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Breast Cancer (Tokyo, Japan) Jan 2022The effectiveness of sentinel lymph node (SLN) mapping and biopsy following neoadjuvant chemotherapy (NAC) in axillary lymph node staging of breast cancer (BCa) patients... (Meta-Analysis)
Meta-Analysis
Sentinel lymph node mapping in breast cancer patients following neoadjuvant chemotherapy: systematic review and meta-analysis about head to head comparison of cN0 and cN + patients.
PURPOSE
The effectiveness of sentinel lymph node (SLN) mapping and biopsy following neoadjuvant chemotherapy (NAC) in axillary lymph node staging of breast cancer (BCa) patients with initial clinical node positive status (cN +) compared to clinical node negative status (cN0) is not yet known. The aim of this meta-analysis was to compare the accuracy of SLN mapping following NAC in cN + and cN0 BCa patients.
METHODS
PubMed and Scopus were comprehensively reviewed to retrieve all the studies that performed SLN mapping/biopsy and standard axillary lymph node dissection on cN0 and cN + BCa patients following NAC. Pooled detection and false negative rates for N0 and N + patients including 95% confidence interval values (95% CI) were evaluated. Odds ratio (OR) and risk difference (RD) of SLN detection failure and false negative results were compared between two groups.
RESULTS
A total of 27 articles were included for SLN detection rate evaluation and 17 for false negative assessment. The OR and RD of detection failure in N + group compared with N0 group following NAC were 2.22 (p = 0.00, 95% CI 1.4-3.4) and 4% (p = 0.00, 95% CI 2-6%), respectively. The OR and RD of false negative rate were 1.6 (p = 0.01, 95% CI 1-2.6) and 8% (p = 0.02, 95% CI 1-14%), respectively.
CONCLUSION
SLN mapping in BCa patients following NAC shows high risk of detection failure and high false negative rate of SLN biopsy in cN + patients. In comparison with cN0 BCa patients, SLN mapping and biopsy after NAC was associated with almost two times higher odds of detection failure and false negative results in cN + patients; therefore, this method should not be recommended in this group of patients.
Topics: Breast Neoplasms; Chemotherapy, Adjuvant; Female; Humans; Neoadjuvant Therapy; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 34341902
DOI: 10.1007/s12282-021-01280-7 -
PloS One 2016With the increased use of neoadjuvant chemotherapy (NAC) in breast cancer, the timing of sentinel lymph node biopsy (SLNB) has become increasingly important. In this... (Meta-Analysis)
Meta-Analysis Review
The Feasibility and Accuracy of Sentinel Lymph Node Biopsy in Initially Clinically Node-Negative Breast Cancer after Neoadjuvant Chemotherapy: A Systematic Review and Meta-Analysis.
BACKGROUND
With the increased use of neoadjuvant chemotherapy (NAC) in breast cancer, the timing of sentinel lymph node biopsy (SLNB) has become increasingly important. In this study, we aimed to evaluate the feasibility and accuracy of SLNB for initially clinically node-negative breast cancer after NAC by conducting a systematic review and meta-analysis.
METHODS
We searched PubMed, Embase, and the Cochrane Library from January 1, 1993 to November 30, 2015 for studies on initially clinically node-negative breast cancer patients who underwent SLNB after NAC followed by axillary lymph node dissection (ALND).
RESULTS
A total of 1,456 patients from 16 studies were included in this review. The pooled identification rate (IR) for SLNB was 96% [95% confidence interval (CI): 95%-97%], and the false negative rate (FNR) was 6% (95% CI: 3%-8%). The pooled sensitivity, negative predictive value (NPV) and accuracy rate (AR) were 94% (95% CI: 92%-97%, I2 = 27.5%), 98% (95% CI: 98%-99%, I2 = 42.7%) and 99% (95% CI: 99%-100%, I2 = 32.6%), respectively. In the subgroup analysis, no significant differences were found in either the IR of an SLNB when different mapping methods were used (P = 0.180) or in the FNR between studies with and without immunohistochemistry (IHC) staining (P = 0.241).
CONCLUSION
Based on current evidence, SLNB is technically feasible and accurate enough for axillary staging in initially clinically node-negative breast cancer patients after NAC.
Topics: Breast Neoplasms; False Negative Reactions; Feasibility Studies; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Neoadjuvant Therapy; Predictive Value of Tests; Publication Bias; Sentinel Lymph Node Biopsy
PubMed: 27606623
DOI: 10.1371/journal.pone.0162605 -
European Journal of Obstetrics,... May 2016Breast cancer is the most common malignancy in women worldwide. Fortunately, the overall survival is good. Therefore it is important to focus on the morbidities related... (Review)
Review
Breast cancer is the most common malignancy in women worldwide. Fortunately, the overall survival is good. Therefore it is important to focus on the morbidities related to breast cancer treatment. One of the most dreaded morbidities is lymphedema. In 2007 the Axillary Reverse Mapping (ARM) was introduced to limit the invasiveness in the axilla during breast cancer surgery. It is hypothesized that ARM is able to limit the incidence of breast cancer related lymphedema (BCRL) considerably. This systematic review aims to answer the following research questions: (1) which approaches for ARM are described? (2) Is ARM surgical feasible and oncological safe? (3) Does ARM decrease the incidence of lymphedema after sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND)? In total 27 papers were retrieved using four electronic databases (PubMed, Web of Science, Medline and Cochrane clinical trials; assessed until May 13, 2015. The level of evidence of these studies was low (mostly level 3). Therefore the conclusions are that the ARM procedure is feasible although ARM-node rates have a broad range. Additionally, from a theoretical point there is a clear benefit from ARM in terms of lymphedema prevention. From a practical point there is little scientific data to support this due to the lack of studies; and especially because of the different methods and definitions for lymphedema used in the different studies.
Topics: Axilla; Breast Cancer Lymphedema; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Lymphatic System; Postoperative Complications; Sentinel Lymph Node Biopsy
PubMed: 27019287
DOI: 10.1016/j.ejogrb.2016.03.014 -
The British Journal of Surgery Feb 2015Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early breast cancer. Currently, no consensus exists on the optimal site of injection of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early breast cancer. Currently, no consensus exists on the optimal site of injection of the radioactive tracer or blue dye.
METHODS
A systematic review and meta-analysis of studies comparing superficial and deep injections of radioactive tracer or blue dye for lymphatic mapping and SLNB was performed. The axillary and extra-axillary sentinel lymph node (SLN) identification rates obtained by lymphoscintigraphy and intraoperative SLNB were evaluated. Pooled odds ratios (ORs) and 95 per cent c.i. were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0·050).
RESULTS
Thirteen studies were included in the meta-analysis. There was no significant difference between superficial and deep injections of radioactive tracer for axillary SLN identification on lymphoscintigraphy (OR 1·59, 95 per cent c.i. 0·79 to 3·17), during surgery (OR 1·27, 0·60 to 2·68) and for SLN identification using blue dye (OR 1·40, 0·83 to 2·35). The rate of extra-axillary SLN identification was significantly greater when deep rather than superficial injection was used (OR 3·00, 1·92 to 4·67). The discordance rate between superficial and deep injections ranged from 4 to 73 per cent for axillary and from 0 to 61 per cent for internal mammary node mapping.
CONCLUSION
Both superficial and deep injections of radioactive tracer and blue dye are effective for axillary SLN identification. Clinical consequences of discordance rates between the two injection techniques are unclear. Deep injections are associated with significantly greater extra-axillary SLN identification; however, this may not have a significant impact on clinical management.
Topics: Breast Neoplasms; Cohort Studies; Coloring Agents; Female; Humans; Image-Guided Biopsy; Injections; Intraoperative Care; Lymph Nodes; Lymphatic Metastasis; Lymphoscintigraphy; Radioactive Tracers; Radioisotopes; Randomized Controlled Trials as Topic; Sentinel Lymph Node Biopsy; Treatment Outcome
PubMed: 25511661
DOI: 10.1002/bjs.9673 -
Annals of Surgical Oncology Aug 2020Several randomized controlled trials (RCTs) have investigated observation or axillary radiotherapy (ART) in place of completion axillary lymph node dissection (cALND)...
Comparing Observation, Axillary Radiotherapy, and Completion Axillary Lymph Node Dissection for Management of Axilla in Breast Cancer in Patients with Positive Sentinel Nodes: A Systematic Review.
PURPOSE
Several randomized controlled trials (RCTs) have investigated observation or axillary radiotherapy (ART) in place of completion axillary lymph node dissection (cALND) for management of positive sentinel nodes (SNs) in clinically node-negative women with breast cancer. The optimal treatment strategy for this population is not known.
METHODS
MEDLINE, Embase, and EBM Reviews-NHS Economic Evaluation Database were searched from inception until July 2019. A systematic review and narrative summary was performed of RCTs comparing observation or ART versus cALND in clinically node-negative female breast cancer patients with positive SNs. The Cochrane risk of bias tool for RCTs was used to assess risk of bias. Outcomes of interest included overall survival (OS), disease-free survival (DFS), axillary recurrence, and axillary surgery-related morbidity.
RESULTS
Three trials compared observation with cALND, and two trials compared ART with cALND. No studies blinded participants or personnel, and there was heterogeneity in inclusion criteria, study design, and follow-up. Neither observation nor ART resulted in statistically inferior 5- or 8-year OS or DFS compared with cALND. There was also no statistically significant increase in axillary recurrences associated with either approach. Four trials reported morbidity outcomes, and all showed cALND was associated with significantly more lymphedema, paresthesia, and shoulder dysfunction compared with observation or ART.
CONCLUSIONS
Women with clinically node-negative breast cancer and positive SNs can safely be managed without cALND.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Randomized Controlled Trials as Topic; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Watchful Waiting
PubMed: 32020394
DOI: 10.1245/s10434-020-08225-y -
Breast (Edinburgh, Scotland) Aug 2014Management of the ICBN during axillary dissection is controversial and the division of ICBN is often trivialised. The effect of dividing the ICBN, and its association... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Management of the ICBN during axillary dissection is controversial and the division of ICBN is often trivialised. The effect of dividing the ICBN, and its association with sensory disturbance, is unclear. A systematic review and meta-analysis was performed to evaluate the effect of preserving the ICBN during axillary dissection.
METHODS
A systematic literature review and meta-analysis is performed according to the PRISMA and Cochrane Collaboration guidelines.
RESULTS
Three RCTs and four non-RCTs were reviewed. A meta-analysis demonstrated that the incidence of sensory disturbance was significantly lower with preservation of ICBN compared to division of the ICBN with Mantel-Haenzel combined odds ratio 0.31 (0.17-0.57, 95% CI). There was relatively low level of heterogeneity (I(2) = 19%, χ(2) = 2.48, df = 2). The sensory disturbance was more likely to be hyposensitivity when compared to hypersensitivity (p < 0.0001). No difference on number of lymph nodes dissected or operating time was noted.
CONCLUSION
This meta-analysis demonstrates that division of the ICBN is associated with higher risk of sensory disturbance, and that the nature of this sensory disturbance is more likely to be hyposensitivity, attributable to reduced nerve function.
Topics: Axilla; Breast Neoplasms; Female; Humans; Hyperesthesia; Hypesthesia; Intercostal Nerves; Lymph Node Excision; Neuralgia; Organ Sparing Treatments; Randomized Controlled Trials as Topic
PubMed: 24582033
DOI: 10.1016/j.breast.2014.01.014 -
Breast Cancer Research and Treatment Apr 2021Marking of cytology-proven metastatic axillary lymph node in breast cancer patients before neoadjuvant treatment and its subsequent surgical retrieval have been shown to... (Review)
Review
BACKGROUND
Marking of cytology-proven metastatic axillary lymph node in breast cancer patients before neoadjuvant treatment and its subsequent surgical retrieval have been shown to reduce the false-negative rate of sentinel lymph node biopsy. A systematic review was performed to evaluate different strategies in nodal marking and localization.
METHODS
PubMed, Embase, EBSCOhost, and the Cochrane library literature databases were searched systematically to address the identification rate and retrieval rate of marked axillary lymph nodes. Studies were eligible if they performed nodal marking before neoadjuvant treatment, followed by selective extirpation of these marked axillary lymph nodes in definitive surgery RESULTS: Fifteen studies with a total of 703 patients were included. Index axillary lymph nodes were marked by clips or tattooed prior to the commencement of neoadjuvant treatment. In our pooled analysis, eighty-eight percent of the clipped nodes and ninety-seven percent of the tattooed nodes were successfully retrieved. Among these patients, seventy-seven percent of these marked axillary lymph nodes were also sentinel lymph nodes.
CONCLUSION
Marking and selectively removing cytology-proven metastatic axillary lymph nodes after neoadjuvant treatment is feasible. An acceptably high nodal retrieval rate could be achieved using various methods of nodal marking and localization techniques.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Neoadjuvant Therapy; Neoplasm Staging; Sentinel Lymph Node Biopsy
PubMed: 33611665
DOI: 10.1007/s10549-021-06118-6 -
Health Technology Assessment... Jan 2015In breast cancer patients, sentinel lymph node biopsy is carried out at the same time as the removal of the primary tumour to postoperatively test with histopathology... (Review)
Review
A systematic review and economic evaluation of intraoperative tests [RD-100i one-step nucleic acid amplification (OSNA) system and Metasin test] for detecting sentinel lymph node metastases in breast cancer.
BACKGROUND
In breast cancer patients, sentinel lymph node biopsy is carried out at the same time as the removal of the primary tumour to postoperatively test with histopathology for regional metastases in the sentinel lymph node. Those patients with positive test results are then operated on 2-4 weeks after primary surgery to remove the lymph nodes from the axilla (axillary lymph node dissection, ALND). New molecular tests RD-100i [one-step nucleic acid amplification (OSNA); based on messenger RNA amplification to identify the cytokeratin-19 (CK19) gene marker] (Sysmex, Norderstedt, Germany) and Metasin (using the CK19 and mammaglobin gene markers) (Cellular Pathology, Princess Alexandra Hospital NHS Trust, Harlow, UK) are intended to provide an intraoperative diagnosis, thereby avoiding the need for postoperative histopathology and, in positive cases, a second operation for ALND.
OBJECTIVE
To evaluate the clinical effectiveness and cost-effectiveness of using OSNA and Metasin in the NHS in England for the intraoperative diagnosis of sentinel lymph nodes metastases, compared with postoperative histopathology, the current standard.
DATA SOURCES
Electronic databases including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library and the Health Economic Evaluations Database as well as clinical trial registries, grey literature and conference proceedings were searched up to July 2012.
REVIEW METHODS
A systematic review of the evidence was carried out using standard methods. Single-gate studies were used to estimate the accuracy of OSNA with histopathology as the reference standard. The cost-effectiveness analysis adapted an existing simulation model of the long-term costs and health implications of early breast cancer diagnostic outcomes. The model accounted for the costs of an extended first operation with intraoperative testing, the loss of health-related quality of life (disutility) from waiting for postoperative test results, disutility and costs of a second operation, and long-term costs and disutility from lymphoedema related to ALND, adjuvant therapy, locoregional recurrence and metastatic recurrence.
RESULTS
A total of 724 references were identified in the searches, of which 17 studies assessing test accuracy were included in the review, 15 on OSNA and two on Metasin. Both Metasin studies were unpublished. OSNA sensitivity of 84.5% [95% confidence interval (CI) 74.7% to 91.0%] and specificity of 91.8% (95% CI 87.8% to 94.6%) for patient nodal status were estimated in a meta-analysis of five studies [unadjusted for tissue allocation bias (TAB)]. At these values and a 20% node-positive rate, OSNA resulted in lifetime discounted cost-savings of £498 and a quality-adjusted life-year (QALY) loss of 0.048 relative to histopathology, that is, £4324 saved per QALY lost. The most favourable plausible scenario for OSNA in terms of the node-positive rate (range 10-40%), diagnostic accuracy values (91.3% sensitivity and 94.2% specificity, from three reports that adjusted for TAB), the costs of histopathology, OSNA and second surgery, and long-term costs and utilities resulted in a maximum saving per QALY lost of £10,500; OSNA sensitivity and specificity would need to be ≥ 95% for this figure to be ≥ £20,000.
LIMITATIONS
There is limited evidence on the diagnostic test accuracy of intraoperative tests. The quality of information on costs of resource utilisation during the diagnostic pathway is low and no evidence exists on the disutility of waiting for a second surgery. No comparative studies exist that report clinical outcomes of intraoperative diagnostic tests. These knowledge gaps have more influence on the decision than current uncertainty in the performance of postoperative histopathology in standard practice.
CONCLUSIONS
One-step nucleic acid amplification is not cost-effective for the intraoperative diagnosis of sentinel lymph node metastases. OSNA is less accurate than histopathology and the consequent loss of health benefits in this patient group is not compensated for by health gains elsewhere in the health system that may be obtained with the cost-savings made. The evidence on Metasin is insufficient to evaluate its cost-effectiveness.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42012002889.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Axilla; Breast Neoplasms; Cost-Benefit Analysis; England; Humans; Intraoperative Period; Lymph Nodes; Lymphatic Metastasis; Nucleic Acid Amplification Techniques; Quality of Life; Quality-Adjusted Life Years; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; State Medicine
PubMed: 25586547
DOI: 10.3310/hta19020 -
Annals of Surgical Oncology Mar 2024Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND.
METHODS
A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method.
RESULTS
A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen.
CONCLUSIONS
To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.
Topics: Humans; Female; Seroma; Lymph Node Excision; Mastectomy, Segmental; Drainage; Disease Progression; Axilla; Surgeons; Breast Neoplasms
PubMed: 38038792
DOI: 10.1245/s10434-023-14631-9 -
PloS One 2016The axillary reverse mapping (ARM) technique has recently been developed to prevent lymphedema by preserving the arm lymphatic drainage during sentinel lymph node biopsy... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The axillary reverse mapping (ARM) technique has recently been developed to prevent lymphedema by preserving the arm lymphatic drainage during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) procedures. The objective of this systematic review and meta-analysis was to evaluate the feasibility and oncological safety of ARM.
METHODS
We searched Medline, Embase, Web of science, Scopus, and the Cochrane Library for relevant prospective studies. The identification rate of ARM nodes, the crossover rate of SLN-ARM nodes, the proportion of metastatic ARM nodes, and the incidence of complications were pooled into meta-analyses by the random-effects model.
RESULTS
A total of 24 prospective studies were included into meta-analyses, of which 11 studies reported ARM during SLNB, and 18 studies reported ARM during SLNB. The overall identification rate of ARM nodes was 38.2% (95% CI 32.9%-43.8%) during SLNB and 82.8% (78.0%-86.6%) during ALND, respectively. The crossover rate of SLN-ARM nodes was 19.6% (95% CI 14.4%-26.1%). The metastatic rate of ARM nodes was 16.9% (95% CI 14.2%-20.1%). The pooled incidence of lymphedema was 4.1% (95% CI 2.9-5.9%) for patients undergoing ARM procedure.
CONCLUSIONS
The ARM procedure was feasible during ALND. Nevertheless, it was restricted by low identification rate of ARM nodes during SLNB. ARM was beneficial for preventing lymphedema. However, this technique should be performed with caution given the possibility of crossover SLN-ARM nodes and metastatic ARM nodes. ARM appeared to be unsuitable for patients with clinically positive breast cancer due to oncological safety concern.
Topics: Arm; Axilla; Breast Neoplasms; Coloring Agents; Feasibility Studies; Female; Humans; Injections, Intradermal; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Lymphatic System; Lymphatic Vessels; Lymphedema; Preoperative Care; Prospective Studies; Sentinel Lymph Node Biopsy
PubMed: 26919589
DOI: 10.1371/journal.pone.0150285