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The Lancet. Oncology Oct 2016With the advent of sentinel lymph node biopsy, surgical methods for accurately staging the axilla in patients with early-stage breast cancer have become progressively... (Review)
Review
With the advent of sentinel lymph node biopsy, surgical methods for accurately staging the axilla in patients with early-stage breast cancer have become progressively less extensive, with formal axillary lymph node dissection confined to a dwindling group of patients. Although details of methods for sentinel lymph node biopsy have yet to be standardised, this technique is now widely practised and accepted as standard of care worldwide. In the past 5 years, attention has focused on minimisation of surgical morbidity by restricting further axillary surgery or considering radiotherapy in patients with a small tumour burden in their sentinel nodes. This change in approach to patients with positive sentinel lymph node biopsies has increased the complexity of axillary management, and any policy of de-escalation and avoidance of morbidity must not compromise patient outcomes. This trend for de-escalation has accompanied a shift in understanding of how any residual tumour burden can be adequately managed without surgical extirpation and reliance on effective adjuvant therapies. Indications for omission of completion axillary lymph node dissection in patients with two or fewer nodes containing macrometastases demand further clarification, together with the roles of preoperative imaging in defining axillary nodal burden, deselection of patients for sentinel lymph node biopsy, and provision of radiotherapy. Downstaging of biopsy-proven node-positive patients with neoadjuvant chemotherapy could safely permit sentinel lymph node biopsy alone when the index node has been successfully retrieved at surgery, while nodal deposits of any size continue to mandate completion axillary lymph node dissection. Developments in molecular imaging technologies and percutaneous biopsy techniques could potentially render sentinel lymph node biopsy redundant in the future.
Topics: Axilla; Breast Neoplasms; Clinical Trials as Topic; Female; Humans; Lymph Node Excision; Sentinel Lymph Node Biopsy
PubMed: 27733269
DOI: 10.1016/S1470-2045(16)30311-4 -
Breast (Edinburgh, Scotland) Mar 2022The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of...
The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013-08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.
Topics: Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Mastectomy; Mastectomy, Segmental; Neoplasm Staging; Sentinel Lymph Node Biopsy
PubMed: 34949533
DOI: 10.1016/j.breast.2021.11.018 -
Breast (Edinburgh, Scotland) Feb 2023Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated after publication...
Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated after publication of ACOSOG Z0011 data in 2010. Currently, prospective randomized surgical trials investigating the omission of SLNB in upfront breast-conserving surgery (BCS) and in the neoadjuvant setting, respectively. Several prospective randomized trials (SOUND, INSEMA, BOOG 2013-08, and NAUTILUS) with axillary observation alone versus SLNB in cN0 patients and primary BCS have primary objectives to evaluate oncologic safety when omitting SLNB. The Italian SOUND trial was the earliest to open in 2012 and has completed accrual in 2017. First oncologic outcome data are expected soon for SOUND and at the end of 2024 for INSEMA. Improvements in systemic treatments for breast cancer have increased the rates of pathologic complete response (pCR) in patients receiving neoadjuvant systemic therapy (NAST), offering the opportunity to de-escalate surgery in patients who have a pCR. Two prospective single-arm trials (EUBREAST-01, ASICS) include only patients with the highest likelihood of having a pCR after NAST (triple-negative or HER2-positive breast cancer) and type of surgery will be defined according to the response to NAST rather than on the classical T and N status. The ongoing trials will hopefully help us to understand whether we might take the best therapeutic decisions without the pathologic evaluation of nodal status.
Topics: Humans; Female; Sentinel Lymph Node Biopsy; Breast Neoplasms; Lymph Node Excision; Axilla; Prospective Studies; Neoadjuvant Therapy; Lymph Nodes; Sentinel Lymph Node
PubMed: 36658052
DOI: 10.1016/j.breast.2023.01.002 -
Journal of Surgical Oncology Jan 2024It is on the backdrop of advances in tumor biology and systemic therapy for breast cancer, that progress in locoregional treatment has focused on management of the... (Review)
Review
It is on the backdrop of advances in tumor biology and systemic therapy for breast cancer, that progress in locoregional treatment has focused on management of the breast for invasive cancer, imaging for staging and therapeutic decision-making, and de-escalation in the management of the axilla.
Topics: Humans; Female; Sentinel Lymph Node Biopsy; Lymphatic Metastasis; Surgical Oncology; Neoplasm Staging; Breast Neoplasms; Lymph Node Excision; Axilla; Lymph Nodes
PubMed: 37994521
DOI: 10.1002/jso.27528 -
Annals of Surgical Oncology Jul 2023
Topics: Humans; Female; Breast Neoplasms; Lymph Node Excision; Sentinel Lymph Node Biopsy; Axilla
PubMed: 36820936
DOI: 10.1245/s10434-023-13299-5 -
Journal of Clinical Oncology : Official... Jan 2024Axillary soft tissue (AXT) involvement with tumor cells extending beyond the positive lymph node (LN+) and extracapsular extension (ECE) has been overlooked in breast...
PURPOSE
Axillary soft tissue (AXT) involvement with tumor cells extending beyond the positive lymph node (LN+) and extracapsular extension (ECE) has been overlooked in breast pathology specimen analysis.
MATERIALS AND METHODS
We analyzed 2,162 LN+ patients, dividing them into four groups on the basis of axillary pathology: (1) LN+ only, (2) LN+ and ECE only, (3) LN+ and AXT without ECE, and (4) LN+ with both AXT and ECE. The primary end points were 10-year locoregional failure (LRF), the 10-year axillary failure, and 10-year distant metastasis rates. Multivariable Cox models, accounting for clinical factors, were fitted using the entire cohort, and subgroups analyses were conducted.
RESULTS
The median follow-up was 9.4 years. The 10-year distant metastasis incidence was 42% for LN + AXT + ECE, 23% for both LN + AXT and LN + ECE only, and 13% for LN+ only. The 10-year axillary failure rates were 4.5% for LN + AXT + ECE, 4.6% for LN + AXT, 0.8% for LN + ECE only, and 1.6% for LN+ only. The 10-year LRF rates were 14% for LN + AXT + ECE, 10% for LN + AXT, 5.7% for LN + ECE only, and 6.2% for LN+ only. Multivariable analysis revealed that AXT was significantly associated with distant metastasis (hazard ratio [HR], 1.6; < .001), locoregional failure (HR, 2.3; < .001), and axillary failure (HR, 3.3; = .003). Subgroup analyses showed that regional LN radiation (RLNR) improved locoregional tumor outcomes with AXT, ECE, or both (HR, 0.5; = .03). Delivering ≤50 Gy to the axilla in the presence of AXT/ECE increased axillary failure (HR, 3.0; = .04). Moreover, when delivering RLNR, axillary LN dissection could be de-escalated to sentinel node biopsy even in the presence of features such as AXT or ECE without significantly increasing any failure outcome: (HR, 1.0; = .92) for LRF, (HR, 1.1; = .94) axillary failure, and (HR, 0.4; = .01) distant metastasis.
CONCLUSION
Routine reporting of axillary tissue involvement, beyond LNs and ECE, is crucial in predicting breast cancer outcomes. Ruling out the presence of AXT is imperative before any form of axillary de-escalation, especially RLNR omission.
Topics: Humans; Female; Breast Neoplasms; Lymphatic Metastasis; Axilla; Sentinel Lymph Node Biopsy; Lymph Node Excision; Tumor Microenvironment
PubMed: 37967296
DOI: 10.1200/JCO.23.01009 -
Journal of Gynecology Obstetrics and... May 2021Outpatient procedure in cancer surgery is one of the tracks to guarantee the quality of care respecting the delay of support. The aim of this study was to assess the...
BACKGROUND
Outpatient procedure in cancer surgery is one of the tracks to guarantee the quality of care respecting the delay of support. The aim of this study was to assess the feasibility and safety of outpatients with axillary lymphadenectomy and the postoperative morbidity after outpatient's procedures compared to patients with classic hospitalization.
METHODS
Patients who underwent axillary lymphadenectomy for breast cancer or melanoma were analyzed. We selected patients having axillary lymphadenectomy only or associated with another operative act compatible with outpatient's procedure (partial mastectomy, lumpectomy or skin excisions).
RESULTS
Three hundred and forty-nine patients were included. Outpatient procedures were performed in 142 patients (40.7%) and inpatient procedures were performed in 207 patients (59.3%). All time complications combined, we found 148 patients with at least one complication: 77 patients (52.0%) and 71 patients (48.0%) in outpatient and inpatient group, respectively (p=0.0002). The main complication was seroma formation, it concerned 104 patients Among them, Seroma formation was more frequent in ambulatory group, 60 patients (57.7%) and 44 patients (42.3%) in traditional hospitalization (p<0.0001) but 58.7% (61/104) needed only one aspiration and all complications were managed in outpatient.
CONCLUSION
Complications (mostly seroma) appeared usually after hospitalization discharge and they were known and simple to take in charge. A precise preoperative information concerning post-operative morbidity, specially seroma allows a better comprehension and acceptation of this side effect. We believe that this surgery is feasible and safe in outpatient procedure.
Topics: Adult; Aged; Aged, 80 and over; Ambulatory Surgical Procedures; Axilla; Breast Neoplasms; Feasibility Studies; Female; Hospitalization; Humans; Lymph Node Excision; Male; Mastectomy, Segmental; Melanoma; Middle Aged; Postoperative Complications; Retrospective Studies; Seroma; Skin Neoplasms; Young Adult
PubMed: 33022447
DOI: 10.1016/j.jogoh.2020.101931 -
Expert Review of Medical Devices Oct 2022In patients with non-palpable breast cancer, the availability of wireless localization techniques facilitates removal of the target lesion. One such technique uses a...
INTRODUCTION
In patients with non-palpable breast cancer, the availability of wireless localization techniques facilitates removal of the target lesion. One such technique uses a radar reflector for localization (RRL). This study evaluates the feasibility and effectiveness of RRL to guide excision of axillary lymph nodes in patients with node-positive breast cancer.
METHODS
Our Breast Cancer Database was queried for patients diagnosed with breast cancer, between 5/2017 and 10/2021, who underwent preoperative placement of a radar reflector into a biopsy proven axillary lymph node. Clinicopathologic data were reported using descriptive statistics.
RESULTS
Twenty patients underwent preoperative placement of a radar reflector into the axilla. Intraoperatively, the clip and radar reflector were successfully removed in all patients. Among the 10 patients treated with NAC, 5 patients achieved an axillary pathologic complete response (pCR) and were spared a complete axillary lymph node dissection (cALND). Among the entire cohort, RRL resulted in a 53% reduction in the number of lymph nodes removed.
CONCLUSIONS
Wireless localization of axillary lymph nodes is safe and feasible. The technique ensures excision of biopsy proven positive axillary lymph nodes and enables a targeted approach to assessing the axilla, both in the setting of NAC and upfront surgery.
Topics: Humans; Female; Axilla; Breast Neoplasms; Sentinel Lymph Node Biopsy; Radar; Lymphatic Metastasis; Neoadjuvant Therapy; Lymph Nodes; Lymph Node Excision; Neoplasm Staging
PubMed: 36345879
DOI: 10.1080/17434440.2022.2139177 -
Clinical Imaging Nov 2023Breast cancer is the most common malignant disease of women in the world. Breast cancer often metastasizes to axillary lymph nodes. Accurate assessment of the status of... (Review)
Review
Breast cancer is the most common malignant disease of women in the world. Breast cancer often metastasizes to axillary lymph nodes. Accurate assessment of the status of axillary lymph nodes is crucial to the staging and treatment of breast cancer. None of the methods used clinically for preoperative noninvasive examination of axillary lymph nodes can accurately identify cancer cells from a molecular level. In recent years, with the in-depth study of lymph node metastases, the mechanisms and molecular imaging of lymph node metastases in breast cancer have been reported. In this review, we highlight the new progress in the study of the main mechanisms of lymph node metastases in breast cancer. In addition, we analyze the advantages and disadvantages of traditional preoperative axillary lymph node imaging methods for breast cancer, and list molecular imaging methods that can accurately identify breast cancer cells in lymph nodes.
Topics: Female; Humans; Lymphatic Metastasis; Breast Neoplasms; Lymph Nodes; Molecular Imaging; Axilla; Lymph Node Excision; Neoplasm Staging
PubMed: 37757640
DOI: 10.1016/j.clinimag.2023.109985 -
Breast (Edinburgh, Scotland) Oct 2015Primary aim is to give an overview of changes in axillary staging and treatment of breast cancer patients. Secondly, we aim to identify patients with a high arm/shoulder... (Review)
Review
Primary aim is to give an overview of changes in axillary staging and treatment of breast cancer patients. Secondly, we aim to identify patients with a high arm/shoulder morbidity risk, and describe a strategy to improve early detection and treatment. Recent and initiated studies on axillary staging and treatment were evaluated and clustered for clinically node negative and clinically node positive breast cancer patients, together with studies on pathology, detection and (surgical) prevention and treatment of lymphedema. For clinically node negative patients, the indication for axillary lymph node dissection in sentinel node positive patients is fading. On the contrary, clinically node positive patients are routinely subjected to an axillary lymph node dissection, in combination with other therapies associated with an increased lymphedema risk, such as mastectomy, adjuvant radiation- and (taxane-based) chemotherapy. Techniques for prevention, early detection and (surgical) treatment of lymphedema are being developed. Axillary staging and treatment in breast cancer patients with a clinically node negative status will become less invasive, thereby reducing the incidence of morbidity. Nevertheless, in patients with a clinically node positive status, aggressive treatment will still be required for oncologic control. For these patients, a surveillance program should be implemented in order to apply (curative) surgical treatment for lymphedema.
Topics: Arm; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Lymphedema; Neoplasm Staging; Risk Factors; Sentinel Lymph Node Biopsy; Shoulder
PubMed: 26051795
DOI: 10.1016/j.breast.2015.04.008