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Fairhurst K, McIntosh SA, Cutress RI, Potter S. Current axillary management of patients with early breast cancer and low-volume nodal disease undergoing primary surgery: results of a United Kingdom national practice survey. Breast Cancer Res Treat 2024; 206:465-471. [PMID: 38724821 PMCID: PMC11208217 DOI: 10.1007/s10549-024-07328-4] [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: 10/21/2023] [Accepted: 03/28/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE UK NICE guidelines recommend axillary node clearance (ANC) should be performed in all patients with biopsy-proven node-positive breast cancer having primary surgery. There is, however, increasing evidence such extensive surgery may not always be necessary. Targeted axillary dissection (TAD) may be an effective alternative in patients with low-volume nodal disease who are clinically node negative (cN0) but have abnormal nodes detected radiologically. This survey aimed to explore current management of this group to inform feasibility of a future trial. METHODS An online survey was developed to explore current UK management of patients with low-volume axillary disease and attitudes to a future trial. The survey was distributed via breast surgery professional associations and social media from September to November 2022. One survey was completed per unit and simple descriptive statistics used to summarise the results. RESULTS 51 UK breast units completed the survey of whom 78.5% (n = 40) reported performing ANC for all patients with biopsy-proven axillary nodal disease having primary surgery. Only 15.7% of units currently performed TAD either routinely (n = 6, 11.8%) or selectively (n = 2, 3.9%). There was significant uncertainty (83.7%, n = 36/43) about the optimal surgical management of these patients. Two-thirds (n = 27/42) of units felt an RCT comparing TAD and ANC would be feasible. CONCLUSIONS ANC remains standard of care for patients with low-volume node-positive breast cancer having primary surgery in the UK, but considerable uncertainty exists regarding optimal management of this group. This survey suggests an RCT comparing the outcomes of TAD and ANC may be feasible.
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Affiliation(s)
- K Fairhurst
- Centre for Surgical Research, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - S A McIntosh
- Patrick G Johnston Centre for Cancer Research, Queens University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, Northern Ireland
| | - R I Cutress
- Somers Cancer Research Building, University of Southampton and University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - S Potter
- Centre for Surgical Research, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Kontos M, Kanavidis P, Kühn T, Masannat Y, Gulluoglu B. Targeted axillary dissection: worldwide variations in clinical practice. Breast Cancer Res Treat 2024; 204:389-396. [PMID: 38175449 DOI: 10.1007/s10549-023-07204-7] [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: 08/02/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Targeted axillary dissection (TAD) for the axillary staging of clinically node-positive (cN +) breast cancer patients converting to clinically node negative post neoadjuvant chemotherapy (NAC), has gained popularity due to its minimal false negative rate and low arm morbidity. The aim of this study is to shed more light on the variation in the clinical practice globally in terms of indications and perceived limitations of TAD. METHODS A panel of expert breast surgeons constructed a structured questionnaire comprising of 18 questions and asked surgeons worldwide for their opinions and routine practice on TAD. The questionnaire was electronically distributed and answers were collected between May 1st and August 1st 2022. RESULTS Responses included 137 entries from 36 countries. Of them, 73.7% consider TAD for cN + patients planned to receive NAC. Among them, the greatest number of respondents (45%) perform the procedure for tumours up to T3, whereas 27% regardless of T-stage. The majority (42%) perform TAD on patients with 1-3 positive nodes and only 30% consider TAD when matted nodes are present. HER2 positive and Triple Negative subtypes are more likely to undergo TAD than Luminal A and B (86%, 79.1%, 39.5%, and 62.8%, respectively). Maximum acceptable lymph node burden is median 3 nodes for any subtype with a tendency to accept more positive nodes for Triple Negative. CONCLUSION This study demonstrates the differences in current practice regarding TAD as well as the fact that the biology of the tumour heavily affects the method of axillary staging.
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Affiliation(s)
- Michalis Kontos
- National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Yazan Masannat
- Broomfield Hospital, Mid and South Essex NHS Trust, Chelmsford, UK, Broomfield, UK
- University of Aberdeen, School of Medicine, Medical Science and Nutrition, Aberdeen, UK
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Žatecký J, Coufal O, Zapletal O, Kubala O, Kepičová M, Faridová A, Rauš K, Gatěk J, Kosáč P, Peteja M. Ideal marker for targeted axillary dissection (IMTAD): a prospective multicentre trial. World J Surg Oncol 2023; 21:252. [PMID: 37596658 PMCID: PMC10439625 DOI: 10.1186/s12957-023-03147-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: 07/15/2023] [Accepted: 08/15/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Targeted axillary dissection (TAD) is an established method for axillary staging in patients with breast cancer after neoadjuvant chemotherapy (NAC). TAD consists of sentinel lymph node biopsy and initially pathological lymph node excision, which must be marked by a reliable marker before NAC. METHODS The IMTAD study is a prospective multicentre trial comparing three localisation markers for lymph node localisation (clip + iodine seed, magnetic seed, carbon suspension) facilitating subsequent surgical excision in the form of TAD. The primary outcome was to prospectively compare the reliability, accuracy, and safety according to complication rate during marker implantation and detection and marker dislodgement. RESULTS One hundred eighty-nine patients were included in the study-in 135 patients clip + iodine seed was used, in 30 patients magnetic seed and in 24 patients carbon suspension. The complication rate during the marker implantation and detection were not statistically significant between individual markers (p = 0.263; p = 0.117). Marker dislodgement was reported in 4 patients with clip + iodine seed localisation (3.0%), dislodgement did not occur in other localisation methods (p = 0.999). The false-negativity of sentinel lymph node (SLN) was observed in 8 patients, the false-negativity of targeted lymph nodes (TLN) wasn´t observed at all, the false-negativity rate (FNR) from the subcohort of ypN + patients for SLN is 9.6% and for TLN 0.0%. CONCLUSION The IMTAD study indicated, that clip + iodine seed, magnetic seed and carbon suspension are statistically comparable in terms of complications during marker implantation and detection and marker dislodgement proving their safety, accuracy, and reliability in TAD. The study confirmed, that the FNR of the TLN was lower than the FNR of the SLN proving that the TLN is a better marker for axillary lymph node status after NAC. TRIAL REGISTRATION NCT04580251. Name of registry: Clinicaltrials.gov. Date of registration: 8.10.2020.
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Affiliation(s)
- Jan Žatecký
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic.
- Department of Surgery, Silesian Hospital in Opava, Opava, Czech Republic.
- Faculty of Public Policies, The Institute of Paramedical Health Studies, Silesian University, Opava, Czech Republic.
| | - Oldřich Coufal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondřej Zapletal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Otakar Kubala
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Markéta Kepičová
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Adéla Faridová
- Oncogynecology Centre, The Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Karel Rauš
- Oncogynecology Centre, The Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Jiří Gatěk
- Department of Surgery, EUC Clinic Zlín, Zlín, Czech Republic
- Tomáš Baťa University in Zlín, Zlín, Czech Republic
| | - Peter Kosáč
- Department of Surgery, EUC Clinic Zlín, Zlín, Czech Republic
| | - Matúš Peteja
- Department of Surgery, Silesian Hospital in Opava, Opava, Czech Republic
- Faculty of Public Policies, The Institute of Paramedical Health Studies, Silesian University, Opava, Czech Republic
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Lee J, Park HY. ASO Author Reflections: Axillary Surgery for Breast Cancer: From Back to the Future, and Beyond. Ann Surg Oncol 2023; 30:4678-4679. [PMID: 36988751 DOI: 10.1245/s10434-023-13259-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Jeeyeon Lee
- Department of Surgery, School of Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Ho Yong Park
- Department of Surgery, School of Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea.
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