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1
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Gentile D, Tinterri C. Sentinel lymph node biopsy versus axillary lymph node dissection in breast cancer patients undergoing mastectomy. Minerva Surg 2024; 79:545-557. [PMID: 39555937 DOI: 10.23736/s2724-5691.24.10485-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2024]
Abstract
Axillary lymph node dissection (ALND) has been a cornerstone of breast cancer (BC) treatment, traditionally ensuring loco-regional control but associated with significant morbidity. Recent advancements suggest sentinel lymph node biopsy (SLNB) as a less invasive alternative. This review examines the outcomes of omitting ALND in BC patients with positive sentinel lymph nodes (SLNs) undergoing mastectomy. We conducted a comprehensive review of historical comparative studies and pivotal randomized clinical trials. Key sources included the ACOSOG Z0011 and SINODAR-ONE trials, alongside retrospective studies and ongoing trials like SENOMAC and POSNOC. Historical studies predominantly focused on patients undergoing breast-conserving surgery, revealing low recurrence rates and comparable survival outcomes between SLNB alone and ALND. Retrospective analyses of mastectomy patients indicated that omitting ALND did not significantly impact recurrence-free survival (RFS) or overall survival (OS). The SINODAR-ONE trial sub-analysis, involving 218 mastectomy patients, found no significant differences in 5-year OS and RFS between ALND and SLNB groups. The SENOMAC trial similarly showed non-inferior outcomes for mastectomy patients treated without ALND. The ongoing POSNOC trial aims to provide further insights, particularly focusing on the subgroup of mastectomy patients. Emerging evidence supports the feasibility of omitting ALND in BC patients with positive SLNs undergoing mastectomy, potentially reducing surgical morbidity without compromising oncological outcomes. However, further randomized clinical trials are essential to confirm these findings and refine treatment guidelines, ensuring optimal patient care.
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Affiliation(s)
- Damiano Gentile
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy -
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy -
| | - Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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2
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You JY, Lee ES, Lim SK, Kwon Y, Jung SY. Could axillary lymph node dissection be omitted in the mastectomy patient with tumor positive sentinel node? Front Oncol 2023; 13:1181069. [PMID: 37427099 PMCID: PMC10325642 DOI: 10.3389/fonc.2023.1181069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/19/2023] [Indexed: 07/11/2023] Open
Abstract
Background Recent data from the ACOSOG Z0011 trial suggest that axillary lymph node dissection (ALND) may not be necessary for patients with positive sentinel lymph node biopsy (SLNB) receiving breast-conserving surgery (BCS) with irradiation. However, consensus statements and guidelines have recommended that patients undergoing mastectomy with tumor-positive sentinel node undergo completion ALND. In this study, we compared the locoregional recurrence rate of patients with tumor-positive sentinel nodes among three groups: mastectomy with SLNB, mastectomy with ALND and BCS with SLNB. Method We identified 6,163 women with invasive breast cancer who underwent surgical resection at our institution between January 2000 and December 2011. Clinicopathologic data obtained from the prospectively collected medical database were analyzed retrospectively. Among the patients with sentinel node positive, mastectomy with SLNB was performed in 39 cases, mastectomy with ALND in 181 cases, and BCS with SLNB in 165 cases. The primary end point was the loco-regional recurrence rate. Results Clinicopathologic characteristics were similar among the groups. There were no cases of loco-regional recurrence in the sentinel groups. At a median follow-up of 61.0 months (last follow-up May 2013), the loco-regional recurrence rate of each group was 0% for BCS with SLNB and mastectomy with SLNB only, and 1.7% for mastectomy with ALND (p=0.182). Conclusion In our study, there was no significant difference in loco-regional recurrence rates between groups. This result lends weight to the argument that SLNB without ALND may be a reasonable management for selected patients with appropriate surgery and adjuvant systemic therapy.
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Affiliation(s)
- Ji Young You
- Breast and Endocrine Division, Department of Surgery, Korea University Medical Center, Seoul, Republic of Korea
| | - Eun Sook Lee
- Center for Breast Cancer, National Cancer Center, Research Institute and Hospital, Goyang, Gyeonggi, Republic of Korea
| | - Siew Kuan Lim
- Department of Surgery, Breast Service, Changi General Hospital, Singapore, Singapore
| | - Youngmee Kwon
- Center for Breast Cancer, National Cancer Center, Research Institute and Hospital, Goyang, Gyeonggi, Republic of Korea
| | - So-Youn Jung
- Center for Breast Cancer, National Cancer Center, Research Institute and Hospital, Goyang, Gyeonggi, Republic of Korea
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3
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Liu Y, Fan Y, Jin Z, Cui M, Yu X, Jin F, Wang X. Axillary management for early invasive breast cancer patients: Who will truly benefit? Front Oncol 2022; 12:989975. [PMID: 36046051 PMCID: PMC9421357 DOI: 10.3389/fonc.2022.989975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe implementation of sentinel lymph node biopsy (SLNB) and further completion axillary lymph node dissection (cALND) after positive sentinel lymph nodes (SLNs) on early invasive breast cancer patients should be cautiously tailored. Identifying predictors for SLN and non-sentinel lymph node (nSLN) metastases can help surgeons make better surgical decisions.MethodsA retrospective case-control study was designed and a total of 560 eligible patients were enrolled consecutively. They were all diagnosed in our center and received appropriate medical care. According to the metastasis of SLN and nSLN, they were divided into metastatic and non-metastatic groups on two successive occasions to investigate the relationship between clinical factors, pathological factors, hematological factors and lymph node metastasis.ResultsIn total, 101 (18.04%) patients developed SLN metastases, including 98 patients with macro-metastases and 3 patients with micro-metastases. Out of 97 patients receiving further cALND, 20 patients (20.62%) developed nSLN metastases. Multivariate analysis revealed that “high expression of Ki-67” and “lymphatic invasion” predicted a higher risk of SLN metastasis; and “increased number of positive SLNs” and “increased systemic inflammation index (SII)” predicted a higher risk of nSLN metastasis.ConclusionSurgery for early invasive breast cancer patients should be more customized and precise. Appropriate axillary management is necessary for patients with the associated predictors.
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Affiliation(s)
- Yanbiao Liu
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Yan Fan
- Department of Pediatrics, The First Hospital of China Medical University, Shenyang, China
- Department of Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China
- Research Unit of General Surgery, Department of Breast Surgery and Surgical Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Zining Jin
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Mengyao Cui
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Xinmiao Yu
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Feng Jin
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
| | - Xu Wang
- Department of Breast Surgery, The 1st Affiliated Hospital, China Medical University, Shenyang, China
- *Correspondence: Xu Wang,
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Tinterri C, Gentile D, Gatzemeier W, Sagona A, Barbieri E, Testori A, Errico V, Bottini A, Marrazzo E, Dani C, Dozin B, Boni L, Bruzzi P, Fernandes B, Franceschini D, Spoto R, Torrisi R, Scorsetti M, Santoro A, Canavese G. Preservation of Axillary Lymph Nodes Compared with Complete Dissection in T1-2 Breast Cancer Patients Presenting One or Two Metastatic Sentinel Lymph Nodes: The SINODAR-ONE Multicenter Randomized Clinical Trial. Ann Surg Oncol 2022; 29:5732-5744. [PMID: 35552930 DOI: 10.1245/s10434-022-11866-w] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/20/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The SINODAR-ONE trial is a prospective noninferiority multicenter randomized study aimed at assessing the role of axillary lymph node dissection (ALND) in patients undergoing either breast-conserving surgery or mastectomy for T1-2 breast cancer (BC) and presenting one or two macrometastatic sentinel lymph nodes (SLNs). The endpoints were to evaluate whether SLN biopsy (SLNB) only was associated with worsening of the prognosis compared with ALND in terms of overall survival (OS) and relapse. METHODS Patients were randomly assigned (1:1 ratio) to either removal of ≥ 10 axillary level I/II non-SLNs followed by adjuvant therapy (standard arm) or no further axillary treatment (experimental arm). RESULTS The trial started in April 2015 and ceased in April 2020, involving 889 patients. Median follow-up was 34.0 months. There were eight deaths (ALND, 4; SNLB only, 4), with 5-year cumulative mortality of 5.8% and 2.1% in the standard and experimental arm, respectively (p = 0.984). There were 26 recurrences (ALND 11; SNLB only, 15), with 5-year cumulative incidence of recurrence of 6.9% and 3.3% in the standard and experimental arm, respectively (p = 0.444). Only one axillary lymph node recurrence was observed in each arm. The 5-year OS rates were 98.9% and 98.8%, in the ALND and SNLB-only arm, respectively (p = 0.936). CONCLUSIONS The 3-year survival and relapse rates of T1-2 BC patients with one or two macrometastatic SLNs treated with SLNB only, and adjuvant therapy, were not inferior to those of patients treated with ALND. These results do not support the use of routine ALND.
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Affiliation(s)
- Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Damiano Gentile
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | | | - Andrea Sagona
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Erika Barbieri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alberto Testori
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Valentina Errico
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alberto Bottini
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Carla Dani
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Beatrice Dozin
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Luca Boni
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Paolo Bruzzi
- Department of Epidemiology, Biostatistics and Clinical Trials, IRCCS S. Martino, IST, Genoa, Italy
| | - Bethania Fernandes
- Department of Pathology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ruggero Spoto
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Rosalba Torrisi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giuseppe Canavese
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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5
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Moorman AM, Rutgers EJT, Kouwenhoven EA. Omitting SLNB in Breast Cancer: Is a Nomogram the Answer? Ann Surg Oncol 2021; 29:2210-2218. [PMID: 34739639 DOI: 10.1245/s10434-021-11007-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUNDS Sentinel lymph node biopsy (SLNB) is standard care as a staging procedure in patients with invasive breast cancer. The axillary recurrence rate, even after positive SLNB, is low. This raises serious doubts regarding the clinical value of SLNB in early breast cancer. The purpose of this study is to select patients with low suspected axillary burden in whom SLNB might be omitted. PATIENTS AND METHODS We retrospectively analyzed 2015 primary breast cancer patients between 2007 and 2015, with 982 patients allocated to the training and 961 to the validation cohort. Variables associated with nodal disease were analyzed and used to build a nomogram for predicting nodal disease. RESULTS A total of 32.8% of patients had macrometastatic disease. A predictive model was constructed based on age, cN0, morphology, grade, multifocality, and tumor size with an area under the receiver operating characteristic curve (AUC) of 0.83. Considering a false-negative rate of 5%, 32.8% of patients could be spared axillary surgery. In a subanalysis of patients with relatively favorable characteristics, 26.8% had less than 5% chance of macrometastases. CONCLUSIONS We present a model with excellent predictive value that can select one-third of patients in whom SLNB is deemed not necessary because of less than 5% chance of nodal involvement. Whether missing 1 in 20 patients with macrometastatic disease is worthwhile balanced against preventing side-effects of the SLN procedure remains to be established. A number of ongoing large prospective trials evaluating the outcome of omitting SLNB are awaited. Meanwhile, this nomogram may be used for individual decision-making.
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Affiliation(s)
- A M Moorman
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands.
| | - E J Th Rutgers
- Department of Surgery, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - E A Kouwenhoven
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands
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6
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Andersson Y, Bergkvist L, Frisell J, de Boniface J. Omitting completion axillary lymph node dissection after detection of sentinel node micrometastases in breast cancer: first results from the prospective SENOMIC trial. Br J Surg 2021; 108:1105-1111. [PMID: 34010418 DOI: 10.1093/bjs/znab141] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/03/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Completion axillary lymph node dissection has been abandoned widely among patients with breast cancer and sentinel lymph node micrometastases, based on evidence from prospective RCTs. Inclusion in these trials has been subject to selection bias, with patients undergoing mastectomy being under-represented. The aim of the SENOMIC (omission of axillary lymph node dissection in SENtinel NOde MICrometases) trial was to confirm the safety of omission of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastases, and including patients undergoing mastectomy. METHODS The prospective SENOMIC multicentre cohort trial enrolled patients with breast cancer and sentinel lymph node micrometastases who had breast-conserving surgery or mastectomy at one of 23 Swedish hospitals between October 2013 and March 2017. No completion axillary lymph node dissection was performed. The primary endpoint was event-free survival, with a trial accrual target of 452 patients. Survival proportions were based on Kaplan-Meier survival estimates. RESULTS The trial included 566 patients. Median follow-up was 38 (range 7-67) months. The 3-year event-free survival rate was 96.2 per cent, based on 26 reported breast cancer recurrences, including five isolated axillary recurrences. The unadjusted 3-year event-free survival rate was higher than anticipated, but differed between patients who had mastectomy and those who underwent breast-conserving surgery (93.8 versus 97.8 per cent respectively; P = 0.011). Patients who underwent mastectomy had significantly worse tumour characteristics. On univariable Cox proportional hazards regression analysis, patients who had mastectomy without adjuvant radiotherapy had a significantly higher risk of recurrence than those who underwent breast-conserving surgery (hazard ratio 2.91, 95 per cent c.i. 1.25 to 6.75). CONCLUSION After 3 years, event-free survival was excellent in patients with breast cancer and sentinel node micrometastases despite omission of axillary lymph node dissection. Long-term follow-up and continued enrolment of patients having mastectomy, especially those not receiving adjuvant radiotherapy, are of utmost importance.
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Affiliation(s)
- Y Andersson
- Department of Surgery, Västmanland County Hospital, Västerås, Sweden.,Centre for Clinical Research Uppsala University, Västmanland County Hospital, Västerås, Sweden
| | - L Bergkvist
- Department of Surgery, Västmanland County Hospital, Västerås, Sweden.,Centre for Clinical Research Uppsala University, Västmanland County Hospital, Västerås, Sweden
| | - J Frisell
- Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
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7
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8
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Kuru B. The Adventure of Axillary Treatment in Early Stage Breast Cancer. Eur J Breast Health 2020; 16:1-15. [PMID: 31912008 DOI: 10.5152/ejbh.2019.5157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 10/14/2019] [Indexed: 01/12/2023]
Abstract
Axillary lymph node dissection (ALND) which was an essential part of breast cancer treatment and the gold standard in evaluation of the status of axillary lymph node had notorious with increased arm morbidity and reduction of quality of life. Sentinel lymph node biopsy (SLNB) accurately stages the axilla in early breast cancer and ALND is omitted in SLNB negative patients. In patients with positive SLNB the omission of ALND with or without replacement of axillary radiotherapy has also been recommended by guidelines. The neoadjuvant chemotherapy (NAC) which has been increasingly used for large breast cancers to downstage the tumours for allowing breast conserving surgery and decreasing mastectomy rate has also been used in axillary node positive patients to reduce the need for ALND. The issues surrounding the treatment of axilla in patients treated with NAC; application and false negative rate of SLNB, number of identified sentinel lymph nodes, and axillary radiotherapy instead of ALND are currently the discussed and practiced hot topics. The quests for decreasing arm morbidity without compromising outcome in breast cancer treatment which have begun with the invention of SLNB continue for axilla conserving surgery. This article reviews the adventure of axillary treatment in breast cancer patients treated with or without NAC.
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Affiliation(s)
- Bekir Kuru
- Department of General Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
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9
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Serquiz N, Moro L, Menossi CA, Almeida NR, Baccarin G, de Paiva Silva GR, Shinzato JY, Derchain S, Jales RM. Perinodal fibrosis developed after ultrasonography-guided core-needle biopsy of a contrast-enhanced ultrasound-detected sentinel axillary node interferes with subsequent surgical sentinel node dissection. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:445-452. [PMID: 31359458 DOI: 10.1002/jcu.22765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 06/13/2019] [Accepted: 07/15/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate perinodal fibrosis after 14-gauge staging core-needle biopsy (CNB) of the axillary sentinel lymph node (SLN) identified using contrast-enhanced ultrasonography (CEUS) and its interference with subsequent surgical SLN dissection in breast cancer patients. METHODS Frequencies or means of main clinical, sonographic, pathological, and surgical characteristics were calculated. We also compared patient groups with and without perinodal pathological fibrosis. RESULTS Forty-eight patients who underwent CEUS + CNB and axillary surgery were eligible for this cross-sectional study. Axillary surgical specimens showed perinodal fibrosis in 9/48 (18.7%) patients. Interference with SLN dissection was reported in 4/48 (8.3%) patients (two hematomas, three abnormal palpation findings, and four difficult dissections). The overall surgical detection rate of SLN was 43/48 (89.6%). In the majority of cases, perinodal fibrosis was described as moderate (4/9 [44.4%]) or severe (4/9 [44.4%]). The mean time elapsed between CEUS + CNB and axillary dissection was shorter in patients with perinodal fibrosis (P = .04). Interference with SLN dissection was only reported in patients with perinodal fibrosis (P < .001). Surgical SLN detection was successful in all nine cases in which perinodal pathological fibrosis or interference with SLN dissection was reported. CONCLUSION Perinodal fibrosis may impair the surgical SLN dissection in early stage breast cancer patients who were staged using CEUS + CNB using a14-gauge needle.
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Affiliation(s)
- Nicoli Serquiz
- Faculty of Medical Sciences, Imaging Section, Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Luciano Moro
- Department of Radiology, Faculty of Medicine, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Carlos A Menossi
- Faculty of Medical Sciences, Imaging Section, Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Natalie R Almeida
- Faculty of Medical Sciences, Imaging Section, Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Gabrielle Baccarin
- Faculty of Medical Sciences, Imaging Section, Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Geisilene R de Paiva Silva
- Faculty of Medical Sciences, Imaging Section, Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Julia Y Shinzato
- Faculty of Medical Sciences, Imaging Section, Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Sophie Derchain
- Faculty of Medical Sciences, Imaging Section, Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Rodrigo M Jales
- Faculty of Medical Sciences, Imaging Section, Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
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10
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Andersson Y, Bergkvist L, Frisell J, de Boniface J. Do clinical trials truly mirror their target population? An external validity analysis of national register versus trial data from the Swedish prospective SENOMIC trial on sentinel node micrometastases in breast cancer. Breast Cancer Res Treat 2019; 177:469-475. [PMID: 31236811 PMCID: PMC6661061 DOI: 10.1007/s10549-019-05328-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 12/31/2022]
Abstract
Purpose Increasing evidence suggests that completion axillary lymph node dissection (ALND) may be omitted in breast cancer patients with limited axillary nodal metastases. However, the representativeness of trial participants for the original clinical practice population, and thus, the generalizability of published trials have been questioned. We propose the use of background data from national registers as a means to assess whether trial participants mirror their target population and to strengthen the generalizability and implementation of trial outcomes. Methods The Swedish prospective SENOMIC trial, omitting a completion ALND in breast cancer patients with sentinel lymph node micrometastases, reached full target accrual in 2017. To assess the generalizability of trial results for the target population, a comparative analysis of trial participants versus cases reported to the Swedish National Breast Cancer Register (NKBC) was performed. Results Comparing 548 trial participants and 1070 NKBC cases, there were no significant differences in age, tumor characteristics, breast surgery, or adjuvant treatment. Only the mean number of sentinel lymph nodes with micrometastasis per individual was lower in trial participants than in register cases (1.06 vs. 1.09, p = 0.037). Conclusions Patients included in the SENOMIC trial are acceptably representative of the Swedish breast cancer target population. There were some minor divergences between trial participants and the NKBC population, but taking these into consideration, upcoming trial outcomes should be generalizable to breast cancer patients with micrometastases in their sentinel lymph node biopsy.
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Affiliation(s)
- Y Andersson
- Department of Surgery, Västmanland County Hospital, SE- 72189, Västerås, Sweden. .,Center for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden.
| | - L Bergkvist
- Department of Surgery, Västmanland County Hospital, SE- 72189, Västerås, Sweden.,Center for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
| | - J Frisell
- Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
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11
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Ozkurt E, Yardımcı E, Tükenmez M, Ersoy YE, Yilmaz R, Cabioğlu N, Karanlık H, Kulle CB, Malya FU, Önder S, Gucin Z, İğci A, Özmen V, Dinççağ AS, Müslümanoğlu M. Intraoperative palpation of sentinel lymph nodes can accurately predict axilla in early breast cancer. Breast J 2019; 25:96-102. [DOI: 10.1111/tbj.13149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 04/09/2018] [Accepted: 04/19/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Enver Ozkurt
- Department of General Surgery, Breast Unit Istanbul University Istanbul Faculty of Medicine Topkapi, Istanbul Turkey
| | - Erkan Yardımcı
- Faculty of Medicine, Department of General Surgery Bezmialem Vakif University Topkapi, Istanbul Turkey
| | - Mustafa Tükenmez
- Department of General Surgery, Breast Unit Istanbul University Istanbul Faculty of Medicine Topkapi, Istanbul Turkey
| | - Yeliz Emine Ersoy
- Faculty of Medicine, Department of General Surgery Bezmialem Vakif University Topkapi, Istanbul Turkey
| | - Ravza Yilmaz
- Istanbul Faculty of Medicine, Department of Radiology Istanbul University Topkapi, Istanbul Turkey
| | - Neslihan Cabioğlu
- Department of General Surgery, Breast Unit Istanbul University Istanbul Faculty of Medicine Topkapi, Istanbul Turkey
| | - Hasan Karanlık
- Department of General Surgery Istanbul University Istanbul Institute of Oncology Topkapi, Istanbul Turkey
| | - Cemil Burak Kulle
- Department of General Surgery, Breast Unit Istanbul University Istanbul Faculty of Medicine Topkapi, Istanbul Turkey
| | - Fatma Umit Malya
- Faculty of Medicine, Department of General Surgery Bezmialem Vakif University Topkapi, Istanbul Turkey
| | - Semen Önder
- Istanbul Faculty of Medicine, Department of Pathology Istanbul University Topkapi, Istanbul Turkey
| | - Zuhal Gucin
- Faculty of Medicine, Department of Pathology Bezmialem Vakif University Topkapi, Istanbul Turkey
| | - Abdullah İğci
- Department of General Surgery, Breast Unit Istanbul University Istanbul Faculty of Medicine Topkapi, Istanbul Turkey
| | - Vahit Özmen
- Department of General Surgery, Breast Unit Istanbul University Istanbul Faculty of Medicine Topkapi, Istanbul Turkey
| | - Ahmet Sait Dinççağ
- Department of General Surgery, Breast Unit Istanbul University Istanbul Faculty of Medicine Topkapi, Istanbul Turkey
| | - Mahmut Müslümanoğlu
- Department of General Surgery, Breast Unit Istanbul University Istanbul Faculty of Medicine Topkapi, Istanbul Turkey
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12
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Kim GR, Choi JS, Han BK, Lee JE, Nam SJ, Ko EY, Ko ES, Lee SK. Preoperative Axillary US in Early-Stage Breast Cancer: Potential to Prevent Unnecessary Axillary Lymph Node Dissection. Radiology 2018; 288:55-63. [DOI: 10.1148/radiol.2018171987] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Ga Ram Kim
- From the Department of Radiology, Inha University School of Medicine, Incheon, Republic of Korea (G.R.K.); and Departments of Radiology (J.S.C., B.K.H., E.Y.K., E.S.K.) and Surgery (J.E.L., S.J.N., S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seou 137-710, Republic of Korea
| | - Ji Soo Choi
- From the Department of Radiology, Inha University School of Medicine, Incheon, Republic of Korea (G.R.K.); and Departments of Radiology (J.S.C., B.K.H., E.Y.K., E.S.K.) and Surgery (J.E.L., S.J.N., S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seou 137-710, Republic of Korea
| | - Boo-Kyung Han
- From the Department of Radiology, Inha University School of Medicine, Incheon, Republic of Korea (G.R.K.); and Departments of Radiology (J.S.C., B.K.H., E.Y.K., E.S.K.) and Surgery (J.E.L., S.J.N., S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seou 137-710, Republic of Korea
| | - Jeong Eon Lee
- From the Department of Radiology, Inha University School of Medicine, Incheon, Republic of Korea (G.R.K.); and Departments of Radiology (J.S.C., B.K.H., E.Y.K., E.S.K.) and Surgery (J.E.L., S.J.N., S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seou 137-710, Republic of Korea
| | - Seok Jin Nam
- From the Department of Radiology, Inha University School of Medicine, Incheon, Republic of Korea (G.R.K.); and Departments of Radiology (J.S.C., B.K.H., E.Y.K., E.S.K.) and Surgery (J.E.L., S.J.N., S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seou 137-710, Republic of Korea
| | - Eun Young Ko
- From the Department of Radiology, Inha University School of Medicine, Incheon, Republic of Korea (G.R.K.); and Departments of Radiology (J.S.C., B.K.H., E.Y.K., E.S.K.) and Surgery (J.E.L., S.J.N., S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seou 137-710, Republic of Korea
| | - Eun Sook Ko
- From the Department of Radiology, Inha University School of Medicine, Incheon, Republic of Korea (G.R.K.); and Departments of Radiology (J.S.C., B.K.H., E.Y.K., E.S.K.) and Surgery (J.E.L., S.J.N., S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seou 137-710, Republic of Korea
| | - Se Kyung Lee
- From the Department of Radiology, Inha University School of Medicine, Incheon, Republic of Korea (G.R.K.); and Departments of Radiology (J.S.C., B.K.H., E.Y.K., E.S.K.) and Surgery (J.E.L., S.J.N., S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seou 137-710, Republic of Korea
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Attene F, Paliogiannis P, Scognamillo F, Trignano E, Pala C, Trignano M. Axillary Lymph Node Dissection in Patients with Breast Cancer and Sentinel Lymph Node Micrometastasis or Isolated Tumor Cells: Is it Necessary? TUMORI JOURNAL 2018; 98:320-3. [DOI: 10.1177/030089161209800307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Sentinel lymph node biopsy is the standard method for axillary lymph node staging in patients with early stage breast cancer. The aim of the study was to evaluate the necessity of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastasis or isolated tumor cells. Methods Sentinel lymph node biopsy was performed in 136 patients for breast cancer staging: 16 of them (11.7%) were found to have micrometastasis or isolated tumor cells and underwent axillary lymph node dissection. Micrometastases were considered when tumor invasion was <2 mm and >0.2 mm in diameter and isolated tumor cells when detected alone or in clusters of <0.2 mm in diameter. The dissection of the three axillary lymph node levels of Berg was performed in all cases. Results Two patients (12.5%) presented isolated tumor cells and 14 (87.5%) micrometastasis in the sentinel lymph node. Among them, 25% presented nonsentinel axillary lymph node tumor invasion, whereas 75% had no further nodal involvement. Conclusions Results suggest that micrometastasis or isolated tumor cells of the sentinel lymph node represent the only site of cancer involvement of the axilla, especially in patients with early breast tumors, and that axillary lymph node dissection may be unnecessary in these cases and represent an overtreatment.
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Affiliation(s)
- Federico Attene
- Department of Surgical, Microsurgical and Medical
Sciences, University of Sassari, Sassari, Italy
| | - Panagiotis Paliogiannis
- Department of Surgical, Microsurgical and Medical
Sciences, University of Sassari, Sassari, Italy
| | - Fabrizio Scognamillo
- Department of Surgical, Microsurgical and Medical
Sciences, University of Sassari, Sassari, Italy
| | - Emilio Trignano
- Department of Surgical, Microsurgical and Medical
Sciences, University of Sassari, Sassari, Italy
| | - Carlo Pala
- Department of Surgical, Microsurgical and Medical
Sciences, University of Sassari, Sassari, Italy
| | - Mario Trignano
- Department of Surgical, Microsurgical and Medical
Sciences, University of Sassari, Sassari, Italy
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Sávolt Á, Péley G, Polgár C, Udvarhelyi N, Rubovszky G, Kovács E, Győrffy B, Kásler M, Mátrai Z. Eight-year follow up result of the OTOASOR trial: The Optimal Treatment Of the Axilla - Surgery Or Radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: A randomized, single centre, phase III, non-inferiority trial. Eur J Surg Oncol 2017; 43:672-679. [PMID: 28139362 DOI: 10.1016/j.ejso.2016.12.011] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/03/2016] [Accepted: 12/05/2016] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The National Institute of Oncology, Budapest conducted a single centre randomized clinical study. The OTOASOR (Optimal Treatment Of the Axilla - Surgery Or Radiotherapy) trial compares completion of axillary lymph node dissection (cALND) to regional nodal irradiation (RNI) in patients with sentinel lymph node metastasis (pN1sn) in stage I-II breast cancer. PATIENTS AND METHODS Patients with primary invasive breast cancer (cN0 and cT ≤ 3 cm) were randomized before surgery for cALND (standard treatment) or RNI (investigational treatment). Sentinel lymph nodes (SN) were investigated with serial sectioning at 0.5 mm levels by hematoxylin-eosin staining. Investigational treatment arm patients received 50 Gy RNI instead of cALND. Adjuvant treatment and follow up were performed according to the actual guidelines. Between August 2002 and June 2009, 1054 patients were randomized for cALND and 1052 patients for RNI. SN was evaluated in 2073 patients and was positive in 526 patients (25.4%). 474 cases were evaluable (244 in the cALND and 230 in the RNI arm), and in the cALND group 94 of 244 patients (38.5%) who underwent completion axillary surgery has additional positive nodes. The two arms were well balanced according to the majority of main prognostic factors. Primary endpoint was axillary recurrence and secondary endpoints were overall survival (OS) and disease-free survival (DFS). RESULTS Mean follow-up was 97 months (Q1-Q3: 80-120). Axillary recurrence was 2.0% in cALND arm vs. 1.7% in RNI arm (p = 1.00). OS at 8 years was 77.9% vs. 84.8% (p = 0.060), and DFS was 72.1% in cALND arm and 77.4% after RNI (p = 0.51). The results show that RNI is statistically not inferior to cALND treatment. CONCLUSIONS The long term follow-up results of this prospective-randomized trial suggest that RNI without cALND does not increase the risk of axillary failure in selected patients with early-stage invasive breast cancer (cT ≤ 3 cm, cN0) and pN1(sn). Axillary radiotherapy should be an alternative treatment for selected patients with sentinel lymph node metastases.
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Affiliation(s)
- Á Sávolt
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary.
| | - G Péley
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - C Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - N Udvarhelyi
- Department of Pathology, National Institute of Oncology, Budapest, Hungary
| | - G Rubovszky
- Department of Pathology, National Institute of Oncology, Budapest, Hungary
| | - E Kovács
- Department of Diagnostic Imaging, National Institute of Oncology, Budapest, Hungary
| | - B Győrffy
- MTA TTK Momentum Cancer Biomarker Res. Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - M Kásler
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Z Mátrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
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Abstract
Surgical and radiation therapy for DCIS and early stage 1 and 2 invasive breast cancer is detailed and described.
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Van Berckelaer C, Huizing M, Van Goethem M, Vervaecke A, Papadimitriou K, Verslegers I, Trinh BX, Van Dam P, Altintas S, Van den Wyngaert T, Huyghe I, Siozopoulou V, Tjalma WAA. Preoperative ultrasound staging of the axilla make's peroperative examination of the sentinel node redundant in breast cancer: saving tissue, time and money. Eur J Obstet Gynecol Reprod Biol 2016; 206:164-171. [PMID: 27697620 DOI: 10.1016/j.ejogrb.2016.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 08/31/2016] [Accepted: 09/10/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the role of preoperative axillary staging with ultrasound (US) and fine needle aspiration cytology (FNAC). Can we avoid intraoperative sentinel lymph node (SLN) examination, with an acceptable revision rate by preoperative staging? DESIGN This study is based on the retrospective data of 336 patients that underwent US evaluation of the axilla as part of their staging. A FNAC biopsy was performed when abnormal lymph nodes were visualized. Patients with normal appearing nodes on US or a benign diagnostic biopsy had removal of the SLNs without intraoperative pathological examination. We calculated the sensitivity, specificity and accuracy of US/FNAC in predicting the necessity of an axillary lymphadenectomy. Subsequently we looked at the total cost and the operating time of 3 models. Model A is our study protocol. Model B is a theoretical protocol based on the findings of the Z0011 trial with only clinical preoperative staging and in Model C preoperative staging and intraoperative pathological examination were both theoretically done. sentinel node, staging, ultrasound, preoperative axillary staging, FNAC, axilla RESULTS: The sensitivity, specificity and accuracy are respectively 0.75 (0.66-0.82), 1.00 (0.99-1.00) and 0.92 (0.88-0.94). Only 26 out of 317 (8.2%) patients that successfully underwent staging needed a revision. The total cost of Model A was 1.58% cheaper than Model C and resulted in a decrease in operation time by 9,46%. The benefits compared with Model B were much smaller. CONCLUSION Preoperative US/FNAC staging of the axillary lymph nodes can avoid intraoperative examination of the sentinel node with an acceptable revision rate. It saves tissue, reduces operating time and decreases healthcare costs in general.
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Affiliation(s)
- Christophe Van Berckelaer
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Manon Huizing
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Mireille Van Goethem
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Andrew Vervaecke
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Konstantinos Papadimitriou
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Inge Verslegers
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Bich X Trinh
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Peter Van Dam
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Sevilay Altintas
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Tim Van den Wyngaert
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Ivan Huyghe
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Vasiliki Siozopoulou
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Wiebren A A Tjalma
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium.
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Tinterri C, Canavese G, Bruzzi P, Dozin B. SINODAR ONE, an ongoing randomized clinical trial to assess the role of axillary surgery in breast cancer patients with one or two macrometastatic sentinel nodes. Breast 2016; 30:197-200. [PMID: 27406897 DOI: 10.1016/j.breast.2016.06.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/14/2016] [Accepted: 06/15/2016] [Indexed: 12/15/2022] Open
Abstract
Sentinel lymph node biopsy alone is the current surgical axillary treatment for early-stage breast cancer patients with a negative sentinel lymph node (SLN). The possibility to omit axillary dissection also in presence of positive SLNs has been promoted by the American College of Surgeons Oncology Group (ASOCOG) Z0011 randomized trial. Several limitations and evidences of potential selection bias made this trial fairly controversial. Stronger evidence than currently available is needed on the safety of foregoing axillary dissection in well-defined populations of patients with positive SLNs. The Italian multicentre SINODAR ONE randomized trial here presented was designed with this aim.
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Affiliation(s)
- Corrado Tinterri
- Breast Unit, Cancer Center, IRCCS Clinical Institute Humanitas, Rozzano, MI, Italy
| | - Giuseppe Canavese
- Breast Unit, Cancer Center, IRCCS Clinical Institute Humanitas, Rozzano, MI, Italy
| | - Paolo Bruzzi
- Clinical Epidemiology, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Beatrice Dozin
- Clinical Epidemiology, IRCCS AOU San Martino-IST, Genoa, Italy.
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Jorns JM, Kidwell KM. Sentinel Lymph Node Frozen-Section Utilization Declines After Publication of American College of Surgeons Oncology Group Z0011 Trial Results With No Change in Subsequent Surgery for Axillary Lymph Node Dissection. Am J Clin Pathol 2016; 146:57-66. [PMID: 27373347 DOI: 10.1093/ajcp/aqw078] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To evaluate use of sentinel lymph node (SLN) frozen section (FS) before and after publication of the Z0011 trial. METHODS We identified 116 pre-Z0011 and 134 post-Z0011 patients from 18 months before and after Z0011-initiated changes. Clinicopathologic features were assessed by chart review. RESULTS Post-Z0011 SLN FS use markedly declined when performed with breast-conserving therapy (BCT) (P < .0001), with SLN FS in 53 (73.6%) of 72 and 19 (25.0%) of 76 in pre- and post-Z0011 groups, respectively. There was post-Z0011 decline in axillary lymph node dissection (ALND) (P = .014) but no difference in later procedures for ALND. SLN positivity was associated with larger (≥1.6 cm) tumor size (P = .002). Nodal upstage was more frequent with invasive lobular (3/32; 9.4%) vs other invasive (2/188; 1.1%) subtypes. CONCLUSIONS Our findings support reduced need for SLN FS for BCT patients post-Z0011. However, those with specific clinicopathologic features may derive greater benefit from SLN FS.
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Predicting Non-sentinel Lymph Node Metastasis in a Chinese Breast Cancer Population with 1-2 Positive Sentinel Nodes: Development and Assessment of a New Predictive Nomogram. World J Surg 2016; 39:2919-27. [PMID: 26324157 DOI: 10.1007/s00268-015-3189-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND We have developed a new nomogram to predict the probability of a patient with 1-2 metastatic sentinel lymph nodes (SLNs) to present further axillary disease. METHODS Data were collected from 480 patients who were diagnosed with 1-2 positive lymph nodes and thus underwent axillary lymph node dissection between March 2005 and June 2011. Clinical and pathological features of the patients were assessed with multivariable logistic regression. The Shanghai Cancer Center Non-SLN nomogram (SCC-NSLN) was created from the logistic regression model. This new model was subsequently applied to 481 patients from July 2011 to December 2013. The predictive accuracy of the SCC-NSLN nomogram was measured by calculating the area under the receiver operating characteristic curve (AUC). RESULTS Based on the results of the univariate analysis, the variables that were significantly associated with the incidence of non-SLN metastasis in an SLN-positive patient included lymphovascular invasion, neural invasion, the number of positive SLNs, the number of negative SLNs, and the size of SLN metastasis (P < 0.05). Using multivariate analysis, lymphovascular invasion, the number of positive SLNs, the number of negative SLNs, and the size of SLN metastasis were identified as independent predictors of non-SLN metastasis. The SCC-NSLN nomogram was then developed using these four variables. The new model was accurate and discriminating on both the modeling and validation groups (AUC: 0.7788 vs 0.7953). The false-negative rates of the SCC-NSLN nomogram were 3.54 and 9.29 % for the predicted probability cut-off points of 10 and 15 % when applied to patients who have 1-2 positive SLNs. CONCLUSION The SCC-NSLN nomogram could serve as an acceptable clinical tool in clinical discussions with patients. The omission of ALND might be possible if the probability of non-SLN involvement is <10 and <15 % in accordance with the acceptable risk determined by medical staff and patients.
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Lee J, Kim SW, Son SH. Dosimetric evaluation of incidental irradiation to the axilla during whole breast radiotherapy for patients with left-sided early breast cancer in the IMRT era. Medicine (Baltimore) 2016; 95:e4036. [PMID: 27368030 PMCID: PMC4937944 DOI: 10.1097/md.0000000000004036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The purpose of this study was to compare the dosimetric parameters for incidental irradiation to the axilla during whole breast radiotherapy (WBRT) with 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT). Twenty left breast cancer patients treated with WBRT after breast-conserving surgery (BCS) were enrolled in this study. Remnant breast tissue, 3 levels of the axilla, heart, and lung were delineated. We used 2 different radiotherapy methods: 3D-CRT with field-in-field technique and 7-field fixed-beam IMRT. The target coverage of IMRT was significantly better than that of 3D-CRT (Dmean: 49.72 ± 0.64 Gy vs 50.24 ± 0.66 Gy, P < 0.001; V45: 93.19 ± 1.40% vs 98.59 ± 0.30%, P < 0.001; V47.5: 86.43 ± 2.72% vs 95.00 ± 0.02%, P < 0.001, for 3D-CRT and IMRT, respectively). In the IMRT plan, a lower dose was delivered to a wider region of the heart and lung. Significantly lower axillary irradiation was shown throughout each level of axilla by IMRT compared to 3D-CRT (Dmean for level I: 42.58 ± 5.31 Gy vs 14.49 ± 6.91 Gy, P < 0.001; Dmean for level II: 26.25 ± 10.43 Gy vs 3.41 ± 3.11 Gy, P < 0.001; Dmean for level III: 6.26 ± 4.69 Gy vs 1.16 ± 0.51 Gy, P < 0.001; Dmean for total axilla: 33.9 ± 6.89 Gy vs 9.96 ± 5.21 Gy, P < 0.001, for 3D-CRT and IMRT, respectively). In conclusion, the incidental dose delivered to the axilla was significantly lower for IMRT compared to 3D-CRT. Therefore, IMRT, which only includes the breast parenchyma, should be cautiously used in patients with limited positive sentinel lymph nodes and who do not undergo complete axillary lymph node dissection.
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Affiliation(s)
- Jayoung Lee
- Department of Radiation Oncology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Shin-Wook Kim
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Hyun Son
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Correspondence: Seok Hyun Son, Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56 Dongsu-ro, Bupyeong-gu, Incheon 21431, Republic of Korea (e-mail: )
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Franceschini G, Martin Sanchez A, Di Leone A, Magno S, Moschella F, Accetta C, Masetti R. New trends in breast cancer surgery: a therapeutic approach increasingly efficacy and respectful of the patient. G Chir 2016; 36:145-52. [PMID: 26712068 DOI: 10.11138/gchir/2015.36.4.145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The surgical management of breast cancer has undergone continuous and profound changes over the last 40 years. The evolution from aggressive and mutilating treatment to conservative approach has been long, but constant, despite the controversies that appeared every time a new procedure came to light. Today, the aesthetic satisfaction of breast cancer patients coupled with the oncological safety is the goal of the modern breast surgeon. Breast-conserving surgery with adjuvant radiotherapy is considered the gold standard approach for patients with early stage breast cancer and the recent introduction of "oncoplastic techniques" has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. New surgical procedures called "conservative mastectomies" are emerging as techniques that combine oncological safety and cosmesis by entirely removing the breast parenchyma sparing the breast skin and nipple-areola complex. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy and new therapeutic strategies are emerging in patients with a pathological positivity in sentinel lymph node biopsy. The present work will highlight the new surgical treatment options increasingly efficacy and respectful of breast cancer patients.
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Cyr AE, Tucker N, Ademuyiwa F, Margenthaler JA, Aft RL, Eberlein TJ, Appleton CM, Zoberi I, Thomas MA, Gao F, Gillanders WE. Successful Completion of the Pilot Phase of a Randomized Controlled Trial Comparing Sentinel Lymph Node Biopsy to No Further Axillary Staging in Patients with Clinical T1-T2 N0 Breast Cancer and Normal Axillary Ultrasound. J Am Coll Surg 2016; 223:399-407. [PMID: 27212005 DOI: 10.1016/j.jamcollsurg.2016.04.048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/21/2016] [Accepted: 04/21/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Axillary surgery is not considered therapeutic in patients with clinical T1-T2 N0 breast cancer. The importance of axillary staging is eroding in an era in which tumor biology, as defined by biomarker and gene expression profile, is increasingly important in medical decision making. We hypothesized that axillary ultrasound (AUS) is a noninvasive alternative to sentinel lymph node biopsy (SLNB), and AUS could replace SLNB without compromising patient care. STUDY DESIGN Patients with clinical T1-T2 N0 breast cancer and normal AUS were eligible for enrollment. Subjects were randomized to no further axillary staging (arm 1) vs SLNB (arm 2). Descriptive statistics were used to describe the results of the pilot phase of the randomized controlled trial. RESULTS Sixty-eight subjects were enrolled in the pilot phase of the trial (34 subjects in arm 1, no further staging; 32 subjects in arm 2, SLNB; and 2 subjects voluntarily withdrew from the trial). The median age was 61 years (range 40 to 80 years) in arm 1 and 59 years (range 31 to 81 years) in arm 2, and there were no significant clinical or pathologic differences between the arms. Median follow-up was 17 months (range 1 to 32 months). The negative predictive value (NPV) of AUS for identification of clinically significant axillary disease (>2.0 mm) was 96.9%. No axillary recurrences have been observed in either arm. CONCLUSIONS Successful completion of the pilot phase of the randomized controlled trial confirms the feasibility of the study design, and provides prospective evidence supporting the ability of AUS to exclude clinically significant disease in the axilla. The results provide strong support for a phase 2 randomized controlled trial.
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Affiliation(s)
- Amy E Cyr
- Department of Surgery, Washington University School of Medicine, St Louis, MO.
| | - Natalia Tucker
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Foluso Ademuyiwa
- Department of Medicine, Washington University School of Medicine, St Louis, MO
| | | | - Rebecca L Aft
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Timothy J Eberlein
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | | | - Imran Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Maria A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Feng Gao
- Department of Surgery, Washington University School of Medicine, St Louis, MO; Division of Biostatistics, Washington University School of Medicine, St Louis, MO
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Eghtedari M, Yang WT. Advances in Breast Ultrasound. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0140-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Liu M, Wang S, Cui S, Duan X, Fan Z, Yu Z. The feasibility of the ACOSOG Z0011 Criteria to Chinese Breast Cancer Patients: A Multicenter Study. Sci Rep 2015; 5:15241. [PMID: 26472518 PMCID: PMC4607940 DOI: 10.1038/srep15241] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 09/18/2015] [Indexed: 12/21/2022] Open
Abstract
The aim of this study was to determine the feasibility of the Z0011 criteria to Chinese breast cancer patients. An survey about the Z0011 trial was distributed and we collected 658 consecutive patients with axillary lymph node dissection (ALND) after positive sentinel lymph node (SLN) biopsy from five centers’ databases and grouped them as eligible or ineligible for omitting ALND according to the Z0011 criteria. The eligible group was compared with the cohort included in the Z0011 trial and with the ineligible group. Of the 427 respondants, 106 (24.8%) and 130 (30.4%)would not routinely perform ALND in patients meeting Z0011 criteria before and after learning of the trial results, respectively. Among the 658 patients, 151 (22.9%) were eligible and 507 were ineligible for omitting ALND. The clinicopathologic factors were not statistically different between the eligible group and the Z0011 cohort. Compared with the eligible Group, the ineligible group had significantly more T2 and T3 stage tumors, positive lymph nodes(LNs) and positive non-sentinel lymph nodes (NSLNs) (P < 0.01). The findings suggest good exportability of the Z0011 criteria to Chinese patients omitting ALND, but application of Z0011 as national treatment guideline still needs additional time and effort.
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Affiliation(s)
- Miao Liu
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Shu Wang
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Shude Cui
- Department of Breast Surgery, Cancer Center of Henan Province, China
| | - Xuening Duan
- Breast Disease's Center, The first Affiliated Hospital of Peking University, China
| | - Zhimin Fan
- Department of Breast Surgery, The First Affiliated Hospital of Jilin Univesity, China
| | - Zhigang Yu
- Department of Breast Surgery, The Second Affiliated Hospital of Shandong University, China
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Regional recurrence in the era of sentinel lymph node biopsy. Am J Surg 2015; 210:1155-60; discussion 1160-1. [PMID: 26601646 DOI: 10.1016/j.amjsurg.2015.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 09/01/2015] [Accepted: 09/02/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND The incidence of all-location regional recurrence after sentinel lymph node biopsy is not well documented. This study attempts to identify risk factors. METHODS A prospectively maintained database was queried to identify patients with a regional recurrence of breast cancer after a first operation for invasive unilateral breast cancer. Patients with regional recurrence were compared with those alive and disease free at 5 years. RESULTS Twenty-one of 1,060 patients (2%) experienced a regional recurrence. Most patients (95%) underwent sentinel lymph node biopsy as their axillary staging. Those with regional recurrences had larger tumors (P < .001), higher stage disease (P < .001), more estrogen receptor- and triple-negative breast cancers (P < .001), and more positive lymph nodes (P = .007). Mastectomy (P = .001) and receipt of neoadjuvant and/or chemotherapy (P < .001) were more common among those with regional recurrences. CONCLUSIONS Regional recurrence of breast cancer occurs infrequently. Risk factors include high-risk cancers, higher stage at presentation, nodal involvement, and need for therapies reflecting higher risk biology.
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Gallegos-Arreola MP, Figuera LE, Flores-Ramos LG, Puebla-Pérez AM, Zúñiga-González GM. Association of the Alu insertion polymorphism in the progesterone receptor gene with breast cancer in a Mexican population. Arch Med Sci 2015; 11:551-60. [PMID: 26170848 PMCID: PMC4495151 DOI: 10.5114/aoms.2015.52357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 10/12/2013] [Accepted: 11/17/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The progesterone receptor (PR) gene plays an important role in reproduction-related events. Data on polymorphisms in the PR gene have revealed associations with cancer, particularly for the Alu insertion polymorphism, which has been suggested to affect progesterone receptor function and contribute to tumor promotion in the mammary gland. MATERIAL AND METHODS We examined the role of the Alu insertion polymorphism in the PR gene by comparing the genotypes of 209 healthy Mexican women with those of 481 Mexican women with breast cancer (BC). RESULTS The genotype frequencies observed in the controls and BC patients were 0% and 4% for T2/T2 (Alu insertion), 16% and 21% for T1/T2, and 84% and 75% for T1/T1 (Alu deletion), respectively. The obtained odds ratio (OR) was 1.7, with a 95% confidence interval (95% CI) of 1.1-2.6, p = 0.009, for the T1/T2-T2/T2 genotypes. The association was also evident when the distributions of the T1/T2-T2/T2 genotypes in patients in the following categories were compared: obesity grade II (OR = 1.81, 95% CI: 1.03-3.18, p = 0.039) and the chemotherapy response (OR = 1.91, 95% CI: 1.27-3.067, p = 0.002). CONCLUSIONS The T1/T2-T2/T2 genotypes of the Alu insertion polymorphism in the PR gene are associated with BC susceptibility in the analyzed Mexican population.
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Affiliation(s)
- Martha Patricia Gallegos-Arreola
- Laboratorio de Genética Molecular, División de Medicina Molecular, Centro de Investigación Biomédica de Occidente (CIBO), Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Jalisco, México
| | - Luis E. Figuera
- División de Genética, CIBO, CMNO, IMSS, Guadalajara, Jalisco, México
- Doctorado en Genética Humana, CUCS-U de G, Guadalajara, Jalisco, México
| | - Liliana Gómez Flores-Ramos
- Laboratorio de Genética Molecular, División de Medicina Molecular, Centro de Investigación Biomédica de Occidente (CIBO), Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Jalisco, México
- Doctorado en Genética Humana, CUCS-U de G, Guadalajara, Jalisco, México
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Li CZ, Zhang P, Li RW, Wu CT, Zhang XP, Zhu HC. Axillary lymph node dissection versus sentinel lymph node biopsy alone for early breast cancer with sentinel node metastasis: A meta-analysis. Eur J Surg Oncol 2015; 41:958-66. [PMID: 26054706 DOI: 10.1016/j.ejso.2015.05.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/21/2015] [Accepted: 05/06/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In early breast cancer patients with sentinel node metastasis, the effect of axillary lymph node dissection (ALND) is controversial. The purpose of this study is to compare the safety and efficacy of sentinel lymph node biopsy (SLNB) alone versus ALND in patients with early breast cancer and sentinel node metastasis. METHODS We searched PubMed, Embase, Web of Science, and Cochrane Library databases from 1965 to February 2014. All data were analyzed using Review Manager Software 5.2. RESULTS 12 studies, which included 130,575 patients from five randomized controlled trials and seven observational studies, met our inclusion criteria. 26,870 early breast cancer patients underwent SLNB alone and 103,705 underwent ALND. Patients underwent ALND had more paresthesia (risk ratio [RR] 0.26, 95% confidence interval [CI] 0.20-0.33; p < 0.01) and lymphedema (RR 0.28, 95% CI 0.20-0.41; p < 0.01) than those had SLNB alone. There were no significant differences in overall survival (hazard ratio [HR] 0.95, 95% CI 0.85-1.06; p = 0.35), disease-free survival (HR 1.00, 95% CI 0.98-1.02, p = 0.96), and locoregional recurrence (RR 0.92, 95% CI 0.59-1.44; p = 0.73). CONCLUSION Current evidence indicates that axillary dissection may be omitted in early breast cancer patients with sentinel lymph metastasis.
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Affiliation(s)
- C Z Li
- Oncological Surgery, Affiliate Hospital of Hebei United University, Tangshan 063000, Hebei, China
| | - P Zhang
- Nursing and Rehabilitation College, Hebei United University, Tangshan 063000, Hebei, China
| | - R W Li
- Oncological Surgery, Affiliate Hospital of Hebei United University, Tangshan 063000, Hebei, China
| | - C T Wu
- Oncological Surgery, Affiliate Hospital of Hebei United University, Tangshan 063000, Hebei, China
| | - X P Zhang
- Oncological Surgery, Affiliate Hospital of Hebei United University, Tangshan 063000, Hebei, China
| | - H C Zhu
- Oncological Surgery, Affiliate Hospital of Hebei United University, Tangshan 063000, Hebei, China.
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Yao K, Liederbach E, Pesce C, Wang CH, Winchester DJ. Impact of the American College of Surgeons Oncology Group Z0011 Randomized Trial on the Number of Axillary Nodes Removed for Patients with Early-Stage Breast Cancer. J Am Coll Surg 2015; 221:71-81. [PMID: 25899731 DOI: 10.1016/j.jamcollsurg.2015.02.035] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/25/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Z0011 trial showed similar outcomes between sentinel node biopsy (SNB) alone and axillary node dissection (ALND) for early-stage breast cancer, but few studies have examined Z0011's impact on practice patterns. STUDY DESIGN Using the National Cancer Data Base, we examined use of SNB alone in patients who did and did not fulfill Z0011 eligibility criteria from 1998 to 2011. Because the National Cancer Data Base does not specifically identify SNB vs ALND, we categorized removal of ≤4 nodes as SNB only and ≥10 nodes as ALND. RESULTS Of 74,309 lumpectomy patients who fulfilled Z0011 criteria; 17,630 (23.7%) had a ≤4 nodes removed, 15,619 (21.0%) had 5 to 9 nodes removed, and 41,060 (55.3%) had ≥10 nodes removed. The proportion of lumpectomy patients receiving SNB increased from 6.1% in 1998 to 23.0% in 2009 to 56.0% in 2011 (p < 0.001). Independent predictors of ALND in lumpectomy patients were triple-negative tumors, younger than 50 years old, African-American race, size ≥3.0 cm, ≥2 positive nodes, invasive lobular carcinoma, grade III disease, and lymph node macrometastases. Patients outside of Z0011 criteria also underwent SNB alone: 54% of patients with tumors >5 cm, 52.5% who received no radiation therapy or accelerated partial breast irradiation, 35.9% with clinically positive nodes, 22.3% who underwent mastectomy, and 12.9% who had >3 tumor-positive nodes. CONCLUSIONS The use of SNB alone for patients fulfilling Z0011 criteria has increased substantially from 2009 to 2011. A considerable proportion of patients falling outside of Z0011 eligibility criteria were also treated with SNB alone.
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Affiliation(s)
- Katharine Yao
- Department of Surgery, Evanston Hospital, Evanston, IL; Department of Surgery, NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, Chicago, IL.
| | | | - Catherine Pesce
- Department of Surgery, Evanston Hospital, Evanston, IL; Department of Surgery, NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Chi-Hsiung Wang
- Center for Biomedical Research Informatics, Evanston Hospital, Evanston, IL
| | - David J Winchester
- Department of Surgery, Evanston Hospital, Evanston, IL; Department of Surgery, NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, Chicago, IL
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Gallegos-Arreola MP, Figuera-Villanueva LE, Ramos-Silva A, Salas-González E, Puebla-Pérez AM, Peralta-Leal V, García-Ortiz JE, Dávalos-Rodríguez IP, Zúñiga-González GM. The association between the 844ins68 polymorphism in the CBS gene and breast cancer. Arch Med Sci 2014; 10:1214-24. [PMID: 25624861 PMCID: PMC4296076 DOI: 10.5114/aoms.2014.47830] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 01/05/2013] [Accepted: 03/07/2013] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The cystathionine beta synthase (CBS) gene plays an important role in homocysteine metabolism because it catalyzes the first step of the transsulfuration pathway, during which homocysteine is converted to cystathionine. Polymorphisms of CBS have been associated with cancer. MATERIAL AND METHODS We examined the role of the 844ins68 polymorphism by comparing the genotypes of 371 healthy Mexican women with the genotypes of 323 Mexican women with breast cancer (BC). RESULTS The observed genotype frequencies for controls and BC patients were 1% and 2% for Ins/Ins, 13% and 26% for W/Ins, and 86% and 72% for W/W, respectively. We found that the odds ratio (OR) was 2.2, with a 95% confidence interval (95% CI) of 1.5-3.3, p = 0.0001. The association was also evident when comparing the distribution of the W/Ins-Ins/Ins genotypes in patients in the following categories: 1) menopause and high γ-glutamyltransferase (GGT) levels (OR of 2.17, 95% CI: 1.17-4.26, p = 0.02), 2) chemotherapy response and high lactate dehydrogenase (LDH) levels (OR 2.2, 95% CI: 1.08-4.4, p = 0.027), 3) chemotherapy response and high GGT levels (OR 2.46, 95% CI: 1.2-4.8, p = 0.007), and 4) body mass index (BMI) and III-IV tumor stage (OR 3.2, 95% CI: 1.2-8.3, p = 0.013). CONCLUSIONS We conclude that the genotypes W/Ins-Ins/Ins of the 844ins68 polymorphism in the CBS gene contribute significantly to BC susceptibility in the analyzed sample from the Mexican population.
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Affiliation(s)
- Martha Patricia Gallegos-Arreola
- Laboratorio de Genética Molecular, División de Medicina Molecular, Centro de Investigación Biomédica de Occidente (CIBO), Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Jalisco, México
| | | | - Adriana Ramos-Silva
- Laboratorio de Genética Molecular, División de Medicina Molecular, Centro de Investigación Biomédica de Occidente (CIBO), Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Jalisco, México
- Doctorado en Farmacología, CUCS, UdeG, Guadalajara, Jalisco, México
| | | | | | - Valeria Peralta-Leal
- Facultad de Medicina e Ingeniería en Sistemas Computacionales (FMeISC), Universidad Autónoma de Tamaulipas, Matamoros, Tamaulipas, México
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Atalay C. New concepts in axillary management of breast cancer. World J Clin Oncol 2014; 5:895-900. [PMID: 25493227 PMCID: PMC4259951 DOI: 10.5306/wjco.v5.i5.895] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 05/31/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023] Open
Abstract
In the last decades, surgical treatment of breast cancer has evolved from more extensive procedures like radical mastectomy to less invasive breast conserving surgery. Similarly, surgical management of axilla has enormously changed from routine axillary dissection to sentinel lymph node biopsy. Traditional surgical approach to the axilla in case of sentinel lymph node negativity is to avoid completion axillary dissection. However, surgeons even avoid performing axillary dissection in selected patients with positive sentinel lymph node in clinical practice depending on the recent randomized controlled studies supporting this concept. All of the recent changes in the management of positive axilla necessitate surgeons to refresh their knowledge on this challenging topic.
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Ngui NK, Elder EE, Jayasinghe UW, French J. Relevance of the American College of Surgeons Oncology Group Z0011 Trial to breast cancer in the Australian setting. ANZ J Surg 2014; 83:924-8. [PMID: 24289051 DOI: 10.1111/ans.12388] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Conventional wisdom suggests that a patient with a positive sentinel node requires a completion axillary clearance to obtain full staging and durable regional control. However, this dictum has been challenged by the recent American College of Surgeons Oncology Group Z0011 Trial demonstrating that women with node-positive breast cancer who underwent sentinel node biopsy only, and were treated with breast conserving surgery and radiation, had equivalent locoregional recurrence and survival rates to those who had a completion axillary clearance. The aim of our study was to determine what the clinical impact of the Z0011 findings might be if patients were managed according to the Z0011 criteria in an Australian teaching hospital setting. METHODS We performed a retrospective review, using prospectively collected data, of all female patients with breast cancer assessed at the Westmead Breast Cancer Institute in 2010 and identified the subgroup who would potentially have fulfilled all Z0011 criteria. The characteristics and management of this group were compared with node-positive and to mastectomy patient subgroups. RESULTS A total of 280 patients with invasive breast cancer were identified. Twenty-six patients satisfied all Z0011 criteria, representing 9.3% of all patients and 21.5% of node-positive patients. Twenty-two (84.6%) patients had a subsequent axillary clearance, with six (27.3%) having additional positive nodes. CONCLUSIONS The Z0011 study is relevant to 9.3% of all breast cancer patients and 21.5% of node-positive breast cancer patients treated in a major Australian teaching hospital.
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Affiliation(s)
- Nicholas K Ngui
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
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Rubio IT, Espinosa-Bravo M, Rodrigo M, Diaz MAV, Hardisson D, Sagasta A, Dueñas B, Peg V. Nomogram including the total tumoral load in the sentinel nodes assessed by one-step nucleic acid amplification as a new factor for predicting nonsentinel lymph node metastasis in breast cancer patients. Breast Cancer Res Treat 2014; 147:371-80. [DOI: 10.1007/s10549-014-3108-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 08/18/2014] [Indexed: 01/17/2023]
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Reynders A, Brouckaert O, Smeets A, Laenen A, Yoshihara E, Persyn F, Floris G, Leunen K, Amant F, Soens J, Van Ongeval C, Moerman P, Vergote I, Christiaens MR, Staelens G, Van Eygen K, Vanneste A, Van Dam P, Colpaert C, Neven P. Prediction of non-sentinel lymph node involvement in breast cancer patients with a positive sentinel lymph node. Breast 2014; 23:453-9. [DOI: 10.1016/j.breast.2014.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 01/26/2014] [Accepted: 03/16/2014] [Indexed: 10/25/2022] Open
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Rubio IT, Diaz-Botero S, Esgueva A, Espinosa-Bravo M. Positive sentinel lymph node: the evolution of axillary surgery and intraoperative assessment of sentinel lymph nodes. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Axillary lymph node dissection (ALND) has been the treatment for breast cancer in patients with sentinel lymph node (SLN) biopsy metastasis for prognostic information, local control and maybe for a small survival benefit. In recent years, clinicians have been questioning the need for axillary dissection in patients with positive SLN as the rate of axillary recurrences remains low when no ALND is performed in this group. Several variables incorporated in nomograms have been examined to predict axillary metastasis in patients with SLN metastasis and these nomograms have helped to determine which patients can spare the morbidity of the ALND. The combined multimodality in breast cancer treatments and the improvement in targeted therapies based in tumor biology have contributed to the low recurrence rates in early-stage breast cancer. As the multimodal treatment and the screening programs will improve, more patients with SLN metastasis will spare an ALND without compromising their oncologic outcome.
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Affiliation(s)
- Isabel T Rubio
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d`Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sebastian Diaz-Botero
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d`Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Esgueva
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d`Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Martín Espinosa-Bravo
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d`Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Offersen BV, Nielsen HM, Overgaard M, Overgaard J. Is regional nodes radiotherapy an alternative to surgery? Breast 2014; 22 Suppl 2:S118-28. [PMID: 24074772 DOI: 10.1016/j.breast.2013.07.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Sentinel node biopsy (SN) in breast cancer treatment was introduced in the mid-1990s in order to be able to stage patients before decision of definitive surgery. Since then, both the pathological examinations of the SN and the systemic adjuvant treatment have improved and cause new challenges in the correct decision making regarding whether or not to radically treat the axilla in case of a positive SN. In SN positive patients, current St. Gallen guidelines support no completion ALND (axillary lymph node dissection) in clinically node-negative patients with 1-2 macrometastatic sentinel nodes operated with breast conservation and receiving tangential field adjuvant radiotherapy (RT). ALND is being questioned due to increased morbidity compared with SN biopsy alone, and to limited long term benefit on disease free survival in selected patients. An alternative to ALND is treating the axilla with nodal RT although this treatment is mostly used as adjuvant treatment after ALND in high risk patients. Few studies have investigated the benefit of nodal RT compared to ALND, and no consensus has yet been reached. Clinical decision making regarding treating the axilla should be based on relevant data, and in this review studies aiming at deciding whether or not and how the axilla should be treated in SN positive patients will be discussed. Furthermore treatment choice will be discussed, since besides ALND, both breast irradiation and nodal irradiation might cure residual disease after SN. Also the issue of improved systemic adjuvant treatment will be discussed in relation to eventually no regional axillary treatment.
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Reimer T, Hartmann S, Stachs A, Gerber B. Local treatment of the axilla in early breast cancer: concepts from the national surgical adjuvant breast and bowel project B-04 to the planned intergroup sentinel mamma trial. Breast Care (Basel) 2014; 9:87-95. [PMID: 24944550 PMCID: PMC4038316 DOI: 10.1159/000360411] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Local treatment of the axilla in clinically node-negative, early-stage breast cancer patients has been hotly debated after the release of the American College of Surgeons Oncology Group (ACOSOG) Z0011 findings. However, this review does not focus on the 'Z0011-eligible' patients alone, because this subgroup represents a minority of our patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB). The following topics are discussed: axillary diagnostics, timing of axillary procedures in the neoadjuvant setting, long-term follow-up of SLNB trials, omission of axillary surgery in randomized trials, management of the involved axilla with low tumor volume, positive sentinel lymph nodes and BCS, involved sentinel lymph nodes and mastectomy, and axillary radiotherapy. Finally, the current innovative study concepts (i.e. Sentinel Node versus Observation after Axillary Ultrasound (SOUND) and Intergroup Sentinel Mamma (INSEMA)) including patients with axillary observation alone in clinically node-negative women are presented.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Germany
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Kobayashi R, Shiraishi K, Iwase S, Ohtomo K, Nakagawa K. Omission of axillary lymph node dissection for clinically node negative early-stage breast cancer patients. Breast Cancer 2014; 22:657-63. [PMID: 24756246 DOI: 10.1007/s12282-014-0532-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 04/07/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND For clinically node negative (N0) breast cancer patients, sentinel node (SN) biopsy (SNB) is a standard technique and complete axillary lymph node dissection (ALND) remains the standard treatment when the SN is positive. However, the American College of Surgeons Oncology Group Z0011 trial and the International Breast Cancer Study Group 23-01 trial showed that SNB without ALND can offer excellent regional control and equal survival compared with ALND for limited macrometastatic and micrometastatic SN involvement, respectively. We retrospectively evaluated axillary control rates in clinically N0 patients who had no axillary surgical treatment. METHODS Data on 158 patients who underwent breast-conserving therapy without any axillary surgical procedure between 1994 and 2010 were extracted. The last follow-up was on May 2013, and the overall median follow-up period was 119.0 months. RESULTS Of all 158 patients, 10 (6.3 %) and 3 (1.9 %) developed locoregional and axillary recurrences, respectively. The 10-year locoregional and axillary recurrence rates were 5.8 and 2.1 %, respectively. The 5- and 10-year overall survival rates were 94.0 and 84.8 %, respectively. Cases with axillary recurrence tended to have common risk factors for recurrence. CONCLUSION Even if SNB and ALND were omitted, local and regional recurrence rates were very low among clinically N0 patients and were at the same levels shown in recent trials. This suggests that at least ALND might be safely avoided in clinically N0 patients without any obvious risk factors regardless of axillary nodal status after SNB.
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Affiliation(s)
- Reiko Kobayashi
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kenshiro Shiraishi
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Satoru Iwase
- Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Kuni Ohtomo
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Moorman AM, Bourez RLJH, Heijmans HJ, Kouwenhoven EA. Axillary ultrasonography in breast cancer patients helps in identifying patients preoperatively with limited disease of the axilla. Ann Surg Oncol 2014; 21:2904-10. [PMID: 24715214 DOI: 10.1245/s10434-014-3674-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The sentinel lymph node biopsy (SLNB) procedure is the method of choice for the identification and monitoring of regional lymph node metastases in patients with breast cancer. In the case of a positive sentinel lymph node (SLN), additional lymph node dissection is still warranted for regional control, although 40-65 % have no additional axillary disease. Recent studies show that after breast-conserving surgery, SLNB, and adjuvant systemic therapy, there is no significant difference between recurrence-free period and overall survival if there are ≤2 positive axillary nodes. The purpose of this study was preoperative identification of patients with limited axillary disease (≤2 macrometastases) by using ultrasonography. METHODS Data from 1,103 consecutive primary breast cancer patients with tumors smaller than 50 mm, no palpable adenopathy, and a maximum of 2 SLNs with macrometastases were collected. The variable of interest was US of the axilla. RESULTS Of the 1,103 patients included, 1,060 remained after exclusion criteria. Of these, 102 (9.6 %) had more than 2 positive axillary nodes on ALND. Selected by unsuspected US, the chance of having >2 positive lymph nodes (LNs) is substantially lower (4.2 %). This is significant on univariate and multivariate analysis. After excluding the patients with extracapsular extension of the SLN, the chance of having >2 positive LNs is only 2.6 %. For pT1-2, this is 2.2 %. CONCLUSIONS The risk of more than 2 positive axillary nodes is relatively small in patients with cT1-2 breast cancer. US of the axilla helps in further identifying patients with a minimal risk of additional axillary disease, putting ALND up for discussion.
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Affiliation(s)
- A M Moorman
- Departments of Surgery, Hospital Group Twente, Almelo, The Netherlands,
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Mohamed OO, Neary PM, Fiuza-Castineira C, O'Donoghue GT. Questioning the role of axillary node dissection in sentinel node positive early stage breast cancer in the South Eastern Cancer Centre. Ir J Med Sci 2014; 184:189-94. [PMID: 24585071 DOI: 10.1007/s11845-014-1085-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 02/08/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Axillary node status is a predictor of breast cancer survival. Axillary node dissection (ALND) following positive sentinel node biopsy (SLNB) is challenged by the American College of Surgeons Z0011 trial, where clinically/radiologically node-negative, SLNB positive early stage patients failed to derive therapeutic benefit from ALND at 6 years. AIMS To quantify the rates of non-sentinel lymph node positivity after ALND in all breast cancer stages. To assess Z0011 trial result application to an Irish patient population. METHODS Retrospective review of a prospectively maintained database of clinically node-negative patients undergoing breast conserving surgery and ALND for a positive SLNB from January 2011 to January 2012. RESULTS Of 174 new breast cancers diagnosed, 144 underwent surgery of which 127 patients were clinically/radiologically node-negative; 46 patients were SLNB positive; 34 (73.9 %) proceeded to ALND. Of 9 T1 tumours, 3 (33.3 %) had further positive nodes on ALND. Of 24 T2 tumours, 11 (45.8 %) had further positive nodes on ALND. All 3 (100 %) T3/T4 tumours had further positive nodes on ALND. Mean numbers of sentinel and axillary nodes harvested were 2.3 and 15.2, respectively. In the SLNB positive, ALND negative group, 12 of 18 (66.7 %) patients were <60 years versus 14 of 17 (82.4 %) in the SLNB positive, ALND positive group. This may be indicative that younger women have a trend toward node positivity following ALND for a positive SLNB. CONCLUSION These data suggest that a significant proportion (41.9 %) of T1/T2 tumours undergoing ALND following positive SLNB have further positive nodes. It may be premature to exclude ALND in patients with T1/T2 tumours following a positive SLNB.
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Affiliation(s)
- O O Mohamed
- South Eastern Cancer Centre, Waterford Regional Hospital, Dunmore Road, Waterford, Ireland
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An independent assessment of the 7 nomograms for predicting the probability of additional axillary nodal metastases after positive sentinel lymph node biopsy in a cohort of British patients with breast cancer. Clin Breast Cancer 2014; 14:272-9. [PMID: 25037530 DOI: 10.1016/j.clbc.2014.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 02/21/2014] [Accepted: 02/24/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Axillary lymph node dissection (ALND) is currently the recommended procedure in patients with tumor-positive sentinel lymph node biopsy (SLNB). A significant proportion of patients with positive SLNs will not have any additional metastases in nonsentinel lymph nodes (NSLNs). Predictive nomograms could identify a subgroup of patients with low or high risk of further disease in whom completion ALND can be avoided or recommended. The aim of this study was to assess the accuracy of the currently available 7 nomograms in a cohort of British patients with breast cancer. PATIENTS AND METHODS A total of 138 patients with positive SLNs who underwent completion ALND were identified. Data were then used to calculate the probability of further metastases in NSLNs predicted by the 7 nomograms that are currently in use: the MSKCC (Memorial Sloan Kettering Cancer Center), Cambridge, Turkish, Stanford, MDACC (University of Texas MD Anderson Cancer Center), Tenon, and MOU (Masarykuv onkologický ústav, Masaryk Memorial Cancer Institute) models. The area under the receiver operating characteristic (ROC) curve (AUC) was calculated for each nomogram. RESULTS Of the 138 patients, 54 (41%) had additional metastases in NSLNs. AUC values for the MSKCC, Cambridge, Turkish, Stanford, MDACC, Tenon, and MOU models are 0.68, 0.68, 0.70, 0.69, 0.56, 0.63, and 0.74, respectively. CONCLUSION The MOU nomogram was more predictive than the other nomograms, with a better AUC value and false-negative rate. None of the models were able to achieve AUC value ≥ 0.80 in a cohort of British patients with breast cancer.
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Greenberg CC, Bafford AC, Golshan M. Is axillary dissection needed in node-positive breast cancer? Expert Rev Anticancer Ther 2014; 8:195-8. [DOI: 10.1586/14737140.8.2.195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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L’exploration et le traitement de la région axillaire des tumeurs infiltrantes du sein (RPC 2013). ONCOLOGIE 2013. [DOI: 10.1007/s10269-013-2337-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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43
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Schipper R, van Roozendaal L, de Vries B, Pijnappel R, Beets-Tan R, Lobbes M, Smidt M. Axillary ultrasound for preoperative nodal staging in breast cancer patients: Is it of added value? Breast 2013; 22:1108-13. [DOI: 10.1016/j.breast.2013.09.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 09/03/2013] [Accepted: 09/10/2013] [Indexed: 10/26/2022] Open
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Sávolt Á, Musonda P, Mátrai Z, Polgár C, Rényi-Vámos F, Rubovszky G, Kovács E, Sinkovics I, Udvarhelyi N, Török K, Kásler M, Péley G. Optimal treatment of the axilla after positive sentinel lymph node biopsy in early invasive breast cancer. Early results of the OTOASOR trial. Orv Hetil 2013; 154:1934-42. [DOI: 10.1556/oh.2013.29765] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction: Sentinel lymph node biopsy alone has become an acceptable alternative to elective axillary lymph node dissection in patients with clinically node-negative early-stage breast cancer. Approximately 70 percent of the patients undergoing breast surgery develop side effects caused by the axillary lymph node dissection (axillary pain, shoulder stiffness, lymphedema and paresthesias). Aim: The current standard treatment is to perform completion axillary lymph node dissection in patients with positive sentinel lymph node biopsy. However, randomized clinical trials of axillary dissection versus axillary irradiation failed to show survival differences between the two types of axillary treatment. The National Institute of Oncology, Budapest conducted a single centre randomized clinical study. The OTOASOR (Optimal Treatment of the Axilla – Surgery or Radiotherapy) trial compares completion axillary lymph node dissection to axillary nodal irradiation in patients with sentinel lymph node-positive primary invasive breast cancer. Method: Patients with primary invasive breast cancer (clinically lymph node negative and less than or equal to 3 cm in size) were randomized before surgery for completion axillary lymph node dissection (arm A–standard treatment) or axillary nodal irradiation (arm B–investigational treatment). Sentinel lymph node biopsy was performed by the radio-guided method. The use of blue-dye was optional. Sentinel lymph nodes were investigated with serial sectioning at 0.5 mm levels by haematoxylin and eosin staining. In the investigational treatment arm patients received 50Gy axillary nodal irradiation instead of completion axillary lymph node dissection. Adjuvant treatment was recommended and patients were followed up according to the actual institutional guidelines. Results: Between August 2002 and June 2009, 2106 patients were randomized for completion axillary lymph node dissection (1054 patients) or axillary nodal irradiation (1052 patients). The two arms were well balanced according to the majority of main prognostic factors. Sentinel lymph node was identified in 2073 patients (98.4%) and was positive in 526 patients (25.4%). Fifty-two sentinel lymph node-positive patients were excluded from the study (protocol violation, patient’s preference). Out of the remaining 474 patients, 244 underwent completion axillary lymph node dissection and 230 received axillary nodal irradiation according to randomization. The mean length of follow-up to the first event and the mean total length of follow-up were 41.9 and 43.3 months, respectively, and there were no significant differences between the two arms. There was no significant difference in axillary recurrence between the two arms (0.82% in arm A and 1.3% in arm B). There was also no significant difference in terms of overall survival between the arms at the early stage follow-up. Conclusions: The authors conclude that after a mean follow-up of more than 40 months axillary nodal irradiation may control the disease in the axilla as effectively as completion axillary lymph node dissection and there was also no difference in terms of overall survival. Orv. Hetil., 154(49), 1934–1942.
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Affiliation(s)
- Ákos Sávolt
- Országos Onkológiai Intézet Emlő- és Lágyrészsebészeti Osztály Budapest Ráth György u. 7–9. 1122
- Marosvásárhelyi Orvosi Egyetem PhD-Iskola Marosvásárhely
| | - Patrick Musonda
- University of East Anglia School of Medicine, Health Policy and Practice Norwich UK
| | - Zoltán Mátrai
- Országos Onkológiai Intézet Emlő- és Lágyrészsebészeti Osztály Budapest Ráth György u. 7–9. 1122
| | - Csaba Polgár
- Országos Onkológiai Intézet Sugárterápiás Központ Budapest
| | | | | | - Eszter Kovács
- Országos Onkológiai Intézet Radiológiai Diagnosztikai Osztály Budapest
| | | | - Nóra Udvarhelyi
- Országos Onkológiai Intézet Daganatpatológiai Központ Budapest
| | - Klára Török
- Országos Onkológiai Intézet Daganatsebészeti Központ Budapest
| | - Miklós Kásler
- Országos Onkológiai Intézet Daganatsebészeti Központ Budapest
| | - Gábor Péley
- Norfolk and Norwich University Hospital Department of General Surgery Norwich UK
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Houvenaeghel G, Classe JM, Barranger E. L’exploration et le traitement de la région axillaire des tumeurs infiltrantes du sein (RPC 2013). ONCOLOGIE 2013. [DOI: 10.1007/s10269-013-2338-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Validation of a breast cancer nomogram for predicting nonsentinel node metastases after minimal sentinel node involvement: Validation of the Helsinki breast nomogram. Breast 2013; 22:787-92. [DOI: 10.1016/j.breast.2013.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 12/28/2012] [Accepted: 02/06/2013] [Indexed: 11/21/2022] Open
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Leenders M, Richir M, Broeders M, Moormann G, Mollema R, Lopes Cardozo A, Meijer S, Schreurs H. Axillary staging by ultrasound-guided fine-needle aspiration cytology in breast cancer patients. Still up to date? Breast J 2013; 19:637-42. [PMID: 24011125 DOI: 10.1111/tbj.12176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To investigate whether clinicopathological features of breast cancer patients could predict the likelihood of lymph node metastases and the likelihood of false-negative results of ultrasound-guided fine-needle aspiration cytology of suspicious lymph nodes (US+FNAC). Between 2004 and 2009, US+FNAC was performed in 1,150 axillae (18 bilateral breast carcinomas). Based on final histologic diagnosis, the true- and false-negative group of US+FNAC were defined. Subsequently, 11 clinicopathological factors were compared between these two groups. These factors were also compared between patients with and patients without lymph node metastases. Of 1,150 axillae, 429 had lymph node metastases at final histology. US+FNAC indicated metastases in 107 axillae. 1,043 axillae were negative by US+FNAC. Final histology showed metastases in 323 of these 1,043 axillae, resulting in a false-negative group of US+FNAC of 31%. Both age <60 years and a cT2/cT3 breast carcinoma were significantly associated with lymph node metastases and with false-negative results of US+FNAC. Lymph node metastases were found in 59.6% of patients <60 years with a cT2/cT3 breast carcinoma. In these patients, 52.3% of the negative US+FNAC results were falsely negative. In patients <60 years with a cT2/cT3 breast carcinoma, we recommend to omit US+FNAC preoperatively and perform a SNB directly, because lymph node metastases were found in 59.6% of these patients and 52.3% of negative US+FNAC results were falsely negative.
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Affiliation(s)
- Martijn Leenders
- Department of Surgery, Medical Centre Alkmaar, Alkmaar, The Netherlands
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Kataria T, Bisht SS, Gupta D, Goyal S, Jassal K, Abhishek A, Sharma K, Pareek P, Kumar V, Jain S, Tayal M, Karthikeyan N. Incidental radiation to axilla in early breast cancer treated with intensity modulated tangents and comparison with conventional and 3D conformal tangents. Breast 2013; 22:1125-9. [PMID: 24012148 DOI: 10.1016/j.breast.2013.07.054] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 04/30/2013] [Accepted: 07/16/2013] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To analyze incidental radiation doses to minimally dissected axilla with Intensity modulated radiotherapy (IMRT), 3D conformal radiotherapy (3DCRT) and standard tangents (ST). METHODS & MATERIALS We prospectively evaluated incidental radiation to axilla in fifty cases of early breast cancer treated with breast conservation surgery with sentinel node biopsy alone followed by whole breast irradiation with IMRT. Three plans were devised for each CT dataset, comprising ST, 3DCRT and IMRT tangents. Doses to axillary nodal levels I, II and III were evaluated for mean dose, V95, V90, V80 and V50. Comparisons were made using ANOVA. RESULTS The mean doses delivered to axilla by the three techniques (IMRT, 3DCRT, ST) were: 78% (range 67-90, SD ± 5.2%), 80% (63-95, ±7.5%) and 87% (73-98, ±4.8%) for level I (IMRT vs ST; p = 0.037); 70% (46-89, ±12.4%), 72% (34-93, ±15.5%) and 65% (29-87, ±11.8%) for level II; and 51% (28-76, ±11.1%), 53% (19-86, ±13.7%) and 41% (6-72, ±10.6%) for level III, respectively. V90 values (volume receiving 90% of dose) for the three techniques were 49% (43-53, ±2.7%), 57% (51-65, ±3.1%) and 73% (65-80, ±3.4%) for level I (IMRT vs. ST; p = 0.029); 35% (26-42, ±4.7%), 41% (33-50, ±4.2%) and 25% (17-36, ±4.5%) for level II (IMRT vs ST; p = 0.068); and 15% (9-22, ±3.4%), 16% (10-24, ±3.7%) and 8 (5-12, ±3.1%) for level III (IMRT vs ST; p = 0.039), respectively. CONCLUSION Axillary levels I and II (lower axilla) receive substantial amount of incidental radiation doses with all the three techniques; however, conformal techniques (IMRT, 3DCRT) deliver significantly lesser incidental radiation to lower axilla than ST technique.
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Affiliation(s)
- Tejinder Kataria
- Radiation Oncology, Medanta - The Medicity, Gurgaon, Haryana, India.
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Sávolt A, Polgár C, Musonda P, Mátrai Z, Rényi-Vámos F, Tóth L, Kásler M, Péley G. Does the result of completion axillary lymph node dissection influence the recommendation for adjuvant treatment in sentinel lymph node-positive patients? Clin Breast Cancer 2013; 13:364-70. [PMID: 23773380 DOI: 10.1016/j.clbc.2013.04.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 04/24/2013] [Accepted: 04/29/2013] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The Hungarian National Institute of Oncology has just closed a single-center randomized clinical study. The Optimal Treatment of the Axilla-Surgery or Radiotherapy (OTOASOR) trial compares completion axillary lymph node dissection (cALND) with regional nodal irradiation (RNI) in patients with sentinel lymph node-positive (SLN+) primary invasive breast cancer. In the investigational treatment arm, patients received 50 Gy RNI instead of cALND. In these patients we had information only about the sentinel lymph node (SLN) status, but the further axillary nodal involvement remained unknown. The aim of this study was to investigate whether the result of cALND influenced the recommendation for adjuvant treatment in patients with SLN+ breast cancer. PATIENTS AND METHODS Patients with SLN+ primary breast cancer were randomized for cALND (arm A, standard treatment) or RNI (arm B, investigational treatment). Adjuvant systemic treatments were given according to the standard institutional protocol, and patients were followed according to the actual institutional guidelines. RESULTS Between August 2002 and June 2009, 474 SLN+ patients were randomized to cALND (arm A, standard treatment = 244 patients) or RNI (arm B, investigational treatment = 230 patients). The 2 arms were well balanced according to the majority of main prognostic factors. However, more patients were premenopausal (34% vs. 27%; P = .095) and had pT2-3 tumors (57% vs. 40%; P = .003) in the completion axillary lymph node dissection (ALND) arm. On the other hand, there were more patients with known human epidermal growth factor receptor type 2 positive tumor (12% vs. 17%, P = .066) in the RNI arm. In the ALND and RNI arms, 78% (190/244) and 69% (159/230), respectively, received chemotherapy (P = .020). Endocrine therapy was administered in 87% (213/244) of the patients in the ALND arm and 89% (204/230) of the patients in the RNI arm (P = .372). Six patients (2.5%) on arm A and 13 patients (5.7%) on arm B received adjuvant trastuzumab treatment (P = not significant). Subgroup analyses explored that more frequent administration of adjuvant chemotherapy in arm A was associated with the higher percentage of premenopausal patients and patients with larger (pT2-3) tumors. CONCLUSIONS The result of cALND after positive SLN biopsy seems to have no major impact on the administration of adjuvant systemic therapy.
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Affiliation(s)
- Akos Sávolt
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary.
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Can axillary reverse mapping avoid lymphedema in node positive breast cancer patients? Eur J Surg Oncol 2013; 39:880-6. [PMID: 23735162 DOI: 10.1016/j.ejso.2013.05.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Revised: 04/03/2013] [Accepted: 05/08/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Tracing lymphatic drainage of the ipsilateral arm of node positive breast cancer patients, termed "axillary reverse mapping" (ARM), has recently been described in several reports. We analyzed our experience with this new technique in patients scheduled for axillary lymph node dissection (ALND) and evaluated its usefulness for reducing the incidence of lymphedema. METHODS Blue dye was injected subcutaneously along the intermuscular groove of the upper inner arm; radioisotope was injected subcutaneously in the interdigital webspace of the hand. All blue and radioactive lymph vessels and lymph nodes were recorded. Only unsuspicious "ARM lymph nodes" located in the lateral part of the axillary basin were preserved. All other level I and II axillary lymph nodes were removed. Resected ARM nodes were immediately separated from all other lymph nodes. RESULTS ARM was performed in 143 patients subsequently undergoing ALND. ARM lymph nodes were successfully identified in 112 cases (78%). In 55 patients at least one ARM lymph node had to be removed. In 14 of these, tumor involvement was confirmed. In 71 patients one or more ARM nodes were preserved. During a median follow-up time of 19 months no axillary recurrence was noted. 35 of 114 evaluated patients developed lymphedema. Preservation of ARM lymph nodes did not significantly decrease the incidence of lymphedema. CONCLUSION ARM is feasible for patients with node positive breast cancer. However, we found no evidence that it reduces the incidence of lymphedema.
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