Axillary dissection can be avoided in the majority of clinically node-negative patients undergoing breast-conserving therapy

Extremely Low Incidence of Local-Regional Recurrences Observed Among T1-2 N1 (1 or 2 Positive SLNs) Breast Cancer Patients Receiving Upfront Mastectomy Without Completion Axillary Node Dissection

BACKGROUND

Completion axillary node dissection (CLND) is routinely omitted in cT1-2 N0 breast cancer treated with upfront, breast-conserving therapy and sentinel node biopsy (SLNB) showing one to two positive sentinel nodes (SLNs). The purpose of this study was to determine the incidence and impact of axillary treatment among patients treated with mastectomy in a contemporary cohort.

METHODS

A prospective, institutional database was reviewed from 2006 to 2015 to identify patients with T1-2 breast cancer treated with upfront mastectomy and SLNB found to have one to two positive SLNs. Patients were stratified by axillary therapy [including CLND and/or post-mastectomy radiation therapy (PMRT)], and clinicopathologic factors and incidence rates of local-regional and distant recurrence were analyzed.

RESULTS

A total of 548 patients were identified, including 126 (23%) without CLND. Rates of PMRT were similar between those with and without CLND (35.3% vs. 28.6%, p = 0.16). On multivariate analysis, two rather than one positive SLN, larger SLN metastasis size, frozen-section analysis of the SLNB, and adjuvant chemotherapy were significantly associated with receipt of CLND. At a median follow-up of 7 years, there were only two local-regional recurrences in the no-CLND group, of which only one was an axillary recurrence. The 5-years incidence rate of LRR was not significantly different for those with and without CLND (1.3% vs. 1.8%, p = 0.93).

CONCLUSIONS

We found extremely low rates of local-regional recurrence among those with T1-2 breast cancer undergoing upfront mastectomy with 1-2 positive SLNs. Further axillary surgery may not be indicated in selected patients treated with a multidisciplinary approach, including adjuvant therapies.

Description of characteristics, management of care and healthcare direct costs of patients with HR+/HER2- early breast cancer in Italy: a real-world study involving administrative and pathological anatomy databases

BACKGROUND

Healthcare administrative and pathological anatomy data were used to identify Italian patients with early breast cancer (EBC) with HR+/HER2- status at high risk of recurrence, evaluating drug utilization and other healthcare resource use in clinical practice.

METHODS

This retrospective analysis, based on 9.4 million of Italian National Health Service beneficiaries, included adult patients with hospitalization discharge diagnosis for EBC in 01/2015-12/2020. Those with HR+/HER2- status were selected; among them, patients that underwent removal of lymph nodes (LN) were analyzed.

RESULTS

Of 24,137 patients with EBC and HR+/HER2- status, 3619 patients (15%) had documented LN removal. Overall, 4.7% of HR+/HER2- patients and 9.9% of patients with LN removal experienced distant relapse over a median follow-up of 33.2 months (Q1-Q3: 17.0-50.6). Local relapse occurred in approximately 9.1-9.3% of patients in each group. Among the 1,175 patients with LN removal that had available pathological anatomy data, 399 (34.0%) had pathological high-risk characteristics and 13.3% experienced distant relapse.

CONCLUSIONS

One in ten patients with EBC who underwent LN removal experienced a relapse, highlighting the strong need to prevent early recurrence.

Axillary lymph node dissection: Dead or still alive?

Although sentinel lymph node biopsy is now the primary method of axillary staging and is therapeutic for patients with limited nodal disease, axillary lymph node dissection (ALND) is still necessary for staging in groups where sentinel lymph node biopsy has not been proven to be accurate and to maintain local control in those with a heavy axillary tumor burden. Additionally, newer approaches to systemic therapy tailored to risk level sometimes necessitate knowledge of the number of involved axillary nodes which can only be obtained with ALND. Ongoing trials will address whether there are additional circumstances where radiotherapy can replace ALND.

Inequalities in the omission of axillary dissection in sentinel lymph node positive patients in the Netherlands: Innovative hospitals are early adopters of a de-escalating approach

During the last decade completion axillary lymph node dissection (cALND) was gradually omitted in sentinel lymph node positive (SLN+) breast cancer patients. However, adoption varies among hospitals. We analyzed factors associated with the omission of cALND in all Dutch SLN+ patients. As one of the focus hospital-related factors we defined "innovative" as the percentage of gene-expression profile (GEP) deployment within the indicated group of patients per hospital as a proxy for early adoption of innovations. cT1-2N0M0 SLN+ patients treated between 2011 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were defined to be innovative based on their GEP use. Multivariable logistic regression (MLR) was performed to assess the relationship between innovative capacity, patient-, treatment- and hospital-related characteristics and cALND performance. 14 317 patients were included. Treatment in a hospital with high innovative capacity was associated with a lower probability of receiving cALND (OR 0.69, OR 0.46 and OR 0.35 in modestly, fairly and very innovative, respectively). Other factors associated with a lower probability of receiving a cALND were age 70 and 79 years and ≥79 years (ORs 0.59 [95% CI: 0.50-0.68] and 0.21 [95% CI: 0.17-0.26]) and treatment in an academic hospital (OR 0.41 [95% CI: 0.33-0.51]). Factors associated with an increased probability of undergoing cALND were HR-/HER2- tumors (OR 1.46 [95% CI: 1.19-1.80]), macrometastatic lymph node involvement (OR 6.37 [95% CI: 5.70-7.13]) and mastectomy (OR 4.57 [95% CI: 4.09-5.10]). Patients treated in a hospital that early adopted innovations were less likely to receive cALND. Our findings endorse the need for studies on barriers and facilitators of implementing innovations.

Conservative axillary surgery is emerging in the surgical management of breast cancer

Axillary lymph node dissection (ALND) has been the standard axillary treatment for breast cancer for a long time. However, ALND is associated with postoperative morbidities, including local sensory dysfunction, reduced shoulder mobility and most notably arm lymphedema. Recently, ALND can be avoided not only in clinically node-negative (cN0) patients with negative sentinel lymph nodes (SLNs), but also in patients with less than 3 positive SLNs receiving breast radiation, axillary radiation, or a combination of the two. Moreover, SLN biopsy has been adopted for use in clinically node-positive (cN +) patients presenting as cN0 after neoadjuvant chemotherapy (NAC); ALND may be avoided in cN + patients who convert to SLN-negative following NAC. Patients who undergo SLN biopsy alone have less postsurgical morbidities than those who undergo ALND. Nevertheless, ALND is still required in a select group of patients. A variety of conservative approaches to ALND have been developed to spare arm lymphatics to minimize arm lymphedema. These conservative procedures seem to decrease the incidence of lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, full conventional ALND removing all microscopic axillary disease may now be unnecessary in both cN0 patients and cN + patients. Regardless, emerging procedures for ALND should still be considered as investigational approaches, as further studies with longer follow-up are necessary to determine the safety of conservative ALND to spare arm lymphatics.

Radiomics-based signature of breast cancer on preoperative contrast-enhanced MRI to predict axillary metastasis

Aim: This study aimed to predict axillary metastasis using radiology features in dynamic contrast-enhanced MRI. Methods: This study included 243 breast lesions confirmed as malignant based on axillary status. Most outcome-predictive features were selected using four machine-learning algorithms. Receiver operating characteristic analysis was used to reflect diagnostic performance. Results: Least absolute shrinkage and selection operator was used to dimensionally reduce 1137 radiomics features to three features. Three optimal radiomics features were used to model construction. The logistic regression model achieved an accuracy of 97% and 85% in the training and test groups. Clinical utility was evaluated using decision curve analysis. Conclusion: The novel combination of radiomics analysis and machine-learning algorithm could predict axillary metastasis and prevent invasive manipulation.

Axilla lymph node dissection can be safely omitted in patients with 1-2 positive sentinel nodes receiving mastectomy: a large multi-institutional study and a systemic meta-analysis

PURPOSE

This study aimed to evaluate whether axillary lymph node dissection (ALND) can be omitted in patients with 1-2 positive sentinel lymph nodes (SLNs) who received total mastectomy (TM).

METHODS

Consecutive breast cancer patients with 1-2 positive SLNs were retrospectively reviewed from a multi-institutional database. Patients were divided into sentinel lymph node biopsy (SLNB) group and ALND group. Administration of adjuvant chemotherapy and survival were compared between groups. To further verify the results, a meta-analysis was also conducted.

RESULTS

Among the 1161 enrolled patients, 893 (76.9%) received ALND and 268 (23.1%) underwent SLNB alone. Administration of chemotherapy was comparable between the two groups (91.1% vs. 90.6%, P = 0.798), which was consistent in TM (P = 0.638) and BCS cohort (P = 0.576). After a median follow-up of 36 months, no significant difference was observed between the two groups in recurrence-free survival (P = 0.583) regardless of surgery of breast. During further meta-analysis, 13 out of 4733 relative studies reported the association of axillary surgery and disease-free survival (DFS) or overall survival (OS) in 1-2 positive SLNs patients. Pooled analysis showed no difference in adjusted DFS (HR 0.84, 95% CI 0.70-1.02) or OS (HR 1.02, 95% CI 0.93-1.11) between SLNB and ALND groups. Survival benefit of ALND remained non-significant after restricting the analysis in four studies with patients only receiving BCS, or in three studies with patients only receiving TM.

CONCLUSION

Further ALND does not impact adjuvant chemotherapy administration or disease outcome in breast cancer patients with 1-2 positive SLNs treated with TM.

Extranodal extension, an international survey on its evaluation and reporting in breast cancer patients

Lymph node metastasis is the most important prognostic factor for breast cancer patients. In addition to the number of nodes involved and the largest metastatic focus, extranodal extension (ENE) is also used to subclassify breast cancer patients into different risk groups. More recently, pathologists are required to report the size/extent of ENE per the new CAP guideline, as it seems to be associated with more axillary nodal burden and/or a worse prognosis. Although the definition of ENE is largely understood and agreed upon among pathologists around the world, evaluation and reporting for the size of ENE are not. To understand current practice, we conducted an international survey among pathologists who are interested in breast pathology. A total of 70 pathologists responded. The results showed that (1) 98% of the participants reported the presence or absence of ENE and 61% also reported the size of ENE in millimeter (mm). (2) There was no uniform method of measuring the size of ENE; 47% measured the largest dimension regardless of orientation, while 30% measured the largest perpendicular distance from the capsule. (3) The most common factors affecting the accuracy in diagnosis of ENE are the presence of lymphovascular invasion (LVI), lack of capsule integrity, and the presence of fatty hilar or fatty replacement of a lymph node. (4) 71% felt that the H&E stain is adequate to evaluate ENE, deeper levels and IHC analysis for vascular and cytokeratin markers can be helpful if needed. (5) 75% agreed that there is an urgent need to standardize the measurement and reporting for ENE. Our survey highlights the variation in ENE evaluation and the need for its standardization in breast cancer patients with axillary node metastasis.

Preservation of Axillary Lymph Nodes Compared with Complete Dissection in T1-2 Breast Cancer Patients Presenting One or Two Metastatic Sentinel Lymph Nodes: The SINODAR-ONE Multicenter Randomized Clinical Trial

BACKGROUND

The SINODAR-ONE trial is a prospective noninferiority multicenter randomized study aimed at assessing the role of axillary lymph node dissection (ALND) in patients undergoing either breast-conserving surgery or mastectomy for T1-2 breast cancer (BC) and presenting one or two macrometastatic sentinel lymph nodes (SLNs). The endpoints were to evaluate whether SLN biopsy (SLNB) only was associated with worsening of the prognosis compared with ALND in terms of overall survival (OS) and relapse.

METHODS

Patients were randomly assigned (1:1 ratio) to either removal of ≥ 10 axillary level I/II non-SLNs followed by adjuvant therapy (standard arm) or no further axillary treatment (experimental arm).

RESULTS

The trial started in April 2015 and ceased in April 2020, involving 889 patients. Median follow-up was 34.0 months. There were eight deaths (ALND, 4; SNLB only, 4), with 5-year cumulative mortality of 5.8% and 2.1% in the standard and experimental arm, respectively (p = 0.984). There were 26 recurrences (ALND 11; SNLB only, 15), with 5-year cumulative incidence of recurrence of 6.9% and 3.3% in the standard and experimental arm, respectively (p = 0.444). Only one axillary lymph node recurrence was observed in each arm. The 5-year OS rates were 98.9% and 98.8%, in the ALND and SNLB-only arm, respectively (p = 0.936).

CONCLUSIONS

The 3-year survival and relapse rates of T1-2 BC patients with one or two macrometastatic SLNs treated with SLNB only, and adjuvant therapy, were not inferior to those of patients treated with ALND. These results do not support the use of routine ALND.

Choice of Mastectomy May Increase the Extent of Axillary Surgery in Women with Breast Cancer

INTRODUCTION

Based on the ACOSOG Z0011 trial, women who undergo breast conservation therapy (BCT) and have limited disease in the axilla on sentinel lymph node (SLN) biopsy do not require axillary lymph node dissection (ALND). In this study we investigate the incidence of ALND in patients undergoing elective mastectomy with limited disease in the axilla to identify how many women may have been spared additional axillary surgery if they chose BCT.

METHODS

All women with invasive breast cancer treated at a single tertiary care breast center from 2010-2018 who were candidates for BCT but elected mastectomy and underwent SLN biopsy were identified through retrospective review of a prospectively maintained database. The primary outcome of interest was the incidence of ALND in women found to have a limited burden of disease in the axilla (1-2 positive SLNs).

RESULTS

The study population comprised 151 patients with invasive breast cancer eligible for BCT who chose mastectomy. On final pathology, 34 patients had 1-2 positive SLNs, and 16 of these patients underwent completion ALND. These 16 patients out of 151 overall lumpectomy candidates electing mastectomy (10.6%) could have been spared ALND if they did not elect mastectomy.

DISCUSSION

BCT candidates electing mastectomy have a 10.6% chance of undergoing more extensive axillary surgery than would have been recommended with BCT alone. The increased risk of undergoing additional axillary surgery should be incorporated into the preoperative discussion for patients choosing between BCT and mastectomy.

The effect of omitting axillary dissection and the impact of radiotherapy on patients with breast cancer sentinel node macrometastases: a cohort study following the ACOSOG Z0011 and AMAROS trials

PURPOSE

To report the outcomes of implementing the ACOSOG Z0011 and AMAROS trials relevant to clinical practice, and to define target groups in whom to avoid or recommend axillary radiotherapy (ART). We also aimed to analyse the reduction in morbidity when axillary lymph node dissection (ALND) was omitted.

METHODS

A retrospective cohort study of T1-T2 patients with macrometastases at sentinel lymph node (SLN) who were treated between 2011 and 2020. Breast surgery included either lumpectomy or mastectomy. Patients with ≤ 2 positive SLN were divided into two cohorts by whether they received ART or not. Survival outcomes and morbidity were analysed by Kaplan-Meyer curves and Cox-regression, respectively.

RESULTS

260 pN1a patients were included and ALND was avoided in 167 (64.2%). According the Z0011 results, 72 (43.1%) received no further ART; and based on AMAROS criteria 95 (56.9%) received ART. Median follow-up was 54 months. The 5-year overall survival was 96.8% in the non-RT cohort and 93.4% in the RT cohort (p = 0.19), while the respective 5-year disease-free survivals were 100% and 92.3% (p = 1.06). Lymphedema developed in 3.6% of patients after SLNB versus 43% after ALND (OR 20.25; 95%CI 8.13-50.43). Decreased upper-extremity range of motion appeared in 8.4% of patients after SLNB versus 31.2% after ALND (OR 4.95; 95%CI 2.45-9.98%).

CONCLUSIONS

Our study confirms that omitting ALND is safe and has high survival rates in patients with T1-T2 tumours and ≤ 2 positive SLNs. Adding ART could be a treatment option for patients who present other risk factors. Avoiding ALND with or without ART was associated with significantly less arm morbidity.

Application of the ACOSOG Z0011 criteria to Chinese patients with breast cancer: a prospective study

Background

Although the ACOSOG Z0011 study showed that axillary lymph node dissection (ALND) could be avoided in a specific population of sentinel lymph node-positive patients, it is not widely accepted by Chinese surgeons. We conducted a prospective single-arm study to confirm whether or not the results of Z0011 are applicable to Chinese patients.

Methods

Patients conforming to the Z0011 criteria were prospectively enrolled at the Peking University People’s Hospital Breast Center from November 2014 to June 2019. The clinicopathological features of the study group were compared with those of the Z0011 study group. Lymphedema after surgery, the incidence of local-regional recurrence, and survival were analyzed.

Results

One hundred forty-two patients who met the Z0011 eligibility criteria were enrolled in this study; 115 underwent sentinel lymph node biopsy (SLNB) alone. Compared with the Z0011 trial, younger patients were included (median age, 52 [26–82] years vs 54 [25–90] years; P = 0.03). For clinical T stage, tumor histology, hormone status, lymphovascular invasion, and the number of positive sentinel lymph nodes (SLNs), no statistically significant differences were observed. More patients received adjuvant chemotherapy and endocrine therapy in this study (90.85% vs 58.0% and 80.99% vs 46.6% respectively, P <0.001). A similar percentage of patients received radiotherapy, but more nodal radiotherapy procedures were carried out in our study (54.5% vs 16.9%). After a median follow-up of 29 months, only 1 patient (0.9%) had ipsilateral breast tumor recurrence, and no regional recurrence occurred.

Conclusion

Our study showed that it is achievable to avoid ALND in patients eligible for Z0011 in China.

Trial registration

ClinicalTrials.gov. Registration number NCT03606616. Retrospectively registered on 31 July 2018.

Outcomes After Sentinel Lymph Node Biopsy and Radiotherapy in Older Women With Early-Stage, Estrogen Receptor-Positive Breast Cancer

IMPORTANCE

Overtreatment of early-stage breast cancer with favorable tumor biology in older patients may be harmful without affecting recurrence and survival. Guidelines that recommend deimplementation of sentinel lymph node biopsy (SLNB) (Choosing Wisely) and radiotherapy (RT) (National Comprehensive Cancer Network) have been published.

OBJECTIVE

To describe the use rates and association with disease recurrence of SLNB and RT in older women with breast cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained patient and clinical data from an integrated cancer registry and electronic health record of a single health care system in Pennsylvania. The cohort was composed of consecutive female patients 70 years or older who were diagnosed with early-stage, estrogen receptor-positive, ERBB2 (formerly HER2)-negative, clinically node-negative breast cancer from January 1, 2010, to December 31, 2018, who were treated at 15 community and academic hospitals within the health system.

EXPOSURES

Sentinel lymph node biopsy and adjuvant RT.

MAIN OUTCOMES AND MEASURES

Primary outcomes were 5-year locoregional recurrence-free survival (LRFS) rate and disease-free survival (DFS) rate after SLNB and after RT. Secondary outcomes included recurrence rate, subgroups that may benefit from SLNB or RT, and use rate of SLNB and RT over time. Propensity scores were used to create 2 cohorts to separately evaluate the association of SLNB and RT with recurrence outcomes. Cox proportional hazards regression model was used to estimate hazard ratios (HRs).

RESULTS

From 2010 to 2018, a total of 3361 women 70 years or older (median [interquartile range {IQR}] age, 77.0 [73.0-82.0] years) with estrogen receptor-positive, ERBB2-negative, clinically node-negative breast cancer were included in the study. Of these women, 2195 (65.3%) received SLNB and 1828 (54.4%) received adjuvant RT. Rates of SLNB steadily increased (1.0% per year), a trend that persisted after the 2016 adoption of the Choosing Wisely guideline. Rates of RT decreased slightly (3.4% per year). To examine patient outcomes and maximize follow-up time, the analysis was limited to cases from 2010 to 2014, identifying 2109 patients with a median (IQR) follow-up time of 4.1 (2.5-5.7) years. In the propensity score-matched cohorts, no association was found between SLNB and either LRFS (HR, 1.26; 95% CI, 0.37-4.30; P = .71) or DFS (HR, 1.92; 95% CI, 0.86-4.32; P = .11). In addition, RT was not associated with LRFS (HR, 0.33; 95% CI, 0.09-1.24; P = .10) or DFS (HR, 0.99; 95% CI, 0.46-2.10; P = .97). Subgroup analysis showed that stratification by tumor grade or comorbidity was not associated with LRFS or DFS. Low absolute rates of recurrence were observed when comparing the groups that received SLNB (3.5%) and those that did not (4.5%) as well as the groups that received RT (2.7%) and those that did not (5.5%).

CONCLUSIONS AND RELEVANCE

This study found that receipt of SLNB or RT was not associated with improved LRFS or DFS in older patients with ER-positive, clinically node-negative breast cancer. Despite limited follow-up time and wide 95% CIs, this study supports the continued deimplementation of both SLNB and RT in accordance with the Choosing Wisely and National Comprehensive Cancer Network guidelines.

Can We Avoid Axillary Lymph Node Dissection (ALND) in Patients with 1-2 Positive Sentinel/Low Axillary Lymph Nodes (SLN/LAS+) in the Indian Setting?

The ACOSOG Z0011 study, heralded as a "practice changing" trial, suggested that women with T1-2 breast cancer with 1-2 SLN+, undergoing breast conservation therapy, need not be offered further ALND. However, whether these results are applicable to all women in the Indian setting, it remains debatable. A retrospective audit of all cN0 operated from 2013 to 2018 was conducted. We analyzed the percentage of additional LN positive (LN+) in the ALND group and compared it to the ACOZOG Z11 trial. Of the 2350 cN0 with EBC who underwent LAS, 687 (29%) had positive lymph nodes on final histopathology. Five hundred ninety-seven (86.9%) patients had 1-2 LN+, 40 (5.8%) patients had 3 LN+, and 50 (7.3%) had 4 or more nodes positive. Demographic features in the ACOSOG Z11 are different from those in our study, looking at ACOZOG Z11 versus our cohort-median pT 1.7 cm versus 3 cm, 45% micrometastasis versus 99.16% macrometastasis, and 28-30% grade 3 tumors versus 73.7%. In our cohort 31.82% of the 1-2 LN positive had additional LN+ on ALND. Keeping in mind the difference in clinicopathological features between our cohort and that of ACOZOG Z0011 and that 31.82% of women had additional LN+ on ALND, it may not be appropriate to apply the results of the ACOSOG Z0011 trial directly to our general population. Possibly, only a select subset of patients who match the trial population of the ACOSOG Z11 could be offered observation of the axilla and validated nomograms can be used to identify high-risk patients.

Axillary Nodal Burden in Breast Cancer Patients With Pre-operative Fine Needle Aspiration-proven Positive Lymph Nodes Compared to Those With Positive Sentinel Nodes

BACKGROUND/AIM

Recent years have seen a considerable shift to a more conservative management of the axilla in patients with positive axillary sentinel lymph nodes. The aim of this study was to determine whether some breast cancer patients with a preoperative ultrasound-guided needle aspiration biopsy proven positive node could potentially be spared an axillary lymph node dissection according to the ACOSOG Z0011 trial criteria.

PATIENTS AND METHODS

A retrospective review was performed involving 623 breast cancer patients who underwent axillary lymph node dissection after either ultrasound-guided needle aspiration biopsy proven positive node or sentinel lymph node biopsy.

RESULTS

Patients with fine needle aspiration biopsy-proven positive node had worse prognosis and a higher nodal burden (6.7 vs 1.9 nodes, p<0.001), compared to those with positive sentinel lymph nodes.

CONCLUSION

Patients with an ultrasound guided needle aspiration biopsy proven positive node are more likely to have tumor with more aggressive pathological characteristics and a higher nodal burden than those with a positive sentinel lymph node biopsy.

Axillary surgery in breast cancer: An updated historical perspective

This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing efforts of researchers toward new challenges, as documented by extensive studies and trials. Axillary surgery has evolved, aiming to offer the best oncologic treatment and improve the quality of life of women. Axillary lymph-node dissection (ALND) has been replaced by sentinel lymph-node biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with minimal morbidity, and becoming the standard of care in the management of breast cancer. However, this is only the beginning. Strategies in defining systemic and radiotherapeutic treatments have gradually been optimized, offering increasingly refined and targeted breast cancer treatment tools. In recent years, the paradigm of completion ALND after a positive SLNB has been questioned, and several studies have led to revolutionary changes in clinical practice. Moreover, the increasingly pivotal role played by neoadjuvant chemotherapy (NAC) has had a profound effect on the extent of axillary surgery, paving the way to a more finite "targeted" procedure in women with node-positive breast cancer who convert to negative nodes clinically after NAC. The utility of SLNB itself and its subsequent omission in women with negative nodes clinically and breast conservative surgery is also under scientific evaluation. The changes over time in the surgical approach to breast cancer have been numerous and significant. The novel emerging perspective characterized by recent advances in biology and genetics, in dedicated axillary ultrasound imaging and chemotherapy regimens, is the present reality that points to the future of axillary node treatment in breast cancer.

Interobserver variability between experienced radiologists in evaluating the number of abnormal lymph nodes seen on preoperative axillary ultrasound

AIM

To determine the interobserver variability of experienced radiologists in evaluating the number of suspicious lymph nodes (LNs) seen on axillary ultrasound (AUS) examination, and to evaluate the effects of clinicopathological features on the discordance.

MATERIAL AND METHODS

A prospective non-randomised triple-blind study was conducted from July 2016 to December 2017 at Shanghai Ruijin Hospital. Three experienced radiologists performed AUS on 462 patients (469 axillae) with invasive breast cancer independently and assessed the number of abnormal LNs during the real-time AUS examination. Interobserver agreement was determined according to the kappa statistic.

RESULTS

The mean numbers of metastatic LNs on final histology study were 0.35, 0.98, 3.05 and 4.70 for patients with 0, 1, 2 and >2 abnormal nodes on preoperative AUS. When the cut-off (the number of abnormal LNs seen on AUS was >1) at which the maximal sum of sensitivity and specificity for diagnosis of ≥3 tumour-involved LNs was achieved was applied, the Az values ranged from 0.776 to 0.811. When the number of abnormal LNs was grouped into two-category classification (0-1 versus ≥2 abnormal LNs detected by AUS), good interobserver agreement (kappa: 0.601-0.687) was found, and disagreement between the radiologists was more frequently found in patients with T2-stage tumour and in those with one or two tumour-involved nodes.

CONCLUSION

Abnormal LN count according to two-category classification (0-1 versus ≥2 abnormal LNs detected by AUS) was a feasible method with good accuracy and high repeatability to select patients with heavy nodal disease in the post-Z0011 trial era.

Predictive factors of lymph node metastasis and effectiveness of intraoperative examination of sentinel lymph node in breast carcinoma: A retrospective Belgian study

Recently, several trials demonstrated the safety of omitting axillary lymph node dissection in clinically N0 patients with positive sentinel nodes in select subgroups. However, this fact is still troublesome to clarify to surgeons and clinicians, as they used to perform intraoperative examination of the sentinel node and axillary dissection for many years. Hence, we decided to review our practice. This is to firstly highlight the predictive factors of node metastasis and secondly, to evaluate the effectiveness of intraoperative examination of the sentinel node. There were 406 total procedures. The rate of positive lymph nodes in the final diagnosis was 27%. Factors associated with metastasis were age, tumour size, TNM classification, tumour grade, vascular invasion, molecular classification and KI-67 index. The rate of reoperation was 6.2% in cases with final positive nodes, however, the complementary ALND was justified in only 2.7%. Forty-nine percent of SLN were examined during surgery (IOESLN), whereby the false negative rate was 11.8%. Sixty-three intraoperative examinations were necessary to prevent a second operation on a patient. We recommend changing the clinical management of the axilla, resulting in fewer ALNDs in selected cN0, SLN-positive patients. In keeping with recent large clinical trial (ACOSOG Z0011, AMAROS and OTOASOR) data, our results support that intraoperative exam in selected cN0, SLN-positive Belgian patients is no longer effective.

Axillary lymph node and non-sentinel lymph node metastasis among the ACOSOG Z0011 eligible breast cancer patients with invasive ductal, invasive lobular, or other histological special types: a multi-institutional retrospective analysis

PURPOSE

Given the histological special types (HST) of breast carcinoma accounted for minority of the Z0011 study population, this study aimed to assess the rates of axillary lymph node (ALN) involvement and non-sentinel lymph node (SLN) metastasis in patients with invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), or other HST.

METHODS

Patients with cT1-2N0M0 breast cancer treated between 2009 and 2018 were retrospectively included from a multi-institutional database. Rates of nodal involvement were analyzed among different histological subgroups. The impact of ALN dissection (ALND) on adjuvant treatment decisions and prognosis were also analyzed among patients with 1-2 + SLNs.

RESULTS

A total of 8294 patients were included: 6854 (82.6%), 257 (3.1%), and 1183 (14.3%) patients with IDC, ILC, and other HST, respectively. IDC patients had a significantly higher rate of ALN metastasis compared with ILC or other HST (31.9% vs. 22.6% vs. 16.4%, P < 0.001). However, in patients with 1-2 + SLNs, rates of non-SLN metastasis were similar among three groups (IDC: n = 182, 28.6% vs. ILC: n = 5, 31.2% vs. other HST: n = 29, 34.9%, P = 0.481). For patients with 1-2 + SLNs, rates of adjuvant chemotherapy and the estimated 3-year recurrence-free survival were similar between the SLN biopsy and ALND arms, regardless of the histological types.

CONCLUSION

Among patients with 1-2 + SLNs, ILC or other HST had similar rates of non-SLN metastasis compared with IDC. Omission of ALND may not influence adjuvant chemotherapy usage or disease outcome regardless of histological types.

De-escalation of axillary surgery in breast cancer patients treated in the neoadjuvant setting: a Dutch population-based study

PURPOSE

An overall trend is observed towards de-escalation of axillary surgery in patients with breast cancer. The objective of this study was to evaluate this trend in patients treated with neoadjuvant systemic therapy (NST).

METHODS

Patients with cT1-4N0-3 breast cancer treated with NST (2006-2016) were selected from the Netherlands Cancer Registry. Patients were classified by clinical node status (cN) and type of axillary surgery. Uni- and multivariable logistic regression analyses were performed to determine the clinicopathological factors associated with performing ALND in cN+ patients.

RESULTS

A total of 12,461 patients treated with NST were identified [5830 cN0 patients (46.8%), 6631 cN+ patients (53.2%)]. In cN0 patients, an overall increase in sentinel lymph node biopsy (SLNB) only (not followed by ALND) was seen from 11% in 2006 to 94% in 2016 (p < 0.001). SLNB performed post-NST increased from 33 to 62% (p < 0.001). In cN+ patients, an overall decrease in ALND was seen from 99% in 2006 to 53% in 2016 (p < 0.001). Age (OR 1.01, CI 1.00-1.02), year of diagnosis (OR 0.47, CI 0.44-0.50), HER2-positive disease (OR 0.62, CI 0.52-0.75), clinical tumor stage (T2 vs. T1 OR 1.32, CI 1.06-1.65, T3 vs. T1 OR 2.04, CI 1.58-2.63, T4 vs. T1 OR 6.37, CI 4.26-9.50), and clinical nodal stage (N3 vs. N1 OR 1.65, CI 1.28-2.12) were correlated with performing ALND in cN+ patients.

CONCLUSIONS

ALND decreased substantially over the past decade in patients treated with NST. Assessment of long-term prognosis of patients in whom ALND is omitted after NST is urgently needed.

The Adventure of Axillary Treatment in Early Stage Breast Cancer

Axillary lymph node dissection (ALND) which was an essential part of breast cancer treatment and the gold standard in evaluation of the status of axillary lymph node had notorious with increased arm morbidity and reduction of quality of life. Sentinel lymph node biopsy (SLNB) accurately stages the axilla in early breast cancer and ALND is omitted in SLNB negative patients. In patients with positive SLNB the omission of ALND with or without replacement of axillary radiotherapy has also been recommended by guidelines. The neoadjuvant chemotherapy (NAC) which has been increasingly used for large breast cancers to downstage the tumours for allowing breast conserving surgery and decreasing mastectomy rate has also been used in axillary node positive patients to reduce the need for ALND. The issues surrounding the treatment of axilla in patients treated with NAC; application and false negative rate of SLNB, number of identified sentinel lymph nodes, and axillary radiotherapy instead of ALND are currently the discussed and practiced hot topics. The quests for decreasing arm morbidity without compromising outcome in breast cancer treatment which have begun with the invention of SLNB continue for axilla conserving surgery. This article reviews the adventure of axillary treatment in breast cancer patients treated with or without NAC.

The changing role of pathologists from morphologists to molecular pathologists in the era of precision medicine

Pathology is the study of human illness. Throughout centuries of scientific discoveries, pathologic examination of tissue samples has been the gold standard for diagnosis and pathologists have been involved in the elucidation of aetiology, assessment of the biology, clinicopathologic correlation and prediction of prognosis. The advances in science and technology and focused interest in breast cancer research have provided ample opportunities for pathologists to participate in better understanding of the basic fundamental cascade of events leading to tumorigenesis in breast cancer. They also partnered with their clinical colleagues and scientists to find more effective therapeutic options. This change has been possible with recognition of the fact that morphology alone may not be sufficient to tell the entire story of clinical behaviour of all breast cancer patients. In addition, the realization of heterogeneity of breast cancer and the differences in the expression of various biomarkers and the observed differences in response to therapy have resulted in extensive efforts to better define the characters of each breast cancer subtype. It is now generally agreed that breast cancer is not a single disease and not all patients with breast cancer can benefit from the same therapy. These changes have brought new challenges for pathologists. Pathologist are now required to not only provide diagnosis, but also study the precise molecular characterization of each individual breast cancer case and play a significant role in the treatment planning of breast cancer patients. This remarkable change in the role of the pathologist require his/her involvement in the modern taxonomy of this disease and to rise to the challenge of genomic medicine and molecular diagnostics, which are the fastest growing areas of medicine. Emphasis should also been placed to create a new morphomolecular pathology and train our young pathologist to expand beyond morphology and to embrace the power of molecular diagnostics, in order to be able to effectively practise in the era of precision medicine.

Management of the axilla in patients with breast cancer and positive sentinel lymph node biopsy: An evidence-based update in a European breast center

The surgical approach to the axilla in breast cancer has been a controversial issue for more than three decades. Data from recently published trials have provided practice-changing recommendations in this scenario. However, further controversies have been triggered in the surgical community, resulting in heterogeneous diffusion of these recommendations. The development of clinical guidelines for the management of the axilla in patients with breast cancer is a work in progress. A multidisciplinary team discussion was held at the research hospital Policlinico San Matteo from the Università degli Studi di Pavia with the aim to update recommendations for the management of the axilla in patients with breast cancer. An evidence-based approach is presented. Our multidisciplinary panel determined that axillary dissection after a positive sentinel lymph node biopsy may be avoided in cN0 patients with micro/macrometastasis to ≤2 sentinel nodes, with age ≥40y, lesions ≤3 cm, who have not received neoadjuvant chemotherapy and have planned breast conservation (BCS) with whole breast radiotherapy (WBRT). Cases with gross (>2 mm) ECE in SLNs are evaluated on individual basis for completion ALND, axillary radiotherapy or omission of both. Patients fulfilling the criteria listed above who undergo mastectomy, may also avoid axillary dissection after multidisciplinary discussion of individual cases for consideration of axillary irradiation. Women 70 years or older with hormone receptors positive invasive lesions ≤3 cm, clinically negative nodes, and serious or multiple comorbidities who undergo BCS with WBRT, may forgo axillary staging/surgery (if mastectomy or larger tumor, comorbidities and life expectancy are taken into account).

Lobular Histology Does Not Predict the Need for Axillary Dissection Among ACOSOG Z0011-Eligible Breast Cancers

BACKGROUND

The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated that axillary lymph node dissection (ALND) may be omitted for women with two or fewer positive sentinel nodes (SLNs) undergoing breast-conservation therapy (BCT). Lobular histology comprises a minority of patients, and applicability to these discohesive cancers has been questioned.

METHODS

From August 2010 to March 2017, patients undergoing BCT for cT1-2N0 cancer with positive SLNs were prospectively managed with ALND for three or more positive SLNs or gross extracapsular extension (ECE). In this study, clinicopathologic characteristics and nodal burden were compared between pure/mixed invasive lobular cancer (ILC) and invasive ductal cancer (IDC) patients.

RESULTS

Among 813 consecutive patients, 104 (12.8%) had ILC and 709 (87.2%) had IDC. ILC was more often multifocal and low grade, and less frequently had lymphovascular invasion (all p < 0.001). ILC more often had SLN macrometastases (81.7% ILC vs. 69.4% IDC; p = 0.01) and more than 2 mm of ECE (30.8% ILC vs. 19.5% IDC; p = 0.03), but the proportions of cases with three or more positive SLNs were similar in the two groups (14.4% ILC vs. 9.9% IDC; p = 0.2). The ALND procedure was performed for 20 ILC patients (19.2%) compared with 97 IDC patients (13.7%) (p = 0.2). Additional positive nodes were found in 80% of the ILC patients versus 56.7% of the IDC patients (p = 0.09). The ALND and nodal burden rates were similar in the estrogen receptor-positive (ER+) subset analysis. In the multivariable analysis, lobular histology (p = 0.03) and larger tumors (p = 0.03) were associated with additional positive nodes. During a median follow-up period of 42 months, there were no isolated axillary recurrences.

CONCLUSIONS

Despite a higher proportion of SLN macrometastases and association with more positive nodes at ALND, lobular histology does not predict the need for ALND. ALND is not indicated on the basis of histology among patients otherwise meeting Z0011 criteria.

MRI evaluation of axillary and intramammary lymph nodes in the postoperative period

Our study aimed to evaluate if breast‐conserving surgery and adjuvant treatment could affect the morphological features of axillary and intramammary lymph nodes on magnetic resonance imaging (MRI) in patients with invasive breast cancer and clinically negative axilla. In this single‐center study, we retrospectively evaluated 50 patients who had (a) breast‐conserving surgery, (b) clinically negative axilla, (c) preoperative MRI within 3 months before surgery, and (d) postoperative MRI within 12 months after surgery. Axillary and intramammary lymph nodes on postoperative MRI were identified and then compared with preoperative MRI by two breast radiologists with regards to the following: enlargement, cortical thickening, presence of fatty hilum, irregularity, heterogeneity, matting, and axillary lymph node asymmetry. Three hundred and two axillary and eight intramammary lymph nodes were evaluated. Enlargement and cortical thickening were seen in 5/50 (10%) patients in three axillary and two intramammary lymph nodes. None of the lymph nodes on postoperative MRI demonstrated occurrence of lack of fatty hilum, irregularity, heterogeneity, matting or axillary lymph node asymmetry. No evidence of recurrence was observed on 2‐year follow‐up. Lymph node enlargement and cortical thickening may be observed in a few patients in the postoperative period. Nevertheless, in patients with clinically negative axilla, these changes in morphology are often related to treatment rather than malignancy and favor short‐term follow‐up as an alternative to lymph node biopsy.

Retrospectively validating the results of the ACOSOG Z0011 trial in a large Asian Z0011-eligible cohort

PURPOSE

The Z0011 trial demonstrated that axillary dissection (ALND) could be omitted during breast-conserving therapy for cT1-2N0 breast cancers with 1-2 metastatic SLNs. However, that result has not been validated in a larger cohort and the significance of the small number of SLNs remains unclear. This study aimed to validate the Z0011 results within an Asian Z0011-eligible cohort and determine whether the number of sentinel lymph nodes (SLNs) influenced the Z0011-based outcomes.

METHODS

Data from Asian patients who fulfilled the Z0011 criteria were collected from five hospitals. Disease recurrence (DR) was compared between patients who underwent ALND or SLN dissection (SLND) alone. Propensity-score matching was performed to reduce the effects of potential selection biases.

RESULTS

During 2010-2016, 1750 Asian patients had 1-2 SLN metastases and fulfilled the Z0011 criteria. These patients included 707 cases treated using SLND alone (40%) and 967 patients with ≤ 2 SLNs (55%). Ninety-five patients (5.4%) experienced DR at a median interval of 50 months, although the rates of DR were similar in the ALND and SLND groups. The adjusted hazard ratios for DR after ALND omission were 0.95 (95% CI 0.55-1.64) among the entire cohort and 0.83 (95% CI 0.34-2.03) among patients with ≤ 2 SLNs.

CONCLUSIONS

In this Asian Z0011-eligible cohort, ALND omission did not increase risk of DR, even among patients with ≤ 2 SLNs. Therefore, the Z0011 strategy might be safely applied in Asia, and a small number of SLNs did not significantly influence this strategy.

Positive sentinel node in luminal A-like breast cancer patients - implications for adjuvant chemotherapy?

BACKGROUND

In luminal A-like breast cancer, the indication for adjuvant chemotherapy still is largely based on lymph nodestatus. Sentinel node (SN) positive patients who are no longer recommended an axillary lymph node dissection (ALND) risk undertreatment, especially if they have ≥4 lymph node metastases (LNMs).

AIM

To quantify the group of SN positive luminal A-like patients with ≥4 LNMs and to investigate if the ratio between positive SNs and examined SNs (SN ratio) can provide information of the axillary tumor burden.

MATERIAL AND METHODS

Nearly 370 patients between 2014-2016 in Western Sweden with a clinically node-negative invasive breast cancer treated with both SNB and subsequent ALND were included. SNB findings were compared to ALND findings and the ability of the SN ratio to describe the axillary tumor burden was evaluated using multivariable analysis.

RESULTS

In total,17.6% of patients with luminal A-like tumors had ≥4 LNMs. The SN ratio was statistically significant for predicting ≥4 LNMs among luminal A-like patients (p = .013, OR 1.89 (95% CI 1.14-3.12) per 0.1 increment in SN ratio).

CONCLUSIONS

One sixth of patients with SN positive luminal A-like tumors risk undertreatment. The SN ratio may aid in identifying many of these patients.

Determining Whether High Nodal Burden in Early Breast Cancer Patients Can Be Predicted Preoperatively to Avoid Sentinel Lymph Node Biopsy

Purpose

The Z0011 trial showed that axillary lymph node dissection (ALND) can be safely avoided in breast cancer patients with low nodal burden (LNB). ALND can be performed in patients with high nodal burden (HNB). We aimed to determine whether HNB in early breast cancer patients can be predicted preoperatively to avoid sentinel lymph node biopsy (SLNB).

Methods

Early invasive breast cancer patients (cT1-2cN0) were retrospectively reviewed. We excluded patients with neoadjuvant chemotherapy and incomplete data. The patients were divided into the following groups based on surgical histology: no positive (N0), LNB, and HNB, defined as 0, 1–2, and ≥ 3 metastatic lymph nodes (LNs), respectively. Of the patients with metastatic nodal disease, only those with ALND were included in the analysis. Clinical, radiological, and histological parameters were evaluated using logistic regression analysis as predictors of HNB versus LNB and N0 combined.

Results

Of the 1,298 included patients, 832 (64.1%), 286 (22.0%), and 180 (13.9%) had N0, LNB, and HNB, respectively. Univariate logistic regression analysis revealed that sonographic features of breast tumor size (p < 0.0001), number of abnormal LNs (p < 0.0001), cortical thickness (p = 0.0002), effacement of the fatty hilum (p < 0.0001), and needle biopsy being performed (p < 0.0001) were indicators of HNB. Breast tumor grade (p = 0.0001) and human epidermal growth factor receptor 2 status (p = 0.0262) were also statistically significant. Among these significant features, multivariable stepwise logistic regression showed that the number of abnormal LNs is the sole independent predictor of HNB (p < 0.0001, area under the curve = 0.774). The positive predictive value of HNB in patients with ≥ 4 abnormal LNs was 92.9%.

Conclusion

The detection of ≥ 4 abnormal LNs on ultrasound can help to identify HNB patients who require upfront ALND and thus avoid SLNB.

Could axillary clearance be avoided in clinically node-negative breast cancer patients with positive nodes diagnosed by ultrasound guided biopsy in the post-ACOSOG Z0011 era?

BACKGROUND AND OBJECTIVES

The role of ultrasound (US) guided biopsy in selecting patients for an upfront lymph node dissection (ALND) has been controversial following the publication of the American College of Surgeons (ACOSOG) Z0011 data. The purpose of this study was to investigate if patients with positive axillary lymph nodes (LNs) proven by US guided biopsy should be recommended for ALND and to analyze the utility of preoperative US and US guided biopsy in planning axillary surgery to avoid both unnecessary ALND and unnecessary SLNB.

METHODS

Patients with a positive preoperative LN biopsy were identified and evaluated to determine their suitability for inclusion according to the criteria proposed in the Z0011 data. The correlation of the number of suspicious nodes found using US with the number of positive nodes on ALND was studied.

RESULTS

A total of 261 breast cancer patients who had a positive preoperative LN needle biopsy were identified, among them, 79 patients with cT1-2N0 breast cancer and ALND were enrolled in the study. Thirty-one patients (39.2%) had ≤2 positive nodes identified in pathology and 10 patients (12.7%) met all of the Z0011 criteria and might have been spared ALND. A significantly greater proportion of women with ≥3 positive nodes during ALND had >1 abnormal LN identified using US compared to women with ≤2 positive LNs found using ALND (66.7% vs. 6.5%, p<0.0001).

CONCLUSION

US with needle biopsy is valuable to patients with multiple suspicious nodes found using US while SLND without US guided needle biopsy is suggested if only one abnormal LN is detected on US in the post-Z0011 era.

Overview of Breast Cancer Therapy

Breast cancer treatment is multidisciplinary. Most women with early stage breast cancer are candidates for breast-conserving surgery with radiotherapy or mastectomy. The risk of local recurrence and the chance of survival does not differ with these approaches. Sentinel node biopsy is used for axillary staging, and individualized approaches are minimizing the need for axillary dissection in women with positive sentinel nodes. Adjuvant systemic therapy is used in most women based on proven survival benefit, and molecular profiling to individualize treatment based on risk is now a clinical reality for patients with hormone receptor-positive cancers.

Changes of breast and axillary surgery patterns in patients with primary breast cancer during the past decade

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.

Is Axillary Sentinel Lymph Node Biopsy Required in Patients Who Undergo Primary Breast Surgery?

Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated for various reasons: i) pN staging information may not be necessary for the postoperative treatment decision regarding adjuvant systemic therapy in the great majority of patients; ii) the SLNB-positive rate is declining below 20% in specialized breast centers; iii) albeit being a minimally invasive procedure, SLNB causes a significant reduction in quality of life in 23% of patients; and iv) previous randomized trials from the pre-SLNB era did not show a disadvantage for patients without axillary surgery with regard to overall survival. These data support the hypothesis that avoiding axillary treatment in patients with clinically and sonographically unsuspicious lymph nodes seems to be a safe option, although omitting axillary surgery may increase the risk of locoregional recurrence. Currently, the information regarding node-positive status is essential to guide postoperative treatment such as systemic or radiation therapies in a non-negligible minority of patients. Three ongoing prospective European trials (SOUND, INSEMA, BOOG 2013-08) with axillary observation alone versus SLNB in cN0 patients and primary breast-conserving surgery have the objective to evaluate oncologic safety when omitting SLNB.

Are Lymph Node Characteristics on Axillary Ultrasound Associated with ≥3 Positive Lymph Nodes in Patients Managed by the American College of Surgeons Oncology Group Z0011 Trial Criteria?

Patients often receive axillary ultrasound-biopsy (AUS-B) before clinical evaluation. One positive biopsy in the absence of palpable disease rarely indicates additional nodal involvement, but it eliminates patients from being managed by the American College of Surgeons Oncology Group Z0011 trial criteria. To determine which patients may benefit from AUS-B, we analyzed whether characteristics on AUS were associated with large-volume axillary disease and, thus, the need for axillary lymph node (LN) dissection. A retrospective review identified patients who met Z0011 criteria and underwent AUS. Clinicopathologic and ultrasound characteristics were compared between patients with ≤2 versus ≥3 positive LNs. Two hundred and seven patients with cT1-2N0 tumors underwent preoperative AUS and breast-conserving surgery. On multivariate analysis, three AUS combinations were associated with ≥3 positive LNs: cortical thickness (CT) > 4 mm + loss of fatty hilum + round shape (P = 0.0218), CT > 4 mm + loss of fatty hilum (P = 0.0211), and CT > 4 mm + round shape (P = 0.0155). Preoperative axillary LN biopsy in patients with a single abnormal LN characteristic on AUS may be unnecessary because a positive finding will eliminate management according to Z0011 criteria. Cortical thickness >4 mm combined with any other abnormal characteristic was associated with ≥3 positive LNs, supporting the performance of AUS-B in this population.

Preoperative predictors of high and low axillary nodal burden in Z0011 eligible breast cancer patients with a positive lymph node needle biopsy result

BACKGROUND

Z0011 trial showed that early breast cancer patients with low axillary nodal burden, may be spared an axillary lymph node dissection with no survival compromise. Axillary lymph node dissection can be reserved for patients with a high axillary nodal burden. We aim to determine the preoperative factors that could distinguish between low and high axillary nodal burden in Z0011 eligible patients with a needle biopsy proven metastatic node.

METHOD

Patients who fulfilled Z0011 trial criteria with a positive lymph node needle biopsy and had axillary lymph node dissection (ALND) were recruited. These patients were classified into low and high nodal burden subgroups, defined as having 1-2 and ≥3 metastatic lymph nodes, respectively. The clinical, radiological and pathological features between the 2 subgroups were compared.

RESULTS

70 (40%) and 105 (60%) patients had low and high nodal burden respectively. The high nodal burden subgroup was more likely to have on ultrasound ≥3 abnormal lymph nodes (37.14% versus 4.29%) (P < 0.0001) and maximum cortical thickness >4 mm (31.43% versus 10.0%) (P = 0.0036). Multivariate analysis revealed abnormal lymph nodes ≥3 to have an odds ratio of 20.72 (95% CI 5.91-72.65) P < 0.0001.

CONCLUSION

≥3 abnormal lymph nodes on ultrasound was the most significant predictor of high nodal burden subgroup in Z0011 eligible patients with a positive lymph node needle biopsy. This information could allow this subgroup to proceed to an upfront ALND and avoid the need of a sentinel lymph node biopsy in the post Z0011 trial era.

Evaluation of sentinel lymph node biopsy prior to axillary lymph node dissection: the role of isolated tumor cells/micrometastases and multifocality/multicentricity-a retrospective study of 1214 breast cancer patients

PURPOSE

Sentinel lymph node biopsy (SLNB) alone has thus become an accepted surgical approach for patients with limited axillary metastatic disease. We investigated to what extent isolated tumor cells (ITC) or micrometastasis in SLNBs is associated with proven tumor cells or metastasis in non-sentinel lymph nodes. Furthermore, we investigated the feasibility of SLNB in multifocal and multicentric tumors as both entities have been considered a contraindication for this technique.

METHODS

1214 women suffering from T1 and T2 invasive breast cancer, with clinically and sonographically insuspect axillary status and undergoing primary breast cancer surgery including SLNB and axillary staging in case of SLN (sentinel lymph node) metastases, were recruited into this multicentered study.

RESULTS

ITC and micrometastases were found in 2.01 and 21.4% of patients with SLN metastases (n = 299). Among patients with sentinel micrometastases, 4.7% showed further axillary micrometastases, while only two patients (3.1%) had two axillary macrometastases. Multifocal and multicentric tumors were diagnosed in 9.3 and 2.6% of our patients who at least had one SLN resected, respectively. Detection rates of SLNs did not differ between the cohorts suffering from unicentric and multifocal or multicentric disease. Moreover, the portion of tumor-free SLNs, the number of SLNs with metastasis as well as the mean number of resected SLNs did not differ.

CONCLUSIONS

No patient with sentinel node micrometastases showed more than two axillary macrometastases. Multifocal and multicentric disease is no contraindication for SLNB.

Evaluation of Sentinel Lymph Node Biopsy and Axillary Lymph Node Dissection for Breast Cancer Treatment Concepts - a Retrospective Study of 1,214 Breast Cancer Patients

Background

Most breast cancer patients require lumpectomy with axillary sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). The ACOSOG Z0011-trial failed to detect significant effects of ALND on disease-free and overall survival among patients with limited sentinel lymph node (SLN) metastases. Intense dose-dense chemotherapy and supraclavicular fossa radiation (SFR) are indicated for patients with extensive axillary metastases. In this multicentered study, we investigated the relevance of ALND after positive SLNB to determine adequate adjuvant therapy.

Methods

We retrospectively analyzed data from 1,214 patients with clinically nodal negative T1-T2 invasive breast cancer undergoing surgery at Hanau City Hospital Breast cancer center.

Results

681 patients underwent ALND after SLNB. 20 patients (8.5%) from the group with 1 or 2 SLN metastases (n = 236) showed more than 3 lymph node metastases after ALND. 13 patients (31.7%) from the group with more than 2 SLN metastases (n = 41) were diagnosed with a minimum of 4 axillary lymph node metastases after ALND.

Conclusions

In 8.5% of the patients with 1 or 2 SLN metastases, ALND detected more than 3 macrometastases, setting the indication for intense dose-dense chemotherapy and SFR. More than 2 SLN metastases, T stage and grading predict lymph node metastases.

The Optimal Treatment Plan to Avoid Axillary Lymph Node Dissection in Early-Stage Breast Cancer Patients Differs by Surgical Strategy and Tumor Subtype

BACKGROUND

Strategies to reduce the likelihood of axillary lymph node dissection (ALND) include application of Z0011 or use of neoadjuvant chemotherapy (NAC). Indications for ALND differ by treatment plan, and nodal pathologic complete response rates after NAC vary by tumor subtype. This study compared ALND rates for cT1-2N0 tumors treated with upfront surgery versus those treated with NAC.

METHODS

The ALND rates for cT1-2N0 breast cancer patients were compared by tumor subtype among women undergoing upfront surgery to NAC. Multivariable analysis with control for age, cT stage, and lymphovascular invasion, and stratification by subtype was performed.

RESULTS

The study identified 1944 cancers in 1907 women who underwent sentinel lymph node (SLN) biopsy with or without ALND (669 upfront breast-conserving surgeries [BCSs], 1004 upfront mastectomies, 271 NACs). Compared with the NAC group, the ALND rates in the BCS group were lower for estrogen receptor (ER), progesterone receptor-positive (PR+), human epidermal growth factor 2-negative (HER2-) tumors (15 vs 34%; p < 0.001). The ALND rates in the upfront mastectomy group were higher than in the NAC group for HER2+ or TN tumors. In the multivariable analysis, receipt of NAC compared with upfront BCS remained significantly associated with higher odds of ALND in the ER/PR+ HER2- subtype (hazard ratio [HR], 3.35; p < 0.001), whereas NAC versus upfront mastectomy remained significantly associated with lower odds of ALND in the HER2+ and TN subtypes (HR for HER2+, 0.19, p < 0.001; HR for TN, 0.25, p = 0.007).

CONCLUSION

The study showed that ALND rates differ according to surgery type and tumor subtype secondary to differing ALND indications and nodal response to NAC. These factors can be used to personalize treatment planning to minimize ALND risk for patients with early-stage breast cancer.

Imaging and pathology features to predict axillary tumor load in breast cancer

AIM

We investigated if imaging and pathology features could help to identify a high axillary tumor burden (ATB) in breast cancer patients, in order to individualize decisions on axillary lymph node (ALN) dissection (ALND).

METHODS

We retrospectively analyzed patients primarily treated with surgery in our unit between 2011 and 2014. We divided the patients in two groups: low ATB (LATB) if ≤ 2 ALN were infiltrated and high ATB (HATB) if > 2 ALN were infiltrated.

RESULTS

Data of 105 patients was included in the study. Axillary ultrasound (AUS) features associated with HATB were any sign of ALN infiltration (76 vs 24%, P = 0.027) and > 2 suspicious ALNs (73% vs 27%, P = 0.018); however, when AUS revealed ≤ 2 suspicious ALNs, 39% of these patients had HATB. Any sign of ALN infiltration on magnetic resonance imaging was associated with HATB (48% vs 52%, P = 0.031). Positive preoperative ALN cytology or biopsy was associated with HATB (53% vs 47%, P = 0.008), while p53 positivity (80% vs 20%) and high histological grade (68% vs. 32%) correlated with LATB (P = 0.05 and P = 0.02, respectively). In multivariate analysis, only positive preoperative ALN cytology or biopsy was associated with HATB (P = 0.038).

CONCLUSIONS

AUS was useful for detecting HATB but was not as effective in patients with LATB. Proving axillary infiltration with AUS-directed cytology or biopsy is the most effective method to predict HATB.

Axillary Dissection and Nodal Irradiation Can Be Avoided for Most Node-positive Z0011-eligible Breast Cancers: A Prospective Validation Study of 793 Patients

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.

De-escalation of axillary surgery in early breast cancer

With the advent of sentinel lymph node biopsy, surgical methods for accurately staging the axilla in patients with early-stage breast cancer have become progressively less extensive, with formal axillary lymph node dissection confined to a dwindling group of patients. Although details of methods for sentinel lymph node biopsy have yet to be standardised, this technique is now widely practised and accepted as standard of care worldwide. In the past 5 years, attention has focused on minimisation of surgical morbidity by restricting further axillary surgery or considering radiotherapy in patients with a small tumour burden in their sentinel nodes. This change in approach to patients with positive sentinel lymph node biopsies has increased the complexity of axillary management, and any policy of de-escalation and avoidance of morbidity must not compromise patient outcomes. This trend for de-escalation has accompanied a shift in understanding of how any residual tumour burden can be adequately managed without surgical extirpation and reliance on effective adjuvant therapies. Indications for omission of completion axillary lymph node dissection in patients with two or fewer nodes containing macrometastases demand further clarification, together with the roles of preoperative imaging in defining axillary nodal burden, deselection of patients for sentinel lymph node biopsy, and provision of radiotherapy. Downstaging of biopsy-proven node-positive patients with neoadjuvant chemotherapy could safely permit sentinel lymph node biopsy alone when the index node has been successfully retrieved at surgery, while nodal deposits of any size continue to mandate completion axillary lymph node dissection. Developments in molecular imaging technologies and percutaneous biopsy techniques could potentially render sentinel lymph node biopsy redundant in the future.

Axillary Nodal Management Following Neoadjuvant Chemotherapy: A Review

Importance

The increasing use of neoadjuvant chemotherapy (NAC) for operable breast cancer has raised questions about optimal local therapy for the axilla.

Observations

Sentinel lymph node biopsy (SLNB) after NAC in patients presenting with clinically negative nodes has an accuracy similar to upfront SLNB and reduces the need for axillary lymph node dissection compared with SLNB prior to NAC. In patients presenting with node-positive disease, clinical trials demonstrate that SLNB after NAC is accurate when 3 or more sentinel nodes are obtained, but long-term outcomes are lacking. The relative importance of pre- and post-NAC stage in predicting risk of locoregional recurrence remains an area of controversy.

Conclusions and Relevance

Neoadjuvant chemotherapy reduces the need for axillary lymph node dissection, and SLNB is an accurate method of determining nodal status after NAC.

Breast cancer

Breast cancer is one of the three most common cancers worldwide. Early breast cancer is considered potentially curable. Therapy has progressed substantially over the past years with a reduction in therapy intensity, both for locoregional and systemic therapy; avoiding overtreatment but also undertreatment has become a major focus. Therapy concepts follow a curative intent and need to be decided in a multidisciplinary setting, taking molecular subtype and locoregional tumour load into account. Primary conventional surgery is not the optimal choice for all patients any more. In triple-negative and HER2-positive early breast cancer, neoadjuvant therapy has become a commonly used option. Depending on clinical tumour subtype, therapeutic backbones include endocrine therapy, anti-HER2 targeting, and chemotherapy. In metastatic breast cancer, therapy goals are prolongation of survival and maintaining quality of life. Advances in endocrine therapies and combinations, as well as targeting of HER2, and the promise of newer targeted therapies make the prospect of long-term disease control in metastatic breast cancer an increasing reality.