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Elghazaly H, Azim HA, Rugo HS, Cameron D, Swain SM, Curigliano G, Harbeck N, Tripathy D, Arun B, Aapro M, Piccart M, Cardoso F, Gligorov J, Elghazawy H, El Saghir NS, Penault-Llorca F, Perez EA, Poortmans P, Abdelaziz H, El-Zawahry HM, Kassem L, Sabry M, Viale G, Al-Sukhun S, Gado N, Leung JWT, Ezz Elarab L, Cardoso MJ, Abdel Karim K, Foheidi M, Elmaadawy MM, Conte P, Selim ASM, Kandil A, Kamal RM, Paltuev RM, Guarneri V, Abulkhair O, Zakaria O, Golshan M, Orecchia R, ElMahdy M, Abdel-Aziz AM, Eldin NB. Tailoring neoadjuvant systemic therapy in breast cancer: "The advent of a personalized approach"-The Breast-Gynecological and Immuno-Oncology International Cancer Conference (BGICC) consensus and recommendations. Cancer 2024; 130:3251-3271. [PMID: 38985794 DOI: 10.1002/cncr.35389] [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: 10/18/2023] [Revised: 02/19/2024] [Accepted: 03/13/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The management of early breast cancer (BC) has witnessed an uprise in the use of neoadjuvant therapy and a remarkable reshaping of the systemic therapy postneoadjuvant treatment in the last few years, with the evolution of many controversial clinical situations that require consensus. METHODS During the 14th Breast-Gynecological and Immuno-Oncology International Cancer Conference held in Egypt in 2022, a panel of 44 BC experts from 13 countries voted on statements concerning debatable challenges in the neo/adjuvant treatment setting. The recommendations were subsequently updated based on the most recent data emerging. A modified Delphi approach was used to develop this consensus. A consensus was achieved when ≥75% of voters selected an answer. RESULTS AND CONCLUSIONS The consensus recommendations addressed different escalation and de-escalation strategies in the setting of neoadjuvant therapy for early BC. The recommendations recapitulate the available clinical evidence and expert opinion to individualize patient management and optimize therapy outcomes. Consensus was reached in 63% of the statements (52/83), and the rationale behind each statement was clarified.
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Affiliation(s)
- Hesham Elghazaly
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hamdy A Azim
- Department of Clinical Oncology, Kasr Alainy School of Medicine, Cairo University, Giza, Egypt
| | - Hope S Rugo
- Department of Medicine, University of California San Francisco Comprehensive Cancer Center, San Francisco, California, USA
| | - David Cameron
- Edinburgh Cancer Research Centre, Institute of Genetics and Cancer, University of Edinburgh and National Health Service Lothian, Edinburgh, UK
| | - Sandra M Swain
- Georgetown Lombardi Comprehensive Cancer Center, MedStar Health, Washington, District of Columbia, USA
| | - Giuseppe Curigliano
- Department of Oncology and Hemato-Oncology, European Institute of Oncology, IRCCS, University of Milano, Milan, Italy
| | - Nadia Harbeck
- Department of Obstetrics and Gynecology and Comprehensive Cancer Center Munich, Breast Center, Ludwig Maximilian University Hospital, Munich, Germany
| | - Debu Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Banu Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matti Aapro
- Breast Center, Clinique de Genolier, Genolier, Switzerland
| | - Martine Piccart
- Institut Jules Bordet and L'Université Libre de Bruxelles, Brussels, Belgium
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Joseph Gligorov
- Medical Oncology Department, L'Assistance Publique-Hôpitaux de Paris, Institute Universitaire de Cancérologie, Sorbonne Université, Paris, France
| | - Hagar Elghazawy
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nagi S El Saghir
- Division of Hematology Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Frederique Penault-Llorca
- National Institute of Health and Medical Research Unit 1240 "Molecular Imaging and Theranostic Strategies", Department of Pathology, Clermont Auvergne University, Center Jean Perrin, Clermont-Ferrand, France
| | - Edith A Perez
- Department of Hematology and Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Philip Poortmans
- Iridium Network and Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium
| | - Hany Abdelaziz
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Heba M El-Zawahry
- Department of Clinical Oncology, Kasr Alainy School of Medicine, Cairo University, Giza, Egypt
| | - Loay Kassem
- Department of Clinical Oncology, Kasr Alainy School of Medicine, Cairo University, Giza, Egypt
| | - Mohamed Sabry
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | | | - Neven Gado
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Jessica W T Leung
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lobna Ezz Elarab
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Maria João Cardoso
- Breast Unit, Champalimaud Clinical Center, Champalimaud Foundation, Faculdade de Medicina, Lisbon, Portugal
| | - Khaled Abdel Karim
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Meteb Foheidi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Adult Medical Oncology, Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs-Western Region, Jeddah, Saudi Arabia
| | - Merit M Elmaadawy
- Diagnostic Radiology Department, Mansoura University, Mansoura, Egypt
| | - Pierfranco Conte
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
- Division of Oncology, Istituto Oncologico Veneto-IRCCS, Padova, Italy
| | - Ashraf S M Selim
- Diagnostic and Interventional Radiology Department, Cairo University, Giza, Egypt
| | - Alaa Kandil
- Department of Clinical Oncology, Alexandria School of Medicine, Alexandria, Egypt
| | - Rasha M Kamal
- Diagnostic and Interventional Radiology Department, Cairo University, Giza, Egypt
| | - Ruslan M Paltuev
- Department of Breast Tumours of Federal State Budgetary Institution "Petrov Research Institute of Oncology", Russian Association of Oncological Mammology, St Petersburg, Russia
| | - Valentina Guarneri
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
- Division of Oncology, Istituto Oncologico Veneto-IRCCS, Padova, Italy
| | - Omalkhair Abulkhair
- Medical Oncology Department, Oncology Services, Alhabib Hospital, Riyad, Saudi Arabia
| | - Omar Zakaria
- Department of Surgery, Cairo University, Cairo, Egypt
| | - Mehra Golshan
- Department of Surgery, Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Roberto Orecchia
- Scientific Directorate, IRCCS European Institute of Oncology, University of Milan, Milan, Italy
| | - Manal ElMahdy
- Department of Pathology, Ain Shams University, Cairo, Egypt
| | - Ahmed M Abdel-Aziz
- Department of Pathology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Nermean Bahie Eldin
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Gentilini OD, Botteri E, Sangalli C, Galimberti V, Porpiglia M, Agresti R, Luini A, Viale G, Cassano E, Peradze N, Toesca A, Massari G, Sacchini V, Munzone E, Leonardi MC, Cattadori F, Di Micco R, Esposito E, Sgarella A, Cattaneo S, Busani M, Dessena M, Bianchi A, Cretella E, Ripoll Orts F, Mueller M, Tinterri C, Chahuan Manzur BJ, Benedetto C, Veronesi P. Sentinel Lymph Node Biopsy vs No Axillary Surgery in Patients With Small Breast Cancer and Negative Results on Ultrasonography of Axillary Lymph Nodes: The SOUND Randomized Clinical Trial. JAMA Oncol 2023; 9:1557-1564. [PMID: 37733364 PMCID: PMC10514873 DOI: 10.1001/jamaoncol.2023.3759] [Citation(s) in RCA: 91] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/29/2023] [Indexed: 09/22/2023]
Abstract
Importance Sentinel lymph node biopsy (SLNB) is the standard of care for axillary node staging of patients with early breast cancer (BC), but its necessity can be questioned since surgery for examination of axillary nodes is not performed with curative intent. Objective To determine whether the omission of axillary surgery is noninferior to SLNB in patients with small BC and a negative result on preoperative axillary lymph node ultrasonography. Design, Setting, and Participants The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) trial was a prospective noninferiority phase 3 randomized clinical trial conducted in Italy, Switzerland, Spain, and Chile. A total of 1463 women of any age with BC up to 2 cm and a negative preoperative axillary ultrasonography result were enrolled and randomized between February 6, 2012, and June 30, 2017. Of those, 1405 were included in the intention-to-treat analysis. Data were analyzed from October 10, 2022, to January 13, 2023. Intervention Eligible patients were randomized on a 1:1 ratio to receive SLNB (SLNB group) or no axillary surgery (no axillary surgery group). Main Outcomes and Measures The primary end point of the study was distant disease-free survival (DDFS) at 5 years, analyzed as intention to treat. Secondary end points were the cumulative incidence of distant recurrences, the cumulative incidence of axillary recurrences, DFS, overall survival (OS), and the adjuvant treatment recommendations. Results Among 1405 women (median [IQR] age, 60 [52-68] years) included in the intention-to-treat analysis, 708 were randomized to the SLNB group, and 697 were randomized to the no axillary surgery group. Overall, the median (IQR) tumor size was 1.1 (0.8-1.5) cm, and 1234 patients (87.8%) had estrogen receptor-positive ERBB2 (formerly HER2 or HER2/neu), nonoverexpressing BC. In the SLNB group, 97 patients (13.7%) had positive axillary nodes. The median (IQR) follow-up for disease assessment was 5.7 (5.0-6.8) years in the SLNB group and 5.7 (5.0-6.6) years in the no axillary surgery group. Five-year distant DDFS was 97.7% in the SLNB group and 98.0% in the no axillary surgery group (log-rank P = .67; hazard ratio, 0.84; 90% CI, 0.45-1.54; noninferiority P = .02). A total of 12 (1.7%) locoregional relapses, 13 (1.8%) distant metastases, and 21 (3.0%) deaths were observed in the SLNB group, and 11 (1.6%) locoregional relapses, 14 (2.0%) distant metastases, and 18 (2.6%) deaths were observed in the no axillary surgery group. Conclusions and Relevance In this randomized clinical trial, omission of axillary surgery was noninferior to SLNB in patients with small BC and a negative result on ultrasonography of the axillary lymph nodes. These results suggest that patients with these features can be safely spared any axillary surgery whenever the lack of pathological information does not affect the postoperative treatment plan. Trial Registration ClinicalTrials.gov Identifier: NCT02167490.
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Affiliation(s)
- Oreste Davide Gentilini
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Breast Surgery Unit, San Raffaele Scientific and Research Hospital, Milan, Italy
| | - Edoardo Botteri
- Division of Epidemiology and Biostatistics, European Institute of Oncology IRCCS, Milan, Italy
- Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Claudia Sangalli
- Clinical Trial Office, European Institute of Oncology IRCCS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Mauro Porpiglia
- Department of Surgical Sciences Gynecology and Obstetrics, City of Health and Science of Turin, Sant’Anna Hospital, University of Turin, Turin, Italy
| | - Roberto Agresti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alberto Luini
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Giuseppe Viale
- Division of Pathology and Laboratory Medicine, European Institute of Oncology IRCCS, Milan, Italy
- Oncology and Oncohematology Department, University of Milan, Milan, Italy
| | - Enrico Cassano
- Division of Breast Imaging, European Institute of Oncology IRCCS, Milan, Italy
| | - Nickolas Peradze
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Giulia Massari
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Virgilio Sacchini
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Oncology and Oncohematology Department, University of Milan, Milan, Italy
| | - Elisabetta Munzone
- Division of Medical Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | | | | | - Rosa Di Micco
- Breast Surgery Unit, San Raffaele Scientific and Research Hospital, Milan, Italy
| | - Emanuela Esposito
- Struttura Complessa (SC) di Chirurgia Oncologica di Senologia, Istituto Nazionale Tumori Napoli, IRCCS, Fondazione Pascale, Naples, Italy
| | - Adele Sgarella
- Breast Center, Department of Surgical Sciences, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Silvia Cattaneo
- Department of General Surgery, Sant’Anna Hospital, Como, Italy
| | - Massimo Busani
- Struttura Semplice Dipartimentale di Chirurgia Senologica Azienda Socio-Sanitaria Territoriale (ASST), Mantova, Italy
| | - Massimo Dessena
- SC di Chirurgia Oncologica e Senologia, Ospedale Oncologico, Azienda Ospedaliera Brotzu, Selargius, Cagliari, Italy
| | - Anna Bianchi
- Breast Unit, Spedali Civili di Brescia, Brescia, Italy
| | - Elisabetta Cretella
- Medical Oncology Division, Azienda Sanitaria dell’Alto Adige, Bolzano, Italy
| | | | - Michael Mueller
- Frauenklinik Inselpital Hospital, Theodor-Kocher-Haus, Bern, Switzerland
| | - Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Chiara Benedetto
- Department of Surgical Sciences Gynecology and Obstetrics, City of Health and Science of Turin, Sant’Anna Hospital, University of Turin, Turin, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Oncology and Oncohematology Department, University of Milan, Milan, Italy
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