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Archives of Gynecology and Obstetrics Feb 2020Data on the optimal treatment strategy for patients undergoing neoadjuvant therapy (NAT) who initially presented with metastatic nodes and convert to node-negative...
Axillary ultrasound for prediction of response to neoadjuvant therapy in the context of surgical strategies to axillary dissection in primary breast cancer: a systematic review of the current literature.
PURPOSE
Data on the optimal treatment strategy for patients undergoing neoadjuvant therapy (NAT) who initially presented with metastatic nodes and convert to node-negative disease (cN+ → ycN0) are limited. Since NAT leads to axillary downstaging in 20-60% of patients, the question arises whether these patients might be offered less-invasive procedures than axillary dissection, such as sentinel node biopsy or targeted removal of lymph nodes marked before therapy.
METHODS
We performed a systematic review of clinical studies on the use of axillary ultrasound for prediction of response to NAT and ultrasound-guided marking of metastatic nodes for targeted axillary dissection.
RESULTS
The sensitivity of ultrasound for prediction of residual node metastasis was higher than that of clinical examination and MRI/PET in most studies; specificity ranged in large trials from 37 to 92%. The diagnostic performance of ultrasound after NAT seems to be associated with tumor subtype: the positive predictive value was highest in luminal, the negative in triple-negative tumors. Several trials evaluated the usefulness of ultrasound for targeted axillary dissection. Before NAT, nodes were most commonly marked using ultrasound-guided clip placement, followed by ultrasound-guided placement of a radioactive seed. After chemotherapy, the clip was detected on ultrasound in 72-83% of patients; a comparison of sonographic visibility of different clips is lacking. Detection rate after radioactive seed placement was ca. 97%.
CONCLUSION
In conclusion, ultrasound improves prediction of axillary response to treatment in comparison to physical examination and serves as a reliable guiding tool for marking of target lymph nodes before the start of treatment. High quality and standardization of the examination is crucial for selection of patients for less-invasive surgery.
Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Ultrasonography
PubMed: 31897672
DOI: 10.1007/s00404-019-05428-x -
Current Oncology (Toronto, Ont.) Mar 2023Landmark trials (Z0011 and AMAROS) have demonstrated that axillary lymph node dissection (ALND) can be safely omitted in patients with breast cancer and 1-2 positive... (Review)
Review
Landmark trials (Z0011 and AMAROS) have demonstrated that axillary lymph node dissection (ALND) can be safely omitted in patients with breast cancer and 1-2 positive sentinel nodes. Extrapolating from these and other cardinal studies such as NSABP B-04, guidelines state that patients with 1-2 needle biopsy-proven positive lymph nodes undergoing upfront surgery can have sentinel lymph node biopsy (SLNB) alone. The purpose of this study is to systematically review the literature to identify studies examining the direct application of SLNB in such patients. EMBASE and Ovid MEDLINE were searched from inception to 3 May 2022. Studies including patients with nodal involvement confirmed on pre-operative biopsy and undergoing SLNB were identified. Studies with neoadjuvant chemotherapy were excluded. Search resulted in 2518 records, of which 68 full-text studies were reviewed, ultimately yielding only 2 studies meeting inclusion criteria. Both studies used targeted axillary surgery (TAS) with pre-operative localization of the biopsy-proven positive node in addition to standard SLNB techniques. In a non-randomized single-center prospective study, Lee et al. report no regional recurrences in patients undergoing TAS or ALND, and no difference in distant recurrence or mortality at 5 years. In the prospective multicenter TAXIS trial by Webber et al., the median number of positive nodes retrieved with TAS in patients undergoing upfront surgery was 2 (1, 4 IQR). Within the subset of patients who underwent subsequent ALND, 61 (70.9%) had additional positive nodes, with 26 (30.2%) patients having ≥4 additional positive nodes. Our review demonstrates that there is limited direct evidence for SLNB alone in clinically node-positive patients undergoing upfront surgery. Available data suggest a high proportion of patients with residual disease in this setting. While the totality of the data, mostly indirect evidence, suggests SLNB alone may be safe, we call on clinicians and researchers to prospectively collect data on this patient population to better inform decision-making.
Topics: Humans; Female; Sentinel Lymph Node Biopsy; Breast Neoplasms; Prospective Studies; Lymph Node Excision; Axilla; Multicenter Studies as Topic
PubMed: 36975448
DOI: 10.3390/curroncol30030235 -
Breast (Edinburgh, Scotland) Oct 2020The axillary reverse mapping (ARM) technique, identify and preserve arm nodes during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), was... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The axillary reverse mapping (ARM) technique, identify and preserve arm nodes during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), was developed to prevent breast-cancer related lymphedema (BCRL) remains controversial.
METHODS
A comprehensive search of Medline Ovid, Pubmed, Web of Science and the Cochrane CENTRAL databases was conducted from the inception till January 2020. The key word including "breast cancer", "axillary reverse mapping", and "lymphedema". Stata 15.1 software was used for the meta-analysis.
RESULTS
As a result, twenty-nine related studies involving 4954 patients met our inclusion criteria. The pooled overall estimate lymphedema incidence was 7% (95% CI 4%-11%, I = 90.35%, P < 0.05), with SLNB showed a relatively lower pooled incidence of lymphedema (2%, 95% CI 1%-3%), I = 26.06%, P = 0.23) than that of ALND (14%, 95% CI 5%-26%, I = 93.28%, P < 0.05) or SLNB and ALND combined (11%, 95% CI 1%-30%). The ARM preservation during ALND procedure could significantly reduce upper extremity lymphedema in contrast with ARM resection (OR = 0.27, 95% CI 0.20-0.36, I = 31%, P = 0.161). Intriguingly, the result favored ALND-ARM over standard-ALND in preventing lymphedema occurrence (OR = 0.21, 95% CI 0.14-0.31, I = 43%, P = 0.153). The risk of metastases in the ARM-nodes was not significantly lower in the patients who had received neoadjuvant chemotherapy, as compared to those without neoadjuvant treatment (OR = 1.20, 95% CI 0.74-1.94, I = 49.4%, P = 0.095).
CONCLUSIONS
ARM was found to significantly reduce the incidence of BCRL. The selection of patients for this procedure should be based on their axillary nodal status. Preoperative neoadjuvant chemotherapy has no significant impact on the ARM lymph node metastasis rate.
Topics: Adult; Aged; Axilla; Breast Cancer Lymphedema; Breast Neoplasms; Female; Humans; Incidence; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Postoperative Complications; Risk Assessment; Sentinel Lymph Node Biopsy
PubMed: 32858404
DOI: 10.1016/j.breast.2020.08.007 -
Clinical & Translational Oncology :... Feb 2023To conduct a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) in women with node-positive breast cancer at diagnosis and... (Review)
Review
PURPOSE
To conduct a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) in women with node-positive breast cancer at diagnosis and node-negative tumour after neoadjuvant therapy, compared to axillary lymph-node dissection.
METHODS
The more relevant databases were searched. Main outcomes were false-negative rate (FNR), sentinel lymph-node identification rate (SLNIR), negative predictive value (NPV), and accuracy. We conducted meta-analyses when appropriate.
RESULTS
Twenty studies were included. The pooled FNR was 0.14 (95% CI 0.11-0.17), the pooled SLNIR was 0.89 (95% CI 0.86-0.92), NPV was 0.83 (95% CI 0.79-0.87), and summary accuracy was 0.92 (95% CI 0.90-0.94). SLNB performed better when more than one node was removed and double mapping was used.
CONCLUSIONS
SLNB can be performed in women with a node-negative tumour after neoadjuvant therapy. It has a better performance when used with previous marking of the affected node and with double tracer.
Topics: Female; Humans; Breast Neoplasms; Lymph Nodes; Neoadjuvant Therapy; Axilla; Sentinel Lymph Node Biopsy; Lymph Node Excision
PubMed: 36153763
DOI: 10.1007/s12094-022-02953-1 -
Archives of Gynecology and Obstetrics Oct 2022Management of regional lymph nodes in breast cancer recurrence has been heterogeneous. To facilitate clinical practice, this review aims to give an overview on the... (Review)
Review
PURPOSE
Management of regional lymph nodes in breast cancer recurrence has been heterogeneous. To facilitate clinical practice, this review aims to give an overview on the prognosis, staging and operative management of (inapparent) regional lymph nodes.
METHODS
Current national and international guidelines are reviewed and a structured search of the literature between Jan 1, 1999 and Feb 1, 2021 on the repeat sentinel node biopsy (re-SNB) procedure was performed.
RESULTS
Positive regional lymph nodes in recurrent breast cancer indicate a poorer outcome with axillary recurrences being the most favorable tumor site among all nodal regions. Most preferred staging method is ultrasound ± guided biopsy. PET-CT, scintimammography, SPECT-CT may improve visualization of affected lymph nodes outside the axilla. Concerning operative management 30 articles on re-SNB were identified with a mean harvesting rate of 66.4%, aberrant drainage and aberrant metastasis in 1/3 of the cases. Total rate of metastasis is 17.9%. After previous axillary dissection (ALND) the re-SNB has a significantly lower harvesting rate and higher aberrant drainage and aberrant metastasis rate. The prognostic outcome after re-SNB has been favorable.
CONCLUSION
Nodal status in recurrent disease has prognostic value. The choice of operative management of clinically inapparent regional lymph nodes during local recurrence should be based on the previous nodal staging method. Patients with previous ALND should be spared a second systematic ALND. Re-SNB or no axillary surgery at all are possible alternatives. Lymphoscintigraphy may be performed to identify extraaxillary drainage. However, for definite recommendations randomized controlled studies are heavily needed.
Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Neoplasm Recurrence, Local; Positron Emission Tomography Computed Tomography; Prognosis; Sentinel Lymph Node Biopsy
PubMed: 35122159
DOI: 10.1007/s00404-021-06352-9 -
Revista Brasileira de Ginecologia E... Nov 2017Axillary web syndrome is characterized as a physical-functional complication that impacts the quality of life of women who have undergone treatment for breast cancer....
Axillary web syndrome is characterized as a physical-functional complication that impacts the quality of life of women who have undergone treatment for breast cancer. The present study aims to verify the physiotherapy treatment available for axillary web syndrome after surgery for breast cancer in the context of evidence-based practice. The selection criteria included papers discussing treatment protocols used for axillary web syndrome after treatment for breast cancer. The search was performed in the MEDLINE, Scopus, PEDro and LILACS databases using the terms , and , focusing on women with a previous diagnosis of breast cancer who underwent surgery with lymphadenectomy as part of their treatment. From the 262 studies found, 4 articles that used physiotherapy treatment were selected. The physiotherapy treatment was based on lymphatic drainage, tissue mobilization, stretching and strengthening. The four selected articles had the same outcome: improvement in arm pain and shoulder function and/or dissipation of the axillary cord. Although axillary web syndrome seems to be as frequent and detrimental as other morbidities after cancer treatment, there are few studies on this subject. The publications are even scarcer when considering studies with an interventional approach. Randomized controlled trials are necessary to support the rehabilitation resources for axillary web syndrome.
Topics: Axilla; Breast Neoplasms; Evidence-Based Medicine; Female; Humans; Lymphatic Diseases; Physical Therapy Modalities; Postoperative Complications; Syndrome
PubMed: 28701024
DOI: 10.1055/s-0037-1604181 -
Breast Cancer Research and Treatment Jul 2024Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS)-guided SLNB. This systematic review and meta-analysis evaluate the diagnostic performance of FS-guided SLNB in early breast cancer.
OBJECTIVES
The objective was to evaluate the diagnostic performance of FS for sentinel lymph node biopsy.
METHODS
Eligibility criteria: Studies where SLNB was performed using FS.
INFORMATION SOURCES
PubMed, EMBASE, Cochrane library and online clinical trial registers. Risk of bias: Articles were assessed for risk of bias using the QUADAS-2 tool.
SYNTHESIS OF RESULTS
The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random-effects model.
RESULTS
A total of 45 articles were retrieved by the initial systematic search. 7 out of the 45 studies comprising a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87-0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9-9.07).
CONCLUSION
Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis.
Topics: Humans; Sentinel Lymph Node Biopsy; Breast Neoplasms; Female; Fluorescein; Lymphatic Metastasis; Sentinel Lymph Node; Axilla; Image-Guided Biopsy
PubMed: 38668856
DOI: 10.1007/s10549-024-07310-0 -
Cirugia Espanola Nov 2020Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in... (Comparative Study)
Comparative Study
Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence.
Topics: Axilla; Biomarkers, Tumor; Breast Neoplasms; Dissection; Female; Humans; Iodine Radioisotopes; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Monitoring, Intraoperative; Neoadjuvant Therapy; Neoplasm Staging; Non-Randomized Controlled Trials as Topic; Observational Studies as Topic; Sentinel Lymph Node Biopsy; Ultrasonography
PubMed: 32386728
DOI: 10.1016/j.ciresp.2020.03.012 -
Annals of Surgical Oncology Feb 2021After the publication of the Z0011 trial, the American Society of Clinical Oncology published an updated clinical practice guideline stating that clinicians should not... (Meta-Analysis)
Meta-Analysis
Axillary Management in Women with Early Breast Cancer and Limited Sentinel Node Metastasis: A Systematic Review and Metaanalysis of Real-World Evidence in the Post-ACOSOG Z0011 Era.
BACKGROUND
After the publication of the Z0011 trial, the American Society of Clinical Oncology published an updated clinical practice guideline stating that clinicians should not recommend axillary lymph node dissection (ALND) for early-stage breast cancer patients with the involvement of one or two sentinel lymph nodes (SLNs). However, these recommendations have been challenged because they were mainly based on data from limited studies. The aim of the current study is to systematically compare the real-world outcomes of SLN biopsy (SLNB) alone and SLNB + ALND in patients with early-stage breast cancers and limited positive SLN metastasis in the post-Z0011 era PATIENTS AND METHODS: We searched articles in the PubMed, EMBASE, and Cochrane library databases. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were recurrence rate and the incidence of lymphedema.
RESULTS
One randomized controlled trial and six retrospective studies with 8864 patients were retrieved. For patients with early-stage breast cancer with one or two SLN metastases, receiving SLNB alone showed no significant difference in OS, DFS, and recurrence rate compared with receiving SLNB + ALND. The incidence of lymphedema in patients who received SLNB alone was significantly lower than those who received SLNB + ALND (odds ratio 1.95, 95% confidence interval 1.02-3.71).
CONCLUSIONS
Current real-world evidence proved that the Z0011 strategy is safe with respect to survival outcomes and effective in reducing the incidence of lymphedema. ALND should be avoided in patients with early-stage breast cancer with one or two SLN metastases in the post-Z0011 era.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Neoplasm Recurrence, Local; Randomized Controlled Trials as Topic; Retrospective Studies; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 32705512
DOI: 10.1245/s10434-020-08923-7 -
American Journal of Surgery Jan 2017Recent discussion has suggested that some cases of ductal carcinoma in situ (DCIS) with high risk of invasive disease may require sentinel lymph node biopsy (SLNB). (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Recent discussion has suggested that some cases of ductal carcinoma in situ (DCIS) with high risk of invasive disease may require sentinel lymph node biopsy (SLNB).
METHODS
Systematic literature review identified 48 studies (9,803 DCIS patients who underwent SLNB). Separate analyses for patients diagnosed preoperatively by core sampling and patients diagnosed postoperatively by specimen pathology were conducted to determine the percentage of patients with axillary nodal involvement. Patient factors were analyzed for associations with risk of nodal involvement.
RESULTS
The mean percentage of positive SLNBs was higher in the preoperative group (5.95% vs 3.02%; P = .0201). Meta-regression analysis showed a direct association with tumor size (P = .0333) and grade (P = .00839) but not median age nor tumor upstage rate.
CONCLUSIONS
The SLNB should be routinely considered in patients with large (>2 cm) high-grade DCIS after a careful multidisciplinary discussion. In the context of breast conserving surgery, the SLNB is not routinely indicated for low- and intermediate-grade DCIS, high-grade DCIS smaller than 2 cm, or pure DCIS diagnosed by definitive surgical excision.
Topics: Breast Neoplasms; Carcinoma, Intraductal, Noninfiltrating; Female; Humans; Needs Assessment; Patient Selection; Sentinel Lymph Node Biopsy
PubMed: 27773373
DOI: 10.1016/j.amjsurg.2016.04.019