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Prathibha S, White M, Kolbow M, Hui JYC, Brauer D, Ankeny J, Jensen EH, LaRocca CJ, Marmor S, Tuttle TM. Omission of axillary lymph node dissection for breast cancer patients with three or more positive sentinel lymph nodes. Breast Cancer Res Treat 2024; 205:127-133. [PMID: 38281296 DOI: 10.1007/s10549-023-07203-8] [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: 03/31/2023] [Accepted: 11/26/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE The ACOSOG Z0011 (Z11) trial assessed the benefit of axillary dissection (ALND) for breast cancer patients with sentinel lymph node (SLN) metastases; however, Z11 excluded patients with ≥ 3 positive SLNs. We analyzed trends in ALND omission in patients with ≥ 3 positive SLNs. METHODS Women with ≥ 3 positive SLNs who underwent breast-conserving surgery (BCS) or mastectomy between 2018 and 2020 in the National Cancer Database were included using SLN codes initiated in 2018. Patients with stage IV disease, recurrent breast cancer, and who underwent neoadjuvant chemotherapy were excluded. A multivariable logistic regression model was utilized to determine the proportion who received ALND and factors associated with ALND omission. A subgroup analysis was performed among patients who met the remainder of the Z11 inclusion criteria (BCS, T1/T2 breast cancer). RESULTS We identified 3654 patients with ≥ 3 positive SLNs. ALND was omitted in 37% of patients, and omission significantly increased from 2018 to 2020 (29% vs. 41%, p < 0.0001). Older age, lower grade tumors, no radiation, non-academic facility, BCS, more SLNs examined and fewer positive SLNs were significantly associated with ALND omission. 942 patients with ≥ 3 positive SLNs met the remainder of the Z11 inclusion criteria. ALND was omitted in 49% of these patients, and omission increased from 2018 to 2020 (44% vs. 49%, p = 0.22). CONCLUSION Approximately one-third of patients with ≥ 3 positive SLNs do not undergo ALND; omission of ALND increased from 2018 to 2020. Studies assessing oncologic outcomes of patients with ≥ 3 positive SLNs who do and do not receive ALND are required.
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Affiliation(s)
- Saranya Prathibha
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - McKenzie White
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Madison Kolbow
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Jane Yuet Ching Hui
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - David Brauer
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Jacob Ankeny
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Eric H Jensen
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Christopher J LaRocca
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Schelomo Marmor
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Todd M Tuttle
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Mayo Mail Code 195, Minneapolis, MN, 55455, USA.
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Laws A, Lagendijk M, Grossmith S, Hughes M, Lin NU, Mittendorf EA, Eliassen AH, King TA, Dominici LS. Long-Term Patient-Reported Arm Symptoms in Breast Cancer Survivors. Ann Surg Oncol 2024; 31:1623-1633. [PMID: 38071708 DOI: 10.1245/s10434-023-14711-w] [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] [Accepted: 11/19/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Understanding long-term arm symptoms in breast cancer survivors is critical given excellent survival in the modern era. METHODS This cross-sectional study included patients treated for stage 0-III breast cancer at our institution from 2002 to 2012. Patient-reported arm symptoms were collected from the EORTC QLQ-BR23 questionnaire. We used linear regression to evaluate adjusted associations between locoregional treatments and the continuous Arm Symptom (AS) score (0-100; higher score reflects more symptoms). RESULTS A total of 1126 patients expressed interest in participating and 882 (78.3%) completed the questionnaire. Mean time since surgery was 10.5 years. There was a broad distribution of locoregional treatments, including axillary lymph node dissection (ALND) in 37.1% of patients, mastectomy with reconstruction in 36.5% of patients, and post-mastectomy radiation in 38.2% of patients. Overall, 64.3% (95% confidence interval [CI] 61.1-67.4%) of patients reported no arm symptoms, 17.0% (95% CI 14.7-19.6%) had one mild symptom, 9.4% (95% CI 7.7-11.5%) had two or more mild symptoms, and 9.3% (95% CI 7.6-11.4%) reported one or more severe symptoms. Adjusted AS scores were significantly higher with ALND versus sentinel node biopsy (β 3.5, p = 0.01), and with autologous reconstruction versus all other breast/reconstructive surgery types (β 4.5-5.5, all p < 0.05). There was a significant interaction between axillary and breast/reconstructive surgery, with the greatest effect of ALND in those with mastectomy with implant (β 9.7) or autologous (β 5.7) reconstruction. CONCLUSIONS One in three patients reported arm symptoms at a mean of 10 years from treatment for breast cancer, although rates of severe symptoms were low (<10%). Attention is warranted to the arm morbidity related to both axillary and breast surgery during treatment counseling and survivorship.
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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, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mirelle Lagendijk
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Samantha Grossmith
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Melissa Hughes
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Nancy U Lin
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - A Heather Eliassen
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Departments of Nutrition and Epidemiology, Harvard TH Chan School of Public Health, 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, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Laura S Dominici
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Alamoodi M, Patani N, Mokbel K, Wazir U, Mokbel K. Reevaluating Axillary Lymph Node Dissection in Total Mastectomy for Low Axillary Burden Breast Cancer: Insights from a Meta-Analysis including the SINODAR-ONE Trial. Cancers (Basel) 2024; 16:742. [PMID: 38398133 PMCID: PMC10886895 DOI: 10.3390/cancers16040742] [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: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Complete axillary lymph node dissection (cALND) was previously the standard of care for breast cancer (BC) patients with axillary node disease or macro-metastases found via sentinel lymph node biopsy (SLNB). However, due to significant morbidity, contemporary management now considers a more selective approach, influenced by studies like ACOSOG Z0011. This trial showed that cALND could be omitted without compromising local control or survival in patients with low axillary nodal disease burden undergoing breast-conserving therapy, radiotherapy, and systemic therapy. The relevance of this approach for women with low axillary nodal burden undergoing total mastectomy (TM) remained unclear. A PubMed search up to September 2023 identified 147 relevant studies, with 6 meeting the inclusion criteria, involving 4184 patients with BC and low-volume axillary disease (1-3 positive lymph nodes) undergoing TM. Postmastectomy radiotherapy receipt was similar in both groups. After a mean 7.2-year follow-up, both the pooled results and the meta-analysis revealed no significant differences in overall survival. The combined analysis of the published studies, including the subgroup analysis of the SINODAR-One trial, indicates no survival advantage for cALND over SLNB in T1-T2 breast cancer patients with 1-3 positive sentinel lymph nodes (pN1) undergoing mastectomy. This suggests that, following a multidisciplinary evaluation, cALND can be safely omitted. However, the impact of other patient, tumor, and treatment factors on survival requires consideration and therefore further prospective trials are needed for conclusive validation.
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Affiliation(s)
- Munaser Alamoodi
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
- Department of Surgery, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Neill Patani
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
- Institute for Women’s Health, University College London, London WC1N 1DZ, UK
| | - Kinan Mokbel
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
- Medical School, University of Exeter, Exeter EX1 2LU, UK
| | - Umar Wazir
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
| | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK; (M.A.); (N.P.); (K.M.); (U.W.)
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Pride RM, Glass CC, Nakhlis F, Laws A, Weiss AC, Bellon JR, Mittendorf EA, King TA, Kantor O. Intraoperative Pathology Assessment May Lead to Overtreatment of the Axilla in Clinically Node-Negative Breast Cancer Patients Undergoing Upfront Mastectomy. Ann Surg Oncol 2023; 30:5978-5987. [PMID: 37436607 DOI: 10.1245/s10434-023-13898-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Randomized trials have established the safety of observation or axillary radiation (AxRT) as an alternative to axillary lymph node dissection (ALND) in patients with limited nodal disease who undergo upfront surgery. Variability remains in axillary management strategies in cN0 patients undergoing mastectomy found to have one to two positive sentinel lymph nodes (SLNs). We examined the impact of intraoperative pathology assessment in axillary management in a national cohort of AMAROS-eligible mastectomy patients. METHODS The National Cancer Database was used to identify AMAROS-eligible cT1-2N0 breast cancer patients undergoing upfront mastectomy and SLN biopsy (SLNB) and found to have one to two positive SLNs, from 2018 to 2019. We constructed a variable defining intraoperative pathology as 'not performed/not acted on' if ALND was either not performed or performed at a later date than SLNB, or 'performed/acted on' if SLNB and ALND were completed on the same day. Adjusted multivariable analysis examined predictors of treatment with both ALND and AxRT. RESULTS Overall, 8222 patients with cT1-2N0 disease underwent upfront mastectomy and had one to two positive SLNs. Intraoperative pathology was performed/acted on in 3057 (37.2%) patients. These patients were significantly more likely to have both ALND and AxRT than those without intraoperative pathology (41.0% vs. 4.9%; p < 0.001). On multivariate analysis, the strongest predictor of receiving both ALND and AxRT was use of intraoperative pathology (odds ratio 8.99, 95% confidence interval 7.70-10.5; p < 0.001). CONCLUSIONS We advocate that consideration should be made for omission of routine intraoperative pathology in mastectomy patients likely to be recommended postmastectomy radiation to minimize axillary overtreatment with both ALND and AxRT in appropriate patients.
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Affiliation(s)
- Robert M Pride
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Charity C Glass
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Faina Nakhlis
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - 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, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anna C Weiss
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jennifer R Bellon
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, 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, Boston, MA, 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, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Tinterri C, Canavese G, Gatzemeier W, Barbieri E, Bottini A, Sagona A, Caraceni G, Testori A, Di Maria Grimaldi S, Dani C, Boni L, Bruzzi P, Fernandes B, Scorsetti M, Zambelli A, Gentile D. Sentinel lymph node biopsy versus axillary lymph node dissection in breast cancer patients undergoing mastectomy with one to two metastatic sentinel lymph nodes: sub-analysis of the SINODAR-ONE multicentre randomized clinical trial and reopening of enrolment. Br J Surg 2023; 110:1143-1152. [PMID: 37471574 PMCID: PMC10492188 DOI: 10.1093/bjs/znad215] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/15/2023] [Accepted: 06/13/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The initial results of the SINODAR-ONE randomized clinical trial reported that patients with T1-2 breast cancer and one to two macrometastatic sentinel lymph nodes treated with breast-conserving surgery, sentinel lymph node biopsy only, and adjuvant therapy did not present worse 3-year survival, regional recurrence, or distant recurrence rates compared with those treated with axillary lymph node dissection. To extend the recommendation of axillary lymph node dissection omission even in patients treated with mastectomy, a sub-analysis of the SINODAR-ONE trial is presented here. METHODS Patients with T1-2 breast cancer and no more than two metastatic sentinel lymph nodes undergoing mastectomy were analysed. After sentinel lymph node biopsy, patients were randomly assigned to receive either axillary lymph node dissection followed by adjuvant treatment (standard arm) or adjuvant treatment alone (experimental arm). The primary endpoint was overall survival. The secondary endpoint was recurrence-free survival. RESULTS A total of 218 patients were treated with mastectomy; 111 were randomly assigned to the axillary lymph node dissection group and 107 to the sentinel lymph node biopsy-only group. At a median follow-up of 33.0 months, there were three deaths (two deaths in the axillary lymph node dissection group and one death in the sentinel lymph node biopsy-only group). There were five recurrences in each treatment arm. No axillary lymph node recurrence was observed. The 5-year overall survival rates were 97.8 and 98.7 per cent in the axillary lymph node dissection treatment arm and the sentinel lymph node biopsy-only treatment arm, respectively (P = 0.597). The 5-year recurrence-free survival rates were 95.7 and 94.1 per cent in the axillary lymph node dissection treatment arm and the sentinel lymph node biopsy treatment arm, respectively (P = 0.821). CONCLUSION In patients with T1-2 breast cancer and one to two macrometastatic sentinel lymph nodes treated with mastectomy, the overall survival and recurrence-free survival rates of patients treated with sentinel lymph node biopsy only were not inferior to those treated with axillary lymph node dissection. To strengthen the conclusion of the trial, the enrolment of patients treated with mastectomy was reopened as a single-arm experimental study. REGISTRATION NUMBER NCT05160324 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | | | - Erika Barbieri
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alberto Bottini
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Sagona
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Giulia Caraceni
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alberto Testori
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Carla Dani
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Luca Boni
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Paolo Bruzzi
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Bethania Fernandes
- Department of Pathology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alberto Zambelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Medical Oncology and Haematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Damiano Gentile
- Breast Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Current Considerations in Surgical Treatment for Adolescents and Young Women with Breast Cancer. Healthcare (Basel) 2022; 10:healthcare10122542. [PMID: 36554065 PMCID: PMC9777860 DOI: 10.3390/healthcare10122542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
Adolescents and young women (AYA) with breast cancer represent a unique patient population, compared to the general population with breast cancer. We performed a literature review to evaluate the factors that influenced the surgical outcomes in this patient population. Fifty-two studies were identified, which evaluated breast surgery type, axillary surgery, contralateral prophylactic mastectomy (CPM), surgical timing, psychological factors, disparities, and imaging use. AYA patients had equivalent oncologic outcomes with breast conserving surgery (BCS) or mastectomy. CPM did not improve survival. There are limited data on axillary management in the AYA population, and while more data would be beneficial, this is currently extrapolated from the general breast cancer population. A shorter time to initiate treatment correlated to better outcomes, and disparities need to be overcome for optimal outcomes. AYA patients appreciated involvement in clinical decisions, and shared decision making should be considered whenever possible. Providers must keep these factors in mind when counseling AYA patients, regarding the surgical management of breast cancer.
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Stafford AP, Hoskin TL, Day CN, Sanders SB, Boughey JC. ASO Author Reflections: Axillary Management in Mastectomy Patients with Limited Nodal Burden. Ann Surg Oncol 2022; 29:4750-4751. [PMID: 35478062 DOI: 10.1245/s10434-022-11826-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/14/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Arielle P Stafford
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Stacy B Sanders
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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