1
|
Cserni G, Brogi E, Cody HS, Deb R, Farshid G, O'Toole S, Provenzano E, Quinn CM, Sahin AA, Schmitt F, Weaver DL, Yamaguchi R, Webster F, Tan PH. Reporting of Surgically Removed Lymph Nodes for Breast Tumors: Recommendations From the International Collaboration on Cancer Reporting. Arch Pathol Lab Med 2022; 146:1308-1318. [PMID: 36270029 DOI: 10.5858/arpa.2022-0060-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The International Collaboration on Cancer Reporting (ICCR), supported by major pathology and cancer organizations, aims at the standardization of evidence-based pathology reporting of different types of cancers, with the inclusion of all parameters deemed to be relevant for best patient care and future data collection. Lymph node metastasis is one of the most important prognostic factors in breast cancer. OBJECTIVE.— To produce a histopathology reporting guide by a panel of recognized experts from the fields of pathology and surgery with elements deemed to be core (required) and noncore (recommended) to report when assessing regional lymph nodes of patients with breast cancer. DATA SOURCES.— Published literature, previous guidelines/recommendations, and current cancer staging principles were the basis of the data set drafted by the expert panel. This was discussed in a series of teleconferences and email communications. The draft data set was then made available for public consultation through the ICCR Web site. After this consultation and ICCR ratification, the data set was finalized. CONCLUSIONS.— The ICCR has published a data set for the reporting of surgically removed lymph nodes (including sentinel lymph node biopsy, axillary lymph node dissection, targeted axillary surgery, and lymph node sampling specimens) for breast tumors. This is part of a series of 4 ICCR breast cancer-related data sets. It includes 10 core elements along with 2 noncore elements. This should allow for synoptic reporting, which is more precise, uniform, and complete than nonsynoptic reporting, and leads to improved patient outcomes.
Collapse
Affiliation(s)
- Gábor Cserni
- From the Department of Pathology, Albert Szent-Györgyi Medical Center, University of Szeged, Szeged, Hungary (Cserni).,The Department of Pathology, Bács-Kiskun County Teaching Hospital, Kecskemét, Hungary (Cserni)
| | - Edi Brogi
- The Department of Pathology (Brogi), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hiram S Cody
- The Breast Service, Department of Surgery (Cody III), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rahul Deb
- The Department of Pathology, Royal Derby Hospital, University Hospitals of Derby and Burton, Derby, United Kingdom (Deb)
| | - Gelareh Farshid
- The Department of Anatomical Pathology, SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia (Farshid).,School of Medicine, Adelaide University, Adelaide, South Australia, Australia (Farshid)
| | - Sandra O'Toole
- The Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia (O'Toole).,Sydney Medical School, University New South Wales, Sydney, New South Wales, Australia (O'Toole)
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Provenzano).,The Department of Histopathology, Addenbrookes Hospital, Cambridge, United Kingdom (Provenzano)
| | - Cecily M Quinn
- The Department of Histopathology, BreastCheck, Irish National Breast Screening Programme & St. Vincent's University Hospital, Dublin, Ireland (Quinn).,University College Dublin, School of Medicine, Dublin, Ireland (Quinn)
| | - Aysegul A Sahin
- Division of Pathology and Laboratory Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas (Sahin)
| | - Fernando Schmitt
- The Department of Pathology, Medical Faculty of Porto University, and Molecular Unit, Institute of Pathology and Immunology of Porto University, Porto, Portugal (Schmitt).,RISE (Health Research Network) @ CINTESIS (Center for Health Technology and Services Research), Porto, Portugal (Schmitt)
| | - Donald L Weaver
- The Department of Pathology, University of Vermont Larner College of Medicine, Burlington (Weaver)
| | - Rin Yamaguchi
- The Department of Pathology and Laboratory Medicine, Kurume University Medical Center, Fukuoka, Japan (Yamaguchi)
| | - Fleur Webster
- International Collaboration on Cancer Reporting, Sydney, NSW, Australia, and ICCR Project Manager, Surry Hills, Australia (Webster)
| | - Puay Hoon Tan
- Cambridge Experimental Cancer Medicine Centre (ECMR), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,The Division of Pathology, Singapore General Hospital, Academia, Singapore (Tan)
| |
Collapse
|
2
|
Downs-Canner S, Cody HS. Five decades of progress in surgical oncology: Breast. J Surg Oncol 2022; 126:852-859. [PMID: 36087082 PMCID: PMC9472874 DOI: 10.1002/jso.27035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 11/06/2022]
Abstract
Surgery remains the single most effective treatment for breast cancer but coincident with a deeper understanding of tumor biology and advances in multidisciplinary care (encompassing breast imaging, systemic adjuvant therapy, radiotherapy, and genomics) continues to de-escalate, supported by strong level I data. We have moved from mastectomy to breast conservation, and from routine axillary dissection to sentinel lymph node biopsy to selective omission of axillary node staging altogether. We have further de-escalated through consensus over margin width in breast conservation, through improvements in neoadjuvant therapy, and by demonstrating no benefit for upfront surgery in patients with stage IV disease. For patients with ipsilateral breast tumor recurrence, reconservation surgery and reirradiation are promising. Cell cycle and immune checkpoint inhibitors, when added to conventional systemic therapy, have now moved beyond stage IV disease to phase III trials in the adjuvant and neoadjuvant settings, promising even further de-escalation of surgery. Finally, with genomic profiling we are moving away from the primacy of axillary node status for prognostication and into a new era allowing prediction of response to therapy.
Collapse
Affiliation(s)
- Stephanie Downs-Canner
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
3
|
Pawloski KR, Sevilimedu V, Twersky R, Tadros AB, Kirstein LJ, Cody HS, Morrow M, Moo TA. Association Between Local Anesthetic Dosing, Postoperative Opioid Requirement, and Pain Scores After Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia. Ann Surg Oncol 2022; 29:1737-1745. [PMID: 34694521 PMCID: PMC11110646 DOI: 10.1245/s10434-021-10981-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/05/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Multimodal analgesia (MMA) during breast surgery reduces postoperative pain and opioid requirements, but the relative contribution of local anesthetic dosing as a component of MMA is not well defined among patients undergoing lumpectomy and sentinel lymph node biopsy (SLNB). PATIENTS AND METHODS We identified consecutive patients who underwent lumpectomy and SLNB with MMA from 1/2019 to 4/2020. Univariable and multivariable linear and logistic regression were used to examine associations between local anesthetics, opioid requirements in the post-anesthesia care unit (PACU), and pain scores in the PACU and on postoperative day (POD) 1. RESULTS In total, 1603 patients [median tumor size, 14 mm (interquartile range 8-20 mm)] were included. The median PACU opioid requirement was 0 morphine milligram equivalents (interquartile range 0-5). PACU maximum pain was none or mild in 58% of patients and moderate to severe in 42%; among 420 survey respondents, 56% reported no or mild pain and 44% reported moderate to severe pain on POD 1. On multivariable analysis that adjusted for routine components of MMA, increasing doses of 0.5% bupivacaine were associated with reduced PACU opioid requirements (β -0.04, 95% confidence interval -0.07 to -0.01, p = 0.011) and lower odds of moderate to severe pain (odds ratio 0.98, 95% confidence interval 0.97-0.99, p < 0.001). Local anesthetics were not associated with pain scores on POD 1. CONCLUSIONS Higher amounts of local anesthetics reduce acute postoperative pain and opioid requirement after lumpectomy and SLNB. Maximizing dosing within weight-based limits is a low-risk, cost-effective pain control strategy that can be used in diverse practice settings.
Collapse
Affiliation(s)
- Kate R Pawloski
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Biostatistics Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rebecca Twersky
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree B Tadros
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Laurie J Kirstein
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
4
|
Pawloski KR, Sevilimedu V, Twersky R, Tadros AB, Kirstein LJ, Cody HS, Morrow M, Moo TA. ASO Visual Abstract: Association Between Local Anesthetic Dosing, Postoperative Opioid Requirement, and Pain Scores After Lumpectomy and Sentinel Lymph Node Biopsy With Multimodal Analgesia. Ann Surg Oncol 2021. [PMID: 34799806 DOI: 10.1245/s10434-021-11067-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rebecca Twersky
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
5
|
Barrio AV, Montagna G, Mamtani A, Sevilimedu V, Edelweiss M, Capko D, Cody HS, El-Tamer M, Gemignani ML, Heerdt A, Kirstein L, Moo TA, Pilewskie M, Plitas G, Sacchini V, Sclafani L, Tadros A, Van Zee KJ, Morrow M. Nodal Recurrence in Patients With Node-Positive Breast Cancer Treated With Sentinel Node Biopsy Alone After Neoadjuvant Chemotherapy-A Rare Event. JAMA Oncol 2021; 7:1851-1855. [PMID: 34617979 DOI: 10.1001/jamaoncol.2021.4394] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Prospective trials have demonstrated sentinel lymph node (SLN) false-negative rates of less than 10% when 3 or more SLNs are retrieved in patients with clinically node-positive breast cancer rendered clinically node-negative with neoadjuvant chemotherapy (NAC). However, rates of nodal recurrence in such patients treated with SLN biopsy (SLNB) alone are unknown because axillary lymph node dissection (ALND) was performed in all patients, limiting adoption of this approach. Objective To evaluate nodal recurrence rates in a consecutive cohort of patients with clinically node-positive (cN1) breast cancer receiving NAC, followed by a negative SLNB using a standardized technique, and no further axillary surgery. Design, Setting, and Participants From November 2013 to February 2019, a cohort of consecutively identified patients with cT1 to cT3 biopsy-proven N1 breast cancer rendered cN0 by NAC underwent SLNB with dual tracer mapping and omission of ALND if 3 or more SLNs were identified and all were pathologically negative. Metastatic nodes were not routinely clipped, and localization of clipped nodes was not performed. The study was performed in a single tertiary cancer center. Intervention Omission of ALND in patients with cN1 breast cancer after NAC if 3 or more SLNs were pathologically negative. Main Outcome and Measures The primary outcome was the rate of nodal recurrence among patients with cN1 breast cancer treated with SLNB alone after NAC. Results Of 610 patients with cN1 breast cancer treated with NAC (median [IQR] age, 49 [40-58] years), 555 (91%) converted to cN0 and underwent SLNB; 234 (42%) had 3 or more negative SLNs and had SLNB alone. Median age was 49 years. Median tumor size was 3 cm; 144 (62%) were ERBB2 (formerly HER2)-positive, and 43 (18%) were triple negative. Most (212 [91%]) received doxorubicin-based NAC, 205 (88%) received adjuvant radiotherapy (RT), and 164 (70%) also received nodal RT. At a median follow-up of 40 months, there was 1 axillary nodal recurrence synchronous with local recurrence in a patient who refused RT. Among patients who received RT (n = 205), there were no nodal recurrences. Conclusions and Relevance This cohort study found that in patients with cN1 disease rendered cN0 with NAC, with 3 or more negative SLNs with SLNB alone, nodal recurrence rates were low, without routine nodal clipping. These findings potentially support omitting ALND in such patients.
Collapse
Affiliation(s)
- Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Varadan Sevilimedu
- Biostatistical Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcia Edelweiss
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Deborah Capko
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laurie Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa Sclafani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Audree Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
6
|
Pawloski KR, Matar R, Sevilimedu V, Tadros AB, Kirstein LJ, Cody HS, Van Zee KJ, Morrow M, Moo TA. Postdischarge Nonsteroidal Anti-Inflammatory Drugs Are not Associated with Risk of Hematoma after Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia. Ann Surg Oncol 2021; 28:5507-5512. [PMID: 34247337 PMCID: PMC8272604 DOI: 10.1245/s10434-021-10446-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022]
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly used in ambulatory breast surgery. The risk of hematoma associated with intraoperative ketorolac is low, but whether concomitant routine discharge with NSAIDs increases the risk of hematoma is unclear. Methods We retrospectively identified patients who underwent lumpectomy and sentinel lymph node biopsy (SLNB), and compared the 30-day risk of hematoma between patients discharged with opioids (opioid period: January 2018–August 2018) and patients discharged with NSAIDs with or without opioids (NSAID period: January 2019–April 2020). The association between study period and hematoma risk was assessed using multivariable models. Covariates included intraoperative ketorolac, home aspirin, and race/ethnicity. During the NSAID period, a survey was used to assess analgesic consumption on postoperative days 1–5. Results In total, 2724 patients were identified: 858 (31%) in the opioid period and 1866 (69%) in the NSAID period. In the NSAID period, 867 (46%) received NSAIDs and opioids, and 999 (54%) received NSAIDs only. Receipt of intraoperative ketorolac was higher in the NSAID period (78 vs. 64%, P < 0.001). The risks of any hematoma (4.1 vs. 3.6%, P = 0.6) and reoperation for bleeding (0.5 vs. 0.6%, P = 0.8) were similar between groups. Study period was not associated with hematoma risk (odds ratio 0.87, 95% confidence interval 0.56–1.35, P = 0.5). Among survey respondents (41%), nonopioid analgesic consumption did not increase after opioids were removed from the discharge regimen (median, 6 pills/group, P = 0.06). Conclusions NSAIDs are associated with a low risk of hematoma after lumpectomy and SLNB, and should be prescribed instead of opioids, unless contraindicated.
Collapse
Affiliation(s)
- Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Regina Matar
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
| |
Collapse
|
7
|
Barrio AV, Montagna G, Mamtani A, Sevilimedu V, Cody HS, El-Tamer M, Gemignani ML, Heerdt AS, Moo TA, Pilewskie M, Plitas G, Sclafani L, Van Zee KJ, Morrow M. Abstract PD4-05: Axillary recurrence is a rare event in node-positive patients. treated with sentinel node biopsy alone after neoadjuvant chemotherapy: Results of a prospective study. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd4-05] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Four prospective multi-institutional trials have demonstrated that clinically node-positive patients (cN1) who receive neoadjuvant therapy (NAC) and convert to cN0 can be reliably staged with sentinel lymph node biopsy (SLNB) with false-negative rates (FNRs) of < 10%, when ≥ 3 SLNs are retrieved. Since study patients all had axillary lymph node dissection (ALND), the rate of axillary recurrence after SLNB alone is unknown. Of concern is the possibility that residual chemotherapy-resistant axillary disease could lead to higher recurrence rates than seen in the primary surgery setting for cN0 patients where SLN FNRs of 5-10% result in axillary recurrence in < 1% of cases. Here we report regional recurrence rates in a prospectively defined cohort of cN1 patients receiving NAC, followed by a negative SLNB using a standardized technique, and no further axillary surgery. Methods: From 06/2014 to 02/2019, patients with cT1-3 biopsy-proven cN1 breast cancer who received NAC and converted to cN0 by physical exam were prospectively managed with SLNB with dual tracer mapping and omission of ALND if ≥ 3 SLNs were pathologically negative. Nodes were not routinely clipped, and retrieval of clipped metastatic nodes was not required. Pathologically negative SLNs were defined as the absence of any metastases including isolated tumor cells. Results: Of 610 cN1 patients treated with NAC, 555 (91%) converted to cN0 and had SLNB; 234 (42%) had ≥ 3 negative SLNs and were treated with SLNB alone. Median patient age was 49 years and median tumor size at presentation was 3 cm; 61% were HER2+ and 18% triple negative. Most (91%) received doxorubicin-based NAC and 88% received adjuvant radiotherapy (RT), with 80% (n = 164) of RT patients receiving nodal RT (Table). At a median follow-up of 35 months, there was only 1 (0.4%) axillary recurrence for the entire cohort, synchronous with a breast recurrence, in a patient who refused RT. Among patients who received RT (n = 205), there were no axillary recurrences. The 4-year rate of distant recurrence for all patients was 6.1% (95% CI, 3.4-10.7%) and 4-year overall survival was 93.9% (95% CI, 87.6-97.1%). Conclusion: In cN1 patients treated with NAC, rates of axillary recurrence in patients with ≥ 3 pathologically negative SLNs treated with SLNB alone were low, without routine nodal clipping. Although further follow-up is needed, multiple studies have shown that nodal recurrence is an early event, particularly in HER2+ and triple negative patients, who comprised the majority of the population. Our findings support omitting ALND in cN1 patients after NAC when the SLNs are negative using an optimal SLNB technique.
Table. Patient PopulationOverall cohort (n = 234)Age, years (median, IQR)49 (40, 58)Tumor size at presentation, cm (median, IQR)3.0 (2.2, 5.0)Number SLNs retrieved (median, IQR)4 (3, 5)Palpable nodes at presentation (n, %)179 (76%)HistologyDuctal211 (90%)Lobular and mixed7 (3%)Micropapillary and mixed10 (4%)Other3 (1%)Occult3 (1%)DifferentiationWell1 (0.5%)Moderate36 (15%)Poor196 (84%)Unknown1 (0.5%)Receptor StatusHR+/HER2-47 (20%)HR+/HER2+80 (34%)HR-/HER2+64 (27%)HR-/HER2-43 (18%)Breast SurgeryBCS118 (50%)Mastectomy116 (50%)Breast pCR¥Yes161 (70%)No70 (30%)NAC regimenAC-T197 (84%)AC-T + carbo15 (6.4%)TC8 (3.4%)Other14 (6%)Neoadjuvant anti-HER2 treatmentHP (dual-therapy)144 (100%)Adjuvant RTYes205 (88%)No*29 (12%)¥3 patients had occult primary breast cancer and were not included in breast pCR calculation; *6/29 patients who did not receive RT enrolled in NSABP B-51
Citation Format: Andrea V Barrio, Giacomo Montagna, Anita Mamtani, Varadan Sevilimedu, Hiram S Cody, III, Mahmoud El-Tamer, Mary L Gemignani, Alexandra S Heerdt, Tracy-Ann Moo, Melissa Pilewskie, George Plitas, Lisa Sclafani, Kimberly J Van Zee, Monica Morrow. Axillary recurrence is a rare event in node-positive patients. treated with sentinel node biopsy alone after neoadjuvant chemotherapy: Results of a prospective study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD4-05.
Collapse
Affiliation(s)
| | | | - Anita Mamtani
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Hiram S Cody
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Tracy-Ann Moo
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - George Plitas
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lisa Sclafani
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
8
|
Van den Bruele AB, Chen I, Sevilimedu V, Le T, Morrow M, Braunstein LZ, Cody HS. Management of ipsilateral breast tumor recurrence following breast conservation surgery: a comparative study of re-conservation vs mastectomy. Breast Cancer Res Treat 2021; 187:105-112. [PMID: 33433775 DOI: 10.1007/s10549-020-06080-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/24/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Breast conservation therapy (BCT) is well established for the management of primary operable breast cancer, with oncologic outcomes comparable to those of mastectomy. It remains unclear whether re-conservation therapy (RCT) is suitable for those patients who develop ipsilateral breast tumor recurrence (IBTR), for whom mastectomy is generally recommended. METHODS We identified women who underwent BCT for invasive or ductal carcinoma in situ and developed IBTR as a first event, comparing the pattern of subsequent events and survival for those treated by RCT versus mastectomy. RESULTS Of 16,968 patents who had BCT, 322 (1.9%) developed an isolated IBTR as a first event between 1999 and 2019. 130 (40%) had RCT and 192 (60%) mastectomy. Compared to mastectomy, the RCT patients were older (66 vs 53, < 0.001), had a longer disease-free interval (DFI: 5.8 vs 2.7 years (p < 0.001)), were less likely to have received RT (p < 0.001), endocrine therapy (ET) (p < 0.005) or combined RT/ET (< 0.001) as initial treatment, but the characteristics of their initial primary cancers and of their IBTR were comparable. At a median follow-up of 10.7 years following initial BCT and 6.5 years following IBTR, there were no differences in BCSS or OS between RCT and mastectomy. CONCLUSION For BCT patients who developed IBTR as a first event, we observed comparable BCSS and OS from time of initial treatment and from time of IBTR, whether treated by RCT or mastectomy. These results support wider consideration of RCT in the management of IBTR, especially in the setting of older age and longer DFI.
Collapse
Affiliation(s)
| | - Ishita Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 300 East 66th St, New York, NY, 10065, USA
| | - Tiana Le
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
9
|
Barrio AV, Downs-Canner S, Edelweiss M, Van Zee KJ, Cody HS, Gemignani ML, Pilewskie ML, Plitas G, El-Tamer M, Kirstein L, Capko D, Patil S, Morrow M. Microscopic Extracapsular Extension in Sentinel Lymph Nodes Does Not Mandate Axillary Dissection in Z0011-Eligible Patients. Ann Surg Oncol 2019; 27:1617-1624. [PMID: 31820212 DOI: 10.1245/s10434-019-08104-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND In the ACOSOG (American College of Surgeons Oncology Group) Z0011 trial and the AMAROS (After Mapping of the Axilla: Radiotherapy or Surgery?) trial, matted nodes with gross extracapsular extension (ECE), a risk factor for locoregional recurrence, were an indication for axillary lymph node dissection (ALND), but the effect of microscopic ECE (mECE) in the sentinel lymph nodes (SLNs) on recurrence was not examined. METHODS Between 2010 and 2017, 811 patients with cT1-2N0 breast cancer and SLN metastasis were prospectively managed according to Z0011 criteria, with ALND for those with more than two positive SLNs or gross ECE. Management of mECE was not specified. In this study, we compare outcomes of patients with one to two positive SLNs with and without mECE, treated with SLN biopsy alone (n = 685). RESULTS Median patient age was 58 years, and median tumor size was 1.7 cm. mECE was identified in 210 (31%) patients. Patients with mECE were older, had larger tumors, and were more likely to be hormone receptor positive and HER2 negative, have two positive SLNs, and receive nodal radiation. At a median follow-up of 41 months, no isolated axillary failures were observed. There were 11 nodal recurrences; two supraclavicular ± axillary, four synchronous with breast, and five with distant failure. The five-year rate of any nodal recurrence was 1.6% and did not differ by mECE (2.3% vs. 1.3%; p = 0.84). No differences were observed in local (p = 0.08) or distant (p = 0.31) recurrence rates by mECE status. CONCLUSIONS In Z0011-eligible patients, nodal recurrence rates in patients with mECE are low after treatment with SLN biopsy alone, even in the absence of routine nodal radiation. The presence of mECE should not be considered a routine indication for ALND.
Collapse
Affiliation(s)
- Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Stephanie Downs-Canner
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marcia Edelweiss
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa L Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Laurie Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Deborah Capko
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
10
|
Flanagan MR, Cody HS. ASO Author Reflections: Sentinel Lymph Node Biopsy for Ductal Carcinoma In Situ with Suspicion for Microinvasion on Core Needle Biopsy. Ann Surg Oncol 2019; 26:704. [PMID: 31444603 DOI: 10.1245/s10434-019-07747-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Meghan R Flanagan
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
11
|
Van Zee KJ, Zabor EC, Di Donato R, Harmon B, Fox J, Morrow M, Cody HS, Fineberg SA. Comparison of Local Recurrence Risk Estimates After Breast-Conserving Surgery for DCIS: DCIS Nomogram Versus Refined Oncotype DX Breast DCIS Score. Ann Surg Oncol 2019; 26:3282-3288. [PMID: 31342373 DOI: 10.1245/s10434-019-07537-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND A ductal carcinoma in situ (DCIS) Nomogram integrating 10 clinicopathologic/treatment factors and a Refined DCIS Score (RDS) that incorporates a genomic assay and three clinicopathologic factors (Oncotype DX DCIS Score) are available to estimate DCIS 10-year local recurrence risk (LRR). This study compared these estimates. METHODS Patients 50 years of age or older with DCIS size 2.5 cm or smaller and a genomic assay available were identified. An RDS within 1-2% of the range of Nomogram LRR estimates obtained by assuming use and non-use of endocrine therapy (Nomogram ± ET) was defined as concordant. Assuming a 10-year risk threshold of 10% for recommending radiation, Nomogram ± ET and RDS estimates were compared, and threshold concordance was determined. RESULTS For 54 (92%) of 59 patients, the RDS and Nomogram ± ET LRR estimates were concordant. For the remaining 5 (8%) of the 59 patients, the RDS LRR estimates were lower than the Nomogram + ET estimates, with an absolute difference of 3-8%, and thus were discordant. For these five patients, the RDS estimates of 10-year LRR were lower than 10% (range 5-8%) and the Nomogram + ET estimates were 10% or higher (range 11-14%). These five patients with both discordant and threshold-discordant estimates all had close margins (≤ 2 mm). CONCLUSIONS Among 92% of women 50 years of age or older with DCIS size 2.5 cm or smaller, free-of-charge online Nomogram 10-year LRR estimates were concordant with those obtained using the commercially available RDS (> $4600). Among the 8% with discordant risk estimates, the RDS appeared to underestimate the LRR and may lead to inappropriate omission of radiotherapy. Unless other data show a clinically significant advantage of the RDS (Oncotype DX DCIS Score), the study data suggest that for women 50 years of age or older with DCIS size 2.5 cm or smaller, its use is not warranted.
Collapse
Affiliation(s)
- Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Emily C Zabor
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Bryan Harmon
- Department of Pathology, Montefiore Medical Center, Bronx, NY, USA
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Susan A Fineberg
- Department of Pathology, Montefiore Medical Center, Bronx, NY, USA
| |
Collapse
|
12
|
Flanagan MR, Stempel M, Brogi E, Morrow M, Cody HS. Is Sentinel Lymph Node Biopsy Required for a Core Biopsy Diagnosis of Ductal Carcinoma In Situ with Microinvasion? Ann Surg Oncol 2019; 26:2738-2746. [PMID: 31147995 DOI: 10.1245/s10434-019-07475-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Among patients with a core biopsy diagnosis of ductal carcinoma in situ (DCIS), approximately 10% have microinvasion (DCISM), which, like DCIS, is subject to upstaging by surgical excision, but for which the rates of T and N upstaging are unknown, as is the role of sentinel lymph node biopsy (SLNB), since current studies of SLNB for DCISM are based on the final pathologic report, not the core needle biopsy. In this study, we identified the rates of T and N upstaging following surgical excision in patients with a suspected versus definite core needle biopsy diagnosis of DCISM. METHODS Overall, 369 consecutive patients (2007-2017) with a core biopsy diagnosis of suspected versus definite DCISM and surgical excision were stratified by extent of DCISM on core biopsy: suspicious focus, single focus, multiple foci/single biopsy, and multiple foci/multiple biopsies. Within strata, we identified clinicopathologic features associated with T and N upstaging. RESULTS Across core biopsy strata, there were no clear differences in imaging characteristics or median invasive tumor size (0.2 cm). Among 105 patients with a core biopsy suspicious for DCISM versus 264 with definite DCISM, 28% and 37%, respectively, were upstaged to at least pT1a, but only 1% and 6%, respectively, to pN1. CONCLUSIONS Although 28% of patients with suspected DCISM on core biopsy were surgically upstaged to invasive cancer, the frequency of pN1 SLN metastasis (1%) was comparable with that of DCIS, and was insufficient to recommend SLNB at initial surgery. SLNB remains reasonable for patients with definite DCISM on core biopsy.
Collapse
Affiliation(s)
- Meghan R Flanagan
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
13
|
Flanagan MR, Stempel M, Brogi E, Morrow M, Cody HS. At surgery for a core needle biopsy diagnosis of ductal carcinoma in situ with microinvasion: Is sentinel lymph node biopsy required? J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Edi Brogi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hiram S. Cody
- Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
14
|
Affiliation(s)
- Hiram S Cody
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
15
|
Boughey JC, Attai DJ, Chen SL, Cody HS, Dietz JR, Feldman SM, Greenberg CC, Kass RB, Landercasper J, Lemaine V, MacNeill F, Song DH, Staley AC, Wilke LG, Willey SC, Yao KA, Margenthaler JA. Contralateral Prophylactic Mastectomy (CPM) Consensus Statement from the American Society of Breast Surgeons: Data on CPM Outcomes and Risks. Ann Surg Oncol 2016; 23:3100-5. [PMID: 27469117 PMCID: PMC4999465 DOI: 10.1245/s10434-016-5443-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Indexed: 01/04/2023]
Affiliation(s)
| | - Deanna J Attai
- Department of Surgery, David Geffen School of Medicine at UCLA, UCLA Health Burbank Breast Care, Burbank, CA, USA
| | | | - Hiram S Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jill R Dietz
- Department of Surgery, Case Western Reserve School of Medicine, Seidman Cancer Center, Cleveland, OH, USA
| | | | | | - Rena B Kass
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | | | | | - Fiona MacNeill
- Department of Surgery, Royal Marsden Hospital, London, UK
| | - David H Song
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | | | - Lee G Wilke
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Shawna C Willey
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Katharine A Yao
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Julie A Margenthaler
- Department of Surgery, Center for Advanced Medicine, Breast Health Center, St. Louis, MO, USA
| |
Collapse
|
16
|
Boughey JC, Attai DJ, Chen SL, Cody HS, Dietz JR, Feldman SM, Greenberg CC, Kass RB, Landercasper J, Lemaine V, MacNeill F, Margenthaler JA, Song DH, Staley AC, Wilke LG, Willey SC, Yao KA. Contralateral Prophylactic Mastectomy Consensus Statement from the American Society of Breast Surgeons: Additional Considerations and a Framework for Shared Decision Making. Ann Surg Oncol 2016; 23:3106-11. [PMID: 27469118 PMCID: PMC4999472 DOI: 10.1245/s10434-016-5408-8] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Indexed: 01/11/2023]
Affiliation(s)
| | - Deanna J Attai
- Department of Surgery, David Geffen School of Medicine at UCLA, UCLA Health Burbank Breast Care, Burbank, CA, USA
| | | | - Hiram S Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jill R Dietz
- Department of Surgery, Case Western Reserve School of Medicine, Seidman Cancer Center, Cleveland, OH, USA
| | | | | | - Rena B Kass
- Department of Surgery, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | | | | | - Fiona MacNeill
- Department of Surgery, Royal Marsden Hospital, London, UK
| | - Julie A Margenthaler
- Department of Surgery, Center for Advanced Medicine, Breast Health Center, St. Louis, MO, USA
| | - David H Song
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | | | - Lee G Wilke
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Shawna C Willey
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Katharine A Yao
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| |
Collapse
|
17
|
Mamtani A, Patil S, Van Zee KJ, Cody HS, Pilewskie M, Barrio AV, Heerdt AS, Morrow M. Age and Receptor Status Do Not Indicate the Need for Axillary Dissection in Patients with Sentinel Lymph Node Metastases. Ann Surg Oncol 2016; 23:3481-3486. [PMID: 27169771 DOI: 10.1245/s10434-016-5259-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The American College of Surgeons Oncology Group Z0011 trial demonstrated the safety of omitting axillary lymph node dissection (ALND) for women with fewer than three positive sentinel lymph nodes (SLNs) who are undergoing breast-conservation therapy (BCT). Because most of the women were postmenopausal with estrogen receptor (ER) positive cancers, applicability of ALND for younger patients and those with triple-negative (TN) or human epidermal growth factor receptor 2 (HER2) overexpressing (HER2+) tumors remains controversial. METHODS From August 2010 to December 2015, patients undergoing BCT for cT1-2N0 disease and found to have positive SLNs were prospectively followed. Axillary lymph node dissection was indicated for more than two positive SLNs or gross extracapsular extension. Clinicopathologic characteristics, axillary surgery, nodal burden, and outcomes were compared between the high-risk patients (TN, HER2+, or age <50 years) and the remaining patients, termed average risk patients. RESULTS Among 701 consecutive patients, 242 (35 %) were high risk: 31 (13 %) with TN, 48 (20 %) with HER2+, 130 (54 %) with age less than 50 years, and 33 (14 %) with more than one high-risk feature. The remaining 459 patients (65 %) were average risk. The high-risk patients were younger, had higher-grade tumors (p < 0.0001), and more often had abnormal nodes imaged (p = 0.02). In this study, SLNB alone was performed for 85 % high-risk versus 82 % average-risk cases (p = 0.39). A median of four versus three SLNs were excised (p = 0.04), and both groups had a median of one positive SLN. Additional positive nodes at ALND were found in 62 % high-risk patients versus 65 % average-risk patients (p = 0.8), with a median of three positive nodes in both groups. During a median follow-up period of 31 months, no patients experienced isolated axillary recurrences. CONCLUSIONS Axillary lymph node dissection was no more likely to be indicated for high-risk patients. For patients undergoing ALND, the nodal burden was similar. For patients otherwise meeting the American College of Surgeons Oncology Group (ACOSOG) Z0011 clinical eligibility criteria, ALND is not indicated on the basis of age or subtype.
Collapse
Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexandra S Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
18
|
Mamtani A, Barrio AV, King TA, Van Zee KJ, Plitas G, Pilewskie M, El-Tamer M, Gemignani ML, Heerdt AS, Sclafani LM, Sacchini V, Cody HS, Patil S, Morrow M. How Often Does Neoadjuvant Chemotherapy Avoid Axillary Dissection in Patients With Histologically Confirmed Nodal Metastases? Results of a Prospective Study. Ann Surg Oncol 2016; 23:3467-3474. [PMID: 27160528 DOI: 10.1245/s10434-016-5246-8] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND In breast cancer patients with nodal metastases at presentation, false-negative rates lower than 10 % have been demonstrated for sentinel node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) when three or more negative sentinel nodes (SLNs) are retrieved. However, the frequency with which axillary dissection (ALND) can be avoided is uncertain. METHODS Among 534 prospectively identified consecutive patients with clinical stages 2 and 3 cancer receiving NAC from November 2013 to November 2015, all biopsy-proven node-positive (N+) cases were identified. Patients clinically node-negative after NAC were eligible for SLNB. The indications for ALND were failed mapping, fewer than three SLNs retrieved, and positive SLNs. RESULTS Of 288 N+ patients, 195 completed surgery, with 132 (68 %) of these patients eligible for SLNB. The median age was 50 years. Of these patients, 73 (55 %) were estrogen receptor-positive (ER+), 21 (16 %) were ER- and human epidermal growth factor receptor-2-positive (HER2+), and 38 (29 %) were triple-negative. In four cases, SLNB was deferred intraoperatively. Among 128 SLNB attempts, three or more SLNs were retrieved in 110 cases (86 %), one or two SLNs were retrieved in 15 cases (12 %), and failed mapping occurred in three cases (2 %). In 66 cases, ALND was indicated: 54 (82 %) for positive SLNs, 9 (14 %) for fewer than three negative SLNs, and 3 (4 %) for failed mapping. Persistent disease was found in 17 % of the patients with fewer than three negative SLNs retrieved. Of the 128 SLNB cases, 62 (48 %) had SLNB alone with three or more SLNs retrieved. Among 195 N+ patients who completed surgery, nodal pathologic complete response (pCR) was achieved for 49 %, with rates ranging from 21 % for ER+/HER2- to 97 % for ER-/HER2+ cases, and was significantly more common than breast pCR in ER+/HER2- and triple-negative cases. CONCLUSIONS Nearly 70 % of the N+ patients were eligible for SLNB after NAC. For 48 %, ALND was avoided, supporting the role of NAC in reducing the need for ALND among patients presenting with nodal metastases.
Collapse
Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Tari A King
- Department of Breast Surgery, Dana Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Alexandra S Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Lisa M Sclafani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
| |
Collapse
|
19
|
Matsen C, Villegas K, Eaton A, Stempel M, Manning A, Cody HS, Morrow M, Heerdt A. Late Axillary Recurrence After Negative Sentinel Lymph Node Biopsy is Uncommon. Ann Surg Oncol 2016; 23:2456-61. [PMID: 26957506 DOI: 10.1245/s10434-016-5151-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study was designed to determine the incidence of late axillary recurrence (AR) in patients with negative sentinel lymph node biopsy (SLNB) and provide a comparison with SLNB positive patients who underwent axillary lymph node dissection (ALND). METHODS Retrospective analysis of prospectively collected data on all breast cancer patients with negative SLNB from January 1997 to December 2000 was performed on a large, institutional database. Primary outcome was cumulative incidence of AR as a first event with/without concurrent local recurrence. SLNB positive patients who went on to ALND during the same timeframe were comparatively analyzed. RESULTS A total of 1529 eligible patients were identified (median age 58 years, median tumor size 1.0 cm): 1297 (85 %) underwent lumpectomy; 1099 (75 %) received adjuvant radiation; and 874 (80 %) were estrogen receptor-positive. At 10.8 (range 0-16) years median follow-up, overall incidence of AR as a first event was low (n = 13). Cumulative incidence was 0.6 % [95 % confidence interval (CI) 0.2-0.9] 5 years after SLNB, and 0.9 % (95 % CI 0.4-1.4, 95 % CI 0.5-1.6) at 10 and 15 years. Late AR (>5 years after surgery) occurred in five patients. Median overall survival after AR was 4.6 years; median distant disease-free survival after AR was 3.8 years. Late AR was also low in a contemporaneous group of SLNB positive patients undergoing ALND. In this group, cumulative incidence of AR was 0.7 % (95 % CI 0.1-1.3) 5 years after surgery, and 0.8 % (95 % CI 0.2-1.5) at 10 and 15 years. DISCUSSION Late AR after negative SLNB is rare; the majority of ARs are in the first 5 years after surgery. Prognosis after these events is poor. SLNB remains a safe and effective procedure for axillary evaluation in breast cancer.
Collapse
Affiliation(s)
- Cindy Matsen
- Breast Care Program, Department of Surgery, Hunstman Cancer Institute at the University of Utah, Salt Lake City, UT, USA.
| | - Kristine Villegas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aidan Manning
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
20
|
Ugras S, Matsen C, Eaton A, Stempel M, Morrow M, Cody HS. Reoperative Sentinel Lymph Node Biopsy is Feasible for Locally Recurrent Breast Cancer, But is it Worthwhile? Ann Surg Oncol 2015; 23:744-8. [PMID: 26644258 DOI: 10.1245/s10434-015-5003-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Reoperative sentinel lymph node biopsy (SLNB) is feasible in patients with local recurrence (LR) of invasive breast cancer but it remains unclear if this procedure affects either treatment or outcome. In this study, we ask whether axillary restaging (vs. none) at the time of LR affects the rate of subsequent events: axillary failure (AF), non-axillary recurrence (NAR), distant metastasis, or death. METHODS We queried our institutional database to identify patients treated surgically for invasive breast cancer with a negative SLNB (1997-2000) who developed ipsilateral breast or chest wall recurrence as a first event. We excluded those with gross nodal disease at the time of LR. The cumulative incidence of subsequent events was estimated using competing risks methodology. RESULTS Of 1527 patients with negative SLN at initial surgery, 83 had an ipsilateral breast (79) or chest wall recurrence (4) with clinically negative regional nodes; 47 (57%) were treated with and 36 (43%) without axillary surgery. Primary tumor characteristics were similar between groups, although time to LR was shorter in the no axillary surgery group (median 3.4 vs. 6.5 years; p < 0.05). All patients in the axillary surgery group and 94% of patients in the no axillary surgery group had surgical excision of their LR, and the use of subsequent radiation and systemic therapy was similar between groups. At a median follow-up of 4.2 years from the time of LR, the rates of AF, NAR, distant metastasis and death were low and did not differ between groups. CONCLUSIONS Among breast cancer patients with LR and clinically negative nodes, our results question the value of axillary restaging but invite confirmation in larger patient cohorts. Since randomized trials support the value of systemic therapy for all patients with invasive LR, reoperative SLNB, although feasible, may not be necessary.
Collapse
Affiliation(s)
- Stacy Ugras
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cindy Matsen
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT, USA
| | - Anne Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
21
|
Abstract
Sentinel lymph node (SLN) biopsy is standard care for patients with cN0 breast cancer. An extensive literature, including seven randomized trials, has established that patients with negative SLN do not require axillary dissection (ALND), that axillary local recurrence after a negative SLN biopsy is rare, that disease-free and overall survival are unaffected by the addition of ALND to SLN biopsy, and that the morbidity of SLN biopsy is substantially less than that of ALND. It is now clear that many patients with positive SLN do not require ALND. In ACOSOG Z0011, 6-year locoregional control and survival were equivalent with versus without the performance of ALND in cT1-2N0 patients with ≤2 positive SLN treated by breast conservation with whole breast radiation therapy. A small but growing body of data now suggests that ALND may not be required for selected patients outside the Z0011 eligibility criteria, specifically those treated by mastectomy (without post-mastectomy radiation therapy), by partial breast irradiation, and by neoadjuvant chemotherapy. Looking ahead, the principal goals of axillary staging, prognostication, and local control will be accomplished by SLN biopsy for a substantial majority of patients, and the role of ALND will continue to diminish.
Collapse
Affiliation(s)
- Alice Y Ho
- From the Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY; Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
| | | |
Collapse
|
22
|
Abstract
Sentinel lymph node (SLN) biopsy is standard care for patients with cN0 breast cancer. An extensive literature, including seven randomized trials, has established that patients with negative SLN do not require axillary dissection (ALND), that axillary local recurrence after a negative SLN biopsy is rare, that disease-free and overall survival are unaffected by the addition of ALND to SLN biopsy, and that the morbidity of SLN biopsy is substantially less than that of ALND. It is now clear that many patients with positive SLN do not require ALND. In ACOSOG Z0011, 6-year locoregional control and survival were equivalent with versus without the performance of ALND in cT1-2N0 patients with ≤2 positive SLN treated by breast conservation with whole breast radiation therapy. A small but growing body of data now suggests that ALND may not be required for selected patients outside the Z0011 eligibility criteria, specifically those treated by mastectomy (without post-mastectomy radiation therapy), by partial breast irradiation, and by neoadjuvant chemotherapy. Looking ahead, the principal goals of axillary staging, prognostication, and local control will be accomplished by SLN biopsy for a substantial majority of patients, and the role of ALND will continue to diminish.
Collapse
Affiliation(s)
- Alice Y Ho
- From the Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY; Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
| | | |
Collapse
|
23
|
Koslow Mautner S, Cody HS. Sentinel Node Biopsy After Neoadjuvant Chemotherapy for Node-Positive Breast Cancer: Does Axillary Ultrasound Improve Performance? J Clin Oncol 2015; 33:3375-3378. [DOI: 10.1200/jco.2014.60.3316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
| | - Hiram S. Cody
- Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
24
|
Affiliation(s)
- Hiram S Cody
- From the Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
| | | |
Collapse
|
25
|
Affiliation(s)
- Hiram S Cody
- Memorial Sloan Kettering Cancer Center, New York, USA,
| |
Collapse
|
26
|
Matsen CB, Mehrara B, Eaton A, Capko D, Berg A, Stempel M, Van Zee KJ, Pusic A, King TA, Cody HS, Pilewskie M, Cordeiro P, Sclafani L, Plitas G, Gemignani ML, Disa J, El-Tamer M, Morrow M. Skin Flap Necrosis After Mastectomy With Reconstruction: A Prospective Study. Ann Surg Oncol 2015; 23:257-64. [PMID: 26193963 DOI: 10.1245/s10434-015-4709-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Rates of mastectomy with immediate reconstruction are rising. Skin flap necrosis after this procedure is a recognized complication that can have an impact on cosmetic outcomes and patient satisfaction, and in worst cases can potentially delay adjuvant therapies. Many retrospective studies of this complication have identified variable event rates and inconsistent associated factors. METHODS A prospective study was designed to capture the rate of skin flap necrosis as well as pre-, intra-, and postoperative variables, with follow-up assessment to 8 weeks postoperatively. Uni- and multivariate analyses were performed for factors associated with skin flap necrosis. RESULTS Of 606 consecutive procedures, 85 (14 %) had some level of skin flap necrosis: 46 mild (8 %), 6 moderate (1 %), 31 severe (5 %), and 2 uncategorized (0.3 %). Univariate analysis for any necrosis showed smoking, history of breast augmentation, nipple-sparing mastectomy, and time from incision to specimen removal to be significant. In multivariate models, nipple-sparing, time from incision to specimen removal, sharp dissection, and previous breast reduction were significant for any necrosis. Univariate analysis of only moderate or severe necrosis showed body mass index, diabetes, nipple-sparing mastectomy, specimen size, and expander size to be significant. Multivariate analysis showed nipple-sparing mastectomy and specimen size to be significant. Nipple-sparing mastectomy was associated with higher rates of necrosis at every level of severity. CONCLUSIONS Rates of skin flap necrosis are likely higher than reported in retrospective series. Modifiable technical variables have limited the impact on rates of necrosis. Patients with multiple risk factors should be counseled about the risks, especially if they are contemplating nipple-sparing mastectomy.
Collapse
Affiliation(s)
- Cindy B Matsen
- Breast Care Team, Department of Surgery, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA.
| | - Babak Mehrara
- Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Deborah Capko
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anastasia Berg
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea Pusic
- Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tari A King
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter Cordeiro
- Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lisa Sclafani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph Disa
- Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
27
|
Matsen CB, Hirsch A, Eaton A, Stempel M, Heerdt A, Van Zee KJ, Cody HS, Morrow M, Plitas G. Extent of microinvasion in ductal carcinoma in situ is not associated with sentinel lymph node metastases. Ann Surg Oncol 2014; 21:3330-5. [PMID: 25092160 DOI: 10.1245/s10434-014-3920-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Ductal carcinoma in situ with microinvasion (DCISM) is a rare diagnosis with a good prognosis. Although nodal metastases are uncommon, sentinel lymph node biopsy (SLNB) remains standard care. Volume of disease in invasive breast cancer is associated with SLNB positivity, and, thus we hypothesized that in a large cohort of patients with DCISM, multiple foci of microinvasion might be associated with a higher risk of positive SLNB. METHODS Records from a prospective institutional database were reviewed to identify patients with DCISM who underwent SLNB between June 1997 and December 2010. Pathology reports were reviewed for number of microinvasive foci and categorized as 1 focus or ≥2 foci. Demographic, pathologic, treatment, and outcome data were obtained and analyzed. RESULTS Of 414 patients, 235 (57 %) had 1 focus of microinvasion and 179 (43 %) had ≥2 foci. SLNB macrometastases were found in 1.4 %, and micrometastases were found in 6.3 %; neither were significantly different between patients with 1 focus versus ≥2 foci (p = 1.0). Patients with positive SLNB or ≥2 foci of microinvasion were more likely to receive chemotherapy. At median 4.9 years (range 0-16.2 years) follow-up, 18 patients, all in the SLNB negative group, had recurred for an overall 5-year recurrence-free proportion of 95.9 %. CONCLUSIONS Even with large numbers, there was no higher risk of nodal involvement with ≥2 foci of microinvasion compared with 1 focus. Number of microinvasive foci and results of SLNB appear to be used in decision making for systemic therapy. Prognosis is excellent.
Collapse
Affiliation(s)
- Cindy B Matsen
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Houssami N, Diepstraten SCE, Cody HS, Turner RM, Sever AR. Clinical utility of ultrasound-needle biopsy for preoperative staging of the axilla in invasive breast cancer. Anticancer Res 2014; 34:1087-1097. [PMID: 24596347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Sentinel node biopsy (SNB) has largely replaced axillary lymph node dissection (ALND) as the standard-of-care for nodal staging in invasive breast cancer. Preoperative imaging-based staging of the axilla using ultrasound with selective ultrasound-guided needle biopsy (UNB) is moderately-sensitive and identifies approximately 50% of patients (pooled estimate from meta-analysis 50%; 95% confidence interval=43%-57%) with axillary nodal metastases prior to surgical intervention. It is also a highly specific staging strategy that allows patients to be triaged to ALND based on a positive result (positive predictive value approximates 100%), thus avoiding two-stage axillary surgery and unnecessary SNB. Axillary UNB has a good clinical utility: based on an updated meta-analysis, we found that a median proportion of 18.4% (inter-quartile range=13.3%-27.4%) from 7,097 patients can be effectively triaged to axillary treatment and can avoid SNB. However, the changing algorithm of axillary surgical treatment means that UNB will have relatively less utility where surgeons omit ALND for minimal nodal metastatic disease. Research that allows enhanced application of ultrasound and UNB to specifically identify and biopsy sentinel nodes and to discriminate between patients with minimal versus advanced nodal metastatic involvement is likely to have the most impact on future management of the axilla in breast cancer.
Collapse
Affiliation(s)
- Nehmat Houssami
- School of Public Health (A27), Sydney Medical School, University of Sydney, Sydney 2006, Australia.
| | | | | | | | | |
Collapse
|
29
|
Sbaity E, Cody HS. Management of axillary staging in breast cancer patients treated with neoadjuvant chemotherapy. Breast Cancer Management 2013. [DOI: 10.2217/bmt.13.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Sentinel lymph node (SLN) biopsy is standard care for patients with cN0 breast cancer, and SLN-negative patients do not require axillary dissection (ALND). It is now clear that many patients with positive SLN do not require ALND. In ACOSOG Z0011, 6-year locoregional control and survival (in cT1–2N0 patients with ≤2 positive SLN treated by breast conservation and whole breast radiotherapy) were comparable for SLN biopsy alone compared to SLN biopsy plus ALND. A growing body of data now suggests that ALND may not be required for selected patients outside the Z0011 eligibility criteria, including those treated with neoadjuvant chemotherapy (NAC). Retrospective and prospective studies confirm that the success of SLN biopsy after NAC is slightly lower and the false-negative rate slightly higher than those of SLN biopsy in general. The performance of SLN biopsy after NAC is optimized by the use of combined dye–isotope mapping and by the removal of at least two SLN. After NAC, ALND remains standard care for those who remain SLN-positive but may not be required for SLN-negative patients. Future trials will focus on patients with proven axillary node metastasis prior to NAC, and ask whether axillary radiotherapy is required for those who become SLN negative, and whether ALND is required for those who remain SLN-positive.
Collapse
Affiliation(s)
- Eman Sbaity
- Surgical Oncology, Memorial Sloan–Kettering Cancer Center, 1275 York Avenue, Box 435, New York, NY 10065, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan–Kettering Cancer Center, Clinical Surgery, Weill Cornell Medical College, 300 East 66th Street, #831, New York, NY 10065, USA
| |
Collapse
|
30
|
Dengel LT, Van Zee KJ, King TA, Stempel M, Cody HS, El-Tamer M, Gemignani ML, Sclafani LM, Sacchini VS, Heerdt AS, Plitas G, Junqueira M, Capko D, Patil S, Morrow M. Axillary dissection can be avoided in the majority of clinically node-negative patients undergoing breast-conserving therapy. Ann Surg Oncol 2013; 21:22-7. [PMID: 23975314 DOI: 10.1245/s10434-013-3200-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The extent to which ACOSOG Z0011 findings are applicable to patients undergoing breast-conserving therapy (BCT) is uncertain. We prospectively assessed how often axillary dissection (ALND) was avoided in an unselected, consecutive patient cohort meeting Z0011 eligibility criteria and whether subgroups requiring ALND could be identified preoperatively. METHODS Patients with cT1,2cN0 breast cancer undergoing BCT were managed without ALND for metastases in <3 sentinel nodes (SNs) and no gross extracapsular extension (ECE). Patients with and without indications for ALND were compared using Fisher's exact and Wilcoxon rank sum tests. RESULTS From August 2010 to November 2012, 2,157 invasive cancer patients had BCT. A total of 380 had histologic nodal metastasis; 93 did not meet Z0011 criteria. Of 287 with ≥1 H&E-positive SN (209 macrometastases), 242 (84 %) had indications for SN only. ALND was indicated in 45 for ≥3 positive SNs (n = 29) or ECE (n = 16). The median number of SNs removed in the SN group was 3 versus 5 in the ALND group (p < 0.0001). Age, hormone receptor and HER2 status, and grade did not differ between groups; tumors were larger in the ALND group (p < 0.0001). Of ALND patients, 72 % had additional positive nodes (median = 1; range 1-19). No axillary recurrences have occurred (median follow-up, 13 months). CONCLUSIONS ALND was avoided in 84 % of a consecutive series of patients having BCT, suggesting that most patients meeting ACOSOG Z0011 eligibility have a low axillary tumor burden. Age, ER, and HER2 status were not predictive of ALND, and the criteria used for ALND (≥3 SNs, ECE) reliably identified patients at high risk for residual axillary disease.
Collapse
Affiliation(s)
- Lynn T Dengel
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Affiliation(s)
- Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
| |
Collapse
|
32
|
Dengel L, Cody HS, King TA, Van Zee KJ, Patil S, Corben A, El-Tamer M, Stempel M, Sclafani LM, Heerdt AS, Gemignani M, Capko D, Sacchini V, Plitas G, Morrow M. The presence and extent of extracapsular extension (ECE) and the need for axillary lymph node dissection (ALND) in patients who meet ACOSOG Z11 eligibility criteria. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.1019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1019 Background: Whether ECE mandates ALND in patients with ≤2 positive sentinel nodes (SN) is controversial. ACOSOG Z11 excluded patients with matted nodes, but did not comment on microscopic ECE. In a prospective, consecutive series of patients, we sought to determine if ECE correlates with the number of positive axillary lymph nodes (LN) and if ECE ≤2mm clinically differs from ECE >2mm. Methods: In 8/2010 an institutional treatment algorithm based on the Z11 results was prospectively applied to consecutive patients having BCS. ALND was performed for ≥3 +SNs. The approach to ECE was not specified. Characteristics of patients with and without ECE were compared with Fisher’s exact test and the Wilcoxon rank sum test. Results: From 8/10-11/12, 2157 invasive breast cancer patients had BCS; 381 had LN metastasis, 287 met Z11 selection criteria, and ALND was avoided in 242 (84%). ECE was present in 111 (39%), of whom 23% had ≥3 +SNs (vs 2% without ECE; p<0.0001) and 35% had ALND (vs 3% without ECE; p<0.0001). The presence of ECE was associated with tumor size (1.9cm vs 1.6; p=.01) but not with age, grade, or receptor status. The degree of ECE was associated with age, grade, number of +SNs, and performance of ALND (Table). In 45 cases, ALND was advised for ≥3 +SNs (n=29) or <3 +SNs with ECE (n=16). 39 patients had ALND and 34 of these had ECE. Additional +LNs were seen in 5/9 patients with ≤2mm ECE and 20/25 with >2mm ECE; median of 1 additional +LN in each group. Seven or more additional +LNs were seen in 6 patients with >2mm ECE; 1 patient with ≤2mm ECE had 6 additional +LNs, the remainder had ≤3. Conclusions: The presence of ECE was associated with ≥3 +SNs and the need for ALND. Only a minority of patients with ≤2mm of ECE had ≥3 +SNs, and nodal disease at ALND in this group was limited, suggesting that ≤2mm ECE may not be an indication for ALND. [Table: see text]
Collapse
Affiliation(s)
- Lynn Dengel
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Hiram S. Cody
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Tari A. King
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Sujata Patil
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | - Deborah Capko
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - George Plitas
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Monica Morrow
- Memorial Sloan-Kettering Cancer Center, New York, NY
| |
Collapse
|
33
|
|
34
|
Cody HS, Houssami N. Axillary management in breast cancer: What's new for 2012? Breast 2012; 21:411-5. [DOI: 10.1016/j.breast.2012.01.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 01/16/2012] [Accepted: 01/22/2012] [Indexed: 02/06/2023] Open
|
35
|
MESH Headings
- Adult
- Aged
- Axilla
- Breast Neoplasms/drug therapy
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Breast Neoplasms, Male/drug therapy
- Breast Neoplasms, Male/pathology
- Breast Neoplasms, Male/surgery
- Carcinoma in Situ/drug therapy
- Carcinoma in Situ/pathology
- Carcinoma in Situ/surgery
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Ductal, Breast/surgery
- Chemotherapy, Adjuvant
- Female
- Follow-Up Studies
- Humans
- Lymph Node Excision
- Lymph Nodes/pathology
- Lymph Nodes/surgery
- Lymphatic Metastasis
- Male
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Micrometastasis
- Neoplasm Recurrence, Local/pathology
- Neoplasm Staging
- Retrospective Studies
- Sentinel Lymph Node Biopsy
Collapse
Affiliation(s)
- John M Lyons
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
| | | | | | | |
Collapse
|
36
|
Abstract
SUMMARY Axillary node status is an important prognostic factor in invasive breast cancer. Axillary lymph node dissection (ALND) was previously the primary management approach; however, sentinel node biopsy (SNB) has largely replaced ALND, which is currently predominantly used to manage SNB-positive patients. Preoperative imaging-based staging of the axilla (with ultrasound, PET or MRI) for the detection of suspicious nodes has been applied to inform and potentially streamline axillary surgical management. Ultrasound with ultrasound-guided needle biopsy is the most accurate imaging-based strategy and has been shown to have clinical utility for preoperative axillary staging. A meta-analysis has reported a median sensitivity of 79.4% and a specificity of 100% for ultrasound-based staging, and estimated that ultrasound-guided needle biopsy triages 55.2% of women with metastatic axillary nodes (or a median of 17.7% of patients) directly to ALND, thereby avoiding unnecessary SNB. Although ultrasound-based staging has had a role in preoperative axillary assessment, it appears likely that this role will be shaped in the future by the ongoing evolution in surgical management of the axilla, particularly in light of recent evidence that challenges the need for ALND in some SNB-positive patients.
Collapse
Affiliation(s)
- Nehmat Houssami
- Screening & Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Stefano Ciatto
- UO Senologia Clinica e Screening Mammografico, Department of Diagnostics, Azienda Provinciale Servizi Sanitari (APSS), Trento, Italy
| | - Robin M Turner
- Screening & Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center (MSKCC), NY, USA
| |
Collapse
|
37
|
|
38
|
Weber WP, Barry M, Stempel MM, Junqueira MJ, Eaton AA, Patil SM, Morrow M, Cody HS. A 10-year trend analysis of sentinel lymph node frozen section and completion axillary dissection for breast cancer: are these procedures becoming obsolete? Ann Surg Oncol 2011; 19:225-32. [PMID: 21647763 DOI: 10.1245/s10434-011-1823-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recent results from the ACOSOG Z0011 trial question the use of intraoperative frozen section (FS) during sentinel lymph node (SLN) biopsy and the role of axillary dissection (ALND) for SLN-positive breast cancer patients. Here we present a 10-year trend analysis of SLN-FS and ALND in our practice. METHODS We reviewed our prospective SLN database over 10 years (1997-2006, 7509 SLN procedures) for time trends and variation between surgeons in the use of SLN-FS and ALND in patients with cN0 invasive breast cancer. RESULTS Use of SLN-FS decreased from 100% to 62% (P < 0.0001) and varied widely by surgeon (66% to 95%). There were no statistically significant trends in the performance of ALND for patients with SLN metastases detected by FS (n = 1370, 99-99%) or routine hematoxylin and eosin (H&E) (n = 333; 69-77%), but only for those detected by serial section H&E with or without immunohistochemistry (n = 438; 73-48%; P = 0.0054) or immunohistochemistry only (n = 294; 48-28%; P < 0.0001). These trends coincided with an increase in the proportion of completion versus immediate ALND (30-40%; P = 0.0710). CONCLUSIONS Over 10 years, we have observed a diminishing rate of SLN-FS and, for patients with low-volume SLN metastases, fewer ALND, trends that suggest a more nuanced approach to axillary management. If the Z0011 selection criteria had been applied to our cohort, 66% of SLN-FS (4159 of 6327) and 48% of ALND (939 of 1953) would have been avoided, sparing 13% of all patients the morbidity of ALND.
Collapse
Affiliation(s)
- Walter P Weber
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Cody HS. SLN biopsy for large and/or multicentric breast cancers: should we worry? Eur J Surg Oncol 2011; 37:386-7. [PMID: 21388775 DOI: 10.1016/j.ejso.2011.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 02/10/2011] [Indexed: 10/18/2022] Open
Affiliation(s)
- Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 300 East 66th St, #831 New York, NY 10065, USA.
| |
Collapse
|
40
|
Boughey JC, Mittendorf EA, Solin LJ, Michael Dixon J, Tuttle TM, Beitsch PD, Cody HS, Leitch AM, Newman LA. Controversies in breast surgery. Ann Surg Oncol 2010; 17 Suppl 3:230-2. [PMID: 20853038 DOI: 10.1245/s10434-010-1264-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Indexed: 12/19/2022]
Affiliation(s)
- Judy C Boughey
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
|
42
|
Port ER, Patil S, Stempel M, Morrow M, Cody HS. Number of lymph nodes removed in sentinel lymph node-negative breast cancer patients is significantly related to patient age and tumor size. Cancer 2010; 116:1987-91. [DOI: 10.1002/cncr.24964] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
43
|
Pugliese MS, Karam AK, Hsu M, Stempel MM, Patil SM, Ho AY, Traina TA, Van Zee KJ, Cody HS, Morrow M, Gemignani ML. Predictors of Completion Axillary Lymph Node Dissection in Patients With Immunohistochemical Metastases to the Sentinel Lymph Node in Breast Cancer. Ann Surg Oncol 2009; 17:1063-8. [DOI: 10.1245/s10434-009-0834-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Indexed: 02/06/2023]
|
44
|
Cody HS. Sentinel-lymph-node biopsy for breast cancer: the story is not yet over. Lancet Oncol 2009; 10:838. [PMID: 19664957 DOI: 10.1016/s1470-2045(09)70223-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
45
|
Karam AK, Hsu M, Patil S, Stempel M, Traina TA, Ho AY, Cody HS, Port ER, Morrow M, Gemignani ML. Predictors of Completion Axillary Lymph Node Dissection in Patients with Positive Sentinel Lymph Nodes. Ann Surg Oncol 2009; 16:1952-8. [DOI: 10.1245/s10434-009-0440-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 03/02/2009] [Accepted: 03/02/2009] [Indexed: 11/18/2022]
|
46
|
Karam A, Stempel M, Cody HS, Port ER. Reoperative Sentinel Lymph Node Biopsy after Previous Mastectomy. J Am Coll Surg 2008; 207:543-8. [DOI: 10.1016/j.jamcollsurg.2008.06.139] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 05/27/2008] [Accepted: 06/03/2008] [Indexed: 10/21/2022]
|
47
|
Cody HS, Van Zee KJ. Predicting Nonsentinel Node Metastases in Sentinel Node-Positive Breast Cancer: What Have We Learned, Can We Do Better, and Do We Need To? Ann Surg Oncol 2008; 15:2998-3002. [DOI: 10.1245/s10434-008-0133-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 08/06/2008] [Indexed: 01/17/2023]
|
48
|
Kayton ML, Delgado R, Busam K, Cody HS, Athanasian EA, Coit D, La Quaglia MP. Experience with 31 sentinel lymph node biopsies for sarcomas and carcinomas in pediatric patients. Cancer 2008; 112:2052-9. [DOI: 10.1002/cncr.23403] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
49
|
Tan LK, Giri D, Hummer AJ, Panageas KS, Brogi E, Norton L, Hudis C, Borgen PI, Cody HS. Occult Axillary Node Metastases in Breast Cancer Are Prognostically Significant: Results in 368 Node-Negative Patients With 20-Year Follow-Up. J Clin Oncol 2008; 26:1803-9. [DOI: 10.1200/jco.2007.12.6425] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose In breast cancer, sentinel lymph node (SLN) biopsy allows the routine performance of serial sections and/or immunohistochemical (IHC) staining to detect occult metastases missed by conventional techniques. However, there is no consensus regarding the optimal method for pathologic examination of SLN, or the prognostic significance of SLN micrometastases. Patients and Methods In 368 patients with axillary node-negative invasive breast cancer, treated between 1976 and 1978 by mastectomy, axillary dissection, and no systemic therapy, we reexamined the axillary tissue blocks following our current pathologic protocol for SLN. Occult lymph node metastases were categorized by pattern of staining (immunohistochemically positive or negative [IHC±], hematoxylin-eosin staining positive or negative [H & E ±]), number of positive nodes (0, 1, > 1), number of metastatic cells (0, 1 to 20, 21 to 100, > 100), and largest cluster size (≤ 0.2 mm [pN0i+], 0.3 to 2.0 mm [pN1mi], > 2.0 mm [pN1a]). We report 20-year results as overall survival (OS), disease-free survival (DFS), and disease-specific death (DSD). Results A total of 23% of patients (83 of 368) were converted to node-positive. Of these, 73% were ≤ 0.2 mm in size (pN0i+), 20% were 0.3 to 2.0 mm (pN1mi), and 6% were more than 2 mm (pN1a). On univariate and multivariate analysis, pattern of staining, number of positive nodes, number of metastatic cells, and cluster size were all significantly related to both DFS and DSD. On multivariate analysis, each of these measures had significance comparable to, or greater than, tumor size, grade or lymphovascular invasion. Conclusion In breast cancer patients staged node-negative by conventional single-section pathology, occult axillary node metastases detected by our current pathologic protocol for SLN are prognostically significant.
Collapse
Affiliation(s)
- Lee K. Tan
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Dilip Giri
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Amanda J. Hummer
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Katherine S. Panageas
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Edi Brogi
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Larry Norton
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Clifford Hudis
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Patrick I. Borgen
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Hiram S. Cody
- From the Department of Pathology; Department of Epidemiology and Biostatistics; Division of Breast Oncology, Department of Medicine; Breast Service, Department of Surgery; and the Memorial Sloan-Kettering Cancer Center, New York, NY
| |
Collapse
|
50
|
Flynn LW, Park J, Patil SM, Cody HS, Port ER. Sentinel lymph node biopsy is successful and accurate in male breast carcinoma. J Am Coll Surg 2008; 206:616-21. [PMID: 18387465 DOI: 10.1016/j.jamcollsurg.2007.11.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 08/26/2007] [Accepted: 11/05/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Men and women with breast cancer have similar risks of morbidity related to axillary lymph node dissection (ALND). Sentinel lymph node (SLN) biopsy minimizes this risk. We report results from the largest series of SLN biopsies for male breast cancer and compare this experience with that of female counterparts treated concurrently. STUDY DESIGN The Memorial Sloan-Kettering Cancer Center SLN biopsy database showed that 7,315 SLN biopsy procedures were performed for primary breast cancer from September 1996 to July 2005. Of these, 78 (1.0%) procedures were performed in men. Followup data were obtained from medical record review. RESULTS SLN biopsy was successful in 76 of 78 (97%) patients. Negative SLNs were found in 39 of 76 (51%) patients. In 3 (8%) patients with negative SLNs, a positive non-SLN was found, identified by intraoperative palpation. Positive SLNs were found in 37 of 76 (49%) patients. In 22 of 37 (59%), node positivity was determined intraoperatively, prompting immediate ALND. In 15 of 37 (41%) patients with positive SLNs, node positivity was determined postoperatively. Of these 15, 9 (60%) underwent completion ALND. In the 2 of 78 (3%) patients with failed SLN biopsy procedures, ALND was performed and yielded positive nodes. At a median followup of 28 months (range 5 to 96 months), there were no axillary recurrences. Compared with their female counterparts, men with breast cancer had larger tumors and were more likely to have positive nodes. CONCLUSIONS SLN biopsy is successful and accurate in male breast cancer patients. Although a larger proportion of men have positive nodes, for men with negative nodes, SLN biopsy may reduce morbidity related to ALND.
Collapse
Affiliation(s)
- Laurie W Flynn
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
| | | | | | | | | |
Collapse
|