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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) Aug 2023Prior data about the influence of age at diagnosis of breast cancer on patient outcomes and survival has been conflicting. Using the Breast Cancer Outcomes Unit database...
Prior data about the influence of age at diagnosis of breast cancer on patient outcomes and survival has been conflicting. Using the Breast Cancer Outcomes Unit database at BC Cancer, this retrospective population-based study identified a cohort of 24,469 patients diagnosed with invasive breast cancer between 2005 and 2014. Median follow-up was 11.5 years. We analyzed clinical and pathological features at diagnosis and treatment specific variables compared across the following age cohorts: <35, 35-39, 40-49, 50-59, 60-69, 70-79, and 80 years of age and older. We assessed the impact of age on breast cancer specific survival (BCSS) and overall survival (OS) by age and subtype. There were distinct clinical-pathological and treatment pattern differences at both extremes of age at diagnosis. Patients <35 and 35-39 years old were more likely to present with higher risk features, HER2 positive or triple-negative biomarkers, and more advanced TNM stage at diagnosis. They were more likely to undergo treatment with mastectomy, axillary lymph node dissection, radiotherapy and chemotherapy. Conversely, patients ≥80 years old were generally more likely to have hormone-sensitive HER2-negative disease, and lower TNM stage at diagnosis. They were less likely to undergo surgery or be treated with radiotherapy and chemotherapy. Both younger and elderly age at breast cancer diagnosis were independent risk factors for poorer prognosis after controlling for subtype, LVI, stage, and treatment factors. This work will help clinicians to more accurately estimate patient outcomes, patterns of relapse, and provide evidence-based treatment recommendations.
Topics: Humans; Aged; Aged, 80 and over; Female; Breast Neoplasms; Mastectomy; Retrospective Studies; Neoplasm Recurrence, Local; Lymph Node Excision; Chemotherapy, Adjuvant
PubMed: 37300985
DOI: 10.1016/j.breast.2023.06.001 -
Journal of Clinical Oncology : Official... Jan 2024
Topics: Humans; Female; Breast Neoplasms; Sentinel Lymph Node Biopsy; Lymph Node Excision; Lymph Nodes; Axilla
PubMed: 38048518
DOI: 10.1200/JCO.23.02121 -
Breast Care (Basel, Switzerland) Dec 2023The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer. (Review)
Review
BACKGROUND
The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer.
SUMMARY
Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement.
KEY MESSAGES
Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.
PubMed: 38130814
DOI: 10.1159/000533748 -
Indian Journal of Surgical Oncology Sep 2023While upper limb lymphoedema following breast and axillary surgery is well established in the literature, breast lymphoedema is rarely documented. Our primary objective...
While upper limb lymphoedema following breast and axillary surgery is well established in the literature, breast lymphoedema is rarely documented. Our primary objective was to identify risk factors of breast lymphoedema, and our secondary aim was to assess the possibility of using a breast ultrasound scan to assess breast lymphoedema. This study was a case series analysis, including patients who had wide local excision for primary breast cancer treatment between January 2013 and January 2018. Patients' demographics, including age, weight, body mass index (BMI), breast volume, tumour characteristics, and histological findings, were noted. All patients had a clinical assessment and ultrasound scan 6 months and 12 months after surgery, comparing ipsilateral to the contralateral breast skin, subcutaneous thickness, as well as parenchymal changes. We have included two hundred eighty-six breast cancer; the mean age was 54.7 years SD 17.3, the mean weight was 76.5 kg SD 12.6, the mean BMI was 31.5 SD 5.2, and the mean breast volume was 1223 ml SD 179. This study identified breast lymphoedema in patients with clinically detected skin oedema in the absence of radiotherapy skin changes; skin and subcutaneous 5 mm added thickness more than the contralateral side, and based on that, 22 patients (7.7%) were found to have breast lymphoedema. We have also found that patients with high BMI, larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance had an increased incidence of breast lymphoedema. The incidence of breast lymphoedema in this cohort was 7.7%. We suggest that breast lymphoedema should be considered if skin and subcutaneous thickness are 5 mm more than the contralateral side in the absence of severe radiotherapy skin changes. Also, we have found that high body mass index (BMI), larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance are associated with an increased incidence of breast lymphoedema.
PubMed: 37900657
DOI: 10.1007/s13193-023-01725-9 -
Surgery Aug 2023Over the past 2 decades, axillary surgical management for breast cancer patients has been reshaped after several practice-changing randomized clinical trials provided... (Review)
Review
Over the past 2 decades, axillary surgical management for breast cancer patients has been reshaped after several practice-changing randomized clinical trials provided evidence to support the de-escalation of axillary surgery, specifically the omission of axillary lymph node dissection, for patients with positive axillary lymph nodes. One such practice-changing trial was the American College of Surgeons Oncology Group Z0011 trial, which showed that patients with clinical T1-2 breast tumors and limited nodal disease (1-2 positive sentinel lymph nodes) who underwent upfront breast-conserving therapy could be safely spared the morbidity of axillary lymph node dissection. American College of Surgeons Oncology Group Z0011 has been criticized as several important groups were excluded, such as patients who underwent a mastectomy, patients with >2 positive sentinel lymph nodes, or patients with imaging-detected lymph node metastases. These exclusions have led to unclear guidelines and very difficult management decisions for many patients with breast cancer who are just outside the Z0011 criteria. Several subsequent trials that investigated sentinel lymph node biopsy alone or sentinel lymph node biopsy plus axillary radiation versus axillary lymph node dissection enrolled patients with higher volumes of disease than American College of Surgeons Oncology Group Z0011, such as mastectomy patients or patients with >2 positive sentinel lymph nodes. The goal of this review is to describe the findings of these trials and to discuss the current best practices regarding axillary management in patients who are candidates for upfront surgery but were excluded from American College of Surgeons Oncology Group Z0011, with a particular focus on patients undergoing mastectomy, patients with >2 positive sentinel lymph nodes, patients with large or multifocal tumors, and patients with imaging-detected biopsy-proven lymph node metastases.
Topics: Humans; Female; Lymphatic Metastasis; Breast Neoplasms; Mastectomy; Sentinel Lymph Node Biopsy; Lymph Node Excision; Sentinel Lymph Node; Axilla; Lymph Nodes
PubMed: 37156648
DOI: 10.1016/j.surg.2023.03.024 -
JAMA Surgery Sep 2023Breast cancer-related lymphedema (BCRL) is a common complication of axillary lymph node dissection (ALND) but can also develop after sentinel lymph node biopsy (SLNB)....
IMPORTANCE
Breast cancer-related lymphedema (BCRL) is a common complication of axillary lymph node dissection (ALND) but can also develop after sentinel lymph node biopsy (SLNB). Several models have been developed to predict the risk of disease development before and after surgery; however, these models have shortcomings that include the omission of race, inclusion of variables that are not readily available to patients, low sensitivity or specificity, and lack of risk assessment for patients treated with SLNB.
OBJECTIVE
To create simple and accurate prediction models for BCRL that can be used to estimate preoperative or postoperative risk.
DESIGN, SETTING, AND PARTICIPANTS
In this prognostic study, women with breast cancer who underwent ALND or SLNB from 1999 to 2020 at Memorial Sloan Kettering Cancer Center and the Mayo Clinic were included. Data were analyzed from September to December 2022.
MAIN OUTCOMES AND MEASURES
Diagnosis of lymphedema based on measurements. Two predictive models were formulated via logistic regression: a preoperative model (model 1) and a postoperative model (model 2). Model 1 was externally validated using a cohort of 34 438 patients with an International Classification of Diseases diagnosis of breast cancer.
RESULTS
Of 1882 included patients, all were female, and the mean (SD) age was 55.6 (12.2) years; 80 patients (4.3%) were Asian, 190 (10.1%) were Black, 1558 (82.8%) were White, and 54 (2.9%) were another race (including American Indian and Alaska Native, other race, patient refused to disclose, or unknown). A total of 218 patients (11.6%) were diagnosed with BCRL at a mean (SD) follow-up of 3.9 (1.8) years. The BCRL rate was significantly higher among Black women (42 of 190 [22.1%]) compared with all other races (Asian, 10 of 80 [12.5%]; White, 158 of 1558 [10.1%]; other race, 8 of 54 [14.8%]; P < .001). Model 1 included age, weight, height, race, ALND/SLNB status, any radiation therapy, and any chemotherapy. Model 2 included age, weight, race, ALND/SLNB status, any chemotherapy, and patient-reported arm swelling. Accuracy was 73.0% for model 1 (sensitivity, 76.6%; specificity, 72.5%; area under the receiver operating characteristic curve [AUC], 0.78; 95% CI, 0.75-0.81) at a cutoff of 0.18, and accuracy was 81.1% for model 2 (sensitivity, 78.0%; specificity, 81.5%; AUC, 0.86; 95% CI, 0.83-0.88) at a cutoff of 0.10. Both models demonstrated high AUCs on external (model 1: 0.75; 95% CI, 0.74-0.76) or internal (model 2: 0.82; 95% CI, 0.79-0.85) validation.
CONCLUSIONS AND RELEVANCE
In this study, preoperative and postoperative prediction models for BCRL were highly accurate and clinically relevant tools comprised of accessible inputs and underscored the effects of racial differences on BCRL risk. The preoperative model identified high-risk patients who require close monitoring or preventative measures. The postoperative model can be used for screening of high-risk patients, thus decreasing the need for frequent clinic visits and arm volume measurements.
Topics: Female; Humans; Middle Aged; Breast Neoplasms; Incidence; Feasibility Studies; Race Factors; Axilla; Lymph Node Excision; Sentinel Lymph Node Biopsy; Lymphedema
PubMed: 37436762
DOI: 10.1001/jamasurg.2023.2414 -
American Journal of Surgery May 2024Among women with early invasive breast cancer and 1-2 positive sentinel nodes, sentinel lymph node biopsy (SLNB) is non-inferior to axillary lymph node dissection...
BACKGROUND
Among women with early invasive breast cancer and 1-2 positive sentinel nodes, sentinel lymph node biopsy (SLNB) is non-inferior to axillary lymph node dissection (ALND). However, preoperative axillary ultrasonography (AxUS) may not be sensitive enough to discriminate burden of nodal metastasis in these patients, potentially leading to overtreatment. This study compares axillary operation rates in patients who did and did not receive preoperative AxUS, assessing its utility and risks for overtreatment.
METHODS
This is a retrospective cohort study of patients with clinical T1/T2 breast tumors who were clinically node negative and underwent an axillary operation.
RESULTS
Patients who had preoperative AxUS received more ALND compared to patients who did not (5.6% vs. 1.4%, p < 0.001). There was no significant difference in the number of additional axillary operations following SLNB (2.1% vs. 2.3%, p = 0.77).
CONCLUSION
Eliminating preoperative AxUS is associated with fewer invasive ALND procedures, without increased rate of axillary reoperations.
Topics: Female; Humans; Breast Neoplasms; Retrospective Studies; Lymphatic Metastasis; Sentinel Lymph Node Biopsy; Lymph Node Excision; Ultrasonography; Axilla; Lymph Nodes; Neoplasm Staging
PubMed: 38490879
DOI: 10.1016/j.amjsurg.2024.03.011 -
European Journal of Surgical Oncology :... Oct 2023Axillary management in cN + axillary nodes after neoadjuvant systemic therapy (NST) in breast cancer (BC) remains under research with the aim of de-escalation of...
BACKGROUND
Axillary management in cN + axillary nodes after neoadjuvant systemic therapy (NST) in breast cancer (BC) remains under research with the aim of de-escalation of axillary node dissection (ALND). Several axillary guided localization techniques have been reported. This study evaluates the safety of intraoperative ultrasound (IOUS) guided targeted axillary dissection (TAD) in a large sample after the results of ILINA trial.
MATERIALS
Prospective data have been collected from October 2015 to June 2022 in patients with cT0-T4 and positive axillary lymph nodes (cN1) treated with NST. Before NST, an ultrasound visible marker was placed into the positive node. After NST, IOUS guided TAD was performed including sentinel node biopsy (SLN). Until December 2019, all patients underwent an ALND after TAD procedure. From January 2020, ALND was spared in those patients with an axillary pathological complete response (pCR).
RESULTS
235 patients were included. pCR (ypT0/is ypN0) was achieved in 29% patients. Identification rate (IR) of the clipped node by IOUS was 96% (95% IC, 92.5-98.1%) and IR of SLN was 95% (95% IC, 90.8-97.2%). False negative rate (FNR) for TAD procedure (SLN + clipped node) was 7.0% (95% IC, 2.3-15.7%), which decreased to 4.9% when a total of 3 or more nodes were removed. Axillary ultrasound before surgery assessed residual disease with an AUC of 0.5241. Residual axillary disease tend to be the most significant factor for axillary recurrences.
CONCLUSIONS
This study confirms the feasibility, safety and accuracy of IOUS guided surgery for axillary staging after NST in node positive BC patients.
Topics: Humans; Female; Neoadjuvant Therapy; Prospective Studies; Feasibility Studies; Lymphatic Metastasis; Neoplasm Staging; Lymph Node Excision; Lymph Nodes; Sentinel Lymph Node Biopsy; Breast Neoplasms; Axilla; Neoplasm, Residual
PubMed: 37244843
DOI: 10.1016/j.ejso.2023.05.013 -
World Journal of Surgical Oncology Dec 2023A connection between lymphovascular invasion and axillary lymph node metastases in breast cancer has been observed, but the findings are inconsistent and primarily based... (Review)
Review
Lymphovascular invasion is a significant risk factor for non-sentinel nodal metastasis in breast cancer patients with sentinel lymph node (SLN)-positive breast cancer: a cross-sectional study.
BACKGROUND
A connection between lymphovascular invasion and axillary lymph node metastases in breast cancer has been observed, but the findings are inconsistent and primarily based on research in Western populations. We investigated the association between lymphovascular invasion and non-sentinel lymph node (non-SLN) metastasis in breast cancer patients with sentinel lymph node (SLN) metastasis in western China.
METHODS
This study comprised 280 breast cancer patients who tested positive for SLN through biopsy and subsequently underwent axillary lymph node dissection (ALND) at The People's Hospital of Guangxi Zhuang Autonomous Region between March 2013 and July 2022. We used multivariate logistic regression analyses to assess the association between clinicopathological characteristics and non-SLN metastasis. Additionally, we conducted further stratified analysis.
RESULTS
Among the 280 patients with positive SLN, only 126 (45%) exhibited non-SLN metastasis. Multivariate logistic regression demonstrated that lymphovascular invasion was an independent risk factor for non-SLN in breast cancer patients with SLN metastasis (OR = 6.11; 95% CI, 3.62-10.32, p < 0.05). The stratified analysis yielded similar results.
CONCLUSIONS
In individuals with invasive breast cancer and 1-2 positive sentinel lymph nodes, lymphovascular invasion is the sole risk factor for non-SLN metastases. This finding aids surgeons and oncologists in devising a plan for local axillary treatment, preventing both over- and undertreatment.
Topics: Humans; Female; Sentinel Lymph Node; Breast Neoplasms; Sentinel Lymph Node Biopsy; Cross-Sectional Studies; Lymph Nodes; China; Lymph Node Excision; Lymphatic Metastasis; Risk Factors; Lymphadenopathy; Axilla
PubMed: 38097994
DOI: 10.1186/s12957-023-03273-6