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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer. Cancers (Basel) 2023; 15:5353. [PMID: 38001613 PMCID: PMC10670757 DOI: 10.3390/cancers15225353] [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: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
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Sun S, Bai J, Wang X. Comparative observation of common tracers in sentinel lymph node biopsy of breast cancer and a study on simplifying its surgical procedure. Front Surg 2023; 10:1180919. [PMID: 37255743 PMCID: PMC10225584 DOI: 10.3389/fsurg.2023.1180919] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/26/2023] [Indexed: 06/01/2023] Open
Abstract
Background Many breast cancer patients have avoided axillary lymph node dissection after sentinel lymph node biopsy (SLNB). During the SLNB operation, the color of lymphatic vessels is sometimes poor and so finding them is difficult. This study observed the tracing effects of three tracer combinations and also reported our experience in simplifying the SLNB program. Methods In total, 123 breast cancer patients whose TNM stage was cT1-2N0M0 were retrospectively studied. According to the tracer used, the patients were divided into the carbon nanoparticle (CNP) group (38 cases), CNP combined with methylene blue (CNP + MB) group (41 cases), and indocyanine green combined with MB (ICG + MB) group (44 cases). All 123 breast cancer cases were also classified into the non-tracking group (53 cases) and tracking group (70 cases) according to the SLNB operation process. The non-tracking group looked for the stained sentinel lymph nodes directly, while the tracking group looked for the stained lymph nodes along the lymphatic vessels. Results The SLN identification rates in the CNP, CNP + MB, and ICG + MB groups were 97.4%, 97.6%, and 95.5% respectively (P > 0.05). The average number of SLNs detected was 4.92 ± 2.06, 5.12 ± 2.18, and 4.57 ± 1.90, respectively (P > 0.05). The ideal display rates of lymphatic vessels in the three groups were 86.8%, 87.8%, and 93.2%, respectively (P > 0.05). The SLN identification rates in the non-tracking and tracking groups were 96.2% and 97.1%, respectively (P > 0.05). The average number of SLNs detected were 5.73 ± 1.76 and 5.70 ± 1.93, respectively (P > 0.05), and the average operation time was 16.47 ± 5.78 and 27.53 ± 7.75 min, respectively (P < 0.05). Conclusion This is the first study to observe the application effect of CNP combined with MB and ICG combined with MB tracers in SLNB of breast cancer patients. No significant difference was observed among the patients in SLN identification and lymphatic vessel display. Omitting the step of searching for lymphatic vessels in SLNB surgery does not reduce the surgical effect, but the reduced operating steps can reduce the surgical time and theoretically reduce postoperative complications.
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative axillary surgery is emerging in the surgical management of breast cancer. Breast Cancer 2023; 30:14-22. [PMID: 36342647 DOI: 10.1007/s12282-022-01409-2] [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: 05/09/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
Axillary lymph node dissection (ALND) has been the standard axillary treatment for breast cancer for a long time. However, ALND is associated with postoperative morbidities, including local sensory dysfunction, reduced shoulder mobility and most notably arm lymphedema. Recently, ALND can be avoided not only in clinically node-negative (cN0) patients with negative sentinel lymph nodes (SLNs), but also in patients with less than 3 positive SLNs receiving breast radiation, axillary radiation, or a combination of the two. Moreover, SLN biopsy has been adopted for use in clinically node-positive (cN +) patients presenting as cN0 after neoadjuvant chemotherapy (NAC); ALND may be avoided in cN + patients who convert to SLN-negative following NAC. Patients who undergo SLN biopsy alone have less postsurgical morbidities than those who undergo ALND. Nevertheless, ALND is still required in a select group of patients. A variety of conservative approaches to ALND have been developed to spare arm lymphatics to minimize arm lymphedema. These conservative procedures seem to decrease the incidence of lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, full conventional ALND removing all microscopic axillary disease may now be unnecessary in both cN0 patients and cN + patients. Regardless, emerging procedures for ALND should still be considered as investigational approaches, as further studies with longer follow-up are necessary to determine the safety of conservative ALND to spare arm lymphatics.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan. .,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.
| | - Masafumi Inokuchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Miki Yokoi-Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Emi Morioka
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Yusuke Haba
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
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Noguchi M, Inokuchi M, Noguchi M, Morioka E, Ohno Y, Kurita T. Axillary surgery for breast cancer: past, present, and future. Breast Cancer 2020; 28:9-15. [PMID: 33165758 DOI: 10.1007/s12282-020-01120-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023]
Abstract
In breast cancer surgery, there has been a major shift toward less invasive local treatment. Although axillary lymph node dissection (ALND) was an integral part of surgical treatment for breast cancer, sentinel lymph node (SLN) biopsy was developed as an accurate method for axillary staging. ALND can be avoided not only in patients with negative SLNs but also in those with one or two positive SLNs receiving breast and/or axillary radiation. On the other hand, ALND has remained the standard treatment for patients with clinically positive nodes. However, axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients receive postoperative chemotherapy and high-risk patients undergo axillary radiation. Standard ALND may not be necessary even for patients with clinically positive nodes who receive axillary radiation and systemic therapy. Thus, the extent of axillary surgery in breast cancer has been decreased with increased use of systemic and radiation therapy.
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Affiliation(s)
- Masakuni Noguchi
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan. .,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan.
| | - Masafumi Inokuchi
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan
| | - Miki Noguchi
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan
| | - Emi Morioka
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan
| | - Yukako Ohno
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan
| | - Tomoko Kurita
- Department of Breast Surgery, Nippon Medical School Hospital, Tokyo, Japan
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Radiologic Mapping for Targeted Axillary Dissection: Needle Biopsy to Excision. AJR Am J Roentgenol 2016; 207:1372-1379. [DOI: 10.2214/ajr.16.16545] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Landin J, Weber WP. Lymph Node Surgery - Stepwise Retirement for the Breast Surgeon? Breast Care (Basel) 2016; 11:282-286. [PMID: 27721717 DOI: 10.1159/000448697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Axillary lymph node dissection (ALND) has been standard of care for all patients with breast cancer until the 1990s. The stepwise retreat of breast surgeons from the axilla began after the introduction of the sentinel lymph node procedure. The evidence based clinical trend toward the omission of ALND has advanced to include patients with affected nodes, and several ongoing randomized controlled trials are evaluating the remaining indications for ALND. Conflicting with this trend toward less axillary surgery, indication and extent of regional nodal irradiation are currently broadened, equally supported by evidence from randomized trials. The present review summarizes this conflicting evidence, presents ongoing trials, and discusses the current and future optimal regional management of patients with affected nodes.
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Affiliation(s)
- Julia Landin
- Breast Center, University Hospital of Basel, Basel, Switzerland
| | - Walter P Weber
- Breast Center, University Hospital of Basel, Basel, Switzerland
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Predictors for extensive nodal involvement in breast cancer patients with axillary lymph node metastases. Breast 2016; 27:175-81. [PMID: 27123958 DOI: 10.1016/j.breast.2016.02.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Various prediction models have been developed to predict the risk of having no additional axillary metastases in patients with a positive sentinel lymph node biopsy (SLNB), thereby disregarding patients with a positive ultrasound-guided lymph node biopsy (UGLNB). However, in the post-Z0011 trial era it is important to identify all patients with extensive nodal involvement for whom axillary treatment might still be beneficial. Therefore, the aim of this study is to identify factors predicting extensive nodal involvement (≥3 positive nodes) in the axilla, with the emphasis on the method of axillary staging: node positivity by UGLNB versus SLNB. METHODS All patients diagnosed with invasive breast cancer between January 2006 and December 2011 at the Máxima Medical Center were included. Univariate and multivariate logistic regression analyses were performed. RESULTS We included 302 cases, representing 301 node positive patients, of whom 177 cases had 1 or 2 positive lymph nodes and 125 cases had ≥3 positive lymph nodes. Multivariate analyses showed that a positive UGLNB (OR = 5.10; 95%CI = 2.78-9.36), lymphovascular invasion (OR = 3.60; 95%CI = 1.79-7.23) and a larger tumor size (OR = 1.03 per mm increase; 95%CI = 1.00-1.06) were significantly associated with extensive nodal involvement in patients with invasive breast cancer. CONCLUSION This study shows that a positive axilla, determined by UGLNB, is the most important factor for predicting further extensive nodal involvement. Hence, the role of axillary staging by ultrasound should be redefined since it might play an important role in selecting patients who may still benefit from axillary treatment.
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Tardivon A, Vincent-Salomon A. Prise en charge des lésions malignes avant chirurgie : état de l’art de la collaboration radiologue pathologiste. IMAGERIE DE LA FEMME 2015. [DOI: 10.1016/j.femme.2015.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Toi M, Winer EP, Benson JR, Inamoto T, Forbes JF, von Minckwitz G, Robertson JFR, Grobmyer SR, Jatoi I, Sasano H, Kunkler I, Ho AY, Yamauchi C, Chow LWC, Huang CS, Han W, Noguchi S, Pegram MD, Yamauchi H, Lee ES, Larionov AA, Bevilacqua JLB, Yoshimura M, Sugie T, Yamauchi A, Krop IE, Noh DY, Klimberg VS. Personalization of loco-regional care for primary breast cancer patients (part 1). Future Oncol 2015; 11:1297-300. [DOI: 10.2217/fon.15.65] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
ABSTRACT Kyoto Breast Cancer Consensus Conference, Kyoto, Japan, 18–20 February 2014 The loco-regional management of breast cancer is increasingly complex with application of primary systemic therapies, oncoplastic techniques and genetic testing for breast cancer susceptibility. Personalization of loco-regional treatment is integral to optimization of breast cancer care. Clinical and pathological tumor stage, biological features and host factors influence loco-regional treatment strategies and extent of surgical procedures. Key issues including axillary staging, axillary treatment, radiation therapy, primary systemic therapy (PST), preoperative hormonal therapy and genetic predisposition were identified and discussed at the Kyoto Breast Cancer Consensus Conference (KBCCC2014). In the first of a two part conference scene, consensus recommendations for axillary management are presented and focus on the following topics: indications for completion axillary lymph node dissection in primary surgical patients with ≤2 macrometastases or any sentinel nodal deposits after PST; the timing of sentinel lymph node biopsy in the context of PST; use of axillary irradiation as a component of primary treatment plans and the role of intraoperative node assessment in the post-Z0011 era.
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Affiliation(s)
- Masakazu Toi
- Breast Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawara-cho, Sakyo-ku, Kyoto 606–8507, Japan
| | - Eric P Winer
- Breast Oncology Center, Dana-Farber Cancer Institute, Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - John R Benson
- Cambridge Breast Unit, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Takashi Inamoto
- Faculty of Health Care, Tenri Health Care University, Nara, Japan
| | - John F Forbes
- Surgical Oncology, University of Newcastle, Newcastle, Australia
| | | | - John FR Robertson
- Breast Surgery, University of Nottingham, Royal Derby Hospital, Nottingham, UK
| | - Stephen R Grobmyer
- Cleveland Clinic & Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Ismail Jatoi
- The University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Hironobu Sasano
- Pathology, Tohoku University School of Medicine, Sendai, Japan
| | - Ian Kunkler
- Edinburgh Cancer Research UK Centre, The University of Edinburgh, UK
| | - Alice Y Ho
- Radiation Oncology, Memorial Sloan–Kettering Cancer Center, NY 10065, USA
| | - Chikako Yamauchi
- Radiation Oncology, Shiga Medical Center for Adults, Moriyama, Japan
| | - Louis WC Chow
- UNIMED Medical Institute/University of Hong Kong, Hong Kong
| | - Chiun-Sheng Huang
- Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wonshik Han
- Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Shinzaburo Noguchi
- Breast & Endocrine Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Mark D Pegram
- Stanford Cancer Institute, School of Medicine, Stanford University, CA 94305, USA
| | | | - Eun-Sook Lee
- Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Alexey A Larionov
- Statistics & Computational Biology Laboratory, University of Cambridge, Cancer Research UK Cambridge Institute, UK
| | - Jose LB Bevilacqua
- Department of Breast Surgery, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - Michio Yoshimura
- Radiation Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Akira Yamauchi
- Breast Center, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Ian E Krop
- Breast Oncology Center, Dana-Farber Cancer Institute, Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - Dong Young Noh
- Surgery, Seoul National University Hospital, Seoul, South Korea
| | - V Suzanne Klimberg
- Surgery, Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, AR 72205, USA
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Long-term follow-up of 5262 breast cancer patients with negative sentinel node and no axillary dissection confirms low rate of axillary disease. Eur J Surg Oncol 2014; 40:1203-8. [DOI: 10.1016/j.ejso.2014.07.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/11/2014] [Accepted: 07/29/2014] [Indexed: 11/21/2022] Open
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Reimer T, Hartmann S, Stachs A, Gerber B. Local treatment of the axilla in early breast cancer: concepts from the national surgical adjuvant breast and bowel project B-04 to the planned intergroup sentinel mamma trial. Breast Care (Basel) 2014; 9:87-95. [PMID: 24944550 PMCID: PMC4038316 DOI: 10.1159/000360411] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Local treatment of the axilla in clinically node-negative, early-stage breast cancer patients has been hotly debated after the release of the American College of Surgeons Oncology Group (ACOSOG) Z0011 findings. However, this review does not focus on the 'Z0011-eligible' patients alone, because this subgroup represents a minority of our patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB). The following topics are discussed: axillary diagnostics, timing of axillary procedures in the neoadjuvant setting, long-term follow-up of SLNB trials, omission of axillary surgery in randomized trials, management of the involved axilla with low tumor volume, positive sentinel lymph nodes and BCS, involved sentinel lymph nodes and mastectomy, and axillary radiotherapy. Finally, the current innovative study concepts (i.e. Sentinel Node versus Observation after Axillary Ultrasound (SOUND) and Intergroup Sentinel Mamma (INSEMA)) including patients with axillary observation alone in clinically node-negative women are presented.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Germany
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