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Roach EA, Weil CR, Cannon G, Grant J, Van Meter M, Boothe D. The Role of Axillary Lymph Node Dissection versus Sentinel Lymph Node Dissection in Breast Cancer Patients with Clinical N2b-N3c Disease Who Receive Adjuvant Radiotherapy. Ann Surg Oncol 2024; 31:4527-4539. [PMID: 38647915 DOI: 10.1245/s10434-024-15280-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND For breast cancer with advanced regional lymph node involvement, axillary lymph node dissection (ALND) remains the standard of care for staging and treating the axilla despite the presence of undissected lymph nodes. The benefit of ALND in this setting is unknown. OBJECTIVES We sought to describe national patterns of care of axillary surgery and its association with overall survival (OS) among women with cN2b-N3c breast cancer who receive adjuvant radiotherapy. PATIENTS AND METHODS We identified female patients with cN2b-N3c breast cancer from 2012 to 2017 from the National Cancer Database. Clinical and demographic information were analyzed using Wilcoxon rank sum and χ2 tests. Predictors of receipt of ALND and predictors of death were identified with multivariable logistic regression modeling. Inverse probability of treatment weighting was implemented to adjust for differences in treatment cohorts. The Kaplan-Meier method was used to evaluate OS. RESULTS We identified 7167 patients. Of these, 922 (13%) received SLNB and 6254 (87%) received ALND; 7% were cN2b, 19% cN3a, 24% cN3b, 19% cN3c, and 31% cN3, not otherwise specified. Predictors of receipt of ALND were age 50-69 years [odds ratio (OR) 1.3, p < 0.01], cN3a (OR 7.6, p < 0.01), cN3b (OR 2.8, p < 0.01), and cN3c (OR 4.2, p < 0.01). Predictors of death included cN3c (OR 1.9, p < 0.01), age 70-90 years (OR 1.5, p = 0.01), and positive surgical margins (OR 1.5, p < 0.01). After cohort balancing, ALND was not associated with improved OS when compared with SLNB (HR 0.99, p = 0.91). CONCLUSIONS ALND in patients with advanced nodal disease was not associated with improved survival compared with SLNB for women who receive adjuvant radiotherapy.
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Affiliation(s)
- Eric A Roach
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Christopher R Weil
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George Cannon
- Department of Radiation Oncology, Intermountain Healthcare, Murray, UT, USA
| | - Jon Grant
- Department of Radiation Oncology, Intermountain Healthcare, Murray, UT, USA
| | - Margaret Van Meter
- Department of Hematology/Oncology, Intermountain Healthcare, Murray, UT, USA
| | - Dustin Boothe
- Department of Radiation Oncology, Intermountain Healthcare, Murray, UT, USA
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2
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Bozhok AA, Kashchenko VA, Ratnikov VA, Gornov SV, Suvorova YV, Manelov AE. [Fluorescence lymphography for sentinal lymph node biopsy in breast cancer]. Khirurgiia (Mosk) 2024:48-54. [PMID: 38380464 DOI: 10.17116/hirurgia202402248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
OBJECTIVE To study diagnostic value of fluorescence lymphography for sentinel lymph node biopsy in breast cancer. MATERIAL AND METHODS The study enrolled 25 patients with breast cancer T1-2N0-1M0 between March 2023 and July 2023. Eight ones underwent neoadjuvant chemotherapy. In 3 patients, morphologically verified metastases cN1 in axillary lymph nodes regressed after treatment. After sentinel lymph node biopsy, all patients underwent standard axillary lymphadenectomy. Subareolar injection of indocyanine green 1 ml (5 mg/ml) was performed immediately before surgery. Fluorescence imaging was performed using the MARS system. RESULTS Detection rate was 100%. Mean number of sentinel lymph nodes was 2. Metastatic lesions of sentinel lymph nodes were observed in 6 patients (24%) with micro-metastases in 2 cases. In 50% of cases, metastatic lesion did not extend beyond sentinel lymph nodes. False negative result was obtained in 1 (4%) patient. Mean number of metastases was 1.8 (max 3 in one patient). CONCLUSION Sentinel lymph node biopsy with fluorescence lymphography is a sensitive method. The advantages of this technique are visualization of subcutaneous lymphatic vessels and skin incision for access to sentinel lymph nodes, as well as visualization of sentinel lymph nodes after skin incision.
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Affiliation(s)
- A A Bozhok
- Saint Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - V A Kashchenko
- Sokolov North-Western Regional Scientific Clinical Center, St. Petersburg, Russia
| | - V A Ratnikov
- Sokolov North-Western Regional Scientific Clinical Center, St. Petersburg, Russia
| | - S V Gornov
- Russian Biotechnological University, Moscow, Russia
| | - Yu V Suvorova
- Sokolov North-Western Regional Scientific Clinical Center, St. Petersburg, Russia
| | - A E Manelov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
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Gasparri ML, Albasini S, Truffi M, Favilla K, Tagliaferri B, Piccotti F, Bossi D, Armatura G, Calcinotto A, Chiappa C, Combi F, Curcio A, Della Valle A, Ferrari G, Folli S, Ghilli M, Listorti C, Mancini S, Marinello P, Mele S, Pertusati A, Roncella M, Rossi L, Rovera F, Segattini S, Sgarella A, Tognali D, Corsi F. Low neutrophil-to-lymphocyte ratio and pan-immune-inflammation-value predict nodal pathologic complete response in 1274 breast cancer patients treated with neoadjuvant chemotherapy: a multicenter analysis. Ther Adv Med Oncol 2023; 15:17588359231193732. [PMID: 37720495 PMCID: PMC10504832 DOI: 10.1177/17588359231193732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/24/2023] [Indexed: 09/19/2023] Open
Abstract
Background Systemic inflammatory markers draw great interest as potential blood-based prognostic factors in several oncological settings. Objectives The aim of this study is to evaluate whether neutrophil-to-lymphocyte ratio (NLR) and pan-immune-inflammation value (PIV) predict nodal pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in node-positive (cN+) breast cancer (BC) patients. Design Clinically, cN+ BC patients undergoing NAC followed by breast and axillary surgery were enrolled in a multicentric study from 11 Breast Units. Methods Pretreatment blood counts were collected for the analysis and used to calculate NLR and PIV. Logistic regression analyses were performed to evaluate independent predictors of nodal pCR. Results A total of 1274 cN+ BC patients were included. Nodal pCR was achieved in 586 (46%) patients. At multivariate analysis, low NLR [odds ratio (OR) = 0.71; 95% CI, 0.51-0.98; p = 0.04] and low PIV (OR = 0.63; 95% CI, 0.44-0.90; p = 0.01) were independently predictive of increased likelihood of nodal pCR. A sub-analysis on cN1 patients (n = 1075) confirmed the statistical significance of these variables. PIV was significantly associated with axillary pCR in estrogen receptor (ER)-/human epidermal growth factor receptor 2 (HER2)+ (OR = 0.31; 95% CI, 0.12-0.83; p = 0.02) and ER-/HER2- (OR = 0.41; 95% CI, 0.17-0.97; p = 0.04) BC patients. Conclusion This study found that low NLR and PIV levels predict axillary pCR in patients with BC undergoing NAC. Registration Eudract number NCT05798806.
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Affiliation(s)
- Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, Lugano, Switzerland
- Centro di Senologia della Svizzera Italiana, Ospedale Regionale di Lugano EOC, Lugano, Switzerland
| | - Sara Albasini
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Marta Truffi
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Karin Favilla
- Scuola di specializzazione in Chirurgia Generale, Università di Milano, Milano, Italy
| | | | | | - Daniela Bossi
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Giulia Armatura
- Chirurgia Generale, Ospedale Centrale di Bolzano, Azienda Sanitaria dell’Alto Adige, Bolzano, Italy
| | - Arianna Calcinotto
- Institute of Oncology Research (IOR), Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Università della Svizzera italiana, Faculty of Biomedical Sciences, Lugano, Switzerland
| | | | - Francesca Combi
- International PhD School in Clinical and Experimental Medicine (CEM), University of Modena and Reggio Emilia, Modena, Italy
- Division of Breast Surgical Oncology, Department of Medical and Surgical, Maternal-Infantile and Adult Sciences, University Hospital of Modena, Modena, Italy
| | - Annalisa Curcio
- Chirurgia Senologica, Ospedale Morgagni Pierantoni, Ausl Romagna, Forlì, Italy
| | - Angelica Della Valle
- General Surgery 3- Breast Surgery, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Secondo Folli
- Breast Unit, Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Matteo Ghilli
- Breast Cancer Centre, University Hospital of Pisa, Pisa, Italy
| | - Chiara Listorti
- Breast Unit, Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Mancini
- Breast Surgery, Department of Surgery, ASST Fatebenefratelli Sacco, Milano, Italy
| | - Peter Marinello
- Chirurgia Generale, Ospedale Centrale di Bolzano, Azienda Sanitaria dell’Alto Adige, Bolzano, Italy
| | - Simone Mele
- Breast Surgery Unit, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Anna Pertusati
- Breast Surgery, Department of Surgery, ASST Fatebenefratelli Sacco, Milano, Italy
| | | | - Lorenzo Rossi
- Centro di Senologia della Svizzera Italiana, Ospedale Regionale di Lugano EOC, Lugano, Switzerland
- Institute of Oncology of Southern Switzerland (IOSI), Bellinzona, Switzerland
| | | | - Silvia Segattini
- Division of Breast Surgical Oncology, Department of Medical and Surgical, Maternal-Infantile and Adult Sciences, University Hospital of Modena, Modena, Italy
| | - Adele Sgarella
- General Surgery 3 – Breast Surgery, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Università degli studi di Pavia, Pavia, Italy
| | - Daniela Tognali
- Chirurgia Senologica, Ospedale Morgagni Pierantoni, Ausl Romagna, Forlì, Italy
| | - Fabio Corsi
- Istituti Clinici Scientifici Maugeri IRCCS, Via Maugeri 4, Pavia, Lombardia, Italy
- Dipartimento di Scienze Biomediche e Cliniche, Università di Milano, Milano, Italy
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Rochlin DH, Barrio AV, McLaughlin S, Van Zee KJ, Woods JF, Dayan JH, Coriddi MR, McGrath LA, Bloomfield EA, Boe L, Mehrara BJ. Feasibility and Clinical Utility of Prediction Models for Breast Cancer-Related Lymphedema Incorporating Racial Differences in Disease Incidence. JAMA Surg 2023; 158:954-964. [PMID: 37436762 PMCID: PMC10339225 DOI: 10.1001/jamasurg.2023.2414] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/31/2023] [Indexed: 07/13/2023]
Abstract
Importance Breast cancer-related lymphedema (BCRL) is a common complication of axillary lymph node dissection (ALND) but can also develop after sentinel lymph node biopsy (SLNB). Several models have been developed to predict the risk of disease development before and after surgery; however, these models have shortcomings that include the omission of race, inclusion of variables that are not readily available to patients, low sensitivity or specificity, and lack of risk assessment for patients treated with SLNB. Objective To create simple and accurate prediction models for BCRL that can be used to estimate preoperative or postoperative risk. Design, Setting, and Participants In this prognostic study, women with breast cancer who underwent ALND or SLNB from 1999 to 2020 at Memorial Sloan Kettering Cancer Center and the Mayo Clinic were included. Data were analyzed from September to December 2022. Main Outcomes and Measures Diagnosis of lymphedema based on measurements. Two predictive models were formulated via logistic regression: a preoperative model (model 1) and a postoperative model (model 2). Model 1 was externally validated using a cohort of 34 438 patients with an International Classification of Diseases diagnosis of breast cancer. Results Of 1882 included patients, all were female, and the mean (SD) age was 55.6 (12.2) years; 80 patients (4.3%) were Asian, 190 (10.1%) were Black, 1558 (82.8%) were White, and 54 (2.9%) were another race (including American Indian and Alaska Native, other race, patient refused to disclose, or unknown). A total of 218 patients (11.6%) were diagnosed with BCRL at a mean (SD) follow-up of 3.9 (1.8) years. The BCRL rate was significantly higher among Black women (42 of 190 [22.1%]) compared with all other races (Asian, 10 of 80 [12.5%]; White, 158 of 1558 [10.1%]; other race, 8 of 54 [14.8%]; P < .001). Model 1 included age, weight, height, race, ALND/SLNB status, any radiation therapy, and any chemotherapy. Model 2 included age, weight, race, ALND/SLNB status, any chemotherapy, and patient-reported arm swelling. Accuracy was 73.0% for model 1 (sensitivity, 76.6%; specificity, 72.5%; area under the receiver operating characteristic curve [AUC], 0.78; 95% CI, 0.75-0.81) at a cutoff of 0.18, and accuracy was 81.1% for model 2 (sensitivity, 78.0%; specificity, 81.5%; AUC, 0.86; 95% CI, 0.83-0.88) at a cutoff of 0.10. Both models demonstrated high AUCs on external (model 1: 0.75; 95% CI, 0.74-0.76) or internal (model 2: 0.82; 95% CI, 0.79-0.85) validation. Conclusions and Relevance In this study, preoperative and postoperative prediction models for BCRL were highly accurate and clinically relevant tools comprised of accessible inputs and underscored the effects of racial differences on BCRL risk. The preoperative model identified high-risk patients who require close monitoring or preventative measures. The postoperative model can be used for screening of high-risk patients, thus decreasing the need for frequent clinic visits and arm volume measurements.
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Affiliation(s)
- Danielle H. Rochlin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrea V. Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarah McLaughlin
- Breast Clinic, Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | - Kimberly J. Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jack F. Woods
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph H. Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michelle R. Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leslie A. McGrath
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily A. Bloomfield
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lillian Boe
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Campbell I, Wetzig N, Ung O, Espinoza D, Farshid G, Collins J, Kollias J, Gebski V, Mister R, Simes RJ, Stockler MR, Gill G. 10-Year axillary recurrence in the RACS SNAC1 randomised trial of sentinel lymph node-based management versus routine axillary lymph node dissection. Breast 2023; 70:70-75. [PMID: 37393644 DOI: 10.1016/j.breast.2023.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Sentinel node-based management (SNBM) is the international standard of care for early breast cancer that is clinically node-negative based on randomised trials comparing it with axillary lymph node dissection (ALND) and reporting similar rates of axillary recurrence (AR) without distant disease. We report all ARs, overall survival, and breast cancer-specific survival at 10-years in SNAC1. METHODS 1.088 women with clinically node-negative, unifocal breast cancers 3 cm or less in diameter were randomly assigned to either SNBM with ALND if the sentinel node (SN) was positive, or to SN biopsy followed by ALND regardless of SN involvement. RESULTS First ARs were more frequent in those assigned SNBM rather than ALND (11 events, cumulative risk at 10-years 1·85%, 95% CI 0·95-3.27% versus 2 events, 0·37%, 95% CI 0·08-1·26%; HR 5·47, 95% CI 1·21-24·63; p = 0·013). Disease-free survival, breast cancer-specific survival, and overall survival were similar in those assigned SNBM versus ALND. Lymphovascular invasion was an independent predictor of AR (HR 6·6, 95% CI 2·25-19·36, p < 0·001). CONCLUSION First ARs were more frequent with SNBM than ALND in women with small, unifocal breast cancers when all first axillary events were considered. We recommend that studies of axillary treatment should report all ARs to give an accurate indication of treatment effects. The absolute frequency of AR was low in women meeting our eligibility criteria, and SNBM should remain the treatment of choice in this group. However, for those with higher-risk breast cancers, further study is needed because the estimated risk of AR might alter their choice of axillary surgery.
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Affiliation(s)
- Ian Campbell
- Department of Surgery, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand; Waikato Hospital, Hamilton, New Zealand.
| | - Neil Wetzig
- Princess Alexandra Hospital, Brisbane, Australia
| | - Owen Ung
- Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - David Espinoza
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Gelareh Farshid
- South Australian Pathology, Royal Adelaide Hospital, Adelaide, Australia
| | - John Collins
- University of Melbourne, Department of Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - James Kollias
- Department of Surgery, University of Adelaide, Adelaide, Australia; Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Val Gebski
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Rebecca Mister
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - R John Simes
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Martin R Stockler
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Grantley Gill
- Emeritus Professor, University of Adelaide, Adelaide, Australia
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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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Gou Z, Lu X, He M, Yu L. Trends in axillary surgery and clinical outcomes among breast cancer patients with sentinel node metastasis. Breast 2022; 63:9-15. [PMID: 35245747 PMCID: PMC8892150 DOI: 10.1016/j.breast.2022.02.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/20/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background There is a lack of studies examining the long-term trend and survival of axillary surgery for breast cancer patients with sentinel node metastasis, especially for the patients with 3–5 node metastases. Methods Breast cancer patients with 1–5 sentinel node metastases from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2016. Our study presented the trend of axillary surgery and assessed the long-term survival of sentinel lymph node biopsy (SLNB) alone vs axillary lymph node dissection (ALND) for those patients. Results Of the 41,996 patients diagnosed with T1-2 breast cancer after lumpectomy and radiation included, 34,940 had 1-2 sentinel node metastases and 7056 had 3-5 sentinel node metastases. The percentage of patients undergoing SLNB alone increased from 22.4% in 2000 to 81.0% in 2016 for patients with 1–2 sentinel node metastases, and quadrupled from 5.2% in 2009 to 20.6% in 2016 for those with 3–5 sentinel node metastases. Completion of ALND did not benefit the long-term survival of 1–2 sentinel node metastasis patients (hazard ratio [HR] = 1.02, P = 0.539), but improved the long-term survival of 3–5 node metastasis patients (HR = 0.73, P < 0.001). Subgroup analysis demonstrated the inferiority of SLNB to ALND in all subgroups of 3–5 sentinel node metastases. Conclusion For patients with T1-2 breast cancer after lumpectomy and radiation, SLNB alone was an efficient and safe surgical choice for 1–2 sentinel node metastases but not for 3–5 sentinel node metastases. It is worth noting that for patients with 3–5 node metastasis, the proportion of omitted ALND quadrupled after 2009. Using SEER database, the research presents the long-term trend and survival of axillary surgery for breast cancer patients with 1-2 and 3-5 sentinel nodes metastasis. For patients with T1-2 breast cancer after lumpectomy and radiation, SLNB alone was efficient for 1–2 sentinel node metastases but not for 3–5 sentinel node metastases. Among patients with 3–5 node metastasis, the proportion of omitted ALND quadrupled from 2009 to 2016.
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Affiliation(s)
- Zongchao Gou
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China; State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
| | - Xunxi Lu
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, People's Republic of China; Institute of Clinical Pathology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Mengting He
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Luoting Yu
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
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Li H, Kang S, Sun L. A Study on the Evaluation of Polyenoic Vegetable Oils and Their Female Health Benefits Based on Time Series Analysis Model: The Case of Peony Seed Oil. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:3127698. [PMID: 35368936 PMCID: PMC8975637 DOI: 10.1155/2022/3127698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/29/2022] [Indexed: 11/17/2022]
Abstract
Polyenoic vegetable oils mainly contain polyenoic acids such as linoleic acid and linolenic acid, as well as active ingredients such as VE, phytosterols, mineral elements, and squalene. Among them, schisandra oil, kiwi seed oil, grape seed oil, maitake fruit oil, and evening primrose seed oil all contain up to 80% or more polyenoic acids. Studies have shown that polygenic vegetable oils have the effects of assisting in lowering blood lipids, antioxidation, delaying ageing, anti-inflammation, sun protection, moisturizing, slimming and weight loss, etc. They can be widely used in nutritional and healthy edible oils, health food, skin care, and cosmetic products and have great prospects for development and utilization. This paper explores the application of artificial neural networks in the analysis of data. A nonlinear time series prediction method based on the BP algorithm is proposed. The prediction accuracy is much higher than that of the traditional method.
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Affiliation(s)
- Haibo Li
- Shengnong Technology Group, Jinzhong, Shanxi 030805, China
| | - Songhao Kang
- College of Engineering, China Agricultural University, Haidian, Beijing 100083, China
| | - Lijuan Sun
- Beijing Madixin Food Technology Co,Ltd., Haidian, Beijing 100036, China
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9
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Influence of rurality on lymph node assessment among women diagnosed with ductal carcinoma in situ and treated with mastectomy, SEER 2000-2015. Breast Cancer Res Treat 2022; 192:211-222. [PMID: 35067778 PMCID: PMC9839433 DOI: 10.1007/s10549-021-06495-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/16/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Despite recommendations from national organizations supporting the use of lymph node assessment (LNA) among patients with ductal carcinoma in situ (DCIS) at time of mastectomy, variation in practice patterns across the United States has been observed. However, few studies have evaluated LNA differences and rurality. METHODS Data from the SEER Patterns of Care studies were used to identify women who underwent mastectomy for newly diagnosed DCIS during 2000, 2005, 2010, and 2015. Weighted multivariate logistic regression was used to evaluate the association between rural-urban residence and the use of LNA. A subgroup analysis was performed comparing the use of axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB). RESULTS Of the 504 patients included in the analysis, approximately 81% underwent LNA at time of mastectomy with lower rates of use observed among rural patients (66%) versus urban patients (82%). In multivariate analysis, LNA increased over time (p < 0.0001), and rural patients were less likely to receive LNA compared to urban patients [adjusted odds ratio (aOR) = 0.19; 95% confidence interval (CI) 0.06-0.66]. However, the likelihood of undergoing ALND relative to SLNB was lower among rural compared to urban patients (aOR = 0.16; 95% CI 0.03-0.73). CONCLUSIONS Over time, the use of LNA with mastectomy has increased among DCIS patients. However, significant rural-urban differences in the use and type of LNA persist. The findings of this study highlight the importance of continued research aimed at examining the impact of rurality on the receipt of high-quality cancer care.
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Selakovic V, Ranisavljevic M, Lukic D, Djuric M. 21 YEARS AFTER INTRODUCING SENTINEL LYMPH NODE BIOPSY IN CLINICAL PRAXIS AT THE ONCOLOGY INSTITUTE OF VOJVODINA. SANAMED 2021. [DOI: 10.24125/sanamed.v16i1.471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Zhang J, Wang T, Yan C, Huang M, Fan Z, Ling R. Clinical Practice Status of Sentinel Lymph Node Biopsy for Early-Stage Breast Cancer Patients in China: A Multicenter Study. Clin Epidemiol 2020; 12:917-924. [PMID: 32943940 PMCID: PMC7478367 DOI: 10.2147/clep.s264349] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/27/2020] [Indexed: 12/21/2022] Open
Abstract
Background Sentinel lymph node biopsy (SLNB) was introduced over 30 years ago, but the application of SLNB in China is unclear. This study aimed to explore the real-world implementation of SLNB among early-stage breast cancer patients in China. Methods A multi-center, retrospective study was conducted among primary breast cancer patients from 37 hospitals in China in 2018. Their clinical data were collected and analyzed, including the implementation status of SLNB in China, subsequent processing of sentinel lymph nodes (SLNs) containing metastases, and the effect of neoadjuvant chemotherapy (NAC) on SLNB. Results SLNB surgery was performed on 43.5% of early-stage breast cancer patients in China and 11,942 patients who underwent SLNB were enrolled in this study. The majority of SLNBs were performed using a single mapping agent. A combination of blue dye and radiotracer or fluorescence imaging was used in only 14.9% of patients. The mean (SD) number of resected SLNs was 4.0 (2.1). For the patients with 1 or 2 positive SLNs, 83.0% of them continued to receive axillary lymph node dissection (ALND), while others did not. For the patients with three or more positive SLNs, 97.2% of them continued to receive ALND, among which 82.9% accepted radiotherapy simultaneously. Of the patients who underwent SLN surgery, 5.5% (654/11,942) were receiving NAC. Among them, 51.9% received SLNB before NAC, and the rest received SLNB after NAC. In biopsy-proven positive nodes, 64.7% positive SLNs turned negative after NAC. Conclusion SLNB has been promoted in China, but it is not widely used compared to in developed countries. Furthermore, the usage of the dual tracer technique in SLNB is not high. Chinese breast surgeons are more conservative regarding the omission of ALND in 1 or 2 SLNs-positive patients.
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Affiliation(s)
- Juliang Zhang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, People's Republic of China
| | - Ting Wang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, People's Republic of China
| | - Changjiao Yan
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, People's Republic of China
| | - Meiling Huang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, People's Republic of China
| | - Zhimin Fan
- Department of Breast Surgery, The First Affiliated Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China
| | - Rui Ling
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, People's Republic of China
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Aubry S, Strassle PD, Maduekwe U, Downs-Canner S. Disparities of Management of the Axilla in Women With Clinically Node Negative Breast Cancer. J Surg Res 2020; 256:13-22. [PMID: 32679224 DOI: 10.1016/j.jss.2020.05.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND In women with clinically node-negative breast cancer, sentinel lymph node biopsy is the first step in axillary staging. A randomized trial published in 2013 concluded that patients with sentinel lymph node micrometastases (N1mi) do not benefit from axillary lymph node dissection (ALND). We hypothesized that disparities exist in management of the axilla in node-negative patients. METHODS We included women aged >40 years with nonmetastatic, clinically node-negative breast cancer from 2014 to 2016 in the National Cancer Database. Women treated neoadjuvantly, with large tumors (cT4), or no tumor (cT0) were excluded. Multivariable logistic regression identified patient and facility characteristics associated with undergoing ALND as first axillary surgery and completion ALND in the setting of N1mi disease. RESULTS Of 273,951 patients, 22,898 (8%) underwent ALND first. These patients were more likely to be Hispanic (OR: 1.21, 95% CI: 1.10, 1.32), have Medicare (OR: 1.13, 95% CI: 1.03, 1.24), be uninsured (OR: 1.28, 95% CI: 1.08, 1.53), have lower educational attainment (OR: 1.24, 95% CI: 1.17, 1.32), be treated at a community hospital (OR: 1.62, 95% CI: 1.52, 1.74), or reside in the South (OR: 1.19, 95% CI: 1.12, 1.26). In the sentinel lymph node biopsy first group, 8,882 (4%) were classified as N1mi and 1,872 (21%) underwent subsequent ALND. These patients were more likely to be Hispanic (OR: 1.70, 95% CI: 1.19, 2.42) and have the lowest income (OR: 1.62, 95% CI: 1.15, 2.27). CONCLUSION Disparities persist in implementation of evidence-based management of the axilla in women with clinically node-negative breast cancer.
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Affiliation(s)
- Staci Aubry
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paula D Strassle
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ugwuji Maduekwe
- Department of Surgical Oncology, University of North Carolina At Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie Downs-Canner
- Department of Surgical Oncology, University of North Carolina At Chapel Hill, Chapel Hill, North Carolina.
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Poodt IGM, Spronk PER, Vugts G, van Dalen T, Peeters MTFDV, Rots ML, Kuijer A, Nieuwenhuijzen GAP, Schipper RJ. Trends on Axillary Surgery in Nondistant Metastatic Breast Cancer Patients Treated Between 2011 and 2015: A Dutch Population-based Study in the ACOSOG-Z0011 and AMAROS Era. Ann Surg 2019; 268:1084-1090. [PMID: 28742702 DOI: 10.1097/sla.0000000000002440] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate patterns of care in axillary surgery for Dutch clinical T1-4N0M0 (cT1-4N0M0) breast cancer patients and to assess the effect of the American College for Surgeons Oncology Group (ACOSOG)-Z0011 and After Mapping of the Axilla: Radiotherapy Or Surgery (AMAROS) trial on axillary surgery patterns in Dutch cT1-2N0M0 sentinel node positive breast cancer patients. BACKGROUND Since publication of the ACOSOG-Z0011 and AMAROS trial, omitting a completion axillary lymph node dissection (cALND) in sentinel node positive breast cancer patients is proposed in selected patients. METHODS Data were obtained from the nationwide Nationaal Borstkanker Overleg Nederland breast cancer audit. Descriptive analyses were used to demonstrate trends in axillary surgery. Multivariable logistic regression analyses were used to identify factors associated with the omission of cALND in cT1-2N0M0 sentinel node-positive breast cancer patients. RESULTS Between 2011 and 2015 in cT1-4N0M0 breast cancer patients, the use of sentinel lymph node biopsy as definitive axillary staging increased from 72% to 93%, and (c)ALND as definitive axillary staging decreased from 24% to 6% (P < 0.001). The use of cALND decreased from 75% to 17% in cT1-2N0 sentinel node-positive patients (P < 0.001). Earlier year of diagnosis, lower age, primary mastectomy, invasive lobular subtype, increasing tumor grade, and treatment in a nonteaching hospital were associated with a lower probability of omitting cALND (P < 0.001). CONCLUSIONS This study shows a trend towards less extensive axillary surgery in Dutch cT1-T4N0M0 breast cancer patients; illustrated by an overall increase of sentinel lymph node biopsy and decrease in cALND. Despite this trend, particularly noticed in cT1-2N0 sentinel node-positive patients after publication of the ACOSOG-Z0011 and AMAROS trial, variations in patterns of care in axillary surgery are still present.
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Affiliation(s)
- Ingrid G M Poodt
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
| | - Pauline E R Spronk
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Research, Dutch Institute for Clinical Auditing (DICA), Leiden, The Netherlands
| | - Guusje Vugts
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
| | - Thijs van Dalen
- Department of Surgery, Diakonessen Hospital, Utrecht, The Netherlands
| | - M T F D Vrancken Peeters
- Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NKI-AVL), Amsterdam, The Netherlands
| | - Marjolijn L Rots
- Department of Surgery, Diakonessen Hospital, Utrecht, The Netherlands
| | - Anne Kuijer
- Department of Surgery, Diakonessen Hospital, Utrecht, The Netherlands
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Si P, Zhang P, Chen T, Liu G, Lu H, Chen H, Wang C, Zhai B, Li W. Positive nonsentinel lymph nodes are associated with poor survival in breast cancer: results from a retrospective study. Clin Transl Oncol 2019; 21:1085-1092. [PMID: 30632009 DOI: 10.1007/s12094-018-02031-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/26/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE The prognostic value of nonsentinel lymph-node (NSLN) status in breast cancer remains unclear. This study was designed to investigate the prognostic value of NSLN status in SLN-positive breast cancer. METHODS Retrospective 873 consecutive primary breast cancer patients from a single institution who were SLN-positive and underwent axillary lymph-node dissection (ALND) were included. Patients with incomplete clinical information or loss of follow-up were excluded. Survival analysis in patients with the same number of positive LNs and patients belonging to the same American Joint Committee on Cancer (AJCC) node (N) classification was performed to establish a proposal for incorporating the NSLN status into the breast cancer staging system. RESULTS The median follow-up was 41 months. Positive NSLN status was a significantly unfavorable factor for recurrence-free survival (RFS) (HR: 4.31, P < 0.001) and distant recurrence-free survival (DRFS) (HR: 3.62, P < 0.001). The survival of patients with one positive SLN and one positive NSLN (N = 97) was significantly worse than that of patients with two positive SLNs (N = 68; RFS, P = 0.011; DRFS, P = 0.027). Positive NSLN status was a significantly unfavorable factor affecting survival in patients with the AJCC N1 classification (N = 806; RFS, HR: 2.85, P = 0.002; DRFS, HR: 2.81, P = 0.004). No significant difference in survival was found between LN-negative (N = 361) and NSLN-negative AJCC N1 classification (N = 363) patients. CONCLUSIONS Positive NSLN status has an independent prognostic value in breast cancer patients with 1-3 positive LNs, and the NSLN status should be incorporated into the breast cancer staging system.
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Affiliation(s)
- P Si
- Department of Breast Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, 450003, Henan, China
| | - P Zhang
- Henan Provincial Food and Drug Evaluation and Inspection Center, Henan Food and Drug Administration, Zhengzhou, 450018, Henan, China
| | - T Chen
- Department of Breast Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China
| | - G Liu
- Department of Breast Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China
| | - H Lu
- Department of Breast Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China
| | - H Chen
- Department of Breast Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China
| | - C Wang
- Department of Breast Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China
| | - B Zhai
- Department of Breast Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, 450003, Henan, China
| | - W Li
- Department of Breast Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, 450003, Henan, China.
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Riedel F, Heil J, Golatta M, Schaefgen B, Hug S, Schott S, Rom J, Schuetz F, Sohn C, Hennigs A. Changes of breast and axillary surgery patterns in patients with primary breast cancer during the past decade. Arch Gynecol Obstet 2018; 299:1043-1053. [PMID: 30478667 DOI: 10.1007/s00404-018-4982-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/16/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE Breast-conserving therapy (BCT) is the standard procedure for most patients with primary breast cancer (BC). By contrast, axillary management is still under transition to find the right balance between avoiding of morbidity, maintaining oncological safety, and performing a staging procedure. The rising rate of primary systemic therapy creates further challenges for surgical management. METHODS Patients with primary, non-metastatic BC treated between 01.01.2003 and 31.12.2016 under guideline-adherent conditions were included in this study. For this prospectively followed cohort, breast and axillary surgery patterns are presented in a time-trend analysis as annual rate data (%) for several subgroups. RESULTS Overall, 6700 patients were included in the analysis. While BCT rates remained high (mean 2003-2016: 70.4%), the proportion of axillary lymph node dissection has declined considerably from 80.1% in 2003 to 16.0% in 2016, while the proportion for sentinel lymph node biopsy (SLND) has increased correspondingly from 10.3 to 76.4%. Among patients with cT1-2, cN0 breast cancer receiving BCT with positive SLND, the rate of axillary completion has decreased from 100% in 2008 to 24.4% in 2016. CONCLUSIONS In the past decade, SLNB has been established as the standard procedure for axillary staging of clinically node-negative patients. Surgical morbidity has been further reduced by the rapid implementation of new evidence from the ACOSOG Z0011 trial into clinical routine. The results reflect the transition towards more individually tailored, less invasive treatment for selected patient subgroups, especially in regards to axillary lymph node management.
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Affiliation(s)
- F Riedel
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - J Heil
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - M Golatta
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - B Schaefgen
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - S Hug
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - S Schott
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - J Rom
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - F Schuetz
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - C Sohn
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - A Hennigs
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
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Radiation Therapy Field Design and Lymphedema Risk After Regional Nodal Irradiation for Breast Cancer. Int J Radiat Oncol Biol Phys 2018; 102:71-78. [DOI: 10.1016/j.ijrobp.2018.03.046] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 03/11/2018] [Accepted: 03/26/2018] [Indexed: 11/18/2022]
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Poodt IG, Rots ML, Vugts G, van Dalen T, Kuijer A, Vriens BE, Nieuwenhuijzen GA, Schipper RJ. The administration of adjuvant chemo(-immuno) therapy in the post ACOSOG-Z0011 era; a population based study. Eur J Surg Oncol 2018; 44:1151-1156. [DOI: 10.1016/j.ejso.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/27/2018] [Accepted: 03/05/2018] [Indexed: 10/17/2022] Open
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Ersoy YE, Kadioglu H. Review of Novel Sentinel Lymph Node Biopsy Techniques in Breast Cancer Patients Treated With Neoadjuvant Chemotherapy. Clin Breast Cancer 2018; 18:e555-e559. [DOI: 10.1016/j.clbc.2018.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 01/16/2018] [Indexed: 01/05/2023]
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Choosing Wisely: Optimizing Routine Workup for the Newly Diagnosed Breast Cancer Patient. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0268-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Qiu SQ, Zhang GJ, Jansen L, de Vries J, Schröder CP, de Vries EGE, van Dam GM. Evolution in sentinel lymph node biopsy in breast cancer. Crit Rev Oncol Hematol 2018; 123:83-94. [PMID: 29482783 DOI: 10.1016/j.critrevonc.2017.09.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 06/12/2017] [Accepted: 09/19/2017] [Indexed: 02/05/2023] Open
Abstract
Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in clinically node-negative (cN0) breast cancer patients without neoadjuvant chemotherapy (NAC). The application of SLNB in patients receiving NAC has also been explored. Evidence supports its use after NAC in pretreatment cN0 patients. Nonetheless, its routine use in all the pretreatment node-positive patients who become cN0 after NAC is unjustified due to the unacceptably high false-negative rate, which can be improved in a subset of patients. Axillary surgery omission in selected patients with a low risk of ALN metastasis has gained more and more research interest because the SLNs are tumor-free in more than 70% of all patients. To avoid drawbacks of conventional mapping methods, novel techniques for SLN detection have been developed and shown to be highly accurate in patients with early breast cancer. This article reviews the progress in SLNB in patients with breast cancer.
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Affiliation(s)
- Si-Qi Qiu
- Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands; Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands; The Breast Center, Cancer Hospital of Shantou University Medical College, Guangdong, China
| | - Guo-Jun Zhang
- The Breast Center, Cancer Hospital of Shantou University Medical College, Guangdong, China; Changjiang Scholar's Laboratory of Shantou University Medical College, Guangdong, China
| | - Liesbeth Jansen
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jakob de Vries
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Carolien P Schröder
- Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Gooitzen M van Dam
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands; Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands.
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Yen TWF, Laud PW, Pezzin LE, McGinley EL, Wozniak E, Sparapani R, Nattinger AB. Prevalence and Consequences of Axillary Lymph Node Dissection in the Era of Sentinel Lymph Node Biopsy for Breast Cancer. Med Care 2018; 56:78-84. [PMID: 29087982 PMCID: PMC5725235 DOI: 10.1097/mlr.0000000000000832] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity. OBJECTIVE Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND. RESEARCH DESIGN/SUBJECTS Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009. MEASURES Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated. RESULTS Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases. CONCLUSIONS In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.
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Affiliation(s)
- Tina W F Yen
- Department of Surgery
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Purushottam W Laud
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Division of Biostatistics
| | - Liliana E Pezzin
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine
| | - Emily L McGinley
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Erica Wozniak
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Rodney Sparapani
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Division of Biostatistics
| | - Ann B Nattinger
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine
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Nielsen Moody A, Bull J, Culpan AM, Munyombwe T, Sharma N, Whitaker M, Wolstenhulme S. Preoperative sentinel lymph node identification, biopsy and localisation using contrast enhanced ultrasound (CEUS) in patients with breast cancer: a systematic review and meta-analysis. Clin Radiol 2017; 72:959-971. [DOI: 10.1016/j.crad.2017.06.121] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/11/2017] [Accepted: 06/26/2017] [Indexed: 01/08/2023]
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Axillary Dissection and Nodal Irradiation Can Be Avoided for Most Node-positive Z0011-eligible Breast Cancers: A Prospective Validation Study of 793 Patients. Ann Surg 2017. [PMID: 28650355 DOI: 10.1097/sla.0000000000002354] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine rates of axillary dissection (ALND) and nodal recurrence in patients eligible for ACOSOG Z0011. BACKGROUND Z0011 demonstrated that patients with cT1-2N0 breast cancers and 1 to 2 involved sentinel lymph nodes (SLNs) having breast-conserving therapy had no difference in locoregional recurrence or survival after SLN biopsy alone or ALND. The generalizability of the results and importance of nodal radiotherapy (RT) is unclear. METHODS Patients eligible for Z0011 had SLN biopsy alone. Prospectively defined indications for ALND were metastases in ≥3 SLNs or gross extracapsular extension. Axillary imaging was not routine. SLN and ALND groups and radiation fields were compared with chi-square and t tests. Cumulative incidence of recurrences was estimated with competing risk analysis. RESULTS From August 2010 to December 2016, 793 patients met Z0011 eligibility criteria and had SLN metastases. Among them, 130 (16%) had ALND; ALND did not vary based on age, estrogen receptor, progesterone receptor, or HER2 status. Five-year event-free survival after SLN alone was 93% with no isolated axillary recurrences. Cumulative 5-year rates of breast + nodal and nodal + distant recurrence were each 0.7%. In 484 SLN-only patients with known RT fields (103 prone, 280 supine tangent, 101 breast + nodes) and follow-up ≥12 months, the 5-year cumulative nodal recurrence rate was 1% and did not differ significantly by RT fields. CONCLUSIONS We confirm that even without preoperative axillary imaging or routine use of nodal RT, ALND can be avoided in a large majority of Z0011-eligible patients with excellent regional control. This approach has the potential to spare substantial numbers of women the morbidity of ALND.
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Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR, Ollila DW, Hansen NM, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, Hunt KK, Morrow M. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA 2017; 318:918-926. [PMID: 28898379 PMCID: PMC5672806 DOI: 10.1001/jama.2017.11470] [Citation(s) in RCA: 1011] [Impact Index Per Article: 144.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
IMPORTANCE The results of the American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial were first reported in 2005 with a median follow-up of 6.3 years. Longer follow-up was necessary because the majority of the patients had estrogen receptor-positive tumors that may recur later in the disease course (the ACOSOG is now part of the Alliance for Clinical Trials in Oncology). OBJECTIVE To determine whether the 10-year overall survival of patients with sentinel lymph node metastases treated with breast-conserving therapy and sentinel lymph node dissection (SLND) alone without axillary lymph node dissection (ALND) is noninferior to that of women treated with axillary dissection. DESIGN, SETTING, AND PARTICIPANTS The ACOSOG Z0011 phase 3 randomized clinical trial enrolled patients from May 1999 to December 2004 at 115 sites (both academic and community medical centers). The last date of follow-up was September 29, 2015, in the ACOSOG Z0011 (Alliance) trial. Eligible patients were women with clinical T1 or T2 invasive breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases. INTERVENTIONS All patients had planned lumpectomy, planned tangential whole-breast irradiation, and adjuvant systemic therapy. Third-field radiation was prohibited. MAIN OUTCOMES AND MEASURES The primary outcome was overall survival with a noninferiority hazard ratio (HR) margin of 1.3. The secondary outcome was disease-free survival. RESULTS Among 891 women who were randomized (median age, 55 years), 856 (96%) completed the trial (446 in the SLND alone group and 445 in the ALND group). At a median follow-up of 9.3 years (interquartile range, 6.93-10.34 years), the 10-year overall survival was 86.3% in the SLND alone group and 83.6% in the ALND group (HR, 0.85 [1-sided 95% CI, 0-1.16]; noninferiority P = .02). The 10-year disease-free survival was 80.2% in the SLND alone group and 78.2% in the ALND group (HR, 0.85 [95% CI, 0.62-1.17]; P = .32). Between year 5 and year 10, 1 regional recurrence was seen in the SLND alone group vs none in the ALND group. Ten-year regional recurrence did not differ significantly between the 2 groups. CONCLUSIONS AND RELEVANCE Among women with T1 or T2 invasive primary breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases, 10-year overall survival for patients treated with sentinel lymph node dissection alone was noninferior to overall survival for those treated with axillary lymph node dissection. These findings do not support routine use of axillary lymph node dissection in this patient population based on 10-year outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00003855.
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Affiliation(s)
- Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karla V Ballman
- Alliance Statistics and Data Center, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
| | - Linda McCall
- Alliance Statistics and Data Center, Duke University, Durham, North Carolina
| | | | - Meghan B Brennan
- Clinical Research Unit/TRIO-US Network, Jonsson Comprehensive Cancer Center, University of California, Los Angeles
| | | | - David W Ollila
- Department of Surgery, University of North Carolina, Chapel Hill
| | - Nora M Hansen
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - A Marilyn Leitch
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Sukamal Saha
- MacLaren Regional Medical Center, Michigan State University, Flint
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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Mamounas EP, Kuehn T, Rutgers EJT, von Minckwitz G. Current approach of the axilla in patients with early-stage breast cancer. Lancet 2017:S0140-6736(17)31451-4. [PMID: 28818521 DOI: 10.1016/s0140-6736(17)31451-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 02/28/2017] [Accepted: 04/10/2017] [Indexed: 02/01/2023]
Abstract
The surgical approach of the axilla in patients with early-stage breast cancer has witnessed considerable evolution during the past 25 years. The previously undisputed gold standard of axillary-lymph-node dissection for staging has now been replaced by sentinel-lymph-node biopsy for patients with clinically negative axilla. For selected patients with limited sentinel-lymph-node involvement, completion axillary-lymph-node dissection can be omitted or replaced by axillary radiotherapy, reducing morbidity. The clinical interest of axillary staging after neoadjuvant chemotherapy is increasing and this approach might contribute to morbidity reduction, and to the further tailoring of future systemic and locoregional treatment decisions by response assessment. Refinement of the sentinel-lymph-node biopsy technique might overcome the slightly impaired success rates in this setting. New techniques for lymphatic mapping attempt to further simplify the procedure. In view of the declining influence of axillary nodal status on adjuvant therapy decision-making, ongoing clinical trials will evaluate whether sentinel-lymph-node biopsy can be avoided altogether in selected patients.
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Affiliation(s)
- Eleftherios P Mamounas
- University of Florida Health Cancer Center-Orlando Health, and University of Central Florida, Orlando, FL, USA.
| | - Thorsten Kuehn
- Interdisciplinary Breast Cancer Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Emiel J T Rutgers
- Netherlands Cancer Institute, Amsterdam, Netherlands; University of Amsterdam, Amsterdam, Netherlands
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26
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Paganelli G, Matteucci F, Gilardi L. Nuclear Medicine in the Clinical Management (ROLL, SNB, and PET). Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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27
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Zada A, Peek MCL, Ahmed M, Anninga B, Baker R, Kusakabe M, Sekino M, Klaase JM, Ten Haken B, Douek M. Meta-analysis of sentinel lymph node biopsy in breast cancer using the magnetic technique. Br J Surg 2016; 103:1409-19. [PMID: 27611729 DOI: 10.1002/bjs.10283] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 05/19/2016] [Accepted: 06/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The standard for sentinel lymph node biopsy (SLNB), the dual technique (radiolabelled tracer and blue dye), has several drawbacks. A novel magnetic technique without these drawbacks has been evaluated in a number of clinical trials. It uses a magnetic tracer and a handheld magnetometer to identify and excise sentinel lymph nodes. A systematic review and meta-analysis was performed to assess the performance and utility of the magnetic in comparison to the standard technique. METHODS MEDLINE, PubMed, Embase and the Cochrane online literature databases were used to identify all original articles evaluating the magnetic technique for SLNB published up to April 2016. Studies were included if they were prospectively conducted clinical trials comparing the magnetic with the standard technique for SLNB in patients with breast cancer. RESULTS Seven studies were included. The magnetic technique was non-inferior to the standard technique (z = 3·87, P < 0·001), at a 2 per cent non-inferiority margin. The mean identification rates for the standard and magnetic techniques were 96·8 (range 94·2-99·0) and 97·1 (94·4-98·0) per cent respectively (risk difference (RD) 0·00, 95 per cent c.i. -0·01 to 0·01; P = 0·690). The total lymph node retrieval was significantly higher with the magnetic compared with the standard technique: 2113 (1·9 per patient) versus 2000 (1·8 per patient) (RD 0·05, 0·03 to 0·06; P = 0·003). False-negative rates were 10·9 (range 6-22) per cent for the standard technique and 8·4 (2-22) per cent for the magnetic technique (RD 0·03, 0·00 to 0·06; P = 0·551). The mean discordance rate was 3·9 (range 1·7-6·9) per cent. CONCLUSION The magnetic technique for SLNB is non-inferior to the standard technique, with a high identification rate but with a significantly higher lymph node retrieval rate.
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Affiliation(s)
- A Zada
- Division of Cancer Studies, King's College, London, UK.,Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - M C L Peek
- Division of Cancer Studies, King's College, London, UK
| | - M Ahmed
- Division of Cancer Studies, King's College, London, UK
| | - B Anninga
- Division of Cancer Studies, King's College, London, UK
| | - R Baker
- School of Business, University of Salford, Salford, UK
| | - M Kusakabe
- Advanced Technology Research Laboratory Research Centre for Food Safety, Graduate School of Agricultural and Life Sciences, Tokyo, Japan
| | - M Sekino
- Department of Electrical Engineering and Information Systems, Graduate School of Engineering, University of Tokyo, Tokyo, Japan
| | - J M Klaase
- Surgical Oncology, Medisch Spectrum Twente, University of Twente, Enschede, The Netherlands
| | - B Ten Haken
- Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - M Douek
- Division of Cancer Studies, King's College, London, UK. .,Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK.
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28
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Peek MC, Charalampoudis P, Anninga B, Baker R, Douek M. Blue dye for identification of sentinel nodes in breast cancer and malignant melanoma: a systematic review and meta-analysis. Future Oncol 2016; 13:455-467. [PMID: 27578614 DOI: 10.2217/fon-2016-0255] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The combined technique (radioisotope and blue dye) is the gold standard for sentinel lymph node biopsy (SLNB) and there is wide variation in techniques and blue dyes used. We performed a systematic review and meta-analysis to assess the need for radioisotope and the optimal blue dye for SLNB. A total of 21 studies were included. The SLNB identification rates are high with all the commonly used blue dyes. Furthermore, methylene blue is superior to iso-sulfan blue and Patent Blue V with respect to false-negative rates. The combined technique remains the most accurate and effective technique for SLNB. In order to standardize the SLNB technique, comparative trials to determine the most effective blue dye and national guidelines are required.
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Affiliation(s)
- Mirjam Cl Peek
- Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
| | | | - Bauke Anninga
- Division of Cancer Studies, King's College London, Guy's Hospital Campus, Great Maze Pond, London, SE1 9RT, UK.,Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
| | - Rose Baker
- School of Business, 612, Maxwell Building, University of Salford, Salford, M5 4WT, UK
| | - Michael Douek
- Division of Cancer Studies, King's College London, Guy's Hospital Campus, Great Maze Pond, London, SE1 9RT, UK.,Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
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29
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Sentinel Lymph Node Biopsy in Breast Cancer: Indications, Contraindications, and Controversies. Clin Nucl Med 2016; 41:126-33. [PMID: 26447368 DOI: 10.1097/rlu.0000000000000985] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Axillary lymph node status, a major prognostic factor in early-stage breast cancer, provides information important for individualized surgical treatment. Because imaging techniques have limited sensitivity to detect metastasis in axillary lymph nodes, the axilla must be explored surgically. The histology of all resected nodes at the time of axillary lymph node dissection (ALND) has traditionally been regarded as the most accurate method for assessing metastatic spread of disease to the locoregional lymph nodes. However, ALND may result in lymphedema, nerve injury, shoulder dysfunction, and other short-term and long-term complications limiting functionality and reducing quality of life. Sentinel lymph node biopsy (SLNB) is a less invasive method of assessing nodal involvement. The concept of SLNB is based on the notion that tumors drain in an orderly manner through the lymphatic system. Therefore, the SLN is the first to be affected by metastasis if the tumor has spread, and a tumor-free SLN makes it highly unlikely for other nodes to be affected. Sentinel lymph node biopsy has become the standard of care for primary treatment of early breast cancer and has replaced ALND to stage clinically node-negative patients, thus reducing ALND-associated morbidity. More than 20 years after its introduction, there are still aspects concerning SLNB and ALND that are currently debated. Moreover, SLNB remains an unstandardized procedure surrounded by many unresolved controversies concerning the technique itself. In this article, we review the main indications, contraindications, and controversies of SLNB in breast cancer in the light of the most recent publications.
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30
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Yen TW, Li J, Sparapani RA, Laud PW, Nattinger AB. The interplay between hospital and surgeon factors and the use of sentinel lymph node biopsy for breast cancer. Medicine (Baltimore) 2016; 95:e4392. [PMID: 27495053 PMCID: PMC4979807 DOI: 10.1097/md.0000000000004392] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Several surgeon characteristics are associated with the use of sentinel lymph node biopsy (SLNB) for breast cancer. No studies have systematically examined the relative contribution of both surgeon and hospital factors on receipt of SLNB. OBJECTIVE To evaluate the relationship between surgeon and hospital characteristics, including a novel claims-based classification of hospital commitment to cancer care (HC), and receipt of SLNB for breast cancer, a marker of quality care. DATA SOURCES/STUDY DESIGN Observational prospective survey study was performed in a population-based cohort of Medicare beneficiaries who underwent incident invasive breast cancer surgery, linked to Medicare claims, state tumor registries, American Hospital Association Annual Survey Database, and American Medical Association Physician Masterfile. Multiple logistic regression models determined surgeon and hospital characteristics that were predictors of SLNB. RESULTS Of the 1703 women treated at 471 different hospitals by 947 different surgeons, 65% underwent an initial SLNB. Eleven percent of hospitals were high-volume and 58% had a high commitment to cancer care. In separate adjusted models, both high HC (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.12-2.10) and high hospital volume (HV, OR 1.90, 95% CI 1.28-2.79) were associated with SLNB. Adding surgeon factors to a model including both HV and HC minimally modified the effect of high HC (OR 1.34, 95% CI 0.95-1.88) but significantly weakened the effect of high HV (OR 1.25, 95% CI 0.82-1.90). Surgeon characteristics (higher volume and percentage of breast cancer cases) remained strong independent predictors of SLNB, even when controlling for various hospital characteristics. CONCLUSIONS Hospital factors are associated with receipt of SLNB but surgeon factors have a stronger association. Since regionalization of breast cancer care in the U.S. is unlikely to occur, efforts to improve the surgical care and outcomes of breast cancer patients must focus on optimizing patient access to SLNB by ensuring hospitals have the necessary resources and training to perform SLNB, staffing hospitals with surgeons who specialize/focus in breast cancer and referring patients who do not have access to SLNB to an experienced center.
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Affiliation(s)
- Tina W.F. Yen
- Department of Surgery, Division of Surgical Oncology
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
- Correspondence: Tina W.F. Yen, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA (e-mail: )
| | - Jianing Li
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rodney A. Sparapani
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Purushuttom W. Laud
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ann B. Nattinger
- Department of Medicine
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
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31
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Radhakrishnan A, Silverman P, Pollack CE, Pfoh ER, Shenk R, Thompson CL. Understanding age and race disparities in the application of sentinel lymph node biopsy in breast cancer. J Investig Med 2016; 64:1241-1245. [PMID: 27466395 DOI: 10.1136/jim-2016-000226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 11/04/2022]
Abstract
Sentinel lymph node biopsy (SLNB) is the standard of care for surgical evaluation of early-stage breast cancer and is being employed as a quality metric for accreditation of breast centers. Previous studies report disparities in SLNB receipt. The goal of this study is to determine SLNB rates and explore rationale for non-receipt of SLNB. Patients with early-stage breast cancer diagnosed between 2010 and 2011 were identified from the University Hospitals Case Medical Center tumor registry. Multivariable logistic models were used to identify clinical and demographic risk factors for patients who did not receive SLNB. We performed chart reviews to elucidate reasons for the lack of SLNB. Our total sample was 479 patients; of them 432 (90.2%) received SLNB. On average, patients who received SLNB were younger than those who did not receive SLNB (61 compared to 79 years, respectively). Patients ≥80 years were 96% less likely to receive SLNB compared to patients <65 years (OR 0.04; 95% CI 0.00 to 0.14). There were no differences in SLNB by race, between patients undergoing Medicare or Medicaid and managed care, by surgeon specialty, or across medical centers. Chart review determined that 45/47 patients did not have SLNB, because it was a clinical decision-making; advanced age (>80 years) was cited in 27/47 women. Older women had much lower odds of receiving SLNB; however, non-receipt of SLNB was often due to a clinical reasoning. Our study highlights the importance of clinical reasoning in receiving SLNB, whereas other studies solely employing administrative databases do not.
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Affiliation(s)
- Archana Radhakrishnan
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Paula Silverman
- Department of Medicine, University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio, USA
| | - Craig Evan Pollack
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth R Pfoh
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Robert Shenk
- Department of Surgery, University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio, USA
| | - Cheryl L Thompson
- Department of Family Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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Karakatsanis A, Christiansen PM, Fischer L, Hedin C, Pistioli L, Sund M, Rasmussen NR, Jørnsgård H, Tegnelius D, Eriksson S, Daskalakis K, Wärnberg F, Markopoulos CJ, Bergkvist L. The Nordic SentiMag trial: a comparison of super paramagnetic iron oxide (SPIO) nanoparticles versus Tc(99) and patent blue in the detection of sentinel node (SN) in patients with breast cancer and a meta-analysis of earlier studies. Breast Cancer Res Treat 2016; 157:281-294. [PMID: 27117158 PMCID: PMC4875068 DOI: 10.1007/s10549-016-3809-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/19/2016] [Indexed: 12/16/2022]
Abstract
The aim of the study is to compare the efficacy of SPIO as a tracer in sentinel node biopsy (SNB) in breast cancer with Tc and patent blue in a multicentre prospective study and perform a meta-analysis of all published studies. It also aims to follow skin discoloration after SPIO injection and describe when and how it resolves. Totally 206 patients with early breast cancer were recruited. Tc and patent blue were administered in standard fashion. Patients were injected with SPIO (Sienna+) preoperatively. SNB was performed and detection rates were recorded for both methods. Skin discoloration was followed and documented postoperatively. Data extraction and subsequent meta-analysis of all previous studies were also performed. SN detection rates were similar between standard technique succeeded and SPIO both per patient (97.1 vs. 97.6 %, p = 0.76) as well as per node (91.3 vs. 93.3 %, p = 0.34), something which was not affected by the presence of malignancy. Concordance rates were also consistently high (98.0 % per patient and 95.9 % per node). Discoloring was present in 35.5 % of patients postoperatively, almost exclusively in breast conservation. It fades slowly and is still detectable in 8.6 % of patients after 15 months. Meta-analysis depicted similar detection rates (p = 0.71) and concordance rates (p = 0.82) per patient. However, it seems that SPIO is characterized by higher nodal retrieval (p < 0.001). SPIO is an effective method for the detection of SN in patients with breast cancer. It is comparable to the standard technique and seems to simplify logistics. Potential skin discoloration is something of consideration in patients planned for breast conservation.
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Affiliation(s)
- Andreas Karakatsanis
- Section for Endocrine and Breast Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
| | - Peer Michael Christiansen
- Breast Unit, Department of Surgery, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
| | - Lone Fischer
- Breast Unit, Department of Surgery, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
| | - Christina Hedin
- Breast Unit, Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Lida Pistioli
- Breast Unit, Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Malin Sund
- Department of Surgical and Perioperative Sciences, Umeå, Sweden
| | | | | | - Daniel Tegnelius
- Breast Unit, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Staffan Eriksson
- Department of Surgery, Västmanland County Hospital, Västerås, Sweden
| | - Kosmas Daskalakis
- Section for Endocrine and Breast Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Fredrik Wärnberg
- Section for Endocrine and Breast Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | | | - Leif Bergkvist
- Center for Clinical Research Uppsala University and Department of Surgery, Västmanland County Hospital, Västerås, Sweden
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Abstract
Breast cancer is the mostly commonly diagnosed cancer in women both in the United States and worldwide. Although advanced age at diagnosis is associated with more favorable tumor biology, mortality rates are comparatively higher in older adults, possibly attributed to advanced stage at presentation. There are minimal specific treatment-based guidelines in elderly patients with cancer, mostly attributable to their limited inclusion on clinical trials. In addition to the existing evidence from clinical trials and retrospective studies, practitioners need to take into consideration functional status, social support, patient preference, presence of comorbidities, and life expectancy when selecting optimal treatment.
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Boone BA, Huynh C, Spangler ML, Sumkin J, Johnson R, McGuire KP, Soran A, Ahrendt GM. Axillary Lymph Node Burden in Invasive Breast Cancer: A Comparison of the Predictive Value of Ultrasound-Guided Needle Biopsy and Sentinel Lymph Node Biopsy. Clin Breast Cancer 2015; 15:e243-8. [DOI: 10.1016/j.clbc.2015.03.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
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35
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Variations in compliance to quality indicators by age for 41,871 breast cancer patients across Europe: A European Society of Breast Cancer Specialists database analysis. Eur J Cancer 2015; 51:1221-30. [DOI: 10.1016/j.ejca.2015.03.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/26/2015] [Accepted: 03/14/2015] [Indexed: 11/24/2022]
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36
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Ahmed M, Anninga B, Goyal S, Young P, Pankhurst QA, Douek M. Magnetic sentinel node and occult lesion localization in breast cancer (MagSNOLL Trial). Br J Surg 2015; 102:646-52. [PMID: 25868072 DOI: 10.1002/bjs.9800] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 10/21/2014] [Accepted: 02/04/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Non-palpable breast cancers require localization-guided surgery and axillary staging using sentinel lymph node biopsy (SLNB). This study investigated the novel technique of magnetic-guided lesion localization and concurrent SLNB, which avoids the need for wire-guided localization and radioisotopes. METHODS An ultrasound-guided intratumoral injection of magnetic tracer (0·5 ml) was performed in a protocol-driven predefined minimum of ten patients with palpable breast cancer to assess the ability of the magnetic tracer safely to localize the tumour at the site of injection and concurrently drain to the lymphatics. Once successful lesion localization had been confirmed (peak magnetometer count retained at the centre of the tumour), the technique was undertaken in a further 20 patients with non-palpable breast cancers awaiting wide local excision and SLNB. All patients underwent SLNB with both the magnetic and standard dual (radioisotope and Patent Blue V dye) techniques. RESULTS Thirty-two patients were recruited, of whom 12 (1 with bilateral disease) presented with palpable and 20 with non-palpable breast cancer. Peak magnetometer counts were retained at the tumour centre in all palpable (13) and non-palpable (20) breast cancers. Re-excisions for involved margins were necessary in two patients with non-palpable breast cancers. The sentinel lymph node identification rates were 28 of 33 procedures for the magnetic technique alone, 32 of 33 for the magnetic technique combined with blue dye, and 32 of 33 for the standard dual technique. CONCLUSION Magnetic lesion localization is feasible, with intratumoral magnetic tracer injection combined with a periareolar injection of blue dye for subsequent SNLB.
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Affiliation(s)
- M Ahmed
- Research Oncology, Division of Cancer Studies, King's College London, London, UK; Department of Breast Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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37
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Kurebayashi J, Miyoshi Y, Ishikawa T, Saji S, Sugie T, Suzuki T, Takahashi S, Nozaki M, Yamashita H, Tokuda Y, Nakamura S. Clinicopathological characteristics of breast cancer and trends in the management of breast cancer patients in Japan: Based on the Breast Cancer Registry of the Japanese Breast Cancer Society between 2004 and 2011. Breast Cancer 2015; 22:235-44. [PMID: 25758809 DOI: 10.1007/s12282-015-0599-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 02/25/2015] [Indexed: 01/15/2023]
Abstract
PURPOSES We conducted a study to analyze the clinicopathological characteristics of breast cancer in Japan registered to the Japanese Breast Cancer Registry of the Japanese Breast Cancer Society (JBCS). Trends in the management of breast cancer patients in Japan were also analyzed. PATIENTS AND METHODS More than 250,000 breast cancer patients were registered to the JBCS registry between 2004 and 2011. Demographic and clinicopathological factors in newly diagnosed primary breast cancer patients were registered to the JBCS through the Web-based system from affiliated institutes nationwide. RESULTS Two distinct peaks were observed, in patients in their late 40s and early 60s, in the population-adjusted age distribution of breast cancer patients. An increased rate of screen-detected breast cancer may contribute to an earlier detection of breast cancer and increased rate of non-invasive ductal carcinoma. The positive rate of either ER or PgR appears to have increased in recent years. The annual rates of patients treated with breast-conserving surgery increased until 2006, but these increases stopped in 2007 and thereafter plateaued at approximately 60 %. The annual rates of patients treated with sentinel lymph node dissection alone have steadily increased. The annual rates of patients treated with preoperative trastuzumab plus chemotherapy have also increased, as well as those treated with postoperative aromatase inhibitors. The annual rates of patients treated with postoperative anthracycline-containing regimens have decreased, whereas those treated with postoperative taxane-containing regimens have increased. The postoperative use of trastuzumab has markedly increased since 2007. CONCLUSION Although this study was based on the registry database, several unique clinicopathological characteristics of breast cancer in Japan have been unveiled. Our results suggest that recent trends in the management of breast cancer patients in Japan were strongly followed by clinical evidence that originated from a number of clinical trials worldwide.
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Affiliation(s)
- Junichi Kurebayashi
- Department of Breast and Thyroid Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan,
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Ahmed M, Anninga B, Pouw JJ, Vreemann S, Peek M, Van Hemelrijck M, Pinder S, Ten Haken B, Pankhurst Q, Douek M. Optimising magnetic sentinel lymph node biopsy in an in vivo porcine model. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2015; 11:993-1002. [PMID: 25680540 DOI: 10.1016/j.nano.2015.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 01/05/2015] [Accepted: 01/20/2015] [Indexed: 12/14/2022]
Abstract
UNLABELLED The magnetic technique for sentinel lymph node biopsy (SLNB) has been evaluated in several clinical trials. An in vivo porcine model was developed to optimise the magnetic technique by evaluating the effect of differing volume, concentration and time of injection of magnetic tracer. A total of 60 sentinel node procedures were undertaken. There was a significant correlation between magnetometer counts and iron content of excised sentinel lymph nodes (SLNs) (r=0.82; P<0.001). Total number of SLNs increased with increasing volumes of magnetic tracer (P<0.001). Transcutaneous magnetometer counts increased with increasing time from injection of magnetic tracer (P<0.0001), plateauing within 60min. Increasing concentration resulted in higher iron content of SLNs (P=0.006). Increasing magnetic tracer volume and injecting prior to surgery improve transcutaneous 'hotspot' identification but very high volumes, increase the number of nodes excised. FROM THE CLINICAL EDITOR Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging of breast cancer patients. Although the current gold standard technique is the combined injection of technetium-labelled nanocolloid and blue dye into the breast, the magnetic technique, using superparamagnetic carboxydextran-coated iron oxide (SPIO), has also been demonstrated as a feasible alternative. In this article, the authors set up to study factors in order to optimize the magnetic tracers.
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Affiliation(s)
- Muneer Ahmed
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK
| | - Bauke Anninga
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK
| | - Joost J Pouw
- Institute for Biomedical Technology and Technical Medicine, Universiteit Twente, Enschede, The Netherlands
| | - Suzan Vreemann
- Institute for Biomedical Technology and Technical Medicine, Universiteit Twente, Enschede, The Netherlands
| | - Mirjam Peek
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK; Institute for Biomedical Technology and Technical Medicine, Universiteit Twente, Enschede, The Netherlands
| | - Mieke Van Hemelrijck
- King's College London, School of Medicine, Cancer Epidemiology Group, Guy's Hospital, London, UK
| | - Sarah Pinder
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK
| | - Bennie Ten Haken
- Institute for Biomedical Technology and Technical Medicine, Universiteit Twente, Enschede, The Netherlands
| | - Quentin Pankhurst
- Institute of Biomedical Engineering, University College London, London, UK
| | - Michael Douek
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK.
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Pouw JJ, Ahmed M, Anninga B, Schuurman K, Pinder SE, Van Hemelrijck M, Pankhurst QA, Douek M, Ten Haken B. Comparison of three magnetic nanoparticle tracers for sentinel lymph node biopsy in an in vivo porcine model. Int J Nanomedicine 2015; 10:1235-43. [PMID: 25709445 PMCID: PMC4334341 DOI: 10.2147/ijn.s76962] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Breast cancer staging with sentinel lymph node biopsy relies on the use of radioisotopes, which limits the availability of the procedure worldwide. The use of a magnetic nanoparticle tracer and a handheld magnetometer provides a radiation-free alternative, which was recently evaluated in two clinical trials. The hydrodynamic particle size of the used magnetic tracer differs substantially from the radioisotope tracer and could therefore benefit from optimization. The aim of this study was to assess the performance of three different-sized magnetic nanoparticle tracers for sentinel lymph node biopsy within an in vivo porcine model. Materials and methods Sentinel lymph node biopsy was performed within a validated porcine model using three magnetic nanoparticle tracers, approved for use in humans (ferumoxytol, with hydrodynamic diameter dH =32 nm; Sienna+®, dH =59 nm; and ferumoxide, dH =111 nm), and a handheld magnetometer. Magnetometer counts (transcutaneous and ex vivo), iron quantification (vibrating sample magnetometry), and histopathological assessments were performed on all ex vivo nodes. Results Transcutaneous “hotspots” were present in 12/12 cases within 30 minutes of injection for the 59 nm tracer, compared to 7/12 for the 32 nm tracer and 8/12 for the 111 nm tracer, at the same time point. Ex vivo magnetometer counts were significantly greater for the 59 nm tracer than for the other tracers. Significantly more nodes per basin were excised for the 32 nm tracer compared to other tracers, indicating poor retention of the 32 nm tracer. Using the 59 nm tracer resulted in a significantly higher iron accumulation compared to the 32 nm tracer. Conclusion The 59 nm tracer demonstrated rapid lymphatic uptake, retention in the first nodes reached, and accumulation in high concentration, making it the most suitable tracer for intraoperative sentinel lymph node localization.
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Affiliation(s)
- Joost J Pouw
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Muneer Ahmed
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK
| | - Bauke Anninga
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK
| | - Kimberley Schuurman
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Sarah E Pinder
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK
| | - Mieke Van Hemelrijck
- Cancer Epidemiology Group, Division of Cancer Studies, King's College London, London, UK
| | - Quentin A Pankhurst
- Healthcare Biomagnetics Laboratory, University College London, London, UK ; Institute of Biomedical Engineering, University College London, London, UK
| | - Michael Douek
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK
| | - Bennie Ten Haken
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
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Leveraging comparative effectiveness research to improve the quality of multidisciplinary care for breast cancer patients. Cancer Treat Res 2015; 164:15-30. [PMID: 25677016 DOI: 10.1007/978-3-319-12553-4_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Breast cancer is the most commonly diagnosed cancer among women. To date, the use of efficacy randomized controlled trials (RCTs) in breast cancer have resulted in dramatic improvements in oncologic outcomes for this disease. However, not every question pertinent to breast cancer is amenable to such efficacy trials. This chapter will discuss some of the unique aspects of breast cancer that make efficacy RCTs challenging and/or impractical, how comparative effectiveness research can be used to address these issues, and identify several key questions which would benefit from ongoing comparative effectiveness research.
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Haffty BG, Mahmoud O. The Evolution of Regional Nodal Irradiation in Breast Cancer. Breast J 2014; 21:32-41. [DOI: 10.1111/tbj.12351] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Bruce G. Haffty
- Department of Radiation Oncology; Rutgers Robert Wood Johnson Medical School; New Jersey Medical School and Cancer Institute of New Jersey; New Brunswick New Jersey
| | - Omar Mahmoud
- Department of Radiation Oncology; Rutgers Robert Wood Johnson Medical School; New Jersey Medical School and Cancer Institute of New Jersey; New Brunswick New Jersey
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Holleczek B, Brenner H. Provision of breast cancer care and survival in Germany - results from a population-based high resolution study from Saarland. BMC Cancer 2014; 14:757. [PMID: 25304931 PMCID: PMC4213502 DOI: 10.1186/1471-2407-14-757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 09/24/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Studies on the implementation of Clinical Practice Guidelines (CPG) and particularly its effect on breast cancer (BRC) survival on a population-level are scant. This population-based high resolution study from Germany aims at providing data on the usage of BRC treatment, the extent of adherence to CPG and, as a novelty, survival of BRC patients according to major recommended treatment options. METHODS Data from the Saarland Cancer Registry including women diagnosed with invasive BRC without distant metastasis and followed up between 2000 and 2009 were used. Provision of cancer care according to major treatment options is presented by age, clinical subtypes of BRC, and over time. Conventional and modeled period analysis was used to derive estimates of most up-to-date 5-year relative survival (RS) and the effect of non-adherence to CPG on relative excess risk of death (RER). RESULTS The study revealed increasing guideline adherence, with high levels already seen for local treatment (e.g. 67% of the BRC patients in 2008/09 received breast conserving surgery), and substantial progress since the millennium change with regard to sentinel node dissection (SND) and adjuvant systemic treatments (e.g. SND and chemotherapy provided to 62% of all patients and 79% of the patients with nodal positive or hormone receptor negative BRC in 2008/09, respectively). It further demonstrated increased cancer related mortality among patients without guideline compliant cancer treatment (e.g. patients with nodal positive and hormone receptor negative BRC who were not treated with chemotherapy had a 5-year RS of 29% (RER: 2.89, 95% CI: 1.46-5.71) compared to 54% for patients obtaining chemotherapy). CONCLUSIONS This study provides data on the implementation of CPG in a highly developed European country and extends available population-based survival data of BRC patients and may provide evidence of increased cancer related excess mortality, if BRC patients do not receive guideline compatible treatment.
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Affiliation(s)
- Bernd Holleczek
- />Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Im Neuenheimer Feld 581, 69120 Heidelberg, Germany
- />Saarland Cancer Registry, Präsident Baltz-Straße 5, 66119 Saarbrücken, Germany
| | - Hermann Brenner
- />Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Im Neuenheimer Feld 581, 69120 Heidelberg, Germany
- />German Cancer Consortium (DKTK), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
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Ahmed M, Purushotham AD, Douek M. Novel techniques for sentinel lymph node biopsy in breast cancer: a systematic review. Lancet Oncol 2014; 15:e351-62. [PMID: 24988938 DOI: 10.1016/s1470-2045(13)70590-4] [Citation(s) in RCA: 220] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The existing standard for axillary lymph node staging in breast cancer patients with a clinically and radiologically normal axilla is sentinel lymph node biopsy with a radioisotope and blue dye (dual technique). The dependence on radioisotopes means that uptake of the procedure is limited to only about 60% of eligible patients in developed countries and is negligible elsewhere. We did a systematic review to assess three techniques for sentinel lymph node biopsy that are not radioisotope dependent or that refine the existing method: indocyanine green fluorescence, contrast-enhanced ultrasound using microbubbles, and superparamagnetic iron oxide nanoparticles. Our systematic review suggested that these new methods for sentinel lymph node biopsy have clinical potential but give high levels of false-negative results. We could not identify any technique that challenged the existing standard procedure. Further assessment of these techniques against the standard dual technique in randomised trials is needed.
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Affiliation(s)
- Muneer Ahmed
- Department of Research Oncology, King's College London, London, UK; Oncology and Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Arnie D Purushotham
- Department of Research Oncology, King's College London, London, UK; Oncology and Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michael Douek
- Department of Research Oncology, King's College London, London, UK; Oncology and Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Chavarri-Guerra Y, St Louis J, Liedke PER, Symecko H, Villarreal-Garza C, Mohar A, Finkelstein DM, Goss PE. Access to care issues adversely affect breast cancer patients in Mexico: oncologists' perspective. BMC Cancer 2014; 14:658. [PMID: 25199766 PMCID: PMC4165903 DOI: 10.1186/1471-2407-14-658] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 08/22/2014] [Indexed: 02/07/2023] Open
Abstract
Background Despite recently implemented access to care programs, Mexican breast cancer (BC) mortality rates remain substantially above those in the US. We conducted a survey among Mexican Oncologists to determine whether practice patterns may be responsible for these differences. Methods A web-based survey was sent to 851 oncologists across Mexico using the Vanderbilt University REDCap database. Analyses of outcomes are reported using exact and binomial confidence bounds and tests. Results 138 participants (18.6% of those surveyed) from the National capital and 26 Mexican states, responded. Respondents reported that 58% of newly diagnosed BC patients present with stage III-IV disease; 63% undergo mastectomy, 52% axillary lymph node dissection (ALND) and 48% sentinel lymph node biopsy (SLNB). Chemotherapy is recommended for tumors > 1 cm (89%), positive nodes (86.5%), triple-negative (TN) (80%) and HER2 positive tumors (58%). Trastuzumab is prescribed in 54.3% and 77.5% for HER2 < 1 cm and > 1 cm tumors, respectively. Tamoxifen is indicated for premenopausal hormone receptor (HR) positive tumors in 86.5% of cases and aromatase inhibitors (AI’s) for postmenopausal in 86%. 24% of physicians reported treatment limitations, due to delayed or incomplete pathology reports and delayed or limited access to medications. Conclusions Even though access to care programs have been recently applied nationwide, women commonly present with advanced BC, leading to increased rates of mastectomy and ALND. Mexican physicians are dissatisfied with access to appropriate medical care. Our survey detects specific barriers that may impact BC outcomes in Mexico and warrant further investigation. Electronic supplementary material The online version of this article (doi:10.1186/1471-2407-14-658) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | - Paul E Goss
- MGH-Avon International Breast Cancer Program, Massachusetts General Hospital, Boston, MA, USA.
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Fan L, Strasser-Weippl K, Li JJ, St Louis J, Finkelstein DM, Yu KD, Chen WQ, Shao ZM, Goss PE. Breast cancer in China. Lancet Oncol 2014; 15:e279-89. [PMID: 24872111 DOI: 10.1016/s1470-2045(13)70567-9] [Citation(s) in RCA: 1021] [Impact Index Per Article: 102.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The health burden of cancer is increasing in China, with more than 1·6 million people being diagnosed and 1·2 million people dying of the disease each year. As in most other countries, breast cancer is now the most common cancer in Chinese women; cases in China account for 12·2% of all newly diagnosed breast cancers and 9·6% of all deaths from breast cancer worldwide. China's proportional contribution to global rates is increasing rapidly because of the population's rising socioeconomic status and unique reproductive patterns. In this Review we present an overview of present control measures for breast cancer across China, and emphasise epidemiological and socioeconomic diversities and disparities in access to care for various subpopulations. We describe demographic differences between China and high-income countries, and also within geographical and socioeconomic regions of China. These disparities between China and high-income countries include younger age at onset of breast cancer; the unique one-child policy; lower rates of provision and uptake for screening for breast cancer; delays in diagnosis that result in more advanced stage of disease at presentation; inadequate resources; and a lack of awareness about breast cancer in the Chinese population. Finally, we recommend key measures that could contribute to improved health outcomes for patients with breast cancer in China.
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Affiliation(s)
- Lei Fan
- International Breast Cancer Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Breast Surgery, Cancer Center and Cancer Institute, Fudan University, Shanghai, China
| | - Kathrin Strasser-Weippl
- International Breast Cancer Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Oncology, Hematology and Palliative Care, Wilhelminen Hospital, Vienna, Austria
| | - Jun-Jie Li
- International Breast Cancer Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Breast Surgery, Cancer Center and Cancer Institute, Fudan University, Shanghai, China
| | - Jessica St Louis
- International Breast Cancer Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dianne M Finkelstein
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ke-Da Yu
- Department of Breast Surgery, Cancer Center and Cancer Institute, Fudan University, Shanghai, China
| | - Wan-Qing Chen
- National Office for Cancer Prevention and Control, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhi-Ming Shao
- Department of Breast Surgery, Cancer Center and Cancer Institute, Fudan University, Shanghai, China
| | - Paul E Goss
- International Breast Cancer Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Offersen BV, Nielsen HM, Overgaard M, Overgaard J. Is regional nodes radiotherapy an alternative to surgery? Breast 2014; 22 Suppl 2:S118-28. [PMID: 24074772 DOI: 10.1016/j.breast.2013.07.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Sentinel node biopsy (SN) in breast cancer treatment was introduced in the mid-1990s in order to be able to stage patients before decision of definitive surgery. Since then, both the pathological examinations of the SN and the systemic adjuvant treatment have improved and cause new challenges in the correct decision making regarding whether or not to radically treat the axilla in case of a positive SN. In SN positive patients, current St. Gallen guidelines support no completion ALND (axillary lymph node dissection) in clinically node-negative patients with 1-2 macrometastatic sentinel nodes operated with breast conservation and receiving tangential field adjuvant radiotherapy (RT). ALND is being questioned due to increased morbidity compared with SN biopsy alone, and to limited long term benefit on disease free survival in selected patients. An alternative to ALND is treating the axilla with nodal RT although this treatment is mostly used as adjuvant treatment after ALND in high risk patients. Few studies have investigated the benefit of nodal RT compared to ALND, and no consensus has yet been reached. Clinical decision making regarding treating the axilla should be based on relevant data, and in this review studies aiming at deciding whether or not and how the axilla should be treated in SN positive patients will be discussed. Furthermore treatment choice will be discussed, since besides ALND, both breast irradiation and nodal irradiation might cure residual disease after SN. Also the issue of improved systemic adjuvant treatment will be discussed in relation to eventually no regional axillary treatment.
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Yen TWF, Laud PW, Sparapani RA, Nattinger AB. Surgeon specialization and use of sentinel lymph node biopsy for breast cancer. JAMA Surg 2014; 149:185-92. [PMID: 24369337 DOI: 10.1001/jamasurg.2013.4350] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema. OBJECTIVE To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon's operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer. DESIGN, SETTING, AND POPULATION A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined. MAIN OUTCOME AND MEASURE Type of axillary surgery performed. RESULTS Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB. CONCLUSIONS AND RELEVANCE Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.
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Affiliation(s)
- Tina W F Yen
- Division of Surgical Oncology, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Purushuttom W Laud
- Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Rodney A Sparapani
- Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Ann B Nattinger
- Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
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Why should breast surgeons use ultrasound? Breast Cancer Res Treat 2014; 145:1-4. [DOI: 10.1007/s10549-014-2926-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/17/2014] [Indexed: 11/26/2022]
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Javid SH, He H, Korde LA, Flum DR, Anderson BO. Predictors and outcomes of completion axillary node dissection among older breast cancer patients. Ann Surg Oncol 2014; 21:2172-80. [PMID: 24585407 DOI: 10.1245/s10434-014-3595-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND The role of completion axillary lymph node dissection (ALND) for older women who had sentinel lymph node-positive (SLN+) invasive breast cancer is unclear. We examined factors predictive of ALND and the association between ALND, adjuvant chemotherapy administration, and survival. METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we reviewed records of women age >65 diagnosed with stage I/II breast cancer from 1998-2005. Adjusted Cox proportional hazards and multivariate logistic regression were used to identify patient and disease variables associated with ALND, and assess association between ALND and all-cause and breast cancer-specific survival. RESULTS Among SLN+ patients, 88 % underwent ALND. Earlier diagnosis year, greater nodal involvement, younger age, registry location, and larger tumor size were all associated with a significantly higher likelihood of ALND. The ALND in SLN+ patients was not significantly associated with 5-year breast cancer-specific survival (hazard ratio [HR] 1.22, 95 % confidence interval [CI] 0.76-1.96). The SLN+ patients who underwent ALND were more likely to receive adjuvant chemotherapy (odds ratio [OR] 1.8, 95 % CI 1.45-2.24). However, younger age (OR 18.0, 95 % CI 14.4-23.9), estrogen receptor-negative (ER-) status (OR 4.2, 95 % CI 3.4-5.3), and fewer comorbidities (OR 2.6, 95 % CI 1.7-4.0) were all more strongly linked to receipt of chemotherapy. CONCLUSIONS ALND for older patients with SLN+ breast cancer is not associated with improved 5-year all-cause or breast cancer-specific survival. Younger age, fewer comorbidities, and estrogen receptor-negative (ER-) status were more strongly associated with receipt of chemotherapy than ALND. Consideration should be given to omitting ALND in older patients, particularly if findings of ALND will not influence adjuvant therapy decisions.
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Affiliation(s)
- Sara H Javid
- Departments of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, USA,
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