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Seminars in Oncology Dec 2020This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing efforts of researchers toward new challenges, as... (Review)
Review
This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing efforts of researchers toward new challenges, as documented by extensive studies and trials. Axillary surgery has evolved, aiming to offer the best oncologic treatment and improve the quality of life of women. Axillary lymph-node dissection (ALND) has been replaced by sentinel lymph-node biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with minimal morbidity, and becoming the standard of care in the management of breast cancer. However, this is only the beginning. Strategies in defining systemic and radiotherapeutic treatments have gradually been optimized, offering increasingly refined and targeted breast cancer treatment tools. In recent years, the paradigm of completion ALND after a positive SLNB has been questioned, and several studies have led to revolutionary changes in clinical practice. Moreover, the increasingly pivotal role played by neoadjuvant chemotherapy (NAC) has had a profound effect on the extent of axillary surgery, paving the way to a more finite "targeted" procedure in women with node-positive breast cancer who convert to negative nodes clinically after NAC. The utility of SLNB itself and its subsequent omission in women with negative nodes clinically and breast conservative surgery is also under scientific evaluation. The changes over time in the surgical approach to breast cancer have been numerous and significant. The novel emerging perspective characterized by recent advances in biology and genetics, in dedicated axillary ultrasound imaging and chemotherapy regimens, is the present reality that points to the future of axillary node treatment in breast cancer.
Topics: Axilla; Breast Neoplasms; Chemotherapy, Adjuvant; History, 15th Century; History, 16th Century; History, 17th Century; History, 18th Century; History, 19th Century; History, 20th Century; History, 21st Century; History, Ancient; History, Medieval; Humans; Lymph Node Excision; Sentinel Lymph Node Biopsy
PubMed: 33131896
DOI: 10.1053/j.seminoncol.2020.09.001 -
Journal of Clinical Oncology : Official... Apr 2023The European Organisation for Research and Treatment of Cancer 10981-22023 AMAROS trial evaluated axillary lymph node dissection (ALND) versus axillary radiotherapy... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
The European Organisation for Research and Treatment of Cancer 10981-22023 AMAROS trial evaluated axillary lymph node dissection (ALND) versus axillary radiotherapy (ART) in patients with cT1-2, node-negative breast cancer and a positive sentinel node (SN) biopsy. At 5 years, both modalities showed excellent and comparable axillary control, with significantly less morbidity after ART. We now report the preplanned 10-year analysis of the axillary recurrence rate (ARR), overall survival (OS), and disease-free survival (DFS), and an updated 5-year analysis of morbidity and quality of life.
METHODS
In this open-label multicenter phase III noninferiority trial, 4,806 patients underwent SN biopsy; 1,425 were node-positive and randomly assigned to either ALND (n = 744) or ART (n = 681).
RESULTS
Per intention-to-treat analysis, 10-year ARR cumulative incidence was 0.93% (95% CI, 0.18 to 1.68; seven events) after ALND and 1.82% (95% CI, 0.74 to 2.94; 11 events) after ART (hazard ratio [HR], 1.71; 95% CI, 0.67 to 4.39). There were no differences in OS (HR, 1.17; 95% CI, 0.89 to 1.52) or DFS (HR, 1.19; 95% CI, 0.97 to 1.46). ALND was associated with a higher lymphedema rate in updated 5-year analyses (24.5% 11.9%; < .001). Quality-of-life scales did not differ by treatment through 5 years. Exploratory analysis showed a 10-year cumulative incidence of second primary cancers of 12.1% (95% CI, 9.6 to 14.9) after ART and 8.3% (95% CI, 6.3 to 10.7) after ALND.
CONCLUSION
This 10-year analysis confirms a low ARR after both ART and ALND with no difference in OS, DFS, and locoregional control. Considering less arm morbidity, ART is preferred over ALND for patients with SN-positive cT1-2 breast cancer.
Topics: Humans; Female; Lymphatic Metastasis; Breast Neoplasms; Axilla; Quality of Life; Sentinel Lymph Node Biopsy; Lymph Node Excision; Lymph Nodes
PubMed: 36383926
DOI: 10.1200/JCO.22.01565 -
Current Problems in Cancer Dec 2019Axillary web syndrome (AWS) refers to the development of fibrotic bands or "cords" in the axilla of patients who have undergone axillary lymph node dissection for breast... (Review)
Review
Axillary web syndrome (AWS) refers to the development of fibrotic bands or "cords" in the axilla of patients who have undergone axillary lymph node dissection for breast cancer. We review the incidence, pathogenesis, risk factors, and management of AWS. AWS is a common complication in patients who undergo axillary lymph node dissection. Even though AWS is self-limited in most cases, it causes significant morbidity. The optimal management of AWS is unclear but physiotherapy appears to be beneficial. The widespread use of less invasive procedures to evaluate the presence of metastasis in the axillary lymph nodes (ie, sentinel lymph node biopsy) is expected to reduce the incidence of AWS. The close collaboration of surgeons, oncologists, and physiotherapists is necessary for the prevention and management of this frequent condition.
Topics: Axilla; Breast Neoplasms; Disease Management; Female; Humans; Incidence; Lymph Node Excision; Lymphatic Diseases; Syndrome
PubMed: 30898366
DOI: 10.1016/j.currproblcancer.2019.02.002 -
The Oncologist Feb 2020The detection of lymph node metastasis affects the management of patients with primary breast cancer significantly in terms of staging, treatment, and prognosis. The... (Review)
Review
The detection of lymph node metastasis affects the management of patients with primary breast cancer significantly in terms of staging, treatment, and prognosis. The main goal for the radiologist is to determine and detect the presence of metastatic disease in nonpalpable axillary lymph nodes with a positive predictive value that is high enough to initially select patients for upfront axillary lymph node dissection. Features that are suggestive of axillary adenopathy may be seen with different imaging modalities, but ultrasound is the method of choice for evaluating axillary lymph nodes and for performing image-guided lymph node interventions. This review aims to provide a comprehensive overview of the available imaging modalities for lymph node assessment in patients diagnosed with primary breast cancer. IMPLICATIONS FOR PRACTICE: The detection of lymph node metastasis affects the management of patients with primary breast cancer. The main goal for the radiologist is to detect lymph node metastasis in patients to allow for the selection of patients who should undergo upfront axillary lymph node dissection. Features that are suggestive of axillary adenopathy may be seen with mammography, computed tomography, and magnetic resonance imaging, but ultrasonography is the imaging modality of choice for evaluating axillary lymph nodes. A normal axillary lymph node is characterized by a reniform shape, a maximal cortical thickness of 3 mm without focal bulging, smooth margins, and, depending on size, a discernable central fatty hilum.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Sensitivity and Specificity; Sentinel Lymph Node Biopsy
PubMed: 32043792
DOI: 10.1634/theoncologist.2019-0427 -
Current Opinion in Oncology Nov 2022The standard of care in breast surgery has changed, from mastectomy to breast conserving surgery whenever possible, and from axillary dissection to sentinel node biopsy.... (Review)
Review
PURPOSE OF REVIEW
The standard of care in breast surgery has changed, from mastectomy to breast conserving surgery whenever possible, and from axillary dissection to sentinel node biopsy. Neoadjuvant systemic approaches have broadened the indications for organ-conserving and less mutilating surgery, but also raise important questions of balancing locoregional treatment de-escalation and protecting excellent long-term outcomes.
RECENT FINDINGS
Recent studies have aimed at investigating the safety of de-escalating surgical approaches not only in the upfront breast surgery situation but also after neoadjuvant systemic therapy. This pertains to both the safety of breast conserving surgery - including more complex oncoplastic approaches - within the new (posttherapeutic) anatomical extent of the residual disease, but more controversially to de-escalating surgical treatment of the axilla. While sentinel node biopsy appears to be the standard of care for node-negative disease also after primary systemic therapy, the optimal procedure in situations of posttherapeutic node-positive disease remains highly controversial.
SUMMARY
Both breast and axillary surgery after neoadjuvant systemic therapy for women with breast cancer has undergone multiple paradigm changes in recent years. For the primary tumor in the breast, breast-conserving surgery constitutes the standard of care, and unnecessary mastectomies should be strongly discouraged. For axillary surgery, sentinel-node biopsy should be aimed at, and completion axillary dissections minimized for situations of extensive disease and or poor neoadjuvant treatment response. Additional techniques such as targeted axillary dissection are currently under evaluation in clinical trials.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Mastectomy; Neoadjuvant Therapy; Sentinel Lymph Node Biopsy
PubMed: 36083127
DOI: 10.1097/CCO.0000000000000906 -
The British Journal of Surgery Aug 2023The initial results of the SINODAR-ONE randomized clinical trial reported that patients with T1-2 breast cancer and one to two macrometastatic sentinel lymph nodes... (Randomized Controlled Trial)
Randomized Controlled Trial
Sentinel lymph node biopsy versus axillary lymph node dissection in breast cancer patients undergoing mastectomy with one to two metastatic sentinel lymph nodes: sub-analysis of the SINODAR-ONE multicentre randomized clinical trial and reopening of enrolment.
BACKGROUND
The initial results of the SINODAR-ONE randomized clinical trial reported that patients with T1-2 breast cancer and one to two macrometastatic sentinel lymph nodes treated with breast-conserving surgery, sentinel lymph node biopsy only, and adjuvant therapy did not present worse 3-year survival, regional recurrence, or distant recurrence rates compared with those treated with axillary lymph node dissection. To extend the recommendation of axillary lymph node dissection omission even in patients treated with mastectomy, a sub-analysis of the SINODAR-ONE trial is presented here.
METHODS
Patients with T1-2 breast cancer and no more than two metastatic sentinel lymph nodes undergoing mastectomy were analysed. After sentinel lymph node biopsy, patients were randomly assigned to receive either axillary lymph node dissection followed by adjuvant treatment (standard arm) or adjuvant treatment alone (experimental arm). The primary endpoint was overall survival. The secondary endpoint was recurrence-free survival.
RESULTS
A total of 218 patients were treated with mastectomy; 111 were randomly assigned to the axillary lymph node dissection group and 107 to the sentinel lymph node biopsy-only group. At a median follow-up of 33.0 months, there were three deaths (two deaths in the axillary lymph node dissection group and one death in the sentinel lymph node biopsy-only group). There were five recurrences in each treatment arm. No axillary lymph node recurrence was observed. The 5-year overall survival rates were 97.8 and 98.7 per cent in the axillary lymph node dissection treatment arm and the sentinel lymph node biopsy-only treatment arm, respectively (P = 0.597). The 5-year recurrence-free survival rates were 95.7 and 94.1 per cent in the axillary lymph node dissection treatment arm and the sentinel lymph node biopsy treatment arm, respectively (P = 0.821).
CONCLUSION
In patients with T1-2 breast cancer and one to two macrometastatic sentinel lymph nodes treated with mastectomy, the overall survival and recurrence-free survival rates of patients treated with sentinel lymph node biopsy only were not inferior to those treated with axillary lymph node dissection. To strengthen the conclusion of the trial, the enrolment of patients treated with mastectomy was reopened as a single-arm experimental study.
REGISTRATION NUMBER
NCT05160324 (http://www.clinicaltrials.gov).
Topics: Humans; Female; Sentinel Lymph Node Biopsy; Sentinel Lymph Node; Breast Neoplasms; Mastectomy; Lymphatic Metastasis; Disease-Free Survival; Lymph Node Excision; Lymph Nodes; Axilla
PubMed: 37471574
DOI: 10.1093/bjs/znad215 -
Ugeskrift For Laeger Mar 2024Surgical treatment of breast cancer has changed towards less invasive procedures as summarised in this review. Breast conserving surgery (BCS) and radiotherapy (RT) are... (Review)
Review
Surgical treatment of breast cancer has changed towards less invasive procedures as summarised in this review. Breast conserving surgery (BCS) and radiotherapy (RT) are now recommended as standard of care. Several flexible marking methods for removal of non-palpable tumours have gradually replaced wire-guided localisation. Neoadjuvant systemic treatment increases tumour shrinkage and BCS and may lead to omission of axillary clearance (AC). The prognostic significance of AC in patients with metastases to 1-2 sentinel nodes at primary surgery is questioned. Results from the SENOMAC trial are expected to change guidelines from AC to axillary RT.
Topics: Female; Humans; Axilla; Breast Neoplasms; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy, Segmental; Sentinel Lymph Node Biopsy
PubMed: 38533870
DOI: 10.61409/V01230033 -
The Breast Journal Jan 2020Axillary dissection has been the standard of care for any patient with clinically positive lymph nodes at initial breast cancer presentation. However, modern... (Review)
Review
Axillary dissection has been the standard of care for any patient with clinically positive lymph nodes at initial breast cancer presentation. However, modern neo-adjuvant therapies can convert positive nodes to negative nodes, especially in the setting of HER2-positive disease. Accurate axillary staging can be achieved after neo-adjuvant therapy in initially node-positive patients using dual tracer lymphatic mapping, removal of three or more lymph nodes, and confirmation of excision of the previously biopsied and clipped lymph node. Currently accruing clinical trials are designed to determine which patients can safely avoid axillary dissection and/or axillary radiation.
Topics: Axilla; Breast Neoplasms; Chemotherapy, Adjuvant; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Lymphedema
PubMed: 31876073
DOI: 10.1111/tbj.13719 -
Breast Disease 2015Various methods are currently used during axillary lymphadenectomy. Our systematic review aims to investigate the potential benefits of bipolar vessel sealing systems... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Various methods are currently used during axillary lymphadenectomy. Our systematic review aims to investigate the potential benefits of bipolar vessel sealing systems (EBVS) over conventional suture ligation during the axillary dissection of breast cancer patients.
METHODS
We searched Medline (1966-2014), Scopus (2004-2014), Popline (1973-2014) Cochrane CENTRAL (1999-2014) and ClinicalTrials.gov (2000-2014) together with reference lists from included studies Statistical meta-analysis was performed using the RevMan 5.1 software.
RESULTS
Four studies were finally included, involving 352 patients. Usage of EBVS significantly increased the number of retrieved axillary lymph nodes (MD 1.67 nodes, 95% CI 0.21, 3.13). Intraoperative times were not affected by these new technique, when compared to traditional suture ligation (MD -10.82 minutes, 95% CI -23.27, 2.70). Neither the volume of postoperative axillary drainage (MD -38.47 ml, 95% CI -110.26, 32.59) nor the duration of drainage (MD -0.49 days, 95% CI -1.23, 0.25) were significantly affected by EBVS application. We observed, however, that bipolar systems may be associated with an increased risk of postoperative seroma formation (OR 2.04, 95% CI 1.13, 3.70).
CONCLUSION
Electrosurgical bipolar vessel sealing systems seem to increase the accuracy of axillary dissection and are equally safe compared to conventional suture ligation regarding intraoperative and postoperative blood loss. They are associated, however, with and increased incidence of seroma formation. Further randomized trials are needed in the field in order to obtain firm conclusions.
Topics: Axilla; Breast Neoplasms; Electrosurgery; Female; Hemostasis, Surgical; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy
PubMed: 25159187
DOI: 10.3233/BD-140383 -
Breast Cancer Research and Treatment Apr 2022Some series have shown increased complications with extended nodal surgery and immediate breast reconstruction (IBR) with implants. We aim to explore complications... (Review)
Review
PURPOSE
Some series have shown increased complications with extended nodal surgery and immediate breast reconstruction (IBR) with implants. We aim to explore complications associated with axillary dissection compared to sentinel lymph node biopsy at a population level.
METHODS
American College of Surgeons National Surgical Quality Improvement Program participant user files from 2008-2018 were searched to create a cohort of female patients undergoing unilateral mastectomy with IBR and axillary surgery for non-metastatic breast cancer. Patients were classified as having sentinel lymph node biopsy (SLNB), axillary dissection (ALND), or sentinel lymph node biopsy and axillary dissection (SLNB + ALND). Baseline demographics were compared, and multivariable logistic regression was to assess for independent predictors of the primary outcome of 30-day morbidity.
RESULTS
Between 2008 and 2018, 18,232 patients had mastectomy and IBR with axillary surgery; 12,632 patients underwent SLNB, 3727 had ALND and 1,873 underwent SLNB + ALND. Mean age of patients in the cohort was 52.5 (SD 11). There was no difference in 30-day morbidity between groups (SLNB: 4.3%, ALND: 4.9%, SLNB + ALND: 4.2%, p = 0.207). Multivariable regression showed that type of axillary surgery was not an independent predictor of 30-day complications (OR 0.78 (95% CI 0.52-1.15) for ALND, and OR 0.87 (95% CI 0.52-1.45) for ALND + SLNB vs SLNB alone). Significant independent predictors for complications were increased BMI (OR 1.06 (95%CI 1.04-1.08)) and increased operative time (OR 1.003 (95% CI 1.001-1.005)).
CONCLUSIONS
ALND does not increase 30-day morbidity in patients undergoing IBR when compared to SLNB. This supports concurrent axillary dissection for IBR patients when indicated.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Mastectomy; Postoperative Complications; Sentinel Lymph Node Biopsy
PubMed: 35152347
DOI: 10.1007/s10549-022-06540-4