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van Nijnatten TJA, Poplack SP, Wijgers RA, Kilburn-Toppin F, Athanasiou A, Chang JM, Smidt ML. Differences in axillary ultrasound protocols among prospective de-escalating axillary surgical staging trials in clinically node negative early breast cancer patients. Eur J Radiol 2024; 181:111775. [PMID: 39369617 DOI: 10.1016/j.ejrad.2024.111775] [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: 08/29/2024] [Revised: 09/30/2024] [Accepted: 10/01/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Surgical axillary staging of the axilla is a topic of debate regarding the potential of de-escalation in clinically node negative (cN0) early breast cancer patients treated with breast-conserving therapy. Axillary ultrasound is important to determine clinical nodal status. The aim of the current narrative review is to provide an overview of prospective trials on de-escalating axillary surgical staging in cN0 early breast cancer patients, with an emphasis on axillary ultrasound protocols. METHODS This narrative review provides an overview of the prospective de-escalating axillary surgical staging trials, in terms of comparing sentinel lymph node biopsy (SLNB) versus complete omission of SLNB, in cT1/2N0 patients treated with breast-conserving therapy. Information from each trial was collected, including reported axillary ultrasound protocols (including cortical thickness cut-off value) and axillary ultrasound-guided biopsy technique (fine-needle aspiration or core-needle biopsy). RESULTS There is one recently published prospective trial and three ongoing prospective trials within the topic of this narrative review. Number of included patients in these trials ranges from 1405 to 5505 patients. The included trials differed whether or not to include patients with suspicious axillary ultrasound findings and a negative ultrasound-guided biopsy. Cortical thickness cut-off value ranged from 2.3 mm to 3.0 mm. Different ultrasound-guided biopsy techniques were performed among the included trials. CONCLUSION Prospective de-escalating axillary surgical staging trials in clinically node negative early breast cancer patients treated with breast-conserving therapy do report differences in terms of axillary ultrasound protocols and ultrasound-guided biopsy techniques. Axillary ultrasound protocols do require uniformity in order to improve extrapolation of these trial results.
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Affiliation(s)
- T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - Research Institute for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - S P Poplack
- Department of Radiology, Stanford University School of Medicine, Palo Alto, USA
| | - R A Wijgers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - F Kilburn-Toppin
- Department of Radiology, Cambridge University Hospital NHS Foundation Trust, United Kingdom
| | - A Athanasiou
- Breast Imaging Department, MITERA Hospital, Athens, Greece
| | - J M Chang
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - M L Smidt
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
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Qiu C, Wei Y, Li J. Can negative axillary ultrasound reliably predict pathologically negative axillary lymph node status in breast cancer patients with cT ≤3 cm, cN0, and HER2-positive?-a retrospective, single-institution study. Gland Surg 2024; 13:1511-1521. [PMID: 39282035 PMCID: PMC11399003 DOI: 10.21037/gs-24-140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 08/15/2024] [Indexed: 09/18/2024]
Abstract
Background Breast cancer (BC) is the leading cancer in women globally, with human epidermal growth factor receptor 2 (HER2)-positive subtype accounting for 15-20% of cases and exhibiting aggressive behavior. The standard of care for operable BC has evolved to include neoadjuvant systemic therapy, which can guide treatment decisions and improve outcomes, particularly in HER2+ BC. This study aims to investigate whether axillary ultrasound has a good negative predictive value (NPV) for early HER2 BC patients and to identify clinicopathological factors that can impact the axillary lymph node metastasis. Methods This retrospective, single-center study evaluated the medical records of 135 patients with HER2+ BC, cT ≤3 cm, and clinically negative axillary lymph nodes from 2018 to 2020. The study aimed to determine the NPV of axillary ultrasound for pathologically negative axillary lymph node status and to identify factors associated with axillary lymph node metastasis. Results The NPV of axillary ultrasound was 78.5%, increasing to 89.6% and 93.3% when considering 0-1 and 0-2 metastatic lymph nodes, respectively. Lymphovascular invasion (LVI) was significantly associated with axillary lymph node metastasis, with a 2.2-fold increased risk. Conclusions Axillary ultrasound shows good predictive value for axillary lymph node negativity in HER2+ BC patients with small tumors. However, the presence of LVI increases the risk of metastasis, suggesting a need for neoadjuvant chemotherapy. These findings contribute to personalized treatment strategies for early HER2+ BC, emphasizing the role of axillary ultrasound in clinical decision-making.
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Affiliation(s)
- Caixin Qiu
- Department of Gastroenterology and Gland Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Medical University, Nanning, China
| | - Yansha Wei
- Department of Radiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Jiehua Li
- Department of Gastroenterology and Gland Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Medical University, Nanning, China
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Kwon Y, Lim J, Ha B, Kim S, Park JH, Lim YA, Kang HJ, Kim D, Lee J. Omission of axillary surgery in cN0, postmenopausal ER-positive/HER2-negative breast cancer patients undergoing breast-conserving treatment. Gland Surg 2024; 13:1408-1417. [PMID: 39282037 PMCID: PMC11399007 DOI: 10.21037/gs-24-146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 08/05/2024] [Indexed: 09/18/2024]
Abstract
Background Previous clinical trials have diminished the significance of lymph node (LN) metastasis and axillary surgery in breast cancer, particularly in cN0, postmenopausal estrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative patients undergoing breast-conserving treatment (BCT). We assessed the replacement of axillary surgery with preoperative imaging modalities by analyzing the proportion of high nodal burden (HNB) patients with ≥3 LN metastases in these patients. Methods We retrospectively identified 333 cN0, postmenopausal ER-positive/HER2-negative breast cancer patients who underwent BCT in two hospitals between January 2003 and December 2017. The proportion of LN metastasis patients and the number of metastatic LN were investigated. Risk factors of LN metastasis were analyzed and recurrence-free survival (RFS) was compared. Results Axillary surgery confirmed LN metastasis in 81 (24.3%) of the cN0 patients. The clinical tumor size (cT) and age were factors associated with LN metastasis [cT: odds ratio (OR), 2.92, 95% confidence interval (CI): 1.69-5.05, P<0.001; age: OR, 0.33, 95% CI: 0.11-0.99, P=0.048]. However, HNB patients with ≥3 LN metastases were 15 (4.5%) of all the patients. There was statistically significant difference in the incidence of HNB between patients with cT1 tumors (3.6%) and those with cT2 tumors (7.4%) (P<0.001). Conclusions In cN0, postmenopausal ER-positive/HER2-negative patients who underwent BCT, patients with cT1 tumors had lower rate of LN metastasis, and there were fewer instances of HNB. Therefore, in these patients, omission of axillary surgery including SLNB can be carefully considered.
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Affiliation(s)
- Yeonjoo Kwon
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
| | - Jihe Lim
- Department of Radiology, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
| | - Boram Ha
- Department of Radiation Oncology, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
| | - Sanghwa Kim
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
| | - Jung Ho Park
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
| | - Young Ah Lim
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
| | - Hee-Joon Kang
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
| | - Doyil Kim
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
| | - Janghee Lee
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong-si, Republic of Korea
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Daly GR, Dowling GP, Said M, Qasem Y, Hembrecht S, Calpin GG, AlRawashdeh MM, Hill ADK. Impact of Sentinel Lymph Node Biopsy on Management of Older Women With Clinically Node-Negative, Early-Stage, ER+/HER2-, Invasive Breast Cancer: A Systematic Review and Meta-Analysis. Clin Breast Cancer 2024:S1526-8209(24)00212-X. [PMID: 39214843 DOI: 10.1016/j.clbc.2024.07.012] [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: 07/09/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 09/04/2024]
Abstract
In 2016 the Choosing Wisely guidelines advised against routine performance of a sentinel lymph node biopsy (SLNB) in women ≥ 70 years of age with clinically node negative (cN0), early-stage, oestrogen receptor positive/ human epidermal growth factor receptor 2 negative (ER+/HER2-), invasive breast cancer. The argument in favour of its continued performance is that it may serve as a useful guide for subsequent management. This systematic review was performed in accordance with the PRISMA guidelines. Studies reporting on rate of adjuvant chemotherapy, adjuvant radiotherapy and performance of completion axillary lymph node dissection (cALND) post SLNB in women aged ≥ 65 years with cN0, early-stage, ER+/HER2-, invasive breast cancer were included. A random effects meta-analysis was performed with summary estimates made using the Mantel-Haenszel method. Dichotomous outcomes were reported as odds ratios (ORs) with 95% confidence intervals (CIs). Ten retrospective studies across 4 countries. Of 105,514 patients, 15,509 had a positive SLNB and 90,005 had a negative SLNB. On meta-analysis, a positive SLNB was significantly associated with receipt of adjuvant chemotherapy (OR 4.64 (95% CI 3.18, 6.77), P < .00001), adjuvant radiotherapy (1.71 (95% CI 1.18, 2.47), P = .005) and undergoing completion axillary lymph node dissection (OR 68.97 (95% CI, 7.47, 636.88), P = .0002). Adjuvant treatment decisions continue to be influenced by SLNB positivity in the era of the Choosing Wisely guidelines. The effects of a positive SLNB and subsequent treatments on outcomes remain inconclusive. However, it is likely clinicians are continuing to over-investigate and over-treat this cohort.
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Affiliation(s)
- Gordon R Daly
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland.
| | - Gavin P Dowling
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Mohammad Said
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Yazan Qasem
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sandra Hembrecht
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Gavin G Calpin
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Ma'en M AlRawashdeh
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Arnold D K Hill
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
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Daly GR, Dowling GP, Hamza E, AlRawashdeh M, Hegarty A, Naz T, McGrath J, Naidoo S, Downey E, Butt A, Power C, Hill ADK. Does Sentinel Lymph Node Biopsy Influence Subsequent Management Decisions in Women With Breast Cancer ≥ 70 Years Old? Clin Breast Cancer 2024; 24:510-518.e4. [PMID: 38821743 DOI: 10.1016/j.clbc.2024.05.002] [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: 04/11/2024] [Revised: 04/30/2024] [Accepted: 05/04/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND There have been ongoing attempts to de-escalate surgical intervention in older breast cancer patients in recent years. However, there remains ongoing hesitancy amongst surgeons to de-implement axillary staging in this cohort. The supporting argument for performing a sentinel lymph node biopsy (SLNB) is that it may guide subsequent management. METHODS A retrospective review was performed of 356 SLNBs, in 342 women ≥ 70 years of age with invasive breast cancer, between 2014 and 2022 in a single institution. Data were collected on patient and tumor characteristics and subsequent management for all patients and for patients with ER+/HER2-, early-stage disease. RESULTS Positive SLNB significantly increased likelihood of receiving adjuvant chemotherapy (CTh) in patients aged 70-75 in all clinical subtypes (OR 4.0, 95% CI, 1.6-10; P = .0035). Positive SLNB did not significantly increase likelihood of receiving adjuvant CTh in patients aged 75-80, however, an Oncotype Dx score of ≥ 26 did (OR 34.50, 95% CI, 3.00-455.2; P = .0103). Positive SLNB was significantly associated with receiving adjuvant radiotherapy (RTh) in all patients aged 70-75 (OR 4.5, 95% CI, 2.0-11; P = .0004) and 75-80 (OR 9.7, 95% CI, 2.7-46; P = .0015). In patients aged ≥ 80 years, positive SLNB did not have a significant influence on subsequent treatments. CONCLUSION In this study, SLNB did not significantly influence subsequent management decisions in patients over 80 and should rarely be performed in this cohort. However, SLNB still had a role in patients aged 70-80 and should be used selectively in this cohort.
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Affiliation(s)
- Gordon R Daly
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland.
| | - Gavin P Dowling
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Eman Hamza
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Ma'en AlRawashdeh
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Aisling Hegarty
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Tarnum Naz
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Jason McGrath
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Sindhuja Naidoo
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Eithne Downey
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Abeeda Butt
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Colm Power
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Arnold D K Hill
- Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Department of Surgery, Beaumont Hospital, Dublin, Ireland
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Zhang Z, Jiang Q, Wang J, Yang X. A nomogram model for predicting the risk of axillary lymph node metastasis in patients with early breast cancer and cN0 status. Oncol Lett 2024; 28:345. [PMID: 38872855 PMCID: PMC11170244 DOI: 10.3892/ol.2024.14478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/14/2024] [Indexed: 06/15/2024] Open
Abstract
Axillary staging is commonly performed via sentinel lymph node biopsy for patients with early breast cancer (EBC) presenting with clinically negative axillary lymph nodes (cN0). The present study aimed to investigate the association between axillary lymph node metastasis (ALNM), clinicopathological characteristics of tumors and results from axillary ultrasound (US) scanning. Moreover, a nomogram model was developed to predict the risk for ALNM based on relevant factors. Data from 998 patients who met the inclusion criteria were retrospectively reviewed. These patients were then randomly divided into a training and validation group in a 7:3 ratio. In the training group, receiver operating characteristic curve analysis was used to identify the cutoff values for continuous measurement data. R software was used to identify independent ALNM risk variables in the training group using univariate and multivariate logistic regression analysis. The selected independent risk factors were incorporated into a nomogram. The model differentiation was assessed using the area under the curve (AUC), while calibration was evaluated through calibration charts and the Hosmer-Lemeshow test. To assess clinical applicability, a decision curve analysis (DCA) was conducted. Internal verification was performed via 1000 rounds of bootstrap resampling. Among the 998 patients with EBC, 228 (22.84%) developed ALNM. Multivariate logistic analysis identified lymphovascular invasion, axillary US findings, maximum diameter and molecular subtype as independent risk factors for ALNM. The Akaike Information Criterion served as the basis for both nomogram development and model selection. Robust differentiation was shown by the AUC values of 0.855 (95% CI, 0.817-0.892) and 0.793 (95% CI, 0.725-0.857) for the training and validation groups, respectively. The Hosmer-Lemeshow test yielded P-values of 0.869 and 0.847 for the training and validation groups, respectively, and the calibration chart aligned closely with the ideal curve, affirming excellent calibration. DCA showed that the net benefit from the nomogram significantly outweighed both the 'no intervention' and the 'full intervention' approaches, falling within the threshold probability interval of 12-97% for the training group and 17-82% for the validation group. This underscores the robust clinical utility of the model. A nomogram model was successfully constructed and validated to predict the risk of ALNM in patients with EBC and cN0 status. The model demonstrated favorable differentiation, calibration and clinical applicability, offering valuable guidance for assessing axillary lymph node status in this population.
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Affiliation(s)
- Ziran Zhang
- Department of Breast Diseases, Jiaxing Maternity and Child Health Care Hospital, Affiliated Women and Children's Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, P.R. China
| | - Qin Jiang
- Department of Breast Diseases, Jiaxing Maternity and Child Health Care Hospital, Affiliated Women and Children's Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, P.R. China
| | - Jie Wang
- Department of Breast Diseases, Jiaxing Maternity and Child Health Care Hospital, Affiliated Women and Children's Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, P.R. China
| | - Xinxia Yang
- Department of Breast Diseases, Jiaxing Maternity and Child Health Care Hospital, Affiliated Women and Children's Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, P.R. China
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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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Ye X, Zhang X, Lin Z, Liang T, Liu G, Zhao P. Ultrasound-based radiomics nomogram for predicting axillary lymph node metastasis in invasive breast cancer. Am J Transl Res 2024; 16:2398-2410. [PMID: 39006270 PMCID: PMC11236629 DOI: 10.62347/kepz9726] [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: 04/05/2024] [Accepted: 05/18/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE To develop a nomogram for predicting axillary lymph node metastasis (ALNM) in patients with invasive breast cancer. METHODS We included 307 patients with clinicopathologically confirmed invasive breast cancer. The cohort was divided into a training group (n=215) and a validation group (n=92). Ultrasound images were used to extract radiomics features. The least absolute shrinkage and selection operator (LASSO) algorithm helped select pertinent features, from which Radiomics Scores (Radscores) were calculated using the LASSO regression equation. We developed three logistic regression models based on Radscores and 2D image features, and assessed the models' performance in the validation group. A nomogram was created from the best-performing model. RESULTS In the training set, the area under the curve (AUC) for the Radscore model, 2D feature model, and combined model were 0.76, 0.85, and 0.88, respectively. In the validation set, the AUCs were 0.71, 0.78, and 0.83, respectively. The combined model demonstrated good calibration and promising clinical utility. CONCLUSION Our ultrasound-based radiomics nomogram can accurately and non-invasively predict ALNM in breast cancer, suggesting potential clinical applications to optimize surgical and medical strategies.
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Affiliation(s)
- Xiaolu Ye
- Guangzhou University of Traditional Chinese Medicine First Affiliated HospitalGuangzhou 510405, Guangdong, China
| | - Xiaoxue Zhang
- Guangzhou University of Chinese MedicineGuangzhou 510006, Guangdong, China
| | - Zhuangteng Lin
- Guangzhou University of Traditional Chinese Medicine First Affiliated HospitalGuangzhou 510405, Guangdong, China
| | - Ting Liang
- Guangzhou University of Traditional Chinese Medicine First Affiliated HospitalGuangzhou 510405, Guangdong, China
| | - Ge Liu
- Guangzhou University of Traditional Chinese Medicine First Affiliated HospitalGuangzhou 510405, Guangdong, China
| | - Ping Zhao
- Guangzhou University of Traditional Chinese Medicine First Affiliated HospitalGuangzhou 510405, Guangdong, China
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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [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: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Heidinger M, Weber WP. Axillary Surgery for Breast Cancer in 2024. Cancers (Basel) 2024; 16:1623. [PMID: 38730576 PMCID: PMC11083357 DOI: 10.3390/cancers16091623] [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: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous 'one size fits all' radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.
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Affiliation(s)
- Martin Heidinger
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Walter P. Weber
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
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de Wild SR, van Roozendaal LM, de Wilt JHW, van Dalen T, van der Hage JA, van Duijnhoven FH, Simons JM, Schipper RJ, de Munck L, van Kuijk SMJ, Boersma LJ, Linn SC, Lobbes MBI, Poortmans PMP, Tjan-Heijnen VCG, van de Vijver KKBT, de Vries J, Westenberg AH, Strobbe LJA, Smidt ML. De-escalation of axillary treatment in the event of a positive sentinel lymph node biopsy in cT1-2 N0 breast cancer treated with mastectomy: nationwide registry study (BOOG 2013-07). Br J Surg 2024; 111:znae077. [PMID: 38597154 PMCID: PMC11004788 DOI: 10.1093/bjs/znae077] [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: 10/18/2023] [Revised: 12/12/2023] [Accepted: 03/01/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Trials have demonstrated the safety of omitting completion axillary lymph node dissection in patients with cT1-2 N0 breast cancer operated with breast-conserving surgery who have limited metastatic burden in the sentinel lymph node. The aim of this registry study was to provide insight into the oncological safety of omitting completion axillary treatment in patients operated with mastectomy who have limited-volume sentinel lymph node metastasis. METHODS Women diagnosed in 2013-2014 with unilateral cT1-2 N0 breast cancer treated with mastectomy, with one to three sentinel lymph node metastases (pN1mi-pN1a), were identified from the Netherlands Cancer Registry, and classified by axillary treatment: no completion axillary treatment, completion axillary lymph node dissection, regional radiotherapy, or completion axillary lymph node dissection followed by regional radiotherapy. The primary endpoint was 5-year regional recurrence rate. Secondary endpoints included recurrence-free interval and overall survival, among others. RESULTS In total, 1090 patients were included (no completion axillary treatment, 219 (20.1%); completion axillary lymph node dissection, 437 (40.1%); regional radiotherapy, 327 (30.0%); completion axillary lymph node dissection and regional radiotherapy, 107 (9.8%)). Patients in the group without completion axillary treatment had more favourable tumour characteristics and were older. The overall 5-year regional recurrence rate was 1.3%, and did not differ significantly between the groups. The recurrence-free interval was also comparable among groups. The group of patients who did not undergo completion axillary treatment had statistically significantly worse 5-year overall survival, owing to a higher percentage of non-cancer deaths. CONCLUSION In this registry study of patients with cT1-2 N0 breast cancer treated with mastectomy, with low-volume sentinel lymph node metastasis, the 5-year regional recurrence rate was low and comparable between patients with and without completion axillary treatment.
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Affiliation(s)
- Sabine R de Wild
- Maastricht University Medical Centre+, Department of Surgery, GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | | | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Thijs van Dalen
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Jos A van der Hage
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgery, Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Janine M Simons
- Maastricht University Medical Centre+, Department of Surgery, GROW School for Oncology and Reproduction, Maastricht, The Netherlands
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | - Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Liesbeth J Boersma
- Maastricht University Medical Centre+, Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Sabine C Linn
- Department of Medical Oncology, Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Marc B I Lobbes
- Department of Medical Imaging, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - Philip M P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Koen K B T van de Vijver
- Department of Pathology, Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- Department of Pathology, University Hospital Ghent—Cancer Research Institute Ghent, Ghent, Belgium
| | - Jolanda de Vries
- Department of Psychology and Health, Tilburg University, Tilburg, the Netherlands
| | - A Helen Westenberg
- Department of Radiation Oncology, Radiotherapiegroep Arnhem, Arnhem, the Netherlands
| | - Luc J A Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marjolein L Smidt
- Maastricht University Medical Centre+, Department of Surgery, GROW School for Oncology and Reproduction, Maastricht, The Netherlands
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12
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Tejedor L, Gómez-Modet S. Reducing axillary surgery in breast cancer. Cir Esp 2024; 102:220-224. [PMID: 37956715 DOI: 10.1016/j.cireng.2023.05.020] [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: 01/05/2023] [Accepted: 05/23/2023] [Indexed: 11/15/2023]
Abstract
This article provides a brief account of the recent evolution of the highly controversial surgical management of the positive axilla in patients with breast cancer, an issue still open to disparate surgical procedures. This short review highlights the reports that supply the rationale for current trends in reducing the aggressiveness of this surgery and discusses the course of the trials still in progress pointing in the same direction, thus supporting the principle of not performing axillary lymph node dissection for staging purposes alone.
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Affiliation(s)
- L Tejedor
- Hospital Universitario Punta de Europa, Universidad de Cádiz, Spain.
| | - S Gómez-Modet
- Hospital Universitario Punta de Europa, Universidad de Cádiz, Spain
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13
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Liu H, Zou L, Xu N, Shen H, Zhang Y, Wan P, Wen B, Zhang X, He Y, Gui L, Kong W. Deep learning radiomics based prediction of axillary lymph node metastasis in breast cancer. NPJ Breast Cancer 2024; 10:22. [PMID: 38472210 PMCID: PMC10933422 DOI: 10.1038/s41523-024-00628-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
This study aimed to develop and validate a deep learning radiomics nomogram (DLRN) for the preoperative evaluation of axillary lymph node (ALN) metastasis status in patients with a newly diagnosed unifocal breast cancer. A total of 883 eligible patients with breast cancer who underwent preoperative breast and axillary ultrasound were retrospectively enrolled between April 1, 2016, and June 30, 2022. The training cohort comprised 621 patients from Hospital I; the external validation cohorts comprised 112, 87, and 63 patients from Hospitals II, III, and IV, respectively. A DLR signature was created based on the deep learning and handcrafted features, and the DLRN was then developed based on the signature and four independent clinical parameters. The DLRN exhibited good performance, yielding areas under the receiver operating characteristic curve (AUC) of 0.914, 0.929, and 0.952 in the three external validation cohorts, respectively. Decision curve and calibration curve analyses demonstrated the favorable clinical value and calibration of the nomogram. In addition, the DLRN outperformed five experienced radiologists in all cohorts. This has the potential to guide appropriate management of the axilla in patients with breast cancer, including avoiding overtreatment.
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Affiliation(s)
- Han Liu
- Department of Ultrasound, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Liwen Zou
- Department of Mathematics, Nanjing University, Nanjing, 210008, China
| | - Nan Xu
- Department of Ultrasound, Jinling Hospital, Medical School of Nanjing University/General Hospital of Eastern Theater Command, Nanjing, 210002, China
| | - Haiyun Shen
- Department of Ultrasound, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Yu Zhang
- Department of Mathematics, Nanjing University, Nanjing, 210008, China
| | - Peng Wan
- College of Computer Science and Technology, Nanjing University of Aeronautics and Astronautics, MIIT Key Laboratory of Pattern Analysis and Machine Intelligence, Nanjing, 211106, China
| | - Baojie Wen
- Department of Ultrasound, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Xiaojing Zhang
- Department of Ultrasound, Taizhou Hospital Affiliated to Nanjing University of Chinese Medicine, Taizhou, 225300, China
| | - Yuhong He
- Department of Ultrasound, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Luying Gui
- School of Mathematics and Statistics, Nanjing University of Science and Technology, Nanjing, 210094, China.
| | - Wentao Kong
- Department of Ultrasound, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China.
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14
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Rocco N, Ghilli M, Curcio A, Bortul M, Burlizzi S, Cabula C, Cabula R, Ferrari A, Folli S, Fortunato L, Frittelli P, Gentilini O, Grendele S, Grassi MM, Grossi S, Magnoni F, Murgo R, Palli D, Rovera F, Sanguinetti A, Taffurelli M, Tazzioli G, Terribile DA, Caruso F, Galimberti V. Is routine axillary lymph node dissection needed to tailor systemic treatments for breast cancer patients in the era of molecular oncology? A position paper of the Italian National Association of Breast Surgeons (ANISC). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107954. [PMID: 38217946 DOI: 10.1016/j.ejso.2024.107954] [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: 12/03/2023] [Revised: 12/17/2023] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND De-escalation of axillary surgery in breast cancer (BC) management began when sentinel lymph node biopsy (SLNB) replaced axillary lymph node dissection (ALND) as standard of care in patients with node-negative BC. The second step consolidated ALND omission in selected subgroups of BC patients with up to two macrometastases and recognized BC molecular and genomic implication in predicting prognosis and planning adjuvant treatment. Outcomes from the recent RxPONDER and monarchE trials have come to challenge the previous cut-off of two SLN in order to inform decisions on systemic therapies for hormone receptor-positive (HR+), human epidermal growth factor receptor type-2 (HER2) negative BC, as the criteria included a cut-off of respectively three and four SLNs. In view of the controversy that this may lift in surgical practice, the Italian National Association of Breast Surgeons (Associazione Nazionale Italiana Senologi Chirurghi, ANISC) reviewed data regarding the latest trials on this topic and proposes an implementation in clinical practice. MATERIAL AND METHODS We reviewed the available literature offering data on the pathological nodal status of cN0 breast cancer patients. RESULTS The rates of pN2 status in cN0 patients ranges from 3.5 % to 16 %; pre-surgical diagnostic definition of axillary lymph node status in cN0 patients by ultrasound could be useful to inform about a possible involvement of ≥4 lymph nodes in this specific sub-groups of women. CONCLUSIONS The Italian National Association of Breast Surgeons (ANISC) considers that for HR + HER2-/cN0-pN1(sn) BC patients undergoing breast conserving treatment the preoperative workup should be optimized for a more detailed assessment of the axilla and the technique of SLNB should be optimized, if considered appropriate by the surgeon, not considering routine ALND always indicated to determine treatment recommendations according to criteria of eligibility to RxPONDER and monarch-E trials.
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Affiliation(s)
- Nicola Rocco
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Matteo Ghilli
- Breast Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Marina Bortul
- SSD Chirurgia Senologica e Breast Unit, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy Naples, Italy
| | - Stefano Burlizzi
- UOSD Chirurgia Senologica, Ospedale "A. Perrino", Brindisi, Italy
| | - Carlo Cabula
- Chirurgia Senologica Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Roberta Cabula
- Cagliari University Hospital, Surgery Unit, Cagliari, Italy
| | - Alberta Ferrari
- SSD Chirurgia Tumori eredo-famigliari, SC Chirurgia Generale 3, Senologia, Fondazione IRCCS Policlinico san Matteo, Pavia, Italy
| | - Secondo Folli
- SC di Chirurgia Oncologica-Senologia, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Lucio Fortunato
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Patrizia Frittelli
- UOC Chirurgia senologica, Ospedale Isola Tiberina Gemelli Isola, Rome, Italy
| | - Oreste Gentilini
- Breast Unit, IRCCS Ospedale San Raffaele di Milano, Milan, Italy
| | - Sara Grendele
- Breast Surgery, Department of Functional Oncology, Alto Vicentino Hospital, Santorso, Vicenza, Italy
| | | | | | - Francesca Magnoni
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Roberto Murgo
- Chirurgia Senologica, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Dante Palli
- UOC di Chirurgia Generale ad Indirizzo Senologico-Breast Unit AUSL Piacenza, Italy
| | - Francesca Rovera
- S.S.D. Breast Unit - Ospedale Universitario, Varese, Italy; Dipartimento di Medicina e Innovazione Tecnologica, Università degli Studi dell'Insubria, Varese, Italy
| | - Alessandro Sanguinetti
- SSD Chirurgia della Mammella - Dipartimento di Chirurgia, Azienda Ospedaliera "S.Maria", Terni, Italy
| | - Mario Taffurelli
- Breast Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | | | | | - Francesco Caruso
- Breast Unit, Humanitas Istituto Clinico Catanese, Misterbianco, (CT), Italy; National Association of Breast Surgeons (ANISC), Italy
| | - Viviana Galimberti
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
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15
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Zaborowski AM, Doogan K, Clifford S, Dowling G, Kazi F, Delaney K, Yadav H, Brady A, Geraghty J, Evoy D, Rothwell J, McCartan D, Heeney A, Barry M, Walsh SM, Stokes M, Kell MR, Allen M, Power C, Hill ADK, Connolly E, Alazawi D, Boyle T, Corrigan M, O’Leary P, Prichard RS. Nodal positivity in patients with clinically and radiologically node-negative breast cancer treated with neoadjuvant chemotherapy: multicentre collaborative study. Br J Surg 2024; 111:znad401. [PMID: 38055888 PMCID: PMC10763529 DOI: 10.1093/bjs/znad401] [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: 05/30/2023] [Revised: 10/06/2023] [Accepted: 11/05/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND The necessity of performing a sentinel lymph node biopsy in patients with clinically and radiologically node-negative breast cancer after neoadjuvant chemotherapy has been questioned. The aim of this study was to determine the rate of nodal positivity in these patients and to identify clinicopathological features associated with lymph node metastasis after neoadjuvant chemotherapy (ypN+). METHODS A retrospective multicentre study was performed. Patients with cT1-3 cN0 breast cancer who underwent sentinel lymph node biopsy after neoadjuvant chemotherapy between 2016 and 2021 were included. Negative nodal status was defined as the absence of palpable lymph nodes, and the absence of suspicious nodes on axillary ultrasonography, or the absence of tumour cells on axillary nodal fine needle aspiration or core biopsy. RESULTS A total of 371 patients were analysed. Overall, 47 patients (12.7%) had a positive sentinel lymph node biopsy. Nodal positivity was identified in 22 patients (29.0%) with hormone receptor+/human epidermal growth factor receptor 2- tumours, 12 patients (13.8%) with hormone receptor+/human epidermal growth factor receptor 2+ tumours, 3 patients (5.6%) with hormone receptor-/human epidermal growth factor receptor 2+ tumours, and 10 patients (6.5%) with triple-negative breast cancer. Multivariable logistic regression analysis showed that multicentric disease was associated with a higher likelihood of ypN+ (OR 2.66, 95% c.i. 1.18 to 6.01; P = 0.018), whilst a radiological complete response in the breast was associated with a reduced likelihood of ypN+ (OR 0.10, 95% c.i. 0.02 to 0.42; P = 0.002), regardless of molecular subtype. Only 3% of patients who had a radiological complete response in the breast were ypN+. The majority of patients (85%) with a positive sentinel node proceeded to axillary lymph node dissection and 93% had N1 disease. CONCLUSION The rate of sentinel lymph node positivity in patients who achieve a radiological complete response in the breast is exceptionally low for all molecular subtypes.
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Affiliation(s)
| | - Katie Doogan
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Siobhan Clifford
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gavin Dowling
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Farah Kazi
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Karina Delaney
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Himanshu Yadav
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Aaron Brady
- Department of Breast Surgery, Bon Secours Hospital Cork, Cork, Ireland
| | - James Geraghty
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Denis Evoy
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Jane Rothwell
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Damian McCartan
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Anna Heeney
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mitchel Barry
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Siun M Walsh
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Maurice Stokes
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Malcolm R Kell
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Allen
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Colm Power
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Arnold D K Hill
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Dhafir Alazawi
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Terence Boyle
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Mark Corrigan
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Peter O’Leary
- Department of Breast Surgery, Bon Secours Hospital Cork, Cork, Ireland
| | - Ruth S Prichard
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
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16
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Vongsaisuwon M, Vacharathit V, Lerttiendamrong B, Manasnayakorn S, Tantiphlachiva K, Vongwattanakit P, Treeratanapun N. Reconsidering the Role of Frozen Section in Sentinel Lymph Node Biopsy for Mastectomy Patients. J Surg Res 2024; 293:64-70. [PMID: 37716102 DOI: 10.1016/j.jss.2023.08.013] [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: 06/23/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION Axillary lymph node dissection was recommended for mastectomy patients with more than two nodal metastases from sentinel lymph node biopsy. Conventionally, intraoperative frozen section was sent routinely to reduce the need for second-stage axillary lymph node dissection; however, recent global trend has seen decreasing usage of the intraoperative analyses. This pilot study conducted in Thailand aimed to evaluate the role of intraoperative frozen section of sentinel lymph node biopsy in early-stage breast cancer patients who underwent mastectomy. METHODS A 5-y retrospective study of 1773 patients was conducted in Thailand. The inclusion criteria were early-stage breast cancer patients with either radiologically negative nodes, or radiographically borderline nodes found to be negative on fine needle aspiration who underwent mastectomy and sentinel lymph node biopsy. Reoperations were indicated when three or more nodal metastases were detected on the pathological analysis. The reoperation rate prevented by frozen section and the reoperation rate needed for those with permanent section alone were reported. RESULTS Among 265 patients, 202 patients underwent concomitant intraoperative frozen section while the remaining 63 patients underwent permanent section alone. Six patients (3.0%) from the frozen section group and one patient (1.6%) from the permanent section group were found with more than two nodal metastases. Despite using intraoperative frozen sections, only one patient from each group required reoperation. There was no significant difference in the number of patients requiring reoperation between the frozen section group and the permanent section group. CONCLUSIONS Our study provides strong evidence to all surgeons that in early breast cancer patients undergoing mastectomy, sentinel lymph node biopsy with permanent section analysis alone may not lower the standard of care compared to using additional intraoperative frozen section analysis. Adopting this practice may lead to decreased operation costs, operative time, and anesthetic side effects.
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Affiliation(s)
- Mawin Vongsaisuwon
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | | | - Sopark Manasnayakorn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kasaya Tantiphlachiva
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Nattanan Treeratanapun
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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17
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Ong C, Blue CM, Khan J, Deng X, Bandyopadhyay D, Louie RJ, McGuire KP. Luminal A Versus B After Choosing Wisely: Does Lymph Node Surgery Affect Oncologic Outcomes? Ann Surg Oncol 2024; 31:335-343. [PMID: 37831277 DOI: 10.1245/s10434-023-14407-1] [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: 06/26/2023] [Accepted: 09/17/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND In 2016, the Choosing Wisely campaign recommended against routine sentinel lymph node biopsy (SLNB) in women ≥ 70 years old diagnosed with early-stage hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer. No distinction is made between luminal A and luminal B phenotypes, despite luminal B being considered more aggressive. This study evaluates the effect of SLNB on oncologic outcomes in HER2- luminal B versus luminal A breast cancer. PATIENTS AND METHODS We performed an IRB-approved, single institution, retrospective cohort study from 2010 to 2020 of women aged ≥ 70 years with clinically node negative, HR+ breast cancer undergoing definitive surgical treatment. Luminal status was defined by gene expression panel testing, Ki67%, and/or pathologic grading. Primary endpoints included locoregional recurrence (LRR), disease free survival (DFS), and overall survival (OS). RESULTS SLNB did not correlate with significant differences in LRR in luminal A (p = 0.92) or luminal B (p = 0.96) disease. SLNB correlated with improved DFS (p < 0.01) and OS (p < 0.001) in luminal A disease, but not in luminal B disease (DFS p = 0.73; OS p = 0.36). On multivariate analysis, age (HR = 1.17; p < 0.01) and tumor size (HR = 1.03; p < 0.05) were associated with DFS, while SLNB was not (p = 0.71). Luminal status (HR = 0.52, p < 0.05), age (HR = 1.15, p < 0.01), and comorbidities (HR = 1.35, p < 0.05) were associated with OS, but not SLNB (p = 0.71). CONCLUSIONS Our results suggest that SLNB may be safely omitted in patients aged ≥ 70 years with luminal B disease given similar LRR in luminal A disease. Our findings suggest that DFS and OS are driven by tumor biology, patient age, and comorbidities rather than receipt of SLNB.
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Affiliation(s)
- Cynthia Ong
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Christian M Blue
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Jamal Khan
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Xiaoyan Deng
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Raphael J Louie
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Kandace P McGuire
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA.
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18
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Pesapane F, Mariano L, Magnoni F, Rotili A, Pupo D, Nicosia L, Bozzini AC, Penco S, Latronico A, Pizzamiglio M, Corso G, Cassano E. Future Directions in the Assessment of Axillary Lymph Nodes in Patients with Breast Cancer. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1544. [PMID: 37763661 PMCID: PMC10534800 DOI: 10.3390/medicina59091544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Breast cancer (BC) is a leading cause of morbidity and mortality worldwide, and accurate assessment of axillary lymph nodes (ALNs) is crucial for patient management and outcomes. We aim to summarize the current state of ALN assessment techniques in BC and provide insights into future directions. Materials and Methods: This review discusses various imaging techniques used for ALN evaluation, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. It highlights advancements in these techniques and their potential to improve diagnostic accuracy. The review also examines landmark clinical trials that have influenced axillary management, such as the Z0011 trial and the IBCSG 23-01 trial. The role of artificial intelligence (AI), specifically deep learning algorithms, in improving ALN assessment is examined. Results: The review outlines the key findings of these trials, which demonstrated the feasibility of avoiding axillary lymph node dissection (ALND) in certain patient populations with low sentinel lymph node (SLN) burden. It also discusses ongoing trials, including the SOUND trial, which investigates the use of axillary ultrasound to identify patients who can safely avoid sentinel lymph node biopsy (SLNB). Furthermore, the potential of emerging techniques and the integration of AI in enhancing ALN assessment accuracy are presented. Conclusions: The review concludes that advancements in ALN assessment techniques have the potential to improve patient outcomes by reducing surgical complications while maintaining accurate disease staging. However, challenges such as standardization of imaging protocols and interpretation criteria need to be addressed. Future research should focus on large-scale clinical trials to validate emerging techniques and establish their efficacy and cost-effectiveness. Over-all, this review provides valuable insights into the current status and future directions of ALN assessment in BC, highlighting opportunities for improving patient care.
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Affiliation(s)
- Filippo Pesapane
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Luciano Mariano
- Breast Imaging Division, AOU Città della Scienza e della Salute di Torino, 10126 Turin, Italy;
| | - Francesca Magnoni
- Division of Breast Surgery, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (F.M.); (G.C.)
- European Cancer Prevention Organization (ECP), 20122 Milan, Italy
| | - Anna Rotili
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Davide Pupo
- Radiology Division, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy;
| | - Luca Nicosia
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Anna Carla Bozzini
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Silvia Penco
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Antuono Latronico
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Maria Pizzamiglio
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
| | - Giovanni Corso
- Division of Breast Surgery, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (F.M.); (G.C.)
- European Cancer Prevention Organization (ECP), 20122 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Enrico Cassano
- Breast Imaging Division, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.R.); (L.N.); (A.C.B.); (S.P.); (A.L.); (M.P.); (E.C.)
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19
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Record SM, Plichta JK. De-Escalation of Axillary Surgery for Older Patients with Breast Cancer: Supporting Data Continue to Accumulate. Ann Surg Oncol 2023; 30:3882-3884. [PMID: 36820936 PMCID: PMC10441034 DOI: 10.1245/s10434-023-13299-5] [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: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Sydney M Record
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
- Duke Cancer Institute, Duke University, Durham, NC, USA.
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA.
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20
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Heidinger M, Maggi N, Dutilh G, Mueller M, Eller RS, Loesch JM, Schwab FD, Kurzeder C, Weber WP. Use of sentinel lymph node biopsy in elderly patients with breast cancer - 10-year experience from a Swiss university hospital. World J Surg Oncol 2023; 21:176. [PMID: 37287038 DOI: 10.1186/s12957-023-03062-1] [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: 03/15/2023] [Accepted: 06/04/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The Choosing Wisely initiative recommended the omission of routine sentinel lymph node biopsy (SLNB) in patients ≥ 70 years of age, with clinically node-negative, early stage, hormone receptor (HR) positive and human epidermal growth factor receptor 2 (Her2) negative breast cancer in August 2016. Here, we assess the adherence to this recommendation in a Swiss university hospital. METHODS We conducted a retrospective single center cohort study from a prospectively maintained database. Patients ≥ 18 years of age with node-negative breast cancer were treated between 05/2011 and 03/2022. The primary outcome was the percentage of patients in the Choosing Wisely target group who underwent SLNB before and after the initiative went live. Statistical significance was tested using chi-squared test for categorical and Wilcoxon rank-sum tests for continuous variables. RESULTS In total, 586 patients met the inclusion criteria with a median follow-up of 2.7 years. Of these, 163 were ≥ 70 years of age and 79 were eligible for treatment according to the Choosing Wisely recommendations. There was a trend toward a higher rate of SLNB (92.7% vs. 75.0%, p = 0.07) after the Choosing Wisely recommendations were published. In patients ≥ 70 years with invasive disease, fewer received adjuvant radiotherapy after omission of SLNB (6.2% vs. 64.0%, p < 0.001), without differences concerning adjuvant systemic therapy. Both short-term and long-term complication rates after SLNB were low, without differences between elderly patients and those < 70 years. CONCLUSIONS Choosing Wisely recommendations did not result in a decreased use of SLNB in the elderly at a Swiss university hospital.
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Affiliation(s)
- Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
- Universitätsspital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Gilles Dutilh
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | - Ruth S Eller
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Julie M Loesch
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Fabienne D Schwab
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Christian Kurzeder
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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21
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Kim SY, Choi Y, Kim YS, Ha SM, Lee SH, Han W, Kim HK, Cho N, Moon WK, Chang JM. Use of imaging prediction model for omission of axillary surgery in early-stage breast cancer patients. Breast Cancer Res Treat 2023; 199:489-499. [PMID: 37097375 DOI: 10.1007/s10549-023-06952-w] [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: 12/21/2022] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE To develop a prediction model incorporating clinicopathological information, US, and MRI to diagnose axillary lymph node (LN) metastasis with acceptable false negative rate (FNR) in patients with early stage, clinically node-negative breast cancers. METHODS In this single center retrospective study, the inclusion criteria comprised women with clinical T1 or T2 and N0 breast cancers who underwent preoperative US and MRI between January 2017 and July 2018. Patients were temporally divided into the development and validation cohorts. Clinicopathological information, US, and MRI findings were collected. Two prediction models (US model and combined US and MRI model) were created using logistic regression analysis from the development cohort. FNRs of the two models were compared using the McNemar test. RESULTS A total of 964 women comprised the development (603 women, 54 ± 11 years) and validation (361 women, 53 ± 10 years) cohorts with 107 (18%) and 77 (21%) axillary LN metastases in each cohort, respectively. The US model consisted of tumor size and morphology of LN on US. The combined US and MRI model consisted of asymmetry of LN number, long diameter of LN, tumor type, and multiplicity of breast cancers on MRI, in addition to tumor size and morphology of LN on US. The combined model showed significantly lower FNR than the US model in both development (5% vs. 32%, P < .001) and validation (9% vs. 35%, P < .001) cohorts. CONCLUSION Our prediction model combining US and MRI characteristics of index cancer and LN lowered FNR compared to using US alone, and could potentially lead to avoid unnecessary SLNB in early stage, clinically node-negative breast cancers.
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Affiliation(s)
- Soo-Yeon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Yunhee Choi
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yeon Soo Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Su Min Ha
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Su Hyun Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Hong-Kyu Kim
- Department of Surgery, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Nariya Cho
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Woo Kyung Moon
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Jung Min Chang
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea.
- Department of Radiology, Seoul National College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea.
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22
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Reimer T. Omission of axillary sentinel lymph node biopsy in early invasive breast cancer. Breast 2023; 67:124-128. [PMID: 36658052 PMCID: PMC9982316 DOI: 10.1016/j.breast.2023.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023] Open
Abstract
Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated after publication of ACOSOG Z0011 data in 2010. Currently, prospective randomized surgical trials investigating the omission of SLNB in upfront breast-conserving surgery (BCS) and in the neoadjuvant setting, respectively. Several prospective randomized trials (SOUND, INSEMA, BOOG 2013-08, and NAUTILUS) with axillary observation alone versus SLNB in cN0 patients and primary BCS have primary objectives to evaluate oncologic safety when omitting SLNB. The Italian SOUND trial was the earliest to open in 2012 and has completed accrual in 2017. First oncologic outcome data are expected soon for SOUND and at the end of 2024 for INSEMA. Improvements in systemic treatments for breast cancer have increased the rates of pathologic complete response (pCR) in patients receiving neoadjuvant systemic therapy (NAST), offering the opportunity to de-escalate surgery in patients who have a pCR. Two prospective single-arm trials (EUBREAST-01, ASICS) include only patients with the highest likelihood of having a pCR after NAST (triple-negative or HER2-positive breast cancer) and type of surgery will be defined according to the response to NAST rather than on the classical T and N status. The ongoing trials will hopefully help us to understand whether we might take the best therapeutic decisions without the pathologic evaluation of nodal status.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059, Rostock, Germany.
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Lee TH, Chang JH, Jang BS, Kim JS, Kim TH, Park W, Kim YB, Kim SS, Han W, Lee HB, Shin KH. Protocol for the postoperative radiotherapy in N1 breast cancer patients (PORT-N1) trial, a prospective multicenter, randomized, controlled, non-inferiority trial of patients receiving breast-conserving surgery or mastectomy. BMC Cancer 2022; 22:1179. [DOI: 10.1186/s12885-022-10285-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
Postoperative radiotherapy (PORT) could be useful for pN1 breast cancer patients who have undergone breast-conserving surgery (BCS) or mastectomy. However, the value of regional nodal irradiation (RNI) for BCS patients, and the indications for post-mastectomy radiotherapy (PMRT) for pN1 breast cancer mastectomy patients, have recently been challenged due to the absence of relevant trials in the era of modern systemic therapy. “PORT de-escalation” should be assessed in patients with pN1 breast cancer.
Methods
The PORT-N1 trial is a multicenter, randomized, phase 3 clinical trial for patients with pN1 breast cancer that compares the outcomes of control [whole-breast irradiation (WBI) and RNI/PMRT] and experimental (WBI alone/no PMRT) groups. PORT-N1 aims to demonstrate non-inferiority of the experimental group by comparing 7-year disease-free survival rates with the control group. Female breast cancer patients with pT1-3 N1 status after BCS or mastectomy are eligible. Participants will be randomly assigned to the two groups in a 1:1 ratio. Randomization will be stratified by surgery type (BCS vs. mastectomy) and histologic subtype (triple-negative vs. non-triple-negative). In patients who receive mastectomy, dissection of ≥5 nodes is required when there is one positive node, and axillary lymph node dissection when there are two or three positive nodes. Patients receiving neoadjuvant chemotherapy are not eligible. RNI includes a “high-tangent” or wider irradiation field. This study will aim to recruit 1106 patients.
Discussion
The PORT-N1 trial aims to verify that PORT de-escalation after BCS or mastectomy is safe for pN1 breast cancer patients in terms of oncologic outcomes and capable of reducing toxicity rates. This trial will provide information crucial for designing PORT de-escalation strategies for patients with pN1 breast cancer.
Trial registration
This trial was registered at ClinicalTrials.gov (NCT05440149) on June 30, 2022.
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24
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Ryu JM, Choi HJ, Park EH, Kim JY, Lee YJ, Park S, Lee J, Park HK, Nam SJ, Kim SW, Lee JH, Lee JE. Relationship Between Breast and Axillary Pathologic Complete Response According to Clinical Nodal Stage: A Nationwide Study From Korean Breast Cancer Society. J Breast Cancer 2022; 25:94-105. [PMID: 35506578 PMCID: PMC9065358 DOI: 10.4048/jbc.2022.25.e17] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/27/2022] [Accepted: 04/03/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose We evaluated the relationship between breast pathologic complete response (BpCR) and axillary pathologic complete response (ApCR) after neoadjuvant chemotherapy (NACT) according to nodal burden at presentation. As the indications for NACT have expanded, clinicians have started clinical trials for the omission of surgery from the treatment plan in patients with excellent responses to NACT. However, the appropriate indications for axillary surgery omission after excellent NACT response remain unclear. Methods Data were collected from patients in the Korean Breast Cancer Society Registry who underwent NACT followed by surgery between 2010 and 2020. We analyzed pathologic axillary nodal positivity after NACT according to BpCR stratified by tumor subtype in patients with cT1-3/N0-2 disease at diagnosis. Results A total of 6,597 patients were identified. Regarding cT stage, 528 (9.5%), 3,778 (67.8%), and 1,268 (22.7%) patients had cT1, cT2, and cT3 disease, respectively. Regarding cN stage, 1,539 (27.7%), 2,976 (53.6%), and 1,036 (18.7%) patients had cN0, cN1, and cN2 disease, respectively. BpCR occurred in 21.6% (n = 1,427) of patients, while ApCR and pathologic complete response (ypCR) occurred in 59.7% (n = 3,929) and ypCR 19.4% (n = 1,285) of patients, respectively. The distribution of biologic subtypes included 2,329 (39.3%) patients with hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-negative disease, 1,122 (18.9%) with HR-positive/HER2-positive disease, 405 (6.8%) with HR-negative/HER2-positive disease, and 2,072 (35.0%) with triple-negative breast cancer . Among the patients with BpCR, 89.6% (1,122/1,252) had ApCR. Of those with cN0 disease, most (99.0%, 301/304) showed ApCR. Among patients with cN1-2 disease, 86.6% (821/948) had ApCR. Conclusion BpCR was highly correlated with ApCR after NACT. In patients with cN0 and BpCR, the risk of missing axillary nodal metastasis was low after NACT. Further research on axillary surgery omission in patients with cN0 disease is needed.
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Affiliation(s)
- Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Jun Choi
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Eun Hwa Park
- Department of Surgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Ji Young Kim
- Department of Surgery, Ajou University Hospital, Suwon, Korea
| | - Young Joo Lee
- Department of Surgery, Asan Medical Center, Seoul, Korea
| | - Seho Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jeeyeon Lee
- Division of Breast Surgery, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Heung Kyu Park
- Department of Breast Cancer Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Seok Jin Nam
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Won Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun-Hee Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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