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Critical Reviews in Oncology/hematology Jul 2023The present white paper, referring to the 4th Assisi Think Tank Meeting on breast cancer, reviews state-of-the-art data, on-going studies and research proposals. <70%... (Review)
Review
The present white paper, referring to the 4th Assisi Think Tank Meeting on breast cancer, reviews state-of-the-art data, on-going studies and research proposals. <70% agreement in an online questionnaire identified the following clinical challenges: 1: Nodal RT in patients who have a) 1-2 positive sentinel nodes without ALND (axillary lymph node dissection); b) cN1 disease transformed into ypN0 by primary systemic therapy and c) 1-3 positive nodes after mastectomy and ALND. 2. The optimal combination of RT and immunotherapy (IT), patient selection, IT-RT timing, and RT optimal dose, fractionation and target volume. Most experts agreed that RT- IT combination does not enhance toxicity. 3: Re-irradiation for local relapse converged on the use of partial breast irradiation after second breast conserving surgery. Hyperthermia aroused support but is not widely available. Further studies are required to finetune best practice, especially given the increasing use of re-irradiation.
Topics: Humans; Female; Breast Neoplasms; Mastectomy; Lymph Node Excision; Sentinel Lymph Node Biopsy; Mastectomy, Segmental; Axilla; Lymph Nodes
PubMed: 37244324
DOI: 10.1016/j.critrevonc.2023.104035 -
American Journal of Surgery Mar 2023Over the past decade, axillary management in breast cancer has fundamentally shifted. The former notion that any degree of axillary nodal involvement warrants axillary... (Review)
Review
Over the past decade, axillary management in breast cancer has fundamentally shifted. The former notion that any degree of axillary nodal involvement warrants axillary lymph node dissection (ALND) has been challenged. Following publication of the ACOSOG Z0011 trial, national trends demonstrated significant reductions in ALND performance. Axillary radiotherapy in lieu of ALND is a consideration for select patients with a positive sentinel lymph node, while ongoing studies are investigating the role of adjuvant regional radiotherapy in women with positive nodes prior to neoadjuvant chemotherapy. Efforts toward de-escalation of axillary surgery continue to evolve, as do the indications for sentinel node biopsy omission in select subsets of patients. This review highlights the recent advances and neoteric approaches to local therapy of the axilla in breast cancer.
Topics: Female; Humans; Breast Neoplasms; Axilla; Lymph Node Excision; Sentinel Lymph Node Biopsy; Sentinel Lymph Node; Lymph Nodes
PubMed: 36522219
DOI: 10.1016/j.amjsurg.2022.11.036 -
Critical Reviews in Oncology/hematology Sep 2018Around 2% of early breast cancer cases treated with axillary lymph node dissection (ALND) underwent axillary recurrence (AR) and it has a deleterious effect in... (Review)
Review
Around 2% of early breast cancer cases treated with axillary lymph node dissection (ALND) underwent axillary recurrence (AR) and it has a deleterious effect in prognosis. Different scenarios have incorporated Sentinel Lymph Node (SLN) Biopsy (SLNB) instead of ALND as part of the standard treatment and more effective systemic treatment has also been incorporated in routine management after first curative surgery and after regional recurrence. However, there is concern about the effect of SLNB alone over AR risk and how to predict and treat AR. SLN biopsy (SLNB) has been largely accepted as a valid option for SLN-negative cases, and recent prospective studies have demonstrated that it is also safe for some SLN-positive cases and both scenarios carry low AR rates. Different studies have identified clinicopathological factors related to aggressiveness as well as high-risk molecular signatures can predict the development of locoregional recurrence. Other publications have evaluated factors affecting prognosis after AR and find that time between initial treatment and AR as well as tumor aggressive behavior influence patient survival. Retrospective and prospective studies indicate that treatment of AR should include local and systemic treatment for a limited time.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Neoplasm Recurrence, Local; Prognosis; Sentinel Lymph Node Biopsy
PubMed: 30097233
DOI: 10.1016/j.critrevonc.2018.06.013 -
Trends of Axillary Treatment in Sentinel Node-Positive Breast Cancer Patients Undergoing Mastectomy.Annals of Surgical Oncology Sep 2023The ACOSOG-Z0011- and the AMAROS-trial obviated the need for axillary surgery in most sentinel node-positive (SLN+) breast cancer patients undergoing breast-conserving...
BACKGROUND
The ACOSOG-Z0011- and the AMAROS-trial obviated the need for axillary surgery in most sentinel node-positive (SLN+) breast cancer patients undergoing breast-conserving surgery (BCS). Data for patients who undergo mastectomy is scarce. The purpose of this study was to investigate patterns of axillary treatment in SLN+ patients treated by mastectomy in the years after the publication of landmark studies regarding axillary treatment in SLN+ breast cancer patients undergoing BCS.
METHODS
This was a population-based study in cT1-3N0M0 breast cancer patients treated by mastectomy and staged as SLN+ between 2009 and 2018. The performance of an axillary lymph node dissection (ALND) and/or administration of postmastectomy radiotherapy (PMRT) were primary outcomes and were studied over time.
RESULTS
The study included 10,633 patients. The frequency of ALND performance decreased from 78% in 2009 to 10% in 2018, whereas PMRT increased from 4 to 49% (P < 0.001). In ≥N1a patients, ALND performance decreased from 93 to 20%, whereas PMRT increased to 70% (P < 0.001). In N1mi and N0itc patients, ALND was abandoned during the study period, whereas PMRT increased to 38% and 13% respectively (P < 0.001), respectively. Age, tumor subtype, N-stage, and hospital type affected the likelihood that patients underwent ALND.
CONCLUSIONS
In this study in SLN+ breast cancer patients undergoing mastectomy, use of ALND decreased drastically over time. By the end of 2018 most ≥N1a patients received PMRT as the only adjuvant axillary treatment, whereas the majority of N1mi and N0itc patients received no additional treatment.
Topics: Humans; Female; Breast Neoplasms; Mastectomy; Lymphatic Metastasis; Sentinel Lymph Node; Lymph Node Excision; Sentinel Lymph Node Biopsy; Mastectomy, Segmental; Lymphadenopathy; Axilla
PubMed: 37225832
DOI: 10.1245/s10434-023-13568-3 -
Minerva Chirurgica Dec 2020
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic Irradiation; Lymphatic Metastasis; Neoplasm, Residual; Randomized Controlled Trials as Topic; Sentinel Lymph Node Biopsy
PubMed: 33006452
DOI: 10.23736/S0026-4733.20.08598-3 -
JAMA Oncology May 2019
Topics: Attitude; Axilla; Breast Neoplasms; Humans; Lymph Node Excision; Surgeons
PubMed: 30869741
DOI: 10.1001/jamaoncol.2019.0031 -
Breast (Edinburgh, Scotland) Mar 2022Long-term follow-up data from multicenter phase III non-inferiority trials confirmed the safety of omission of axillary dissection in selected patients with clinically...
Long-term follow-up data from multicenter phase III non-inferiority trials confirmed the safety of omission of axillary dissection in selected patients with clinically node-negative, sentinel node-positive breast cancer. Several ongoing trials investigate extended eligibility of the Z0011 protocol in the adjuvant setting. De-escalation of axillary surgery in patients with clinically node-positive breast cancer is currently limited to the neoadjuvant setting, where the sentinel procedure is used to determine nodal pathological complete response. Targeted axillary dissection lowers the false-negative rate of the sentinel procedure, which, however, is consistently associated with a very low risk of axillary recurrence in several recent single-center series. Axillary dissection remains standard care in patients with residual disease after neoadjuvant chemotherapy while the results of Alliance A011202 are pending. The TAXIS trial investigates the role of tailored axillary surgery in patients with clinically node-positive breast cancer, a novel concept designed to selectively remove positive nodes in the adjuvant and neoadjuvant setting.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Neoadjuvant Therapy; Sentinel Lymph Node Biopsy
PubMed: 34511332
DOI: 10.1016/j.breast.2021.08.018 -
The Surgeon : Journal of the Royal... Dec 2020Chyle leak following oncological breast and axillary surgery is a rare complication with small number of reported cases in the literature and little formal guidance... (Review)
Review
Chyle leak following oncological breast and axillary surgery is a rare complication with small number of reported cases in the literature and little formal guidance regarding management. We present a review of the current literature and further related guidance from other specialties, along with suggested strategies for identification, diagnosis and management of this uncommon but potentially significant complication.
Topics: Axilla; Breast Neoplasms; Chyle; Female; Humans; Lymph Node Excision; Mastectomy; Postoperative Complications
PubMed: 31932227
DOI: 10.1016/j.surge.2019.12.001 -
Seminars in Radiation Oncology Jul 2022Historically, axillary lymph node dissection was considered necessary for regional control of breast cancer. Moreover, nodal status was the major determinant of the need... (Review)
Review
Historically, axillary lymph node dissection was considered necessary for regional control of breast cancer. Moreover, nodal status was the major determinant of the need for chemotherapy. The increased use of systemic therapy coupled with expanding indications for nodal irradiation has led to interest in optimizing patient outcomes by leveraging the local control benefits of radiotherapy and systemic therapy to decrease the extent of surgery. A series of landmark surgical and radiotherapeutic trials has demonstrated low rates of disease recurrence with concomitant improvements in treatment-associated lymphedema and quality of life with the use of sentinel node biopsy and nodal irradiation as opposed to complete axillary dissection in the management of node positive breast cancer. This chapter will explore the evolution of regional nodal management, culminating in current approaches to tailored patient selection for axillary lymph node dissection, sentinel lymph node biopsy, and adjuvant regional nodal irradiation.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Quality of Life; Sentinel Lymph Node Biopsy
PubMed: 35688520
DOI: 10.1016/j.semradonc.2022.01.004 -
Breast Cancer Research and Treatment Apr 2024Targeted axillary dissection (TAD) for the axillary staging of clinically node-positive (cN +) breast cancer patients converting to clinically node negative post...
PURPOSE
Targeted axillary dissection (TAD) for the axillary staging of clinically node-positive (cN +) breast cancer patients converting to clinically node negative post neoadjuvant chemotherapy (NAC), has gained popularity due to its minimal false negative rate and low arm morbidity. The aim of this study is to shed more light on the variation in the clinical practice globally in terms of indications and perceived limitations of TAD.
METHODS
A panel of expert breast surgeons constructed a structured questionnaire comprising of 18 questions and asked surgeons worldwide for their opinions and routine practice on TAD. The questionnaire was electronically distributed and answers were collected between May 1st and August 1st 2022.
RESULTS
Responses included 137 entries from 36 countries. Of them, 73.7% consider TAD for cN + patients planned to receive NAC. Among them, the greatest number of respondents (45%) perform the procedure for tumours up to T3, whereas 27% regardless of T-stage. The majority (42%) perform TAD on patients with 1-3 positive nodes and only 30% consider TAD when matted nodes are present. HER2 positive and Triple Negative subtypes are more likely to undergo TAD than Luminal A and B (86%, 79.1%, 39.5%, and 62.8%, respectively). Maximum acceptable lymph node burden is median 3 nodes for any subtype with a tendency to accept more positive nodes for Triple Negative.
CONCLUSION
This study demonstrates the differences in current practice regarding TAD as well as the fact that the biology of the tumour heavily affects the method of axillary staging.
Topics: Humans; Female; Sentinel Lymph Node Biopsy; Breast Neoplasms; Neoplasm Staging; Lymph Node Excision; Lymph Nodes; Neoadjuvant Therapy; Axilla
PubMed: 38175449
DOI: 10.1007/s10549-023-07204-7