1
|
Aragón-Sánchez S, Sánchez-Bayona R, López-Marín L, Ciruelos-Gil E, Parrilla-Rubio L, Zaragoza-Ballester P, Galindo-Izquierdo A, García-Chapinal B, Álvaro-Valiente L, Oliver-Pérez MR. De-escalating axillary management after neoadjuvant chemotherapy in breast cancer: The ratio of positive sentinel lymph nodes matters. Surg Oncol 2024; 54:102062. [PMID: 38531288 DOI: 10.1016/j.suronc.2024.102062] [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: 09/17/2023] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND De-escalation of axillary surgery in breast cancer (BC) patients diminishes sequelae without compromising cancer outcomes. Surgical management of the axilla is challenging after neoadjuvant treatment. We aimed to identify the factors associated with residual axillary disease amenable to lymphadenectomy in patients with positive sentinel lymph node biopsy (SLNB). METHODS We conducted a retrospective observational study in Hospital 12 de Octubre (Spain). We included BC patients with positive SLNB who underwent axillary dissection after neoadjuvant chemotherapy. Univariate and multivariate logistic regression models were performed to identify independent predictors of residual axillary disease. We estimated the ratio of positive nodes in SLNB and assessed the diagnostic validity of this ratio in relation to residual axillary disease. RESULTS We included 103 patients in the study. Residual axillary disease was identified in 54 patients (52.4%). Clinically node positive status at diagnosis (OR = 18.3, 95%CI: 4.0-83.6) and a ratio of positive nodes in SLNB ≥0.5 (OR = 6.5, 95%CI 41.7-23.7) were associated with residual axillary disease. The sensitivity and negative predictive value of a ratio of positive nodes in SLNB ≥0.5 were 87% (95%CI 75.1%-94.6%) and 75% (95%CI 55.1%-89.3%), respectively. CONCLUSIONS In our study, for patients with positive SLNB after neoadjuvant chemotherapy, stage N+ at diagnosis and a ratio of positive nodes in SLNB ≥0.5 were independent risk factors of positive residual axillary disease. This ratio is a feasible measure with a good diagnostic validity for residual axillary disease and could be used as a guiding factor in the surgical management of these patients.
Collapse
Affiliation(s)
- S Aragón-Sánchez
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain
| | - R Sánchez-Bayona
- Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain; Department of Medical Oncology. University Hospital 12 de Octubre. Madrid, Spain.
| | - L López-Marín
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain
| | - E Ciruelos-Gil
- Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain; Department of Medical Oncology. University Hospital 12 de Octubre. Madrid, Spain
| | - L Parrilla-Rubio
- Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain; Department of Pathology. University Hospital 12 de Octubre. Madrid, Spain
| | | | - A Galindo-Izquierdo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain; Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
| | - B García-Chapinal
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain
| | - L Álvaro-Valiente
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain
| | - M R Oliver-Pérez
- Department of Obstetrics and Gynaecology. University Hospital 12 de Octubre. Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre [imas12]. Universidad Complutense de Madrid, Madrid, Spain
| |
Collapse
|
2
|
Munck F, Jensen MB, Vejborg I, Gerlach MK, Maraldo MV, Kroman NT, Tvedskov THF. Residual Axillary Metastases in Node-Positive Breast Cancer Patients After Neoadjuvant Treatment: A Register-Based Study. Ann Surg Oncol 2024:10.1245/s10434-024-15354-1. [PMID: 38704502 DOI: 10.1245/s10434-024-15354-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/09/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Lymph node (LN) metastasis after neoadjuvant chemotherapy (NACT) generally warrants axillary lymph node dissection, which opposes guidelines of upfront surgery in many cases. We investigated the risk of having additional metastases in the axilla when the LNs removed by targeted axillary dissection (TAD) harbored metastases after NACT. We aimed to identify subgroups suitable for de-escalated axillary treatment. METHODS This register-based study used data from the Danish Breast Cancer Cooperative Group database. Data were analyzed with logistic regression models. The primary outcome was the metastatic burden in non-TAD LNs in patients with positive TAD LNs after NACT. RESULTS Among 383 patients, < 66.6% positive TAD LNs (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.17-0.62), only isolated tumor cells (ITCs) [OR 0.11, 95% CI < 0.01-0.82], and breast pathological complete response (pCR) [OR 0.07, 95% CI < 0.01-0.56] were associated with a low risk of having more than three positive non-TAD LNs. In 315 patients with fewer than three positive non-TAD LNs, the proportion of positive TAD LNs (OR 0.45, 95% CI 0.27-0.76 for 33.3-66.6% vs. > 66.6%), size of the TAD LN metastasis (OR 0.14, 95% CI 0.04-0.54 for ITC vs. macrometastasis), tumor size at diagnosis (OR 0.30, 95% CI 0.15-0.64 for 20-49 mm vs. ≥ 50 mm) and breast pCR (OR 0.38, 95% CI 0.15-0.96) were associated with residual LN metastases in the axilla. CONCLUSIONS Breast pCR or ITC only in TAD LNs can, with reasonable certainty, preclude more than three positive non-TAD LNs. Additionally, patients with only ITCs in the TAD LN had a low risk of having any non-TAD LN metastases after NACT. De-escalated axillary treatment may be considered in both subgroups.
Collapse
Affiliation(s)
- Frederikke Munck
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark.
| | - Maj-Britt Jensen
- Danish Breast Cancer Group, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations and Capital Mammography Screening, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Maria K Gerlach
- Department of Pathology, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Maja V Maraldo
- Department of Clinical Oncology, Center of Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Tove H F Tvedskov
- Department of Breast Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| |
Collapse
|
3
|
Heidinger M, Weber WP. Axillary Surgery for Breast Cancer in 2024. Cancers (Basel) 2024; 16:1623. [PMID: 38730576 PMCID: PMC11083357 DOI: 10.3390/cancers16091623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous 'one size fits all' radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.
Collapse
Affiliation(s)
- Martin Heidinger
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Walter P. Weber
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| |
Collapse
|
4
|
Bae SJ, Chun JW, Lee SB, Ryu JM, Nam SJ, Jeong J, Park HS, Ahn SG. Outcomes of sentinel node biopsy according to MRI response in an association with the subtypes in cN1-3 breast cancer after neoadjuvant systemic therapy, multicenter cohort study. Breast Cancer Res 2024; 26:66. [PMID: 38632652 PMCID: PMC11022328 DOI: 10.1186/s13058-024-01807-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 03/06/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND This study investigated the feasibility of sentinel lymph node biopsy (SLNB) after neoadjuvant systemic therapy (NAST) in patients with initially high nodal burden. METHODS In the multicenter retrospective cohort, 388 individuals with cN1-3 breast cancer who underwent NAST and had SLNB followed by completion axillary lymph node dissection were included. In an external validation cohort, 267 patients with HER2+ or triple-negative breast cancer (TNBC) meeting similar inclusion criteria were included. Primary outcome was the false-negative rates (FNRs) of SLNB according to the MRI response and subtypes. We defined complete MRI responders as patients who experienced disappearance of suspicious features in the breast and axilla after NAST. RESULTS In the multicenter retrospective cohort, 130 (33.5%) of 388 patients were of cN2-3, and 55 (14.2%) of 388 patients showed complete MRI responses. In hormone receptor-positive HER2- (n = 207), complete and non-complete responders had a high FNRs (31.3% [95% CI 8.6-54.0] and 20.9% [95% CI 14.1-27.6], respectively). However, in HER2+ or TNBC (n = 181), the FNR of complete MRI responders was 0% (95% CI 0-0), whereas that of non-complete responders was 33.3% (95% CI 20.8-45.9). When we validated our findings in the external cohort with HER2+ or TNBC (n = 267), of which 34.2% were cN2-3, the FNRs of complete were 7.1% (95% CI 0-16.7). CONCLUSIONS Our findings suggest that SLNB can be a reliable option for nodal status evaluation in selected patients who have responded well to NAST, especially in HER2+ and TNBC patients who show a complete MRI response.
Collapse
Affiliation(s)
- Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Whan Chun
- Department of Surgery, Asan Medical Center, Seoul, Republic of Korea
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sae Byul Lee
- Department of Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Jai Min Ryu
- Department of Surgery, Samsung Medical Center, Seoul, Republic of Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Seoul, Republic of Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute for Breast Cancer Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
5
|
Houvenaeghel G, de Nonneville A, Cohen M, Sabiani L, Buttarelli M, Charaffe E, Jalaguier A, Bannier M, Tallet A, Viret F, Gonçalves A. Neoadjuvant chemotherapy for breast cancer: Pathologic response rates but not tumor size, has an independent prognostic impact on survival. Cancer Med 2024; 13:e6930. [PMID: 38327130 PMCID: PMC10904968 DOI: 10.1002/cam4.6930] [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: 07/27/2023] [Revised: 12/01/2023] [Accepted: 12/30/2023] [Indexed: 02/09/2024] Open
Abstract
AIM We investigated the pathologic complete response rates (pCR) and survival outcomes of early breast cancer patients who underwent neoadjuvant chemotherapy (NAC) over 14 years at a French comprehensive cancer center and reported pCR and survival outcomes by tumor subtypes and size. METHODS From January 2005 to December 2018, 1150 patients receiving NAC were identified. Correlations between cT stage, breast tumor response, axillary lymph node response, pCR, surgery, and outcomes were assessed. pCR was defined as (ypT0/ypTis) and (ypN0/pN0sn). RESULTS A pCR was reached in 31.7% (365/1150) of patients and was strongly associated with tumor subtypes, but not with tumor size (pretreatment cT category). Luminal-B Her2-negative and triple-negative (TN) subtypes, cN1 status, older age, and no-pCR had an independent negative prognostic value. Overall survival (OS), relapse-free survival (RFS), and metastasis-free survival (MFS) were not significantly different for cT0-1 compared to cT2 stages. In Cox-model adjusted on in-breast pCR and pN status, ypN1 had a strong negative impact (OS, RFS, and MFS: HR = 3.153, 4.677, and 6.133, respectively), higher than no in-breast pCR (HR = 2.369, 2.252, and 2.323). A negative impact of no pCR on OS was observed for cN0 patients and TN tumors (HR = 4.972) or HER2-positive tumors (HR = 11.706), as well as in Luminal-B Her2-negative tumors on MFS (HR = 2.223) and for Luminal-A on RFS (HR = 4.465) and MFS (HR = 4.185). CONCLUSION Achievement of pCR, but not tumor size (pretreatment cT category), has an independent prognostic impact on survival. These results suggest potential NAC benefits in patients with small tumors (<2 cm), even in absence of clinically suspicious lymph nodes. Residual lymph node disease after NAC is the most powerful adverse prognostic factor.
Collapse
Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical OncologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Alexandre de Nonneville
- Department of Medical OncologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Monique Cohen
- Department of Surgical OncologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Laura Sabiani
- Department of Surgical OncologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Max Buttarelli
- Department of Surgical OncologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Emmanuelle Charaffe
- Department of PathologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Aurélie Jalaguier
- Department of RadiologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Marie Bannier
- Department of Surgical OncologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Agnès Tallet
- Department of RadiotherapyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Frédéric Viret
- Department of Medical OncologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| | - Anthony Gonçalves
- Department of Medical OncologyAix‐Marseille University, CNRS, INSERM, Institute Paoli‐Calmettes, CRCMMarseilleFrance
| |
Collapse
|
6
|
Go J, Ahn JH, Park JM, Choi SB, Kim JY, Park HS, Kim SI, Park BW, Park S. Distinct Prognosis of Minimal Residual Disease According to Breast Cancer Subtype in Patients with Breast or Nodal Pathologic Complete Response After Neoadjuvant Chemotherapy. Ann Surg Oncol 2023; 30:7060-7068. [PMID: 37537485 DOI: 10.1245/s10434-023-13938-x] [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: 09/30/2022] [Accepted: 06/27/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE Few studies have reported on patient prognosis according to residual cancer burden after neoadjuvant chemotherapy (NAC). Herein, we evaluated the survival of patients based on residual disease after NAC to identify subpopulations with distinct prognoses. METHODS We retrospectively reviewed 728 patients treated with NAC from 2010 to 2017. Patients were divided into four subgroups depending on post-surgical residual disease according to the staging system: pathological complete response (pCR) (ypT0/TisN0), minimal residual disease (MRD) (ypT1mi/T1aN0 or ypT0/Tis ypN0i+/N1mic), node-only pCR (≥ ypT1b ypN0), and breast-only pCR (ypT0/Tis ≥ ypN1a). Clinicopathological characteristics and survival outcomes were analyzed by adjusting for factors affecting survival. RESULTS Overall, 50.4% (n = 367) of patients achieved pCR, with the MRD group accounting for 16.5% (n = 120). Although age and clinical stage were not different among the study groups, histologic grade, subtypes, chemotherapy response, and local treatment showed differences. Event-free survival (EFS) and overall survival (OS) demonstrated no significant difference between the pCR and MRD groups. In the multivariate analysis, pCR status was the only significant factor in EFS, and no statistical difference was noted between the pCR and MRD groups. However, clinical stage, pCR status, and subtype significantly affected the OS. MRD showed favorable outcomes in terms of both EFS and OS in all subtypes, except for those with triple-negative breast cancer (TNBC). CONCLUSION Patients with MRD showed outcomes comparable to those of patients who achieved pCR and may be candidates for de-escalation of post-NAC treatment, except for those with a TNBC subtype.
Collapse
Affiliation(s)
- Jieon Go
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jee Hyun Ahn
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Min Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Bo Choi
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jee Ye Kim
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyung Seok Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Il Kim
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byeong-Woo Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seho Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
7
|
de Nonneville A, Boudin L, Houvenaeghel G, Gonçalves A, Bertucci F. A machine learning-based algorithm to eliminate breast and axillary surgery in patients with breast cancer and pathological complete response after neoadjuvant chemotherapy. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:397. [PMID: 37970604 PMCID: PMC10632564 DOI: 10.21037/atm-23-689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/22/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Alexandre de Nonneville
- Laboratory of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille, Institut Paoli-Calmettes, INSERM UMR1068, CNRS UMR725, Equipe Labellisée Ligue Nationale Contre Le Cancer, Marseille, France
- Department of Medical Oncology, CRCM, Institut Paoli‑Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Laurys Boudin
- Laboratory of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille, Institut Paoli-Calmettes, INSERM UMR1068, CNRS UMR725, Equipe Labellisée Ligue Nationale Contre Le Cancer, Marseille, France
- Department of Medical Oncology, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - Gilles Houvenaeghel
- Department of Surgical Oncology, CRCM, Institut Paoli‑Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Anthony Gonçalves
- Department of Medical Oncology, CRCM, Institut Paoli‑Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - François Bertucci
- Laboratory of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille, Institut Paoli-Calmettes, INSERM UMR1068, CNRS UMR725, Equipe Labellisée Ligue Nationale Contre Le Cancer, Marseille, France
- Department of Medical Oncology, CRCM, Institut Paoli‑Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| |
Collapse
|
8
|
Laws A, Kantor O, King TA. Surgical Management of the Axilla for Breast Cancer. Hematol Oncol Clin North Am 2023; 37:51-77. [PMID: 36435614 DOI: 10.1016/j.hoc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This review discusses the contemporary surgical management of the axilla in patients with breast cancer. Surgical paradigms are highlighted by clinical nodal status at presentation and treatment approach, including upfront surgery and neoadjuvant systemic therapy settings. This review focuses on the increasing opportunities for de-escalating the extent of axillary surgery in the era of sentinel lymph node biopsy, while also reviewing the remaining indications for axillary clearance with axillary lymph node dissection.
Collapse
Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
9
|
Montagna G. Estimating the Benefit of Preoperative Systemic Therapy to Reduce the Extent of Breast Cancer Surgery: Current Standard and Future Directions. Cancer Treat Res 2023; 188:149-174. [PMID: 38175345 DOI: 10.1007/978-3-031-33602-7_6] [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: 01/05/2024]
Abstract
Once reserved for locally advanced tumors which were deemed inoperable at presentation, preoperative systemic therapy (PST) is nowadays increasingly used to treat early breast cancer. PST allows for in vivo assessment of tumor response, for tailoring of adjuvant systemic therapy and for de-escalation of breast and the axillary surgery. Increased rates of pathological complete response together with more accurate response assessment and surgical planning have led to a significant reduction in surgical morbidity. While surgical assessment remains the standard of care, ongoing studies are evaluating whether surgery can be omitted in patients who achieve a complete pathological response. In this chapter, I will review the impact of PST on surgical de-escalation and the data supporting the safety of this approach.
Collapse
Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66Th Street, New York, NY, 10065, USA.
| |
Collapse
|
10
|
Gasparri ML, de Boniface J, Poortmans P, Gentilini OD, Kaidar-Person O, Banys-Paluchowski M, Di Micco R, Niinikoski L, Murawa D, Bonci EA, Pasca A, Rubio IT, Karadeniz Cakmak G, Kontos M, Kühn T. Axillary surgery after neoadjuvant therapy in initially node-positive breast cancer: international EUBREAST survey. Br J Surg 2022; 109:857-863. [PMID: 35766257 DOI: 10.1093/bjs/znac217] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/17/2022] [Accepted: 05/28/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND There is no consensus on axillary management after neoadjuvant therapy (NAT) in patients with clinically node-positive (cN+) breast cancer. To investigate current clinical practice, an international survey was conducted among breast surgeons and radiation oncologists. The aim of the first part of the survey was to provide a snapshot of international discrepancies regarding axillary surgery in this context. METHODS The European Breast Cancer Research Association of Surgical Trialists (EUBREAST) developed a web-based survey containing 39 questions describing clinical scenarios in the setting of axillary management in patients with cN1 disease converting to ycN0 after NAT. The survey was then distributed to breast surgeons and radiation oncologists via 14 breast cancer societies between April and October 2021. RESULTS Responses from 349 physicians in 45 countries were recorded. The most common post-NAT axillary surgery in patients with cN1 disease converting to ycN0 was targeted axillary dissection (54.2 per cent), followed by sentinel lymph node biopsy (SLNB) alone (20.9 per cent), level 1-2 axillary lymph node dissection (ALND) (18.4 per cent), level 1-3 ALND (4 per cent), and targeted lymph node biopsy (2.5 per cent). For SLNB alone, dual tracers were most commonly used (62.3 per cent). Management varied widely in patients with ambiguous axillary status before initiation of treatment or a residual metastatic burden in the axilla after NAT. In patients with ycN+ tumours, ALND was the preferred surgical approach for 66.8 per cent of respondents. CONCLUSION These results highlight the wide heterogeneity in surgical approaches to the axilla after NAT. To standardize the guidelines, further data from clinical research are urgently needed, which underlines the importance of the ongoing AXSANA (EUBREAST-3) study.
Collapse
Affiliation(s)
- Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, Lugano, CH.,Faculty of Biomedicine, University of the Italian Switzerland (USI), Lugano, Switzerland
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | | | - Orit Kaidar-Person
- Breast Radiation Unit, Oncology Institute, Sheba Hospital Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,GROW-School for Oncology and Developmental Biology or GROW (Maastro), Maastricht University, Maastricht, The Netherlands
| | - Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany.,Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Rosa Di Micco
- Breast Surgery Unit, San Raffaele University Hospital, Milan, Italy
| | - Laura Niinikoski
- Breast Surgery Unit, Comprehensive Cancer Center, Helsinki University Hospital, University of Helsinki, Finland
| | - David Murawa
- Department of General Surgery and Surgical Oncology, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland
| | - Eduard Alexandru Bonci
- Department of Surgical Oncology, "Prof. Dr. Ion Chiricuță" Institute of Oncology, Cluj-Napoca, Romania.,Department of Oncological Surgery and Gynecological Oncology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andrei Pasca
- Department of Surgical Oncology, "Prof. Dr. Ion Chiricuță" Institute of Oncology, Cluj-Napoca, Romania.,Department of Oncological Surgery and Gynecological Oncology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Isabel T Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain
| | - Guldeniz Karadeniz Cakmak
- Zonguldak BEUN The School of Medicine, General Surgery Department, Breast and Endocrine Unit, Kozlu/Zonguldak, Turkey
| | - Michalis Kontos
- 1st Department of Surgery, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Kühn
- Interdisciplinary Breast Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| |
Collapse
|
11
|
Cavalcante FP, Abdala E, Weissmann L, Ferreira CEDS, Amorim G, de Oliveira VM, Guilgen G, Landeiro L, Pinho JRR, Pulchinelli Á, Ribeiro H, Souza R, Rosa DD. Impact of COVID-19 Disease in Early Breast Cancer Management: A Summary of the Current Evidence. JCO Glob Oncol 2022; 8:e2100357. [PMID: 35594492 PMCID: PMC9173577 DOI: 10.1200/go.21.00357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
An expert panel on breast cancer and COVID-19 disease was convened to address the impact of the COVID-19 pandemic for early breast cancer (eBC) management.
Collapse
Affiliation(s)
| | - Edson Abdala
- Department of Infectious and Parasitic Diseases, School of Medicine, University of São Paulo (USP), São Paulo, SP, Brazil
| | - Leonardo Weissmann
- Emílio Ribas Infectious Disease Institute, São Paulo, SP, Brazil
- Unaerp School of Medicine, Guarujá, SP, Brazil
- Brazilian Society of Infectology, São Paulo, SP, Brazil
| | | | - Gilberto Amorim
- Oncologia D'Or, Rio de Janeiro, RJ, Brazil
- Brazilian Breast Cancer Study Group (GBECAM), Porto Alegre, RS, Brazil
| | - Vilmar Marques de Oliveira
- Brazilian Society of Mastology, Rio de Janeiro, RJ, Brazil
- Santa Casa de São Paulo Hospital, São Paulo, SP, Brazil
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | - Gisah Guilgen
- Brazilian Breast Cancer Study Group (GBECAM), Porto Alegre, RS, Brazil
- Curitiba Cancer and Transplant Institute, Curitiba, PR, Brazil
- Nossa Senhora das Graças Hospital, Curitiba, PR, Brazil
| | - Luciana Landeiro
- Núcleo de Oncologia da Bahia (NOB)—Oncoclínicas Group, Salvador, BA, Brazil
| | - João Renato Rebello Pinho
- Albert Einstein Hospital, São Paulo, SP, Brazil
- Hospital das Clínicas, São Paulo, SP, Brazil
- School of Medicine, Medical Research Laboratories LIM 03/07, University of São Paulo, São Paulo, SP, Brazil
| | - Álvaro Pulchinelli
- Brazilian Society of Clinical Pathology/Laboratory Medicine, Rio de Janeiro, RJ, Brazil
- Fleury Group, São Paulo, SP, Brazil
- School of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Heber Ribeiro
- Brazilian Society of Oncology Surgery, Rio de Janeiro, RJ, Brazil
- AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Rafael Souza
- Cancer Treatment Institute (ITC), Campo Grande, MS, Brazil
| | - Daniela Dornelles Rosa
- Brazilian Breast Cancer Study Group (GBECAM), Porto Alegre, RS, Brazil
- Moinhos de Vento Hospital, Porto Alegre, RS, Brazil
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| |
Collapse
|
12
|
Corsi F, Albasini S, Sorrentino L, Armatura G, Carolla C, Chiappa C, Combi F, Curcio A, Della Valle A, Ferrari G, Gasparri ML, Gentilini O, Ghilli M, Listorti C, Mancini S, Marinello P, Meani F, Mele S, Pertusati A, Roncella M, Rovera F, Sgarella A, Tazzioli G, Tognali D, Folli S. Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer: A multicentre study on 1,950 patients. Breast 2021; 60:131-137. [PMID: 34624755 PMCID: PMC8503563 DOI: 10.1016/j.breast.2021.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/30/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Type of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized. PATIENTS AND METHODS 1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR). RESULTS Independent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75-0.80). After external validation the accuracy of the nomogram was confirmed. CONCLUSION The accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients.
Collapse
Affiliation(s)
- Fabio Corsi
- Breast Unit, Department of Surgery, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", Università di Milano, Milan, Italy.
| | - Sara Albasini
- Breast Unit, Department of Surgery, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Luca Sorrentino
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università di Milano, Milan, Italy
| | - Giulia Armatura
- Chirurgia Generale, Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige, Italy
| | - Claudia Carolla
- Breast Unit, Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Francesca Combi
- Breast Unit Azienda Ospedaliero-Universitaria Policlinico Modena, Italy
| | - Annalisa Curcio
- Chirurgia Senologica, Ospedale Morgagni Pierantoni, Ausl Romagna, Forlì, Italy
| | - Angelica Della Valle
- Breast Surgery, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Guglielmo Ferrari
- Breast Surgery Unit, AUSL-IRCCS Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Maria Luisa Gasparri
- Service of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Oreste Gentilini
- Breast Surgery, San Raffaele University and Research Hospital, Milano, Italy
| | - Matteo Ghilli
- Breast Cancer Centre, University Hospital of 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, Italy
| | - Francesco Meani
- Service of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, Lugano, Switzerland
| | - Simone Mele
- Breast Surgery Unit, AUSL-IRCCS Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Anna Pertusati
- General Surgery I, Department of Surgery, ASST Fatebenefratelli Sacco, Milano, Italy
| | | | | | - Adele Sgarella
- Breast Surgery, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Università degli Studi di Pavia, Pavia, Italy
| | - Giovanni Tazzioli
- Breast Unit Azienda Ospedaliero-Universitaria Policlinico Modena, Italy
| | - Daniela Tognali
- Chirurgia Senologica, Ospedale Morgagni Pierantoni, Ausl Romagna, Forlì, Italy
| | - Secondo Folli
- Breast Unit, Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| |
Collapse
|
13
|
Pawloski KR, Tadros AB, El-Tamer M. ASO Author Reflections: Age Is an Important Determinant of Concordance Between 21-Gene Recurrence Scores in Multiple Ipsilateral Breast Carcinomas. Ann Surg Oncol 2021; 28:4263-4264. [PMID: 33415560 DOI: 10.1245/s10434-020-09443-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/19/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
| |
Collapse
|