjuvant systemic therapy varying from 49 to 100%, and the identification rate of the targeted lymph node at surgery from 17 of 24 to 100%. Most studies (40 of 51) were rated as being of fair quality. CONCLUSION Various targeted axillary dissection procedures are used in clinical practice. Owing to study heterogeneity, the optimal targeted lymph node excision technique in terms of identification rate and feasibility could not be determined. Two-step procedures are at risk of not identifying the clipped targeted lymph node on imaging after neoadjuvant systemic therapy.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Thiemo J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Loes F S Kooreman
- Department of Pathology, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Janine M Simons
- Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
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19
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Woodfin AA, Yam C, Teshome M, Kuerer HM, Hunt KK, Meric-Bernstam F, Schaverien M, Barcenas CH, Sun SX. Axillary Nodal Metastases Conversion and Perioperative Complications with Neoadjuvant Pembrolizumab Therapy in Triple-Negative Breast Cancer. Ann Surg Oncol 2024; 31:974-980. [PMID: 37973647 DOI: 10.1245/s10434-023-14541-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Triple-negative breast cancer (TNBC) is known to portend a worse prognosis compared with same-stage, hormone receptor-positive disease. However, with the recent change in practice to include pembrolizumab in neoadjuvant chemotherapy (NAC) for TNBC, an increase in pathologic complete responses (pCRs) has been reported. The perioperative repercussions of adding pembrolizumab to standard NAC regimens for TNBC are currently unknown. We aimed to explore the perioperative implications of adding pembrolizumab to standard NAC regimens for non-metastatic TNBC. METHODS This was a retrospective review of the perioperative outcomes in patients with non-metastatic TNBC treated with pembrolizumab-NAC from January 2018 to October 2022 conducted at a high-volume cancer center. Patient demographics, comorbidities, clinical and pathological staging, NAC treatment regimen, initiation, and completion, as well as date of surgery and postoperative complications were analyzed. RESULTS Of 87 patients, 67.8% had an overall pCR and 86% had an axillary pCR; 37.2% of cN+ patients were spared from axillary lymph node dissection. However, 24.1% of patients experienced surgical complications, 9% of patients were receiving steroids at the time of breast surgery secondary to adverse effects of pembrolizumab-NAC, and 7% underwent a change in the initial surgical plan such as omission of reconstruction. CONCLUSION Pembrolizumab-NAC has not only significant oncologic benefit but also noteworthy perioperative implications in the surgical management of TNBC.
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Affiliation(s)
- Ashley A Woodfin
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Clinton Yam
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Funda Meric-Bernstam
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Mark Schaverien
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos H Barcenas
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susie X Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, The University of Texas, Houston, TX, USA.
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20
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Tauber N, Bjelic-Radisic V, Thill M, Banys-Paluchowski M. Controversies in axillary management of patients with breast cancer - updates for 2024. Curr Opin Obstet Gynecol 2024; 36:51-56. [PMID: 37678325 DOI: 10.1097/gco.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW For some time now, the question of de-escalation in axillary staging in breast cancer patients has been raised. The aim is to improve the patients' quality of life and reduce morbidity by optimizing surgical strategies with a high level of oncological safety. This review offers a current overview of published evidence and clinical practice, aiming to guide the surgical community as they reassess and reshape their practices. RECENT FINDINGS Years after introducing sentinel lymph node biopsy (SLNB) in clinically node negative breast cancer patients several guidelines suggest completely omitting SLNB in older patients with low-risk tumors. It is worth noting that for patients with a metastatic sentinel lymph node in the upfront surgery setting, a de-escalation of axillary surgery may in fact lead to an escalation of radiation therapy. Currently, there is limited evidence on the axillary surgical approach for patients with initially positive node status achieving complete axillary response (ycN0), resulting in heterogenous guideline recommendations. SUMMARY Innovative trials are contributing to a growing evidence on de-escalation of axillary surgery with the aim of reducing arm morbidity and improving long-term health-related quality of life.
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Affiliation(s)
- Nikolas Tauber
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck
| | | | - Marc Thill
- Department of Gynecology and Gynecological Oncology, Breast Center, AGAPLESION Markus Hospital, Frankfurt/M
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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21
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Zhang M, Sun Y, Wu H, Xiao J, Chen W, Wang H, Yang B, Luo H. Prognostic analysis of cT1-3N1M0 breast cancer patients who have responded to neoadjuvant therapy undergoing various axillary surgery and breast surgery based on propensity score matching and competitive risk model. Front Oncol 2024; 14:1319981. [PMID: 38327751 PMCID: PMC10847357 DOI: 10.3389/fonc.2024.1319981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Background Sentinel lymph node biopsy (SLNB) in breast cancer patients with positive clinical axillary lymph nodes (cN1+) remains a topic of controversy. The aim of this study is to assess the influence of various axillary and breast surgery approaches on the survival of cN1+ breast cancer patients who have responded positively to neoadjuvant therapy (NAT). Methods Patients diagnosed with pathologically confirmed invasive ductal carcinoma of breast between 2010 and 2020 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. To mitigate confounding bias, propensity score matching (PSM) analysis was employed. Prognostic factors for both overall survival (OS) and breast cancer-specific survival (BCSS) were evaluated through COX regression risk analysis. Survival curves were generated using the Kaplan-Meier method. Furthermore, cumulative incidence and independent prognostic factors were assessed using a competing risk model. Results The PSM analysis matched 4,890 patients. Overall survival (OS) and BCSS were slightly worse in the axillary lymph node dissection (ALND) group (HR = 1.10, 95% CI 0.91-1.31, p = 0.322 vs. HR = 1.06, 95% CI 0.87-1.29, p = 0.545). The mastectomy (MAST) group exhibited significantly worse OS and BCSS outcomes (HR = 1.25, 95% CI 1.04-1.50, p = 0.018 vs. HR = 1.37, 95% CI 1.12-1.68, p = 0.002). The combination of different axillary and breast surgery did not significantly affect OS (p = 0.083) but did have a significant impact on BCSS (p = 0.019). Competing risk model analysis revealed no significant difference in the cumulative incidence of breast cancer-specific death (BCSD) in the axillary surgery group (Grey's test, p = 0.232), but it showed a higher cumulative incidence of BCSD in the MAST group (Grey's test, p = 0.001). Multivariate analysis demonstrated that age ≥ 70 years, black race, T3 stage, ER-negative expression, HER2-negative expression, and MAST were independent prognostic risk factors for both OS and BCSS (all p < 0.05). Conclusion For cN1+ breast cancer patients who respond positive to NAT, the optimal surgical approach is combining breast-conserving surgery (BCS) with SLNB. This procedure improves quality of life and long-term survival outcomes.
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Affiliation(s)
- Maoquan Zhang
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Yingming Sun
- Department of Medical and Radiation Oncology, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Huasheng Wu
- Department of Hepatobiliary Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Jian Xiao
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Wenxin Chen
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Hebin Wang
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Binglin Yang
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
| | - Huatian Luo
- Department of Breast Surgery, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, Fujian, China
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22
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Blumencranz P, Habibi M, Shivers S, Acs G, Blumencranz LE, Yoder EB, van der Baan B, Menicucci AR, Dauer P, Audeh W, Cox CE. The Predictive Utility of MammaPrint and BluePrint in Identifying Patients with Locally Advanced Breast Cancer Who are Most Likely to Have Nodal Downstaging and a Pathologic Complete Response After Neoadjuvant Chemotherapy. Ann Surg Oncol 2023; 30:8353-8361. [PMID: 37658272 PMCID: PMC10625953 DOI: 10.1245/s10434-023-14027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 07/10/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NCT) increases the feasibility of surgical resection by downstaging large primary breast tumors and nodal involvement, which may result in surgical de-escalation and improved outcomes. This subanalysis from the Multi-Institutional Neo-adjuvant Therapy MammaPrint Project I (MINT) trial evaluated the association between MammaPrint and BluePrint with nodal downstaging. PATIENTS AND METHODS The prospective MINT trial (NCT01501487) enrolled 387 patients between 2011 and 2016 aged ≥ 18 years with invasive breast cancer (T2-T4). This subanalysis includes 146 patients with stage II-III, lymph node positive, who received NCT. MammaPrint stratifies tumors as having a Low Risk or High Risk of distant metastasis. Together with MammaPrint, BluePrint genomically (g) categorizes tumors as gLuminal A, gLuminal B, gHER2, or gBasal. RESULTS Overall, 45.2% (n = 66/146) of patients had complete nodal downstaging, of whom 60.6% (n = 40/66) achieved a pathologic complete response. MammaPrint and combined MammaPrint and BluePrint were significantly associated with nodal downstaging (p = 0.007 and p < 0.001, respectively). A greater proportion of patients with MammaPrint High Risk tumors had nodal downstaging compared with Low Risk (p = 0.007). When classified with MammaPrint and BluePrint, more patients with gLuminal B, gHER2, and gBasal tumors had nodal downstaging compared with HR+HER2-, gLuminal A tumors (p = 0.538, p < 0.001, and p = 0.013, respectively). CONCLUSIONS Patients with genomically High Risk tumors, defined by MammaPrint with or without BluePrint, respond better to NCT and have a higher likelihood of nodal downstaging compared with patients with gLuminal A tumors. These genomic signatures can be used to select node-positive patients who are more likely to have nodal downstaging and avoid invasive surgical procedures.
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Affiliation(s)
| | | | - Steve Shivers
- Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Geza Acs
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | | | | | | | | | | | - Charles E Cox
- Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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Banys-Paluchowski M, Hartmann S, Ditsch N, Krawczyk N, Kühn T, de Boniface J, Banys-Kotomska J, Rody A, Krug D. Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy. Breast Care (Basel) 2023; 18:428-439. [PMID: 38130814 PMCID: PMC10731028 DOI: 10.1159/000533748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer. Summary Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement. Key Messages Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, Rostock, Germany
| | - Nina Ditsch
- Breast Cancer Center, Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Die Filderklinik, Filderstadt, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St. Göran’s Hospital, Stockholm, Sweden
| | - Joanna Banys-Kotomska
- I Department and Clinic of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Yan Y, Jiang T, Sui L, Ou D, Qu Y, Chen C, Lai M, Ni C, Liu Y, Wang Y, Xu D. Combined conventional ultrasonography with clinicopathological features to predict axillary status after neoadjuvant therapy for breast cancer: A case-control study. Br J Radiol 2023; 96:20230370. [PMID: 37750854 PMCID: PMC10646660 DOI: 10.1259/bjr.20230370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate the value of a model combining conventional ultrasonography and clinicopathologic features for predicting axillary status after neoadjuvant therapy in breast cancer. METHODS This retrospective study included 329 patients with lymph node-positive who underwent neoadjuvant systemic treatment (NST) from June 2019 to March 2022. Ultrasound and clinicopathological characteristics of breast lesions and axillary lymph nodes were analyzed before and after NST. The diagnostic efficacy of ultrasound, clinicopathological characteristics, and combined model were evaluated using multivariate logistic regression and receiver operator characteristic curve (ROC) analyses. RESULTS The area under ROC (AUC) for the ability of the combined model to predict the axillary pathological complete response (pCR) after NST was 0.882, that diagnostic effectiveness was significantly better than that of the clinicopathological model (AUC of 0.807) and the ultrasound feature model (AUC of 0.795). In addition, eight features were screened as independent predictors of axillary pCR, including clinical N stage, ERBB2 status, Ki-67, and after NST the maximum diameter reduction rate and margins of breast lesions, the short diameter, cortical thickness, and fatty hilum of lymph nodes. CONCLUSIONS The combined model constructed from ultrasound and clinicopathological features for predicting axillary pCR has favorable diagnostic results, which allowed more accurate identification of BC patients who had received axillary pCR after NST. ADVANCES IN KNOWLEDGE A combined model incorporated ultrasound and clinicopathological characteristics of breast lesions and axillary lymph nodes demonstrated favorable performance in evaluating axillary pCR preoperatively and non-invasively.
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Affiliation(s)
| | | | | | | | - Yiyuan Qu
- The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
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25
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Munck F, Jepsen P, Zeuthen P, Carstensen L, Hauerslev K, Paaskesen CK, Andersen IS, Høyer U, Lanng C, Gerlach MK, Vejborg I, Kroman NT, Tvedskov THF. Comparing Methods for Targeted Axillary Dissection in Breast Cancer Patients: A Nationwide, Retrospective Study. Ann Surg Oncol 2023; 30:6361-6369. [PMID: 37400618 PMCID: PMC10506928 DOI: 10.1245/s10434-023-13792-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/10/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Several techniques exist for performing targeted axillary dissection (TAD) after neoadjuvant chemotherapy with the removal of the sentinel node and a marked metastatic lymph node (LN). Two-step methods include coil-marking of the metastatic LN at diagnosis and re-marking with an intraoperatively identifiable marker before surgery. Because nondetection of the marked lymph node (MLN) warrants axillary clearance and many patients achieve axillary pathological complete response (ax-pCR), the success of TAD is crucial. We compare various two-step TAD methods in a Danish national cohort. METHODS We included patients who received two-step TAD between January 1, 2016 and August 31, 2021. Patients were identified from the Danish Breast Cancer Group database and cross-checked with locally accessible lists. Data were extracted from the patient's medical files. RESULTS We included 543 patients. In 79.4%, preoperative, ultrasound-guided re-marking was possible. Nonidentification of the coil-marked LN was more likely in patients with ax-pCR. The second markers used were hook-wire, iodine seeds, or ink marking on the axillary skin. Of patients with successful secondary marking, the MLN identification rate (IR) was 91%, and the sentinel node (SN) IR was 95%. Marking with iodine seeds was significantly more successful than ink marking with an odds ratio of 5.34 (95% confidence interval 1.62-17.60). The success rate of the complete TAD with the removal of MLN and SN was 82.3%. CONCLUSIONS With two-step TAD, nonidentification of the coiled LN before surgery is frequent, especially in patients with ax-pCR. Despite successful remarking, the IR of the MLN at surgery is inferior to one-step TAD.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark.
| | - Pernille Jepsen
- Department of Breast Surgery, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Pernille Zeuthen
- Department of Surgery and Plastic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | - Lena Carstensen
- Department of Surgery Esbjerg, Hospital of South West Jutland, Esbjerg, Denmark
| | - Katrine Hauerslev
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ute Høyer
- Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
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Ayala de la Peña F, Antolín Novoa S, Gavilá Gregori J, González Cortijo L, Henao Carrasco F, Martínez Martínez MT, Morales Estévez C, Stradella A, Vidal Losada MJ, Ciruelos E. SEOM-GEICAM-SOLTI clinical guidelines for early-stage breast cancer (2022). Clin Transl Oncol 2023; 25:2647-2664. [PMID: 37326826 PMCID: PMC10425528 DOI: 10.1007/s12094-023-03215-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023]
Abstract
Breast cancer is the leading cause of cancer in women in Spain and its annual incidence is rapidly increasing. Thanks to the screening programs in place, nearly 90% of breast cancer cases are detected in early and potentially curable stages, despite the COVID-19 pandemic possibly having impacted these numbers (not yet quantified). In recent years, locoregional and systemic therapies are increasingly being directed by new diagnostic tools that have improved the balance between toxicity and clinical benefit. New therapeutic strategies, such as immunotherapy, targeted drugs, and antibody-drug conjugates have also improved outcomes in some patient subgroups. This clinical practice guideline is based on a systematic review of relevant studies and on the consensus of experts from GEICAM, SOLTI, and SEOM.
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Affiliation(s)
- Francisco Ayala de la Peña
- Department of Medical Oncology, Hospital G. Universitario Morales Meseguer, University of Murcia, Av. Marqués de los Vélez, s/n, 30008, Murcia, Spain.
| | - Silvia Antolín Novoa
- Department of Medical Oncology, Complexo Hospitalario Universitario, A Coruña (CHUAC), Coruña, Spain
| | | | | | | | - María Teresa Martínez Martínez
- Medical Oncology Department, INCLIVA Biomedical Research Institute, Hospital Clínico of Valencia, University of Valencia, 46010, Valencia, Spain
| | | | - Agostina Stradella
- Medical Oncology Department, Institut Català d'Oncologia. L'Hospitalet,, Barcelona, Spain
| | | | - Eva Ciruelos
- Medical Oncology Department, Breast Cancer Unit, University Hospital 12 de Octubre, Madrid, Spain and HM Hospitales, Madrid, Spain
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27
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Valdés Olmos RA, Vidal-Sicart S. Nuclear medicine contribution to precision surgery in breast cancer. Rev Esp Med Nucl Imagen Mol 2023; 42:343-351. [PMID: 37422262 DOI: 10.1016/j.remnie.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
Nuclear medicine has significantly contributed to precision surgery in breast cancer in the past decades. Radioguided surgery (RGS) has enabled sentinel node (SN) biopsy in assessing regional nodal involvement modifying the management of patients with early breast cancer. For the axilla the SN procedure has resulted in fewer complications and better quality of life when compared with axillary lymph node dissection. Originally, SN biopsy principally concerned cT 1-2 tumours without evidence of axillary lymph node metastases. However, in last years SN biopsy is also being offered to patients with large or multifocal tumours, ductal carcinoma in situ, ipsilateral breast cancer relapse, and to patients receiving neoadjuvant systemic treatment (NST) for breast sparing surgery. Parallel to this evolution various scientific associations are trying to homogenise issues such as radiotracer choice, breast injection site, preoperative imaging standardisation and SN biopsy timing in relation to NST as well as management of non-axillary SN metastasis (e.g. internal mammary chain). Additionally, RGS is currently used to accomplish primary breast tumour excision either by intralesional radiocolloid injection or by radioactive iodine seed implantation which is also employed to target metastatic axillary lymph nodes. This latter procedure contributes to manage the node-positive axilla in combination with 18F-FDG PET/CT in an effort to tailor systemic and loco regional treatment.
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Affiliation(s)
- Renato A Valdés Olmos
- Department of Radiology, Section of Nuclear Medicine & Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Hospital Clinic Barcelona, Barcelona, Catalonia, Spain.
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28
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Liang Y, Jian Q, Deng MG, Yi Z, Peng C, Lu C, Yang H, Liu J. Lymph node ratio precisely predicts the benefit of postoperative radiotherapy in esophageal cancer: A retrospective cohort study. Asian J Surg 2023; 46:3680-3686. [PMID: 37059676 DOI: 10.1016/j.asjsur.2023.03.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/27/2023] [Accepted: 03/30/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND The matter of postoperative radiotherapy (PORT) in esophageal cancer (ESCA) was far from conclusive. Some evidence indicated that lymph node status could affect treatment. We evaluated lymph node ratio (LNR) as an indicator that could be applied to predict PORT benefit. METHODS Retrospective cohort study collected the data of N1, N2, N3 stage ESCA patients from the Surveillance, Epidemiology, and End Results database (SEER) to analyze the association between LNR and prognosis from 2004 to 2015. Patients were categorized into two subsets based on the LNR cut-off value of 0.23 using receiver operating characteristic curve (ROC). Kaplan-Meier analysis was utilized to estimate the proportion of overall survival (OS) and esophagus cancer-specific survival (CSS) in two LNR groups. Cox regression analysis and competitive risk model was adopted to investigate the impacts of LNR on prognosis. RESULTS Of 2,165 ESCA patients identified, 1,165 (53.8%) had LNR>0.23. The LNR was an independent prognostic factor and associated with better OS and CSS of LNR≤0.23 (P < 0.001). In competitive risk model, a worse CSS was analyzed of LNR>0.23 (HR = 1.71; 95% CI 1.53-1.91). Subgroup analyses indicated that PORT was associated with favorable OS and CSS. Furthermore, when stratified by Node stage, PORT was associated with a survival benefit only in N1 stage with higher LNR (LNR>0.23) after adjusting for other covariates. CONCLUSIONS LNR exceeding 0.23 was negatively associated with prognosis in ESCA. The survival benefit from PORT in ESCA seems to be limited to LNR of 23% or more only in N1 stage. This study highlights the biomarker meaning of LNR on identifying PORT beneficiary in N1 stage.
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Affiliation(s)
- Yuehui Liang
- Institute of Toxicology, College of Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing, 400038, China; School of Public Health, Wuhan University, Wuhan, 430064, China
| | - Qinghong Jian
- The Affiliated Stomatological Hospital of Southwest Medical University, Luzhou, 646000, China
| | - Ming-Gang Deng
- School of Public Health, Wuhan University, Wuhan, 430064, China
| | - Zongbi Yi
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumour Biological Behaviours, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Chan Peng
- College of Pharmaceutical Sciences, Southwest University, Chongqing, 400715, China
| | - Chunsheng Lu
- School of Public Health, Guizhou Medical University, Guiyang, 550025, China
| | - Huan Yang
- Institute of Toxicology, College of Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jinyi Liu
- Institute of Toxicology, College of Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
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Lu S, Yang J, Wei T, Li Q, Wu Y, Wang Z, Li H, Wang J, Wang X, Lv Q, Chen J. Single-incision endoscope-assisted breast-conserving surgery and sentinel lymph node biopsy: prospective SINA-BCS cohort study. Br J Surg 2023; 110:1076-1079. [PMID: 36945888 DOI: 10.1093/bjs/znad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 03/23/2023]
Affiliation(s)
- Shan Lu
- Breast Centre and National Clinical Research Centre for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
| | - Jiqiao Yang
- Breast Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Tao Wei
- Department of Thyroid Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Qintong Li
- Departments of Obstetrics and Gynaecology and Paediatrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, State Key Laboratory of Biotherapy and Collaborative Innovation Centre of Biotherapy, Sichuan University, Chengdu, China
| | - Yunhao Wu
- Breast Centre and National Clinical Research Centre for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
| | - Zhu Wang
- Laboratory of Molecular Diagnosis of Cancer, West China Hospital of Sichuan University, Chengdu, China
| | - Hongjiang Li
- Breast Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Jing Wang
- Breast Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaodong Wang
- Breast Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Qing Lv
- Breast Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Jie Chen
- Breast Centre and National Clinical Research Centre for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Med-X Centre for Manufacturing, West China Hospital, Sichuan University, Chengdu, China
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30
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Del Castillo A, Gomez-Modet S, Mata JM, Tejedor L. Targeted axillary dissection using Radioguided Occult Lesion Localization technique in the clinically negative marked lymph node after neoadjuvant treatment in breast cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1184-1188. [PMID: 36958951 DOI: 10.1016/j.ejso.2023.03.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/27/2022] [Accepted: 03/09/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE To be aware of the feasibility of targeted axillary dissection (TAD) injecting 99mTechnetium-labeled macroaggregated albumin (99mTc-MAA) preoperatively into the clipped lymph node of patients with axillary complete clinical response (ycN0), after neoadjuvant chemotherapy (NAC) for breast cancer. PATIENTS AND METHODS A retrospective observational study was performed on N1 patients with a clipped positive node and a clinically negative axilla (ycN0) after NAC in one center. The pretreatment positive lymph node was injected with 99mTc-MAA the day before surgery and identified intraoperatively with a radioguided occult lesion localization (ROLL) technique. Patients were subjected to a TAD with the intent of identifying the clipped node and other/s sentinel nodes through a standard sentinel lymph node biopsy (SLNB). RESULTS 54 patients and 55 axillary clipped nodes were included. The clip was intraoperatively encountered in every patient, accomplishing a 100% detection rate, although in one case no lymphatic tissue could be found in the intraoperative frozen section. An axillary lymph node dissection (ALND) was avoided in 62.9% of the cases (34/54). CONCLUSION The use of the ROLL technique is a highly valuable tool since it allows a 100% success rate in retrieving the marker (and a 98.1% rate in detecting the clipped lymph node) in ycN0 breast cancer patients.
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Affiliation(s)
- Ana Del Castillo
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - Susana Gomez-Modet
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - José María Mata
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
| | - Luis Tejedor
- General Surgery Service, Hospital Universitario Punta de Europa, Algeciras, 11207, Spain.
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31
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Munck F, Andersen IS, Vejborg I, Gerlach MK, Lanng C, Kroman NT, Tvedskov THF. Targeted Axillary Dissection with 125I Seed Placement Before Neoadjuvant Chemotherapy in a Danish Multicenter Cohort. Ann Surg Oncol 2023; 30:4135-4142. [PMID: 37062781 PMCID: PMC10250439 DOI: 10.1245/s10434-023-13432-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/13/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Targeted axillary dissection (TAD), with marking of the metastatic lymph node before neoadjuvant chemotherapy (NACT), is increasingly used for breast cancer axillary staging. In the case of axillary pathological complete response (ax-pCR), axillary lymph node clearance can be omitted. Several marking methods exist, most using re-marking before surgery. Feasibility, learning curve, and identification rate (IR) vary. Marking with 125I seed before NACT makes re-marking at surgery redundant, possibly increasing feasibility and IR. Here, TAD with 125I seed placed before NACT is evaluated in a Danish multicenter cohort. METHODS Patients staged with 125I TAD in Denmark between 1 January 2016 and 31 August 2021 were included. Patients were identified in radioactivity-emitting implant registries at the radiology departments and from the Danish Breast Cancer Group database. Data were extracted from patients' medical records. Information on patient/tumor characteristics, 125I seed activity, marking period, TAD success, number of sentinel nodes (SNs), the histopathological status of excised nodes, and whether the marked lymph node (MLN) was an SN were registered. RESULTS 142 patients were included. The IR of the MLN was 99.3%, and the IR of the SLNB was 91.5%. TAD success was 91.5%. Minor challenges in marking or removal of the MLN were noted in three patients. In 72.3% of the patients, the MLN was a sentinel node. Overall, 40.8% had axillary pCR. CONCLUSION TAD with 125I seed marking before NACT is feasible without re-marking at surgery and with only minor surgical challenges. The IR is high. Staging with TAD spares 41% of breast cancer patients an axillary dissection.
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Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark.
| | - Inge S Andersen
- Department of Breast Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Niels T Kroman
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
| | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Gentofte, Denmark
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32
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Banys-Paluchowski M, de Boniface J. Axillary staging in node-positive breast cancer converting to node negativity through neoadjuvant chemotherapy: Current evidence and perspectives. Scand J Surg 2023; 112:117-125. [PMID: 36642957 DOI: 10.1177/14574969221145892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Over the recent years, axillary staging of initially node-positive breast cancer patients converting to clinical node negativity after neoadjuvant chemotherapy has seen rapid changes. This narrative review aims to give a contemporary overview over published evidence and clinical practice, and thus provide some guidance to the surgical community in the process of re-evaluating and re-shaping surgical practice. METHODS The search strategy aimed at finding relevant studies. Only articles in English were considered. RESULTS The introduction of modern techniques offer more precise staging surgery and thus hopefully reduced arm morbidity. Clinical practice has however diverged both within countries and internationally. While some countries have adapted de-escalated axillary staging techniques such as targeted axillary dissection, targeted lymph node biopsy or sentinel lymph node biopsy, others continue to recommend a full axillary lymph node dissection. With the implementation of new techniques, many questions arise, regarding aspects of oncological safety, technical performance, budget and practicality, patient selection and indications for different levels of axillary staging procedures. CONCLUSIONS There is a growing body of evidence on de-escalation of axillary surgery in the setting of cN+ → ycN0 breast cancer treated with neoadjuvant chemotherapy. However, standards differ between countries and future studies are necessary to fully assess the optimal strategy for these patients.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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Chen JH, Canner JK, Myers K, Camp M. Concomitant Use of Biopsy Clips and Wire Localization in Invasive Breast Cancer is Associated With Successful Clip Retrieval. Clin Breast Cancer 2023; 23:e163-e172. [PMID: 36646538 DOI: 10.1016/j.clbc.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/11/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Surgical management of the axilla in patients with clinically node-positive breast cancer has shifted to less invasive surgical approaches, such as sentinel lymph node dissection (SLND) and targeted axillary dissection (TAD). Successful retrieval of the biopsy clip marking the lymph node of interest is crucial for assessment of pathologic response and locoregional disease control. METHODS We performed a retrospective review of patients ≥18 years old with invasive breast cancer and biopsy-proven axillary LN involvement, who underwent LN clip placement from January 2012 to July 2017 at Johns Hopkins Hospital. RESULTS Of the 128 eligible patients, the median age at diagnosis was 51.5 years (range, 23-92 years) with predominately stage T2-3 disease (54.7% T2, 42.2% T3), of ductal histology (76.6%), and located in the upper outer quadrant (42.2%). Among the 63.3% (81) of patients who received neoadjuvant systemic therapy, 43.2% (35) had a partial response and 30.9% (25) had a complete response. Axillary procedures performed consisted of 36.7% (47) SLND/TAD, 53.9% (69) ALND, and 9.4% (12) SLND/TAD with conversion to ALND. The clipped LN was successfully retrieved in 63.8% (30) of SLND/TADs, 39.1% (27) of ALNDs, and 58.3% (7) of SLND/TADs followed by ALND. Pre-operative node localization by wire and/or skin markings was performed for 16.4% (21) of patients. Among these, 90.5% (19) of clipped LNs were successfully retrieved, compared to 42.1% (45) retrieved in axillary procedures without preoperative node localization. CONCLUSION Use of preoperative targeted node localization improved rate of clipped LN retrieval across all three types of axillary procedures.
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Affiliation(s)
- Jennifer H Chen
- School of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Joe K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Kelly Myers
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Melissa Camp
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD.
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Tinterri C, Sagona A, Barbieri E, Di Maria Grimaldi S, Caraceni G, Ambrogi G, Jacobs F, Biondi E, Scardina L, Gentile D. Sentinel Lymph Node Biopsy in Breast Cancer Patients Undergoing Neo-Adjuvant Chemotherapy: Clinical Experience with Node-Negative and Node-Positive Disease Prior to Systemic Therapy. Cancers (Basel) 2023; 15:cancers15061719. [PMID: 36980605 PMCID: PMC10046076 DOI: 10.3390/cancers15061719] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/04/2023] [Accepted: 03/09/2023] [Indexed: 03/16/2023] Open
Abstract
Background: Sentinel lymph node biopsy (SLNB) has emerged as the standard procedure to replace axillary lymph node dissection (ALND) in breast cancer (BC) patients undergoing neo-adjuvant chemotherapy (NAC). SLNB is accepted in clinically node-negative (cN0) patients; however, its role in clinically node-positive (cN+) patients is debatable. Methods: We performed a retrospective analysis of BC patients undergoing NAC and SLNB. Our aim was to evaluate the clinical significance of SLNB in the setting of NAC. This was accomplished by comparing the characteristics and oncological outcomes between cN0 and cN+ patients prior to NAC and type of axillary surgery. Results: A total of 291 patients were included in the analysis: 131 were cN0 and 160 were cN+ who became ycN0 after NAC. At a median follow-up of 43 months, axillary recurrence occurred in three cN0 (2.3%) and two cN+ (1.3%) patients. However, there were no statistically significant differences in oncological outcomes (disease-free survival, distant disease-free survival, overall survival, and breast-cancer-specific survival) between cN0 and cN+ patients nor between patients treated with SLNB only or ALND. Conclusions: SLNB in the setting of NAC is an acceptable procedure with a general good prognosis and low axillary failure rates for both cN0 and cN+ patients.
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Affiliation(s)
- Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
| | - Andrea Sagona
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Erika Barbieri
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | | | - Giulia Caraceni
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Giacomo Ambrogi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
| | - Flavia Jacobs
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Ersilia Biondi
- Division of Breast Surgery, Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, 00168 Rome, Italy
| | - Lorenzo Scardina
- Division of Breast Surgery, Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, 00168 Rome, Italy
| | - Damiano Gentile
- Breast Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Correspondence: ; Tel.: +39-0282243060
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Editorial Comment: Practical Tips for Selecting, and Enhancing Detection of, Breast Biopsy Markers. AJR Am J Roentgenol 2023; 220:370. [PMID: 36069491 DOI: 10.2214/ajr.22.28476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Keelan S, Boland MR, Ryan ÉJ, Moran LR, Davey MG, Lloyd AJ, Elwahab S, Hill ADK. Long-term survival in patients with node-positive breast cancer who undergo sentinel lymph node biopsy alone after neoadjuvant chemotherapy: meta-analysis. Br J Surg 2023; 110:324-332. [PMID: 36512473 DOI: 10.1093/bjs/znac413] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 08/16/2022] [Accepted: 11/02/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NACT) in patients with breast cancer who are initially node-positive but convert to clinically/radiologically node-negative remains controversial. The primary aim was to assess pooled 5-year disease-free (DFS) and overall (OS) survival for patients who are initially node-positive but have a negative SLNB after NACT, and do not proceed to axillary lymph node dissection (ALND). METHODS The study was performed using PRISMA guidelines. A systematic literature search of relevant databases was conducted. The Der Simonian-Laird and Cochran-Mantel-Haenszel methods were used to calculate weighted pooled estimates for OS and DFS for this group compared with patients who had NACT and proceeded to ALND after a negative or positive SLNB. RESULTS Seven studies involving 915 patients who had a negative SLNB after NACT were included. Pooled estimates of 5-year DFS and OS in patients with a negative SLNB after NACT were 86 (95 per cent c.i. 82.1 to 90.3) and 93.1 (87.8 to 97.0) per cent respectively. Patients with a positive SLNB who underwent ALND had reduced 5-year DFS (OR 0.49, 95 per cent c.i. 0.35 to 0.69; P < 0.001) and OS (OR 0.41, 0.16 to 1.02; P = 0.06) compared with those who had a negative SLNB after NACT. There were no differences in DFS for patients who had a negative SLNB only compared with those undergoing ALND with a pCR (OR 1.65, 0.71 to 3.79; P = 0.24). CONCLUSION Patients who are initially node-positive and who achieve a complete clinical/radiological axillary response after NACT with a subsequent negative SLNB have high rates of DFS and OS after 5 years. Patients with residual disease have significantly reduced DFS and further axillary treatment may still be warranted.
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Affiliation(s)
- Stephen Keelan
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Éanna J Ryan
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Laura R Moran
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Angus J Lloyd
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Sami Elwahab
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
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Montagna G. Estimating the Benefit of Preoperative Systemic Therapy to Reduce the Extent of Breast Cancer Surgery: Current Standard and Future Directions. Cancer Treat Res 2023; 188:149-174. [PMID: 38175345 DOI: 10.1007/978-3-031-33602-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Once reserved for locally advanced tumors which were deemed inoperable at presentation, preoperative systemic therapy (PST) is nowadays increasingly used to treat early breast cancer. PST allows for in vivo assessment of tumor response, for tailoring of adjuvant systemic therapy and for de-escalation of breast and the axillary surgery. Increased rates of pathological complete response together with more accurate response assessment and surgical planning have led to a significant reduction in surgical morbidity. While surgical assessment remains the standard of care, ongoing studies are evaluating whether surgery can be omitted in patients who achieve a complete pathological response. In this chapter, I will review the impact of PST on surgical de-escalation and the data supporting the safety of this approach.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66Th Street, New York, NY, 10065, USA.
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Luo Y, Jiang H, Liu C, Zhang C. Axillary Downstaging and the Impact of Clinical Axillary Status on Efficacy of Neoadjuvant Therapy for HER2-Positive Breast Cancer: A Network Meta-Analysis. Technol Cancer Res Treat 2023; 22:15330338221150325. [PMID: 36660776 PMCID: PMC9893393 DOI: 10.1177/15330338221150325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: Lymph node downstaging and the achievement of total-pCR (ypT0/is ypN0) after neoadjuvant therapy are of great importance in HER-2 positive breast cancer. We aim to provide an overall review of neoadjuvant regimens for lymph node downstaging and to indirectly compare the total-pCR by various neoadjuvant regimens with network meta-analysis in HER2-positive patients according to their clinical lymph node status. Methods: Five English databases were searched comprehensively and systematically for relevant RCTs and case-control studies. The data extracted from the included studies were analyzed with the use of Review Manager 5.3 or STATA 15.0 software. Results: A total of 1508 published manuscripts were identified, and 17 studies including 4747 patients were finally included in our analysis. The network meta-analysis of total-pCR showed that dual-target therapy is significantly better than single-target therapy in clinically node-positive patients, and carboplatin performed significantly better than anthracycline in single-target condition. Lapatinib performed poorly in clinically node-positive patients. However, lapatinib in combination with trastuzumab was ranked at the top in the clinically node-negative group, and pertuzumab showed dissatisfied performance in contrast to the primacy of pertuzumab in clinically node-positive groups. Conclusion: In summary, different lymph node statuses led to the diverse first choice of neoadjuvant regimen. We highly recommended TCbHP as the first choice for the neoadjuvant treatment in clinically node-positive HER-2 positive breast cancer. Since lapatinib with trastuzumab ranked top in the clinically node-negative group, we looked forward to discovering the potential value of TKI in clinically node-negative patients, which needs further analysis in the future.
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Affiliation(s)
- Yunzhao Luo
- Beijing Chaoyang Hospital of Capital Medical University, Beijing, China
| | - Hongchuan Jiang
- Beijing Chaoyang Hospital of Capital Medical University, Beijing, China
| | | | - Chao Zhang
- Beijing Chaoyang Hospital of Capital Medical University, Beijing, China
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Galimberti V, Ribeiro Fontana SK, Vicini E, Morigi C, Sargenti M, Corso G, Magnoni F, Intra M, Veronesi P. "This house believes that: Sentinel node biopsy alone is better than TAD after NACT for cN+ patients". Breast 2022; 67:21-25. [PMID: 36566690 PMCID: PMC9803818 DOI: 10.1016/j.breast.2022.12.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
The increased use of neoadjuvant chemotherapy (NACT) has changed the approach to breast surgery. NACT allows de-escalation of surgery by both increasing breast conservation rates (up to 40%), the initial goal of this chemotherapy, and in particular it permits reduces axillary surgery. Furthermore, in relation to the molecular characteristics of the tumor we can have a pathological complete response (pCR) ranging from 20 to 80%. In clinically node positive (cN+) patients who converted to clinically node-negative (cN0) various prospective studies have demonstrated that the false negative rate (FNR) of the sentinel node biopsy (SNB) were higher than the acceptable 10% and strategies to reduce the FNR in cN + patients are being investigated. But all the effort to reduce the FNR does not have clinical prognostic significance. This has already been demonstrated in the literature in different randomized trials with long term follow up. The 10-year follow-up of our study confirmed our preliminary data that the use of standard SNB without the use of clip is acceptable in cN1/2 patients who become cN0 after NAT and will not translate into a worse outcome. In fact, the axillary recurrences were less than 2%. Similar positive data with different follow up were also confirmed by other studies that used SNB alone without TAD. All these studies, with encouraging results on the follow up, confirm that SN surgery alone for selected patients who have an excellent response to NACT is rationale and not oncologically inferior to AD during a short- and long-term follow-up.
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Affiliation(s)
- Viviana Galimberti
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy.
| | | | - Elisa Vicini
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Consuelo Morigi
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Manuela Sargenti
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Giovanni Corso
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy,University of Milan School of Medicine, Milan, Italy
| | - Francesca Magnoni
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy,University of Milan School of Medicine, Milan, Italy
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Wu SY, Li JW, Wu HL, Shao ZM, Liu GY, Hu N. Accuracy of ultrasound-guided targeted fine-needle aspiration in assessing nodal response in node-positive breast cancer after neoadjuvant chemotherapy: prospective feasibility study. Br J Surg 2022; 109:1194-1197. [PMID: 36018290 DOI: 10.1093/bjs/znac277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/19/2022] [Accepted: 07/16/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Si-Yu Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian-Wei Li
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huai-Liang Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhi-Ming Shao
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Guang-Yu Liu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Na Hu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Ultrasound, Fudan University Shanghai Cancer Centre, Shanghai, China
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Simons JM, van Nijnatten TJA, van der Pol CC, van Diest PJ, Jager A, van Klaveren D, Kam BLR, Lobbes MBI, de Boer M, Verhoef C, Sars PRA, Heijmans HJ, van Haaren ERM, Vles WJ, Contant CME, Menke-Pluijmers MBE, Smit LHM, Kelder W, Boskamp M, Koppert LB, Luiten EJT, Smidt ML. Diagnostic Accuracy of Radioactive Iodine Seed Placement in the Axilla With Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer. JAMA Surg 2022; 157:991-999. [PMID: 36069889 PMCID: PMC9453629 DOI: 10.1001/jamasurg.2022.3907] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/18/2022] [Indexed: 12/14/2022]
Abstract
Importance Several less-invasive staging procedures have been proposed to replace axillary lymph node dissection (ALND) after neoadjuvant chemotherapy (NAC) in patients with initially clinically node-positive (cN+) breast cancer, but these procedures may fail to detect residual disease. Owing to the lack of high-level evidence, it is not yet clear which procedure is most optimal to replace ALND. Objective To determine the diagnostic accuracy of radioactive iodine seed placement in the axilla with sentinel lymph node biopsy (RISAS), a targeted axillary dissection procedure. Design, Setting, and Participants This was a prospective, multicenter, noninferiority, diagnostic accuracy trial conducted from March 1, 2017, to December 31, 2019. Patients were included within 14 institutions (general, teaching, and academic) throughout the Netherlands. Patients with breast cancer clinical tumor categories 1 through 4 (cT1-4; tumor diameter <2 cm and up to >5 cm or extension to the chest wall or skin) and pathologically proven positive axillary lymph nodes (ie, clinical node categories cN1, metastases to movable ipsilateral level I and/or level II axillary nodes; cN2, metastases to fixed or matted ipsilateral level I and/or level II axillary nodes; cN3b, metastases to ipsilateral level I and/or level II axillary nodes with metastases to internal mammary nodes) who were treated with NAC were eligible for inclusion. Data were analyzed from July 2020 to December 2021. Intervention Pre-NAC, the marking of a pathologically confirmed positive axillary lymph node with radioactive iodine seed (MARI) procedure, was performed and after NAC, sentinel lymph node biopsy (SLNB) combined with excision of the marked lymph node (ie, RISAS procedure) was performed, followed by ALND. Main Outcomes and Measures The identification rate, false-negative rate (FNR), and negative predictive value (NPV) were calculated for all 3 procedures: RISAS, SLNB, and MARI. The noninferiority margin of the observed FNR was 6.25% for the RISAS procedure. Results A total of 212 patients (median [range] age, 52 [22-77] years) who had cN+ breast cancer underwent the RISAS procedure and ALND. The identification rate of the RISAS procedure was 98.2% (223 of 227). The identification rates of SLNB and MARI were 86.4% (197 of 228) and 94.1% (224 of 238), respectively. FNR of the RISAS procedure was 3.5% (5 of 144; 90% CI, 1.38-7.16), and NPV was 92.8% (64 of 69; 90% CI, 85.37-97.10), compared with an FNR of 17.9% (22 of 123; 90% CI, 12.4%-24.5%) and NPV of 72.8% (59 of 81; 90% CI, 63.5%-80.8%) for SLNB and an FNR of 7.0% (10 of 143; 90% CI, 3.8%-11.6%) and NPV of 86.3% (63 of 73; 90% CI, 77.9%-92.4%) for the MARI procedure. In a subgroup of 174 patients in whom SLNB and the MARI procedure were successful and ALND was performed, FNR of the RISAS procedure was 2.5% (3 of 118; 90% CI, 0.7%-6.4%), compared with 18.6% (22 of 118; 90% CI, 13.0%-25.5%) for SLNB (P < .001) and 6.8% (8 of 118; 90% CI, 3.4%-11.9%) for the MARI procedure (P = .03). Conclusions and Relevance Results of this diagnostic study suggest that the RISAS procedure was the most feasible and accurate less-invasive procedure for axillary staging after NAC in patients with cN+ breast cancer.
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Affiliation(s)
- Janine M. Simons
- Department of Radiotherapy, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
- Department of Surgical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
- Department of Surgical Oncology, Cancer Center, University Medical Center Utrecht, Utrecht, the Netherlands
- GROW—School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Thiemo J. A. van Nijnatten
- GROW—School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, the Netherlands
| | - Carmen C. van der Pol
- Department of Surgical Oncology, Cancer Center, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgical Oncology, Alrijne Hospital, Leiderdorp, the Netherlands
| | - Paul J. van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Boen L. R. Kam
- Department of Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Nuclear Medicine, Diakonessenhuis, Utrecht, the Netherlands
| | - Marc B. I. Lobbes
- GROW—School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, the Netherlands
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - Maaike de Boer
- GROW-School for Oncology and Reproduction, Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Cees Verhoef
- Department of Surgical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Paul R. A. Sars
- Department of Surgical Oncology, Bravis Hospital, Roosendaal, the Netherlands
| | - Harald J. Heijmans
- Department of Surgical Oncology, Hospital Group Twente, Breast Clinic Oost-Nederland, Hengelo, the Netherlands
| | - Els R. M. van Haaren
- Department of Surgical Oncology, Zuyderland Medical Center, Sittard, the Netherlands
| | - Wouter J. Vles
- Department of Surgical Oncology, Ikazia Hospital, Rotterdam, the Netherlands
| | | | | | - Léonie H. M. Smit
- Department of Surgical Oncology, Treant Zorggroep Hospital, Hoogeveen, the Netherlands
| | - Wendy Kelder
- Department of Surgical Oncology, Martini Hospital, Groningen, the Netherlands
| | - Marike Boskamp
- Department of Surgical Oncology, Wilhelmina Hospital, Assen, the Netherlands
| | - Linetta B. Koppert
- Department of Surgical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Ernest J. T. Luiten
- Department of Surgical Oncology, Amphia Hospital, Breda, the Netherlands
- Tawam Breast Care Center, Tawam Hospital, Al Ain, Abu Dhabi Emirate, United Arab Emirates
- Department of Surgery College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi Emirate, United Arab Emirates
| | - Marjolein L. Smidt
- GROW—School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
- Deparment of Surgical Oncology, Maastricht University Medical Center+, Maastricht, the Netherlands
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Huang X, Shi Z, Mai J, Liu C, Liu C, Chen S, Lu H, Li Y, He B, Li J, Cun H, Han C, Chen X, Liang C, Liu Z. An MRI-based Scoring System for Preoperative Prediction of Axillary Response to Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: A Multicenter Retrospective Study. Acad Radiol 2022:S1076-6332(22)00513-X. [DOI: 10.1016/j.acra.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/17/2022] [Accepted: 09/26/2022] [Indexed: 11/29/2022]
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Hartmann S, Kühn T, Hauptmann M, Stickeler E, Thill M, Lux MP, Fröhlich S, Ruf F, Loibl S, Blohmer JU, Kolberg HC, Thiemann E, Weigel M, Solbach C, Kaltenecker G, Paluchowski P, Schrauder MG, Paepke S, Watermann D, Hahn M, Hufnagel M, Lefarth J, Untch M, Banys-Paluchowski M. Axillary Staging after Neoadjuvant Chemotherapy for Initially Node-Positive Breast Carcinoma in Germany: Initial Data from the AXSANA study. Geburtshilfe Frauenheilkd 2022; 82:932-940. [PMID: 36110892 PMCID: PMC9470287 DOI: 10.1055/a-1889-7883] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 06/30/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction To date, the optimal axillary staging procedure for initially node-positive breast carcinoma patients after neoadjuvant chemotherapy (NACT) has been unclear. The aim of the AXSANA study is to prospectively compare different surgical staging techniques with respect to the oncological outcome and quality of life for the patients. Little is known about current clinical practice in Germany. Material and Methods In this paper we analyzed data from patients enrolled in the AXSANA study at German study sites from June 2020 to March 2022. Results During the period under investigation, 1135 patients were recruited at 143 study sites. More than three suspicious lymph nodes were initially found in 22% of patients. The target lymph node (TLN) was marked in 64% of cases. This was done with clips/coils in 83% of patients, with magnetic seeds or carbon suspension in 8% each, and with a radar marker in 1% of patients. After NACT, targeted axillary dissection (TAD) or axillary lymphadenectomy (ALND) were each planned in 48% of patients, and sentinel lymph node biopsy alone (SLNB) in 2%. Clinically, the nodal status after NACT was found to be unremarkable in 65% of cases. Histological lymph node status was correctly assessed by palpation in 65% of patients and by sonography in 69% of patients. Conclusion At the German AXSANA study sites, TAD and ALND are currently used as the most common surgical staging procedures after NACT in initially node-positive breast cancer patients. The TLN is marked with various markers prior to NACT. Given the inadequate accuracy of clinical assessment of axillary lymph node status after NACT, it should be questioned whether axillary dissection after NACT should be performed based on clinical assessment of nodal status alone.
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Affiliation(s)
- Steffi Hartmann
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Rostock, Rostock, Germany
| | - Thorsten Kühn
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Esslingen, Esslingen, Germany,Correspondence/Korrespondenzadresse Prof. Dr. med. Thorsten Kühn Klinik für Frauenheilkunde und GeburtshilfeKlinikum
EsslingenHirschlandstraße 9773730 Esslingen
a. N.Germany
| | - Michael Hauptmann
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Universitätsklinikum Aachen, Aachen, Germany
| | - Marc Thill
- Klinik für Gynäkologie und Gynäkologische Onkologie, AGAPLESION MARKUS KRANKENHAUS, Frankfurt am Main, Germany
| | - Michael P. Lux
- Klinik für Gynäkologie und Geburtshilfe, Frauenklinik St. Louise, Paderborn, St. Josefs-Krankenhaus, Salzkotten, St. Vincenz Krankenhaus GmbH, Paderborn, Germany
| | - Sarah Fröhlich
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Rostock, Rostock, Germany
| | - Franziska Ruf
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Sibylle Loibl
- German Breast Group Forschungs GmbH, Neu-Isenburg, Germany,Centrum für Hämatologie und Onkologie Bethanien, Frankfurt am Main, Germany
| | - Jens-Uwe Blohmer
- Gynäkologie mit Brustzentrum, Charité – Universitätsmedizin, Berlin, Germany
| | | | | | - Michael Weigel
- Brustzentrum Schweinfurt-Mainfranken, Leopoldina-Krankenhaus, Schweinfurt, Germany
| | - Christine Solbach
- Klinik für Gynäkologie und Geburtshilfe, Universität Frankfurt, Brustzentrum, Frankfurt am Main, Germany
| | | | | | | | - Stefan Paepke
- Klinikum rechts der Isar, interdisziplinäres Brustzentrum, Technische Universität München, München, Germany
| | - Dirk Watermann
- Evangelisches Diakoniekrankenhaus, Brustzentrum Südbaden, Freiburg im Breisgau, Germany
| | - Markus Hahn
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Tübingen, Tübingen, Germany
| | | | - Jutta Lefarth
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Memmingen, Memmingen, Germany
| | - Michael Untch
- Klinik für Gynäkologie und Geburtshilfe, interdisziplinäres Brustzentrum, HELIOS Klinikum Berlin Buch, Berlin, Germany
| | - Maggie Banys-Paluchowski
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany,Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
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Fan B, James T. Avoiding Axillary Management Pitfalls After Neoadjuvant Chemotherapy. Ann Surg Oncol 2022; 29:7265-7266. [PMID: 35972664 DOI: 10.1245/s10434-022-12147-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 06/25/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Betty Fan
- Department of Surgery, Division of Surgical Oncology, Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ted James
- Department of Surgery, Breast Care Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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45
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Tasoulis MK, Heil J, Kuerer HM. De-escalating Surgery Among Patients with HER2 + and Triple Negative Breast Cancer. CURRENT BREAST CANCER REPORTS 2022; 14:135-141. [PMID: 35915668 PMCID: PMC9328618 DOI: 10.1007/s12609-022-00453-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2022] [Indexed: 01/09/2023]
Abstract
Purpose of Review De-escalation of surgery has been central in the evolution of multidisciplinary management of breast cancer. Advances in oncology and increasing use of neoadjuvant chemotherapy (NACT) have opened opportunities for further surgical de-escalation especially for HER2 + and triple negative (TN) disease. The aim of this review is to discuss the recent data on de-escalation of surgery as well as the future directions. Recent Findings Patients with TN and HER2 + breast cancer with excellent response to NACT would be the ideal candidates for surgical de-escalation. Post-NACT image-guided biopsy, potentially combined with machine learning algorithms, may accurately identify patients achieving pathologic complete response that would be eligible for clinical trials assessing safety of omission of breast and axillary surgery. Summary Multidisciplinary research is required to further support results of preliminary studies. Current data point towards a future when even less or no surgery may be required for exceptional responders.
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Affiliation(s)
- Marios-Konstantinos Tasoulis
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- Division of Breast Cancer Research, The Institute of Cancer Research, Old Brompton Road, London, SW7 3RP UK
| | - Joerg Heil
- Department of Obstetrics and Gynecology, University Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Henry M. Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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46
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Gasparri ML, de Boniface J, Poortmans P, Gentilini OD, Kaidar-Person O, Banys-Paluchowski M, Di Micco R, Niinikoski L, Murawa D, Bonci EA, Pasca A, Rubio IT, Karadeniz Cakmak G, Kontos M, Kühn T. Axillary surgery after neoadjuvant therapy in initially node-positive breast cancer: international EUBREAST survey. Br J Surg 2022; 109:857-863. [PMID: 35766257 DOI: 10.1093/bjs/znac217] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/17/2022] [Accepted: 05/28/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND There is no consensus on axillary management after neoadjuvant therapy (NAT) in patients with clinically node-positive (cN+) breast cancer. To investigate current clinical practice, an international survey was conducted among breast surgeons and radiation oncologists. The aim of the first part of the survey was to provide a snapshot of international discrepancies regarding axillary surgery in this context. METHODS The European Breast Cancer Research Association of Surgical Trialists (EUBREAST) developed a web-based survey containing 39 questions describing clinical scenarios in the setting of axillary management in patients with cN1 disease converting to ycN0 after NAT. The survey was then distributed to breast surgeons and radiation oncologists via 14 breast cancer societies between April and October 2021. RESULTS Responses from 349 physicians in 45 countries were recorded. The most common post-NAT axillary surgery in patients with cN1 disease converting to ycN0 was targeted axillary dissection (54.2 per cent), followed by sentinel lymph node biopsy (SLNB) alone (20.9 per cent), level 1-2 axillary lymph node dissection (ALND) (18.4 per cent), level 1-3 ALND (4 per cent), and targeted lymph node biopsy (2.5 per cent). For SLNB alone, dual tracers were most commonly used (62.3 per cent). Management varied widely in patients with ambiguous axillary status before initiation of treatment or a residual metastatic burden in the axilla after NAT. In patients with ycN+ tumours, ALND was the preferred surgical approach for 66.8 per cent of respondents. CONCLUSION These results highlight the wide heterogeneity in surgical approaches to the axilla after NAT. To standardize the guidelines, further data from clinical research are urgently needed, which underlines the importance of the ongoing AXSANA (EUBREAST-3) study.
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Affiliation(s)
- Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, Lugano, CH.,Faculty of Biomedicine, University of the Italian Switzerland (USI), Lugano, Switzerland
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | | | - Orit Kaidar-Person
- Breast Radiation Unit, Oncology Institute, Sheba Hospital Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,GROW-School for Oncology and Developmental Biology or GROW (Maastro), Maastricht University, Maastricht, The Netherlands
| | - Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany.,Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Rosa Di Micco
- Breast Surgery Unit, San Raffaele University Hospital, Milan, Italy
| | - Laura Niinikoski
- Breast Surgery Unit, Comprehensive Cancer Center, Helsinki University Hospital, University of Helsinki, Finland
| | - David Murawa
- Department of General Surgery and Surgical Oncology, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland
| | - Eduard Alexandru Bonci
- Department of Surgical Oncology, "Prof. Dr. Ion Chiricuță" Institute of Oncology, Cluj-Napoca, Romania.,Department of Oncological Surgery and Gynecological Oncology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andrei Pasca
- Department of Surgical Oncology, "Prof. Dr. Ion Chiricuță" Institute of Oncology, Cluj-Napoca, Romania.,Department of Oncological Surgery and Gynecological Oncology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Isabel T Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain
| | - Guldeniz Karadeniz Cakmak
- Zonguldak BEUN The School of Medicine, General Surgery Department, Breast and Endocrine Unit, Kozlu/Zonguldak, Turkey
| | - Michalis Kontos
- 1st Department of Surgery, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Kühn
- Interdisciplinary Breast Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
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47
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Porpiglia M, Borella F, Chieppa P, Brino C, Ala A, Marra V, Castellano I, Benedetto C. Carbon tattooing of axillary lymph nodes in breast cancer patients before neoadjuvant chemotherapy: A retrospective analysis. TUMORI JOURNAL 2022:3008916221107712. [PMID: 35751383 DOI: 10.1177/03008916221107712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study aimed to investigate the feasibility and accuracy of tattooing suspicious axillary lymph nodes with carbon suspension at the time of breast cancer (BC) diagnosis and the intraoperative correspondence between tattooed lymph node (TLN) and sentinel lymph node (SLN) in patients who underwent neoadjuvant chemotherapy (NACT). METHODS In this retrospective study, we analyzed consecutive BC patients who underwent NACT, between April 2019 and May 2021, at the Breast Unit of Sant'Anna Hospital in Turin, Italy. Before NACT, all suspicious biopsied lymph nodes were marked with carbon suspension. All SLNs, TLNs, and axillary nodal dissection specimens were sent for histopathological examination. RESULTS The study group included a total of 49 patients with BC. The overall identification rate of TLNs was 83.7% (41/49; 95%, confidence interval - CI 0.70-0.92). In patients who underwent target axillary dissection (TAD) the carbon tattooing had an intraoperative identification rate of 84.4% (27/32; 95% CI 0.67-0.95) while, in the case of axillary lymph node dissection, TLNs were detected in 82.3% (14/17; 95% CI 0.56-0.96) of patients. The correlation between TLN and SLN was 71.8% (23/32). CONCLUSIONS These results confirmed that tattooing axillary lymph nodes has an acceptable identification rate. We also confirmed that this procedure, in addition to SLN biopsy, improves the accuracy of surgical axillary staging.
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Affiliation(s)
- Mauro Porpiglia
- Department of Surgical Sciences, Gynecology and Obstetrics 1, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy.,Breast Unit, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy
| | - Fulvio Borella
- Department of Surgical Sciences, Gynecology and Obstetrics 1, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy.,Breast Unit, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy
| | - Pierluigi Chieppa
- Department of Surgical Sciences, Gynecology and Obstetrics 1, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy
| | - Carola Brino
- Department of Surgical Sciences, Gynecology and Obstetrics 1, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy
| | - Ada Ala
- Department of Surgery, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy
| | - Vincenzo Marra
- Department of Radiology, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy
| | - Isabella Castellano
- Department of Medical Sciences, Pathology Unit, University of Turin, A.O.U. City of Health and Science of Turin, Turin, Italy
| | - Chiara Benedetto
- Department of Surgical Sciences, Gynecology and Obstetrics 1, A.O.U. City of Health and Science of Turin, S. Anna Hospital, Turin, Italy
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48
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Mátrai Z, Kelemen P, Kósa C, Maráz R, Paszt A, Pavlovics G, Sávolt Á, Simonka Z, Tóth D, Kásler M, Kaprin A, Krivorotko P, Vicko F, Pluta P, Kolacinska-Wow A, Murawa D, Jankau J, Ciesla S, Dyttert D, Sabol M, Zhygulin A, Avetisyan A, Bessonov A, Lázár G. Modern Breast Cancer Surgery 1st Central-Eastern European Professional Consensus Statement on Breast Cancer. Pathol Oncol Res 2022; 28:1610377. [PMID: 35783360 PMCID: PMC9240205 DOI: 10.3389/pore.2022.1610377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/29/2022] [Indexed: 12/16/2022]
Abstract
This text is based on the recommendations accepted by the 4th Hungarian Consensus Conference on Breast Cancer, modified on the basis of the international consultation and conference within the frames of the Central-Eastern European Academy of Oncology. The recommendations cover non-operative, intraoperative and postoperative diagnostics, determination of prognostic and predictive markers and the content of cytology and histology reports. Furthermore, they address some specific issues such as the current status of multigene molecular markers, the role of pathologists in clinical trials and prerequisites for their involvement, and some remarks about the future.
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Affiliation(s)
- Zoltán Mátrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Péter Kelemen
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Csaba Kósa
- Department of Surgery, University of Debrecen, Debrecen, Hungary
| | - Róbert Maráz
- Bács-Kiskun County Teaching Hospital, Kecskemét, Hungary
| | - Attila Paszt
- Department of Surgery, Faculty of Medicine, SZTE ÁOK, University of Szeged, Szeged, Hungary
| | | | - Ákos Sávolt
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Zsolt Simonka
- Department of Surgery, Faculty of Medicine, SZTE ÁOK, University of Szeged, Szeged, Hungary
| | - Dezső Tóth
- Department of Surgery, University of Debrecen, Debrecen, Hungary
| | - Miklós Kásler
- Minister of Human Capacities, Government of Hungary, Budapest, Hungary
| | - Andrey Kaprin
- National Medical Research Radiological Center of the Ministry of Health of the Russian Federation, Russian Academy of Sciences, Moscow, Russia
| | - Petr Krivorotko
- N.N.Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Ferenc Vicko
- Medical Faculty Novi Sad, Oncology Institute of Vojvodina Sremska Kamenica, University of Novi Sad, Novi Sad, Serbia
| | - Piotr Pluta
- Department of Surgical Oncology and Breast Diseases, Polish Mother’s Memorial Hospital–Research Institute in Lodz, Lodz, Poland
| | - Agnieszka Kolacinska-Wow
- Department of Head and Neck Cancer Surgery, Medical University of Lodz, Lodz, Poland
- Department of Surgical Oncology, Cancer Center, Medical University of Lodz, Lodz, Poland
| | - Dawid Murawa
- Clinic of Surgical Oncology, Poznan University of Medical Sciences, Poznan, Poland
- General and Oncological Surgery Clinic, Karol Marcinkowski University Hospital, Zielona Gora, Poland
| | - Jerzy Jankau
- Plastic Surgery Department, Medical University of Gdańsk/University Hospitals, Gdansk, Poland
| | - Slawomir Ciesla
- General and Oncological Surgery Clinic, Karol Marcinkowski University Hospital, Zielona Gora, Poland
| | - Daniel Dyttert
- Department of Surgical Oncology, St. Elisabeth Cancer Institute, Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Martin Sabol
- Department of Surgical Oncology, St. Elisabeth Cancer Institute, Medical Faculty, Comenius University, Bratislava, Slovakia
| | | | | | - Alexander Bessonov
- Breast Cancer Department of the LOKOD, N.N.Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - György Lázár
- Department of Surgery, Faculty of Medicine, SZTE ÁOK, University of Szeged, Szeged, Hungary
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Acea-Figueira E, García-Novoa A, Díaz Carballada C, Bouzón Alejandro A, Conde C, Santiago Freijanes P, Mosquera Oses J, Acea-Nebril B. Lymph node staging after primary systemic therapy in women with breast cancer and lymph node involvement at diagnosis. Cir Esp 2022:S2173-5077(22)00158-2. [PMID: 35660095 DOI: 10.1016/j.cireng.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The main objective of this study is to analyze the efficacy of combined axillary marking (lymph node clipping and sentinel lymph node biopsy (SLNB)) for axillary staging in patients with primary systemic treatment (PST) and pathologically confirmed node-positive breast cancer at diagnosis. The secondary objective is to determine the impact of lymph node marking in the suppression of axillary lymph node dissection (ALND) in the study group. METHODS We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and a SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an ALND. The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS Eighty one patients met the inclusion criteria. We identified and extirpated the clip/ wire-marked node in 80 of 81 patients (98.8%), with SLNB performed successfully in 88,9% of patients. The SLN and wire-marked node matched in 78.9% of patients; 76.2% of patients did not undergo ALND. CONCLUSIONS The combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and PST offers a high identification rate (98.8%) and a high correlation between the wire-marked lymph node and the SLN (78.9%). This procedure has enabled the suppression of ALND in 76.2% of patients.
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Affiliation(s)
- Eva Acea-Figueira
- Servicio de Cirugía General, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Alejandra García-Novoa
- Servicio de Cirugía General, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain.
| | - Carlota Díaz Carballada
- Servicio de Ginecología, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Alberto Bouzón Alejandro
- Servicio de Cirugía General, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Carmen Conde
- Servicio de Ginecología, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Paz Santiago Freijanes
- Servicio de Anatomía Patológica, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Joaquín Mosquera Oses
- Servicio de Radiología, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Benigno Acea-Nebril
- Servicio de Cirugía General, Unidad de Mama, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
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50
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de Boniface J, Frisell J, Kühn T, Wiklander-Bråkenhielm I, Dembrower K, Nyman P, Zouzos A, Gerber B, Reimer T, Hartmann S. False-negative rate in the extended prospective TATTOO trial evaluating targeted axillary dissection by carbon tattooing in clinically node-positive breast cancer patients receiving neoadjuvant systemic therapy. Breast Cancer Res Treat 2022; 193:589-595. [PMID: 35451733 PMCID: PMC9114094 DOI: 10.1007/s10549-022-06588-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/27/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE In clinically node-positive breast cancer patients receiving neoadjuvant systemic therapy (NST), nodal metastases can be initially marked and then removed during surgical axillary staging. Marking methods vary significantly in terms of feasibility and cost. The purpose of the extended TATTOO trial was to report on the false-negative rate (FNR) of the low-cost method carbon tattooing. METHODS The international prospective single-arm TATTOO trial included clinically node-positive breast cancer patients planned for NST from November 2017 to January 2021. For the present analysis, patients who received both the targeted procedure with or without an additional sentinel lymph node (SLN) biopsy and a completion axillary lymph node dissection (ALND) were selected. Primary endpoint was the FNR. RESULTS Out of 172 included patients, 149 had undergone a completion ALND. The detection rate for the tattooed node was 94.6% (141 out of 149). SLN biopsy was attempted in 132 out of 149 patients with a detection rate of 91.7% (121 out of 132). SLN and tattooed node were identical in 58 out of 121 individuals (47.9%). The combined procedure, i.e. targeted axillary dissection (TAD) was successful in 147 of 149 cases (98.7%). Four out of 65 patients with a clinically node-negative status after NST had a negative TAD but metastases on ALND, corresponding to a FNR of 6.2%. All false-negative TAD procedures were performed in the first 2 years of the trial (2018-2019, p = 0.022). CONCLUSION Carbon tattooing is a feasible marking method for TAD with a high detection rate and an acceptably low FNR. The TATTOO trial was preregistered as prospective trial before initiation at the University of Rostock, Germany (DRKS00013169).
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Affiliation(s)
- Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
- Department of Surgery, Breast Centre, Capio St. Göran's Hospital, Mariebergsporten 2, 11219, Stockholm, Sweden.
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine and Sarcoma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Thorsten Kühn
- Department of Obstetrics and Gynecology, Klinikum Esslingen, Esslingen, Germany
| | | | - Karin Dembrower
- Department of Radiology, Capio St. Göran's Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Per Nyman
- Department of Surgery, Skaraborg Hospital, Lidköping, Sweden
| | - Athanasios Zouzos
- Department of Mammography, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Bernd Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Steffi Hartmann
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
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