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Liu Y, Fan Y, Jin Z, Cui M, Yu X, Jin F, Wang X. Axillary management for early invasive breast cancer patients: Who will truly benefit? Front Oncol 2022; 12:989975. [PMID: 36046051 PMCID: PMC9421357 DOI: 10.3389/fonc.2022.989975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe implementation of sentinel lymph node biopsy (SLNB) and further completion axillary lymph node dissection (cALND) after positive sentinel lymph nodes (SLNs) on early invasive breast cancer patients should be cautiously tailored. Identifying predictors for SLN and non-sentinel lymph node (nSLN) metastases can help surgeons make better surgical decisions.MethodsA retrospective case-control study was designed and a total of 560 eligible patients were enrolled consecutively. They were all diagnosed in our center and received appropriate medical care. According to the metastasis of SLN and nSLN, they were divided into metastatic and non-metastatic groups on two successive occasions to investigate the relationship between clinical factors, pathological factors, hematological factors and lymph node metastasis.ResultsIn total, 101 (18.04%) patients developed SLN metastases, including 98 patients with macro-metastases and 3 patients with micro-metastases. Out of 97 patients receiving further cALND, 20 patients (20.62%) developed nSLN metastases. Multivariate analysis revealed that “high expression of Ki-67” and “lymphatic invasion” predicted a higher risk of SLN metastasis; and “increased number of positive SLNs” and “increased systemic inflammation index (SII)” predicted a higher risk of nSLN metastasis.ConclusionSurgery for early invasive breast cancer patients should be more customized and precise. Appropriate axillary management is necessary for patients with the associated predictors.
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Affiliation(s)
- Yanbiao Liu
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Yan Fan
- Department of Pediatrics, The First Hospital of China Medical University, Shenyang, China
- Department of Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China
- Research Unit of General Surgery, Department of Breast Surgery and Surgical Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Zining Jin
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Mengyao Cui
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Xinmiao Yu
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Feng Jin
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Xu Wang
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
- *Correspondence: Xu Wang,
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Cha C, Kim EY, Kim SY, Ryu JM, Park MH, Lee S, Suh YJ, Choi N, Hong H, Kim HS, Chung MS. Impact of the ACOSOG Z0011 trial on surgical practice in Asian patients: trends in axillary surgery for breast cancer from a Korean Breast Cancer Registry analysis. World J Surg Oncol 2022; 20:198. [PMID: 35698188 PMCID: PMC9195282 DOI: 10.1186/s12957-022-02673-4] [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: 10/04/2021] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Since the publication of the Z0011 trial, practice-changing clinical guidelines for breast surgery have been developed. Although recent studies confirmed the feasibility of the Z0011 strategy in Asian populations, there has been no study on the trends of axillary surgery in Asian cohort. This study aimed to investigate the time trend of axillary surgery for breast cancer from a Korean Breast Cancer Registry to understand the impact of the Z0011 trial in Asian patients. Methods We collected prospectively constructed data from the nationwide Korean Breast Cancer Registry (KBCR). We identified patients who underwent sentinel node biopsy followed by breast-conserving surgery from 2011 to 2018 and were found to have pathological stage T1-2N1-3M0 disease. Regression analyses were performed to compare the downward trend of axillary lymph node dissection (ALND) in Korean cohort with that previously reported in a Dutch cohort. Results From KBCR data, 7478 patients met the inclusion criteria. The proportion of ALND significantly decreased from 2011 (76.6%) to 2018 (47.5%). Multivariate analysis revealed that earlier years at diagnosis, larger tumor size, and lymphatic invasion were associated with a higher odds ratio of performing ALND. Compared to the Dutch cohort, the downward trend of ALND in Korea was significantly more gradual (annual percent change: 37.2 vs. 5.8%, p < 0.001). Conclusions This study demonstrated a downward trend of ALND in Korean patients with breast cancer. However, the rate of decrease was significantly slower than that in the Dutch cohort.
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Affiliation(s)
- Chihwan Cha
- Department of Surgery, Hanyang University College of Medicine, 222, Wangsimni-ro, Seongdong-gu, 04764, Seoul, South Korea
| | - Eun Young Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung Yong Kim
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Chungnam, South Korea
| | - Jai Min Ryu
- Department of Surgery, Samsung Comprehensive Cancer Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Min Ho Park
- Department of Surgery, Chonnam National University Medical School & Hospital, Gwangju, South Korea
| | - Seokwon Lee
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Young-Jin Suh
- Department of Surgery, The Catholic University of Korea St. Vincent's Hospital, Suwon, South Korea
| | - Nayeon Choi
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, South Korea
| | - Hanpyo Hong
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, South Korea
| | - Hyung Suk Kim
- Department of Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Gyeonggi-do, South Korea
| | - Min Sung Chung
- Department of Surgery, Hanyang University College of Medicine, 222, Wangsimni-ro, Seongdong-gu, 04764, Seoul, South Korea.
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Tinterri C, Gentile D, Gatzemeier W, Sagona A, Barbieri E, Testori A, Errico V, Bottini A, Marrazzo E, Dani C, Dozin B, Boni L, Bruzzi P, Fernandes B, Franceschini D, Spoto R, Torrisi R, Scorsetti M, Santoro A, Canavese G. Preservation of Axillary Lymph Nodes Compared with Complete Dissection in T1-2 Breast Cancer Patients Presenting One or Two Metastatic Sentinel Lymph Nodes: The SINODAR-ONE Multicenter Randomized Clinical Trial. Ann Surg Oncol 2022; 29:5732-5744. [PMID: 35552930 DOI: 10.1245/s10434-022-11866-w] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/20/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The SINODAR-ONE trial is a prospective noninferiority multicenter randomized study aimed at assessing the role of axillary lymph node dissection (ALND) in patients undergoing either breast-conserving surgery or mastectomy for T1-2 breast cancer (BC) and presenting one or two macrometastatic sentinel lymph nodes (SLNs). The endpoints were to evaluate whether SLN biopsy (SLNB) only was associated with worsening of the prognosis compared with ALND in terms of overall survival (OS) and relapse. METHODS Patients were randomly assigned (1:1 ratio) to either removal of ≥ 10 axillary level I/II non-SLNs followed by adjuvant therapy (standard arm) or no further axillary treatment (experimental arm). RESULTS The trial started in April 2015 and ceased in April 2020, involving 889 patients. Median follow-up was 34.0 months. There were eight deaths (ALND, 4; SNLB only, 4), with 5-year cumulative mortality of 5.8% and 2.1% in the standard and experimental arm, respectively (p = 0.984). There were 26 recurrences (ALND 11; SNLB only, 15), with 5-year cumulative incidence of recurrence of 6.9% and 3.3% in the standard and experimental arm, respectively (p = 0.444). Only one axillary lymph node recurrence was observed in each arm. The 5-year OS rates were 98.9% and 98.8%, in the ALND and SNLB-only arm, respectively (p = 0.936). CONCLUSIONS The 3-year survival and relapse rates of T1-2 BC patients with one or two macrometastatic SLNs treated with SLNB only, and adjuvant therapy, were not inferior to those of patients treated with ALND. These results do not support the use of routine ALND.
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Affiliation(s)
- Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Damiano Gentile
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | | | - Andrea Sagona
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Erika Barbieri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alberto Testori
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Valentina Errico
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alberto Bottini
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Carla Dani
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Beatrice Dozin
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Luca Boni
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Paolo Bruzzi
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Bethania Fernandes
- Department of Pathology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ruggero Spoto
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Rosalba Torrisi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giuseppe Canavese
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Wang X, Gao Y, Yang X, Kong X, Wang Z, Fang Y, Wang J. Omitting ALND Is Not Safe for a Cohort of Early-Stage Breast Cancer Patients with 1-2 SLNs Macro-Metastases and Breast-Conserving Therapy: A Single-Center Retrospective Study. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:1262-1268. [PMID: 33083292 PMCID: PMC7548499 DOI: 10.18502/ijph.v49i7.3579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Omitting axillary lymph node dissection (ALND) is recommended for early-stage breast cancer patients with 1–2 sentinel lymph nodes (SLNs) macro-metastases and breast-conserving therapy. However, it is not safe for part of patients, so it is significant to find risk factors and develop a predictive model of non-SLNs metastases in breast cancer patients with 1–2 SLNs macro-metastases and breast-conserving therapy. Methods: This retrospective study enrolled 228 breast cancer patients with 1–2 SLNs macro-metastases who underwent ALND and breast-conserving surgery between Jan 2012 and Dec 2017 at Cancer Hospital Chinese Academy of Medical Sciences. Chi-square test and backward stepwise binary logistic regression were used to find factors that influenced non-SLN metastases, then a predictive model was formulated and obtained its area under the curve. Results: Tumor pathologic invasion size, number of positive SLNs and ALN status on imaging was associated with non-SLNs metastases. The predictive model was also formulated based on these three factors to assess and the area under the curve of model was 0.708. Conclusion: We developed a predictive model to assess the high-risk cohort of patients of non-SLNs metastases which can be an auxiliary tool for doctors.
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Affiliation(s)
- Xiangyu Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yinqi Gao
- Department of Oncology, Capital Medical University Electric Power Teaching Hospital, Beijing, 100073, China
| | - Xue Yang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Xiangyi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zixing Wang
- School of Basic Medical Sciences, Jining Medical University, Jining, 272067, China
| | - Yi Fang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jing Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
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External Validation of the SERC Trial Population: Comparison with the Multicenter French Cohort, the Swedish and SENOMIC Trial Populations for Breast Cancer Patients with Sentinel Node Micro-Metastasis. Cancers (Basel) 2020; 12:cancers12102924. [PMID: 33050650 PMCID: PMC7600229 DOI: 10.3390/cancers12102924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/17/2022] Open
Abstract
Simple Summary After the results of many trials, it is now accepted to omit axillary dissection in selected patients with limited axillary involvement. However, the external validity of these trials is questionable. Our study aimed to evaluate the accuracy of the real French population representativity in the SERC (Sentinelle Envahi et Randomisation du Curage) trial population for patients with breast cancer (BC) associated with sentinel node (SN) micro-metastasis and the differences between the studied population and the real French population. The secondary aim was to compare the French and the Swedish populations of patients with SN micro-metastasis. The findings of our study in addition to the previously demonstrated concordance between the SENOMIC (Sentinelle node Micrometastasis) trial and the Swedish National Breast Cancer Registry (NKBC) populations implied that the results of both the SERC and the SENOMIC trials can be applied to both the French and Swedish real populations. Abstract Many trials confirmed the safety of omitting axillary dissection in the selected patients treated for early breast cancer. The external validity of these trials is questionable. Our study aimed to evaluate the accuracy of the French population representativity in the SERC trial and the differences between these two populations as well as comparing the French and the Swedish populations (the SENOMIC trial population and the Swedish National Breast Cancer Registry (NKBC) cohort) of patients with sentinel node (SN) micro-metastasis. A higher rate of smaller tumors and grade 1 tumors was observed in the French cohort when compared to the SERC population. Our findings conclude that both French populations show similar characteristics. Positive non-sentinel node (NSN) rates at completion axillary lymph node dissection (ALND) were 10.28 % and 11.3 % in the SERC trial and French cohort, respectively (p = 0.5). The rate of grade 1 tumors was lower in the SENOMIC trial (16.2%) and in the NKBC cohort (17.4%) compared to the SERC trial population (27.3%) and the French cohort (34.4%). Our findings in addition to the previously demonstrated concordance between the SENOMIC trial and the NKBC populations imply that the results of both the SERC and the SENOMIC trials can be applied to both French and Swedish real populations.
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Predictive factors of lymph node metastasis and effectiveness of intraoperative examination of sentinel lymph node in breast carcinoma: A retrospective Belgian study. Ann Diagn Pathol 2020; 49:151607. [PMID: 32949894 DOI: 10.1016/j.anndiagpath.2020.151607] [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: 04/10/2020] [Revised: 08/17/2020] [Accepted: 08/17/2020] [Indexed: 11/22/2022]
Abstract
Recently, several trials demonstrated the safety of omitting axillary lymph node dissection in clinically N0 patients with positive sentinel nodes in select subgroups. However, this fact is still troublesome to clarify to surgeons and clinicians, as they used to perform intraoperative examination of the sentinel node and axillary dissection for many years. Hence, we decided to review our practice. This is to firstly highlight the predictive factors of node metastasis and secondly, to evaluate the effectiveness of intraoperative examination of the sentinel node. There were 406 total procedures. The rate of positive lymph nodes in the final diagnosis was 27%. Factors associated with metastasis were age, tumour size, TNM classification, tumour grade, vascular invasion, molecular classification and KI-67 index. The rate of reoperation was 6.2% in cases with final positive nodes, however, the complementary ALND was justified in only 2.7%. Forty-nine percent of SLN were examined during surgery (IOESLN), whereby the false negative rate was 11.8%. Sixty-three intraoperative examinations were necessary to prevent a second operation on a patient. We recommend changing the clinical management of the axilla, resulting in fewer ALNDs in selected cN0, SLN-positive patients. In keeping with recent large clinical trial (ACOSOG Z0011, AMAROS and OTOASOR) data, our results support that intraoperative exam in selected cN0, SLN-positive Belgian patients is no longer effective.
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7
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Huang TW, Su CM, Tam KW. Axillary Management in Women with Early Breast Cancer and Limited Sentinel Node Metastasis: A Systematic Review and Metaanalysis of Real-World Evidence in the Post-ACOSOG Z0011 Era. Ann Surg Oncol 2020; 28:920-929. [PMID: 32705512 DOI: 10.1245/s10434-020-08923-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/04/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND After the publication of the Z0011 trial, the American Society of Clinical Oncology published an updated clinical practice guideline stating that clinicians should not recommend axillary lymph node dissection (ALND) for early-stage breast cancer patients with the involvement of one or two sentinel lymph nodes (SLNs). However, these recommendations have been challenged because they were mainly based on data from limited studies. The aim of the current study is to systematically compare the real-world outcomes of SLN biopsy (SLNB) alone and SLNB + ALND in patients with early-stage breast cancers and limited positive SLN metastasis in the post-Z0011 era PATIENTS AND METHODS: We searched articles in the PubMed, EMBASE, and Cochrane library databases. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were recurrence rate and the incidence of lymphedema. RESULTS One randomized controlled trial and six retrospective studies with 8864 patients were retrieved. For patients with early-stage breast cancer with one or two SLN metastases, receiving SLNB alone showed no significant difference in OS, DFS, and recurrence rate compared with receiving SLNB + ALND. The incidence of lymphedema in patients who received SLNB alone was significantly lower than those who received SLNB + ALND (odds ratio 1.95, 95% confidence interval 1.02-3.71). CONCLUSIONS Current real-world evidence proved that the Z0011 strategy is safe with respect to survival outcomes and effective in reducing the incidence of lymphedema. ALND should be avoided in patients with early-stage breast cancer with one or two SLN metastases in the post-Z0011 era.
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Affiliation(s)
- Tzu-Wen Huang
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Ming Su
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
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8
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Garcia-Etienne CA, Ferrari A, Della Valle A, Lucioni M, Ferraris E, Di Giulio G, Squillace L, Bonzano E, Lasagna A, Rizzo G, Tancredi R, Scotti Foglieni A, Dionigi F, Grasso M, Arbustini E, Cavenaghi G, Pedrazzoli P, Filippi AR, Dionigi P, Sgarella A. Management of the axilla in patients with breast cancer and positive sentinel lymph node biopsy: An evidence-based update in a European breast center. Eur J Surg Oncol 2019; 46:15-23. [PMID: 31445768 DOI: 10.1016/j.ejso.2019.08.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/22/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023] Open
Abstract
The surgical approach to the axilla in breast cancer has been a controversial issue for more than three decades. Data from recently published trials have provided practice-changing recommendations in this scenario. However, further controversies have been triggered in the surgical community, resulting in heterogeneous diffusion of these recommendations. The development of clinical guidelines for the management of the axilla in patients with breast cancer is a work in progress. A multidisciplinary team discussion was held at the research hospital Policlinico San Matteo from the Università degli Studi di Pavia with the aim to update recommendations for the management of the axilla in patients with breast cancer. An evidence-based approach is presented. Our multidisciplinary panel determined that axillary dissection after a positive sentinel lymph node biopsy may be avoided in cN0 patients with micro/macrometastasis to ≤2 sentinel nodes, with age ≥40y, lesions ≤3 cm, who have not received neoadjuvant chemotherapy and have planned breast conservation (BCS) with whole breast radiotherapy (WBRT). Cases with gross (>2 mm) ECE in SLNs are evaluated on individual basis for completion ALND, axillary radiotherapy or omission of both. Patients fulfilling the criteria listed above who undergo mastectomy, may also avoid axillary dissection after multidisciplinary discussion of individual cases for consideration of axillary irradiation. Women 70 years or older with hormone receptors positive invasive lesions ≤3 cm, clinically negative nodes, and serious or multiple comorbidities who undergo BCS with WBRT, may forgo axillary staging/surgery (if mastectomy or larger tumor, comorbidities and life expectancy are taken into account).
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Affiliation(s)
- Carlos A Garcia-Etienne
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy.
| | - Alberta Ferrari
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Angelica Della Valle
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Marco Lucioni
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Elisa Ferraris
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giuseppe Di Giulio
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Luigi Squillace
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Elisabetta Bonzano
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Angioletta Lasagna
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Gianpiero Rizzo
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Richard Tancredi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Andrea Scotti Foglieni
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Francesca Dionigi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Maurizia Grasso
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Eloisa Arbustini
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giorgio Cavenaghi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Paolo Pedrazzoli
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Andrea R Filippi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Paolo Dionigi
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Adele Sgarella
- Breast Center, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
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Garcia-Etienne CA, Mansel RE, Tomatis M, Heil J, Biganzoli L, Ferrari A, Marotti L, Sgarella A, Ponti A. Trends in axillary lymph node dissection for early-stage breast cancer in Europe: Impact of evidence on practice. Breast 2019; 45:89-96. [PMID: 30925382 DOI: 10.1016/j.breast.2019.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 03/07/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Data from recently published trials have provided practice-changing recommendations for the surgical approach to the axilla in breast cancer. Patients with T1-2 lesions, treated with breast conservation, who have not received neoadjuvant chemotherapy and have 1-2 positive sentinel nodes (Z0011-criteria) may avoid axillary lymph node dissection (ALND). We aim to describe the dissemination of this practice in Europe over an extended period of time. METHODS Our source of data was the eusomaDB, a central data warehouse of prospectively collected information of the European Society of Breast Cancer Specialists (EUSOMA). We identified cases fulfilling Z0011-criteria from 2005 to 2016 from 34 European breast centers and report trends in ALND. Data derived from Germany, Italy, Belgium, Switzerland, Austria, and Netherlands. RESULTS 6671 patients fulfilled Z0011-criteria. Rates of ALND showed a statistically significant decrease from 2010 (89%) to 2011 (73%), reaching 46% in 2016 (p < 0.001). After multivariable analysis, factors associated with higher probability of ALND were earlier year of surgery, younger age, increasing tumor size and grade, and being operated in Italy (p < 0.001). The minimum and maximal rates of ALND in the most recent two-year period (2015-2016) were 0% and 83% in two centers located in different countries (p < 0.001). CONCLUSION Our study demonstrates, a decrease in rates of ALND that started after year 2010 through the end of the study period. Wide differences were observed among centers and countries indicating the need to spread unified clinical guidelines in Europe to allow for homogeneous evidence-based practice patterns.
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Affiliation(s)
- Carlos A Garcia-Etienne
- Breast Surgery, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Italy.
| | | | - Mariano Tomatis
- AOU Città della Salute e della Scienza, CPO Piemonte and EUSOMA Data Centre, Turin, Italy
| | | | | | - Alberta Ferrari
- Breast Surgery, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Italy
| | | | - Adele Sgarella
- Breast Surgery, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Italy
| | - Antonio Ponti
- AOU Città della Salute e della Scienza, CPO Piemonte and EUSOMA Data Centre, Turin, Italy
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Huang TW, Kuo KN, Chen KH, Chen C, Hou WH, Lee WH, Chao TY, Tsai JT, Su CM, Huang MT, Tam KW. Recommendation for axillary lymph node dissection in women with early breast cancer and sentinel node metastasis: A systematic review and meta-analysis of randomized controlled trials using the GRADE system. Int J Surg 2016; 34:73-80. [DOI: 10.1016/j.ijsu.2016.08.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 10/21/2022]
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11
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Azghadi S, Daly M, Mayadev J. Practice Patterns of Radiation Field Design for Sentinel Lymph Node-Positive Early-Stage Breast Cancer. Clin Breast Cancer 2016; 16:410-417.e3. [PMID: 27266803 DOI: 10.1016/j.clbc.2016.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 04/06/2016] [Accepted: 05/09/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent randomized trials have led to decreased use of completion axillary lymph node dissection (ALND) in early-stage breast cancer patients with a positive sentinel lymph node (SLN), causing controversy surrounding radiotherapy coverage of the axilla. We investigated the practice variation among radiation oncologists for regional nodal coverage for clinicopathologic scenarios and evaluated axillary field design decision-making processes. MATERIALS AND METHODS A customized, web-based questionnaire was e-mailed to 983 community (n = 617) and academic (n = 366) radiation oncologists with a breast cancer subspecialty practicing in the United States. The survey consisted of 18 multiple-choice questions evaluating general clinical preferences surrounding radiation therapy (RT) field design for patients with early-stage breast cancer and a positive SLN. Seven case scenarios were developed to investigate the field design in the setting of specific clinical and pathologic risk factors. Nodal coverage was classified as standard tangents (STs), high tangents (HTs), STs and a supraclavicular field (SCF), or STs and full axillary coverage (AX). RESULTS A total of 145 evaluable responses were collected, with a response rate of 15.0%. Of the respondents, 12 (8.3%) reported using completion ALND for patients with 1 to 3 positive SLNs without extracapsular extension (ECE) and 66 (45.5%) performed ALND with 1 to 3 positive SLNs with ECE. For micrometastatic SLNs, with no lymphovascular system invasion, 115 (87.1%) used STs or HTs. The use of neoadjuvant chemotherapy (NAC) influenced RT field design for patients with a positive SLN without ECE, with 64 (48.5%) using STs and SCF or STs and AX treatment without NAC and 94 (70.7%) using SCF and AX after NAC. With macrometastatic SLN involvement, most respondents preferred SCF (45.27%) and AX (45.66%). In contrast, for micrometastatic involvement, HTs (43.61%) were frequently chosen. Forty (27.8%) reported using online predictive nomograms to predict further axillary involvement, with no difference between the academic and community radiation oncologists (P = .11). CONCLUSION In SLN biopsy-positive early-stage breast cancer with omission of completion ALND, axillary RT is increasing used to cover the undissected axilla. Most respondents use SCF or AX for patients with low to intermediate pathologic features. Online prediction nomograms are used by a few practitioners to assist in clinical decision-making in this setting.
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Affiliation(s)
- Soheila Azghadi
- Department of Radiation Oncology, University of California, Davis, School of Medicine, Sacramento, CA
| | - Megan Daly
- Department of Radiation Oncology, University of California, Davis, School of Medicine, Sacramento, CA
| | - Jyoti Mayadev
- Department of Radiation Oncology, University of California, Davis, School of Medicine, Sacramento, CA.
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12
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Goyal A, Dodwell D. POSNOC: A Randomised Trial Looking at Axillary Treatment in Women with One or Two Sentinel Nodes with Macrometastases. Clin Oncol (R Coll Radiol) 2015; 27:692-5. [PMID: 26254841 DOI: 10.1016/j.clon.2015.07.005] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/17/2015] [Indexed: 11/26/2022]
Affiliation(s)
- A Goyal
- Royal Derby Hospital, Derby, UK.
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13
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Vernet-Tomás M, Baños N, Sabadell D, Corominas JM, Mestre-Fusco A, Suárez-Piñera M, Carreras R. p53 expression in breast cancer predicts tumors with low probability of non-sentinel nodes infiltration. J Obstet Gynaecol Res 2015; 41:1115-21. [PMID: 25657069 DOI: 10.1111/jog.12670] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/29/2014] [Indexed: 12/22/2022]
Abstract
AIM Several predictive tools of non-sentinel lymph nodes neoplastic involvement when a positive sentinel lymph node is found have been described. However, molecular factors have been rarely evaluated to build these tools. The aim of this study was to establish which factors predicted non-sentinel lymph nodes infiltration in our setting, including some molecular factors. MATERIAL AND METHODS We carried out a retrospective review of 161 patients with breast cancer and a positive sentinel lymph node who had undergone axillary lymph node dissection, none of whom had received neoadjuvant treatment. Features evaluated as predictive factors for non-sentinel node positivity were: menopausal status, tumor size, histological subtype, histological grade, lymphovascular invasion, extracapsular invasion, Ki67 index, hormonal receptors, CerbB2 and p53 expression, size of sentinel lymph node metastases and number of sentinel lymph nodes affected. RESULTS Tumor size (P = 0.001), size of sentinel lymph node metastases (P = 0.001), lobular invasive carcinoma (P = 0.05) and lymphovascular invasion (P = 0.006) were significantly associated with non-sentinel lymph node positivity. Tumor p53 positive expression was strongly associated with non-sentinel lymph node negativity (P = 0.000). In multivariate analysis, all these factors but tumor size maintained their significance. The discrimination power of the model calculated by the area under the receiver-operator curve was 0.811 (95% confidence interval, 0.741-0.880). CONCLUSION p53 expression in breast cancer was highly predictive of non-sentinel lymph node negativity in our study. New studies should evaluate if it would be useful to add p53 expression to other existing predictive tools.
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Affiliation(s)
- Maria Vernet-Tomás
- Obstetrics and Gynecology Department, Hospital del Mar, Bellaterra, Spain.,Breast Surgery, Breast Functional Unit, Hospital del Mar, Bellaterra, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Nuria Baños
- Obstetrics and Gynecology Department, Hospital del Mar, Bellaterra, Spain
| | - Dolors Sabadell
- Obstetrics and Gynecology Department, Hospital del Mar, Bellaterra, Spain.,Breast Surgery, Breast Functional Unit, Hospital del Mar, Bellaterra, Spain
| | - Josep-Maria Corominas
- Pathology Department, Hospital del Mar, Bellaterra, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | | | | | - Ramon Carreras
- Obstetrics and Gynecology Department, Hospital del Mar, Bellaterra, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
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14
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Giuliano AE, Bosserman LD, Edge SB, Weaver DL, Lyman GH. Reply to I.A. Voutsadakis et al and A. Goyal et al. J Clin Oncol 2014; 32:3902-4. [PMID: 25245450 DOI: 10.1200/jco.2014.57.7361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Donald L Weaver
- University of Vermont College of Medicine and Vermont Cancer Center, Burlington, VT
| | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
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