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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 Axillary lymph-node dissection (ALND) has been replaced by sentinel lymph-node biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with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 -
Journal of Clinical Oncology : Official... Mar 2022The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of the condition. We offer a critical evaluation of the literature on prospective surveillance and early management for cancer-related lymphedema and evaluate the effect of such programs in preventing chronic lymphedema (CRD42019137965).
METHODS
Five databases and two registries were searched for randomized controlled trials or observational studies that assessed the incidence or prevalence of lymphedema associated with participation in a prospective surveillance program, published until February 26, 2021. Numbers triggered for early lymphedema management, resolved, and chronic lymphedema were extracted. Pooled relative risk (trials) and pooled rate (cumulative incidence; observational studies) of chronic lymphedema was calculated. Subgroup analyses assessed the effect of study design, length of follow-up, and extent of axillary surgery.
RESULTS
Twenty-three studies were included, of which 21 studies evaluated breast cancer-related arm lymphedema (BCRaL). Participation in prospective surveillance with early management reduced the risk of chronic BCRaL versus usual care (relative risk 0.31; 95% CI, 0.10 to 0.95; two randomized controlled trials; N = 106). The pooled rate of chronic BCRaL was 4% (95% CI, 3 to 6; 15 observational studies; N = 3,545), and 6% (95% CI, 4 to 9) when restricted to participants with axillary lymph node dissection (12 studies; N = 1,527).
CONCLUSION
The findings suggest that participation in prospective surveillance with early management reduces the risk of chronic BCRaL. Only a minority of patients at high risk of lymphedema because of axillary surgery developed chronic lymphedema. More robust research is needed to determine whether prospective surveillance with early management can reduce the risk of chronic lymphedema, particularly among cancer survivors other than breast cancer.
Topics: Axilla; Breast Cancer Lymphedema; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphedema; Prospective Studies
PubMed: 35077194
DOI: 10.1200/JCO.21.01681 -
Annals of Surgical Oncology Sep 2022The SINODAR-ONE trial is a prospective noninferiority multicenter randomized study aimed at assessing the role of axillary lymph node dissection (ALND) in patients... (Randomized Controlled Trial)
Randomized Controlled Trial
Preservation of Axillary Lymph Nodes Compared with Complete Dissection in T1-2 Breast Cancer Patients Presenting One or Two Metastatic Sentinel Lymph Nodes: The SINODAR-ONE Multicenter Randomized Clinical Trial.
BACKGROUND
The SINODAR-ONE trial is a prospective noninferiority multicenter randomized study aimed at assessing the role of axillary lymph node dissection (ALND) in patients undergoing either breast-conserving surgery or mastectomy for T1-2 breast cancer (BC) and presenting one or two macrometastatic sentinel lymph nodes (SLNs). The endpoints were to evaluate whether SLN biopsy (SLNB) only was associated with worsening of the prognosis compared with ALND in terms of overall survival (OS) and relapse.
METHODS
Patients were randomly assigned (1:1 ratio) to either removal of ≥ 10 axillary level I/II non-SLNs followed by adjuvant therapy (standard arm) or no further axillary treatment (experimental arm).
RESULTS
The trial started in April 2015 and ceased in April 2020, involving 889 patients. Median follow-up was 34.0 months. There were eight deaths (ALND, 4; SNLB only, 4), with 5-year cumulative mortality of 5.8% and 2.1% in the standard and experimental arm, respectively (p = 0.984). There were 26 recurrences (ALND 11; SNLB only, 15), with 5-year cumulative incidence of recurrence of 6.9% and 3.3% in the standard and experimental arm, respectively (p = 0.444). Only one axillary lymph node recurrence was observed in each arm. The 5-year OS rates were 98.9% and 98.8%, in the ALND and SNLB-only arm, respectively (p = 0.936).
CONCLUSIONS
The 3-year survival and relapse rates of T1-2 BC patients with one or two macrometastatic SLNs treated with SLNB only, and adjuvant therapy, were not inferior to those of patients treated with ALND. These results do not support the use of routine ALND.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy; Neoplasm Recurrence, Local; Prospective Studies; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 35552930
DOI: 10.1245/s10434-022-11866-w -
JAMA Oncology Dec 2021Prospective trials have demonstrated sentinel lymph node (SLN) false-negative rates of less than 10% when 3 or more SLNs are retrieved in patients with clinically...
IMPORTANCE
Prospective trials have demonstrated sentinel lymph node (SLN) false-negative rates of less than 10% when 3 or more SLNs are retrieved in patients with clinically node-positive breast cancer rendered clinically node-negative with neoadjuvant chemotherapy (NAC). However, rates of nodal recurrence in such patients treated with SLN biopsy (SLNB) alone are unknown because axillary lymph node dissection (ALND) was performed in all patients, limiting adoption of this approach.
OBJECTIVE
To evaluate nodal recurrence rates in a consecutive cohort of patients with clinically node-positive (cN1) breast cancer receiving NAC, followed by a negative SLNB using a standardized technique, and no further axillary surgery.
DESIGN, SETTING, AND PARTICIPANTS
From November 2013 to February 2019, a cohort of consecutively identified patients with cT1 to cT3 biopsy-proven N1 breast cancer rendered cN0 by NAC underwent SLNB with dual tracer mapping and omission of ALND if 3 or more SLNs were identified and all were pathologically negative. Metastatic nodes were not routinely clipped, and localization of clipped nodes was not performed. The study was performed in a single tertiary cancer center.
INTERVENTION
Omission of ALND in patients with cN1 breast cancer after NAC if 3 or more SLNs were pathologically negative.
MAIN OUTCOME AND MEASURES
The primary outcome was the rate of nodal recurrence among patients with cN1 breast cancer treated with SLNB alone after NAC.
RESULTS
Of 610 patients with cN1 breast cancer treated with NAC, 555 (91%) converted to cN0 and underwent SLNB; 234 (42%) had 3 or more negative SLNs and had SLNB alone. The median (IQR) age of these 234 patients was 49 (40-58) years; median tumor size was 3 cm; 144 (62%) were ERBB2 (formerly HER2)-positive, and 43 (18%) were triple negative. Most (212 [91%]) received doxorubicin-based NAC; 205 (88%) received adjuvant radiotherapy (RT), and 164 (70%) also received nodal RT. At a median follow-up of 40 months, there was 1 axillary nodal recurrence synchronous with local recurrence in a patient who refused RT. Among patients who received RT (n = 205), there were no nodal recurrences.
CONCLUSIONS AND RELEVANCE
This cohort study found that in patients with cN1 disease rendered cN0 with NAC, with 3 or more negative SLNs with SLNB alone, nodal recurrence rates were low, without routine nodal clipping. These findings potentially support omitting ALND in such patients.
Topics: Axilla; Breast Neoplasms; Cohort Studies; Female; Humans; Lymph Node Excision; Middle Aged; Neoadjuvant Therapy; Prospective Studies; Sentinel Lymph Node Biopsy
PubMed: 34617979
DOI: 10.1001/jamaoncol.2021.4394 -
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