-
BMJ Clinical Evidence Feb 2011Breast cancer affects at least 1 in 10 women in the UK, but most present with primary operable disease, which has an 80% 5-year survival rate overall. (Review)
Review
INTRODUCTION
Breast cancer affects at least 1 in 10 women in the UK, but most present with primary operable disease, which has an 80% 5-year survival rate overall.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions after breast-conserving surgery for ductal carcinoma in situ? What are the effects of treatments for primary operable breast cancer? What are the effects of interventions in locally advanced breast cancer (stage 3B)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 83 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: adding chemotherapy (cyclophosphamide/methotrexate/fluorouracil and/or anthracycline and/or taxane-based regimens), or hormonal treatment to radiotherapy; adjuvant treatments (aromatase inhibitors, adjuvant anthracycline regimens, tamoxifen); axillary clearance; axillary dissection plus sentinel node dissection; axillary radiotherapy; axillary sampling; combined chemotherapy plus tamoxifen; chemotherapy plus monoclonal antibody (trastuzumab); extensive surgery; high-dose chemotherapy; hormonal treatment; less extensive mastectomy; less than whole-breast radiotherapy plus breast-conserving surgery; multimodal treatment; ovarian ablation; primary chemotherapy; prolonged adjuvant combination chemotherapy; radiotherapy (after breast-conserving surgery, after mastectomy, plus tamoxifen after breast-conserving surgery, to the internal mammary chain, and to the ipsilateral supraclavicular fossa, and total nodal radiotherapy); sentinel node biopsy; and standard chemotherapy regimens.
Topics: Breast Neoplasms; Chemotherapy, Adjuvant; Humans; Mastectomy; Mastectomy, Segmental; Radiotherapy, Adjuvant; Sentinel Lymph Node Biopsy
PubMed: 21718560
DOI: No ID Found -
European Journal of Surgical Oncology :... Dec 2008Sentinel node biopsy became the standard of care before consensus on the technique was reached and without randomized studies having shown a similar or decreased... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Sentinel node biopsy became the standard of care before consensus on the technique was reached and without randomized studies having shown a similar or decreased axillary recurrence rate. The purpose of this study was to evaluate studies reporting on patients with a negative sentinel node biopsy.
METHODS
We performed a systematic review and meta-analysis of the literature for studies concerning clinically node-negative breast cancer patients with a tumour-negative sentinel node biopsy and no subsequent axillary node dissection. The axillary recurrence rate was determined, as well as the sensitivity of the sentinel node procedure and the differences in lymphatic mapping techniques.
RESULTS
Forty-eight studies concerning 14 959 sentinel node-negative breast cancer patients followed for a median of 34 months were selected. Sixty-seven patients developed an axillary recurrence, resulting in a recurrence rate of 0.3%. The sensitivity of the sentinel node biopsy was 100%. Uni- and multivariable variable analyses showed that the lowest recurrence rates were reported in studies performed in cancer centres, in studies that described the use of (99m)Tc-sulphur colloid, and also when investigators used the superficial injection technique or evaluated the harvested sentinel nodes with haematoxylin-eosin and immunohistochemistry staining (p<0.01).
CONCLUSIONS
In this systematic literature review, the axillary recurrence rate in sentinel node-negative patients is 0.3%, which is well within the desired range. The median sensitivity of the procedure appears to be as high as 100%. The recurrence rate is influenced by the differences in the lymphatic mapping technique.
Topics: Axilla; Breast Neoplasms; False Negative Reactions; Female; Humans; Incidence; Lymph Nodes; Lymphatic Metastasis; Neoplasm Recurrence, Local; Prognosis; Sentinel Lymph Node Biopsy
PubMed: 18406100
DOI: 10.1016/j.ejso.2008.01.034 -
Systematic Reviews Oct 2022The development of risk prediction models for breast cancer lymphedema is increasing, but few studies focus on the quality of the model and its application. Therefore,... (Review)
Review
PURPOSE
The development of risk prediction models for breast cancer lymphedema is increasing, but few studies focus on the quality of the model and its application. Therefore, this study aimed to systematically review and critically evaluate prediction models developed to predict breast cancer-related lymphedema.
METHODS
PubMed, Web of Science, Embase, MEDLINE, CNKI, Wang Fang DATA, Vip Database, and SinoMed were searched for studies published from 1 January 2000 to 1 June 2021. And it will be re-run before the final analysis. Two independent investigators will undertake the literature search and screening, and discrepancies will be resolved by another investigator. The Prediction model Risk Of Bias Assessment Tool will be used to assess the prediction models' risk of bias and applicability.
RESULTS
Seventeen studies were included in the systematic review, including 7 counties, of which 6 were prospective studies, only 7 models were validation studies, and 4 models were externally validated. The area under the curve of 17 models was 0.680~0.908. All studies had a high risk of bias, primarily due to the participants, outcome, and analysis. The most common predictors included body mass index, radiotherapy, chemotherapy, and axillary lymph node dissection.
CONCLUSIONS
The predictive factors' strength, external validation, and clinical application of the breast cancer lymphedema risk prediction model still need further research. Healthcare workers should choose prediction models in clinical practice judiciously.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42021258832.
Topics: Breast Cancer Lymphedema; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphedema; Prospective Studies
PubMed: 36229876
DOI: 10.1186/s13643-022-02084-2 -
Annals of Surgical Oncology Aug 2020Several randomized controlled trials (RCTs) have investigated observation or axillary radiotherapy (ART) in place of completion axillary lymph node dissection (cALND)...
Comparing Observation, Axillary Radiotherapy, and Completion Axillary Lymph Node Dissection for Management of Axilla in Breast Cancer in Patients with Positive Sentinel Nodes: A Systematic Review.
PURPOSE
Several randomized controlled trials (RCTs) have investigated observation or axillary radiotherapy (ART) in place of completion axillary lymph node dissection (cALND) for management of positive sentinel nodes (SNs) in clinically node-negative women with breast cancer. The optimal treatment strategy for this population is not known.
METHODS
MEDLINE, Embase, and EBM Reviews-NHS Economic Evaluation Database were searched from inception until July 2019. A systematic review and narrative summary was performed of RCTs comparing observation or ART versus cALND in clinically node-negative female breast cancer patients with positive SNs. The Cochrane risk of bias tool for RCTs was used to assess risk of bias. Outcomes of interest included overall survival (OS), disease-free survival (DFS), axillary recurrence, and axillary surgery-related morbidity.
RESULTS
Three trials compared observation with cALND, and two trials compared ART with cALND. No studies blinded participants or personnel, and there was heterogeneity in inclusion criteria, study design, and follow-up. Neither observation nor ART resulted in statistically inferior 5- or 8-year OS or DFS compared with cALND. There was also no statistically significant increase in axillary recurrences associated with either approach. Four trials reported morbidity outcomes, and all showed cALND was associated with significantly more lymphedema, paresthesia, and shoulder dysfunction compared with observation or ART.
CONCLUSIONS
Women with clinically node-negative breast cancer and positive SNs can safely be managed without cALND.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Randomized Controlled Trials as Topic; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Watchful Waiting
PubMed: 32020394
DOI: 10.1245/s10434-020-08225-y -
The British Journal of Surgery Feb 2016Axillary reverse mapping (ARM) assesses the lymphatic drainage of the arm simultaneously with that of the breast, enabling preservation of arm lymphatics during axillary... (Review)
Review
BACKGROUND
Axillary reverse mapping (ARM) assesses the lymphatic drainage of the arm simultaneously with that of the breast, enabling preservation of arm lymphatics during axillary surgery for breast cancer. This article systematically reviews the evidence on the lymphoedema rate and oncological safety of the ARM technique.
METHODS
PubMed, Embase and the Cochrane Library were searched systematically for studies that addressed the use of ARM during axillary surgery in breast cancer. Studies were eligible if they performed ARM during sentinel node biopsy (SNB) or axillary node clearance (ANC) for breast cancer in prospective studies of more than 50 patients, with assessment of lymphoedema and oncological outcomes during a minimum follow-up of 6 months.
RESULTS
Eight studies reported data on ARM in 1142 patients undergoing axillary surgery for breast cancer. Lymphoedema rates ranged from 0 to 6 per cent during ARM-assisted SNB, and from 5.9 to 24 per cent during ARM lymphatic preservation at ANC. Crossover nodes between the arm and breast lymphatics were identified in 0-10 per cent of patients, and metastases were present in 0-20 per cent of these patients. ARM nodes were not preserved in between 11 and 18 per cent of patients with ARM nodes identified, and metastases were detected in 0-19 per cent of these patients.
CONCLUSION
ARM can achieve low rates of lymphoedema, but the risk of metastasis in crossover and clinically suspicious ARM nodes, or those in close proximity to an involved sentinel node, warrants their excision.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Prognosis; Sentinel Lymph Node Biopsy
PubMed: 26661686
DOI: 10.1002/bjs.10041 -
European Journal of Surgical Oncology :... Mar 2011Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) are used to assess axillary nodal status in breast cancer, but are invasive procedures... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) are used to assess axillary nodal status in breast cancer, but are invasive procedures associated with morbidity, including lymphoedema. This systematic review evaluates the diagnostic accuracy of positron emission tomography (PET), with or without computed tomography (CT), for assessment of axillary nodes in early breast cancer.
METHODS
Eleven databases including MEDLINE, EMBASE and the Cochrane Library, plus research registers and conference proceedings, were searched in April 2009. Study quality was assessed using the QUality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist. Sensitivity and specificity were meta-analysed using a bivariate random effects approach.
RESULTS
Across 26 studies evaluating PET or PET/CT (n = 2591 patients), mean sensitivity was 63% (95% CI: 52-74%; range 20-100%) and mean specificity 94% (95% CI: 91-96%; range 75-100%). Across 7 studies of PET/CT (n = 862), mean sensitivity was 56% (95% CI: 44-67%) and mean specificity 96% (90-99%). Across 19 studies of PET-only (n = 1729), mean sensitivity was 66% (50-79%) and mean specificity 93% (89-96%). Mean sensitivity was 11% (5-22%) for micrometastases (≤2 mm; five studies; n = 63), and 57% (47-66%) for macrometastases (>2 mm; four studies; n = 111).
CONCLUSIONS
PET had lower sensitivity and specificity than SLNB. Therefore, replacing SLNB with PET would avoid the adverse effects of SLNB, but lead to more false negative patients at risk of recurrence and more false positive patients undergoing unnecessary ALND. The present evidence does not support the routine use of PET or PET-CT for the assessment of the clinically negative axilla.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymphatic Metastasis; Neoplasm Staging; Positron-Emission Tomography; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Tomography, X-Ray Computed
PubMed: 21269795
DOI: 10.1016/j.ejso.2011.01.003 -
Surgical Oncology Jun 2022Given numerous publications and clinical trials regarding axillary management in breast cancer, we sought to summarize this complex literature to help clarify this field... (Review)
Review
BACKGROUND
Given numerous publications and clinical trials regarding axillary management in breast cancer, we sought to summarize this complex literature to help clarify this field for clinicians. This systematic review focuses on the role of irradiation of the axillary nodes (locoregional nodal irradiation [LRNI]) in the management of the axilla in patients with early-stage breast cancer in various clinical settings.
METHODS
We searched MEDLINE and EMBASE databases, the Cochrane library, the proceedings of the ASCO, the ASTRO, the ESMO, the ESTRO, and the San Antonio Breast Cancer Symposium (2016-2019) meetings. The quality of the studies was assessed with design-specific tools. The study was registered in PROSPERO.
RESULTS
We included one systematic review, one individual patient data (IPD) meta-analysis, and five randomized controlled trials (RCTs). After axillary lymph node dissection (ALND), LRNI resulted in small benefits in breast cancer specific mortality, locoregional recurrence, and distant metastases-free survival but not overall survival. After a positive sentinel node biopsy (SLNB), LRNI may provide equivalent locoregional control and disease-free survival (DFS) compared to ALND with a lower risk of lymphedema. No randomized data is available for the neoadjuvant setting.
CONCLUSIONS
The summary of the role of radiation, is relevant to radiation oncologists for choosing the correct cohort of patient requiring LRNI and to surgeons making clinical decisions regarding the timing and type of breast reconstruction offered to patients.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Sentinel Lymph Node Biopsy
PubMed: 35550974
DOI: 10.1016/j.suronc.2022.101754 -
PloS One 2016The axillary reverse mapping (ARM) technique has recently been developed to prevent lymphedema by preserving the arm lymphatic drainage during sentinel lymph node biopsy... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The axillary reverse mapping (ARM) technique has recently been developed to prevent lymphedema by preserving the arm lymphatic drainage during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) procedures. The objective of this systematic review and meta-analysis was to evaluate the feasibility and oncological safety of ARM.
METHODS
We searched Medline, Embase, Web of science, Scopus, and the Cochrane Library for relevant prospective studies. The identification rate of ARM nodes, the crossover rate of SLN-ARM nodes, the proportion of metastatic ARM nodes, and the incidence of complications were pooled into meta-analyses by the random-effects model.
RESULTS
A total of 24 prospective studies were included into meta-analyses, of which 11 studies reported ARM during SLNB, and 18 studies reported ARM during SLNB. The overall identification rate of ARM nodes was 38.2% (95% CI 32.9%-43.8%) during SLNB and 82.8% (78.0%-86.6%) during ALND, respectively. The crossover rate of SLN-ARM nodes was 19.6% (95% CI 14.4%-26.1%). The metastatic rate of ARM nodes was 16.9% (95% CI 14.2%-20.1%). The pooled incidence of lymphedema was 4.1% (95% CI 2.9-5.9%) for patients undergoing ARM procedure.
CONCLUSIONS
The ARM procedure was feasible during ALND. Nevertheless, it was restricted by low identification rate of ARM nodes during SLNB. ARM was beneficial for preventing lymphedema. However, this technique should be performed with caution given the possibility of crossover SLN-ARM nodes and metastatic ARM nodes. ARM appeared to be unsuitable for patients with clinically positive breast cancer due to oncological safety concern.
Topics: Arm; Axilla; Breast Neoplasms; Coloring Agents; Feasibility Studies; Female; Humans; Injections, Intradermal; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Lymphatic System; Lymphatic Vessels; Lymphedema; Preoperative Care; Prospective Studies; Sentinel Lymph Node Biopsy
PubMed: 26919589
DOI: 10.1371/journal.pone.0150285 -
Annals of Surgery Mar 2019The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND. (Meta-Analysis)
Meta-Analysis
Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer: A Systematic Review and Meta-analysis.
OBJECTIVE
The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND.
SUMMARY OF BACKGROUND DATA
Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity.
METHODS
PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV).
RESULTS
Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%.
CONCLUSION
Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Minimally Invasive Surgical Procedures; Neoadjuvant Therapy; Neoplasm Staging
PubMed: 30312200
DOI: 10.1097/SLA.0000000000003075 -
World Journal of Surgery Oct 2023The omission of axillary lymph node dissection (ALND) in patients with breast cancer who have metastatic sentinel lymph nodes (SLNs) undergoing mastectomy remains... (Meta-Analysis)
Meta-Analysis Review
Can Axillary Lymph Node Dissection be Omitted in Breast Cancer Patients with Metastatic Sentinel Lymph Nodes Undergoing Mastectomy? A Systematic Review and Meta-Analysis of Real-World Evidence.
BACKGROUND
The omission of axillary lymph node dissection (ALND) in patients with breast cancer who have metastatic sentinel lymph nodes (SLNs) undergoing mastectomy remains controversial. This meta-analysis explored the clinicopathological factors affecting the selection of ALND and the influences of ALND on survival outcomes in patients receiving mastectomy with positive SLNs.
METHODS
Eligible studies published prior to 31 December 2022 were selected by searching the Embase, Web of Science and PubMed databases. Pooled analyses were performed using the number of events for clinicopathological parameters and HRs with 95% CIs for survival outcomes including disease-free survival (DFS), overall survival (OS), distant recurrence-free survival (DRFS) and locoregional recurrence-free survival (LRFS).
RESULTS
A total of 10 retrospective studies enrolling only breast cancer patients with limited SLN metastases (no more than 3 positive SLNs or micrometastatic SLNs) undergoing mastectomy were included. Performing ALND in mastectomy patients who had limited SLN metastases was significantly correlated with invasive ductal carcinomas, larger tumors, lymphovascular invasion, higher tumor grade, macrometastatic SLNs, more positive SLNs, extranodal extension, positive surgical margins, negative ER, administration of adjuvant chemotherapy and nonwhite race (P < 0.05). However, performing ALND did not result in significantly longer OS, DFS, LRFS or DRFS (P > 0.05) in these patients.
CONCLUSION
The present meta-analysis indicated that ALND may be safely avoided in patients with breast cancer who had limited SLN metastases undergoing mastectomy. Further well-designed randomized clinical trials are warranted to validate our results.
Topics: Humans; Female; Breast Neoplasms; Sentinel Lymph Node; Mastectomy; Sentinel Lymph Node Biopsy; Retrospective Studies; Lymphatic Metastasis; Axilla; Lymph Node Excision
PubMed: 37249632
DOI: 10.1007/s00268-023-07072-8