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European Journal of Cancer (Oxford,... Mar 2013The Z0011-study, a landmark randomised controlled trial (RCT) challenged the benefits of complete axillary lymph node dissection (ALND) compared with sentinel lymph node... (Review)
Review
BACKGROUND
The Z0011-study, a landmark randomised controlled trial (RCT) challenged the benefits of complete axillary lymph node dissection (ALND) compared with sentinel lymph node dissection only (SLND) in breast cancer patients with positive sentinel nodes. The study, however, has been criticised for lack of power and low applicability. The aim of this review was to systematically assess the evidence on the comparative benefits and harms of ALND versus SLND for sentinel node positive breast cancer patients.
METHODS
We systematically searched PubMed, Embase, the Cochrane Library, and reference lists of pertinent review articles from January 2006 to August 2011. We dually reviewed the literature and rated the risk of bias of each study. For effectiveness, we included RCTs and observational studies of at least 1 year follow-up. In addition, we considered studies conducted in sentinel node-negative women to assess the risk of harms. If data were sufficient, we conducted random effects meta-analysis of outcomes of interest.
RESULTS
Meta-analysis of three studies with 50,120 patients indicated similar 5-year survival and regional recurrence rates between patients treated with ALND or SLND, although prognostic tumour characteristics varied among the 3 study-populations. Results from 6 studies on more than 11,500 patients reported a higher risk for harms for ALND than SLND. Long-term evidence on pertinent health outcomes is missing.
CONCLUSION
The available evidence indicates that for some women with early invasive breast cancer SLND appears to be a justifiable alternative to ALND. Surgeons need to discuss advantages and disadvantages of both approaches with their patients.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Meta-Analysis as Topic; Neoplasm Invasiveness; Sentinel Lymph Node Biopsy
PubMed: 23084155
DOI: 10.1016/j.ejca.2012.09.010 -
Clinical & Translational Oncology :... Sep 2022We conducted a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) after the neoadjuvant chemotherapy, compared to axillary lymph-node... (Review)
Review
PURPOSE
We conducted a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) after the neoadjuvant chemotherapy, compared to axillary lymph-node dissection, in terms of false-negative rate (FNR) and sentinel lymph-node identification rate (SLNIR), sensitivity, negative predictive value (NPV), need for axillary lymph-node dissection (ALND), morbidity, preferences, and costs.
METHODS
MEDLINE, Embase, Scopus, and The Cochrane Library were searched. We assessed the quality of the included systematic reviews using AMSTAR2 tool, and estimated the degree of overlapping of the individual studies on the included reviews.
RESULTS
Six systematic reviews with variable quality were selected. We observed a very high overlapping degree across the included reviews. The FNR and the SLNIR were quite consistent (FNR 13-14%; SLNIR ~ 90% or higher). In women with initially clinically node-negative breast cancer, the FNR was better (6%), with similar SLNIR (96%). The included reviews did not consider the other prespecified outcomes.
CONCLUSIONS
It would be reasonable to suggest performing an SLNB in patients treated with NACT, adjusting the procedure to the previous marking of the affected lymph node, using double tracer, and biopsy of at least three sentinel lymph nodes. More well-designed research is needed. PROSPERO registration number: CRD42020114403.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Neoadjuvant Therapy; Neoplasm Staging; Sentinel Lymph Node Biopsy
PubMed: 35414152
DOI: 10.1007/s12094-022-02824-9 -
Clinical Radiology Nov 2017To evaluate whether contrast-enhanced ultrasound (CEUS)-guided core biopsy of the sentinel lymph node (SLN) could identify metastatic nodes preoperatively and reduce the... (Review)
Review
Preoperative sentinel lymph node identification, biopsy and localisation using contrast enhanced ultrasound (CEUS) in patients with breast cancer: a systematic review and meta-analysis.
AIM
To evaluate whether contrast-enhanced ultrasound (CEUS)-guided core biopsy of the sentinel lymph node (SLN) could identify metastatic nodes preoperatively and reduce the number of surgical SLN biopsies in patients with breast cancer and normal axillary B-mode ultrasound; and to establish whether CEUS SLN identification and localisation is a viable alternative to standard lymphatic mapping using isotope and blue dye.
MATERIALS AND METHODS
A search of several electronic databases was performed and identified studies were assessed using QUADAS-2 for methodological quality. Pooled estimates of sensitivity and specificity for identification of nodal metastases were calculated.
RESULTS
Eleven prospective studies and one retrospective study with 1,520 participants were included. The SLN identification and localisation rate for CEUS-guided skin marking was 70-100%, CEUS guided-wire localisation was 89-97%, and CEUS-guided iodine-125 (I) seed localisation was 60%. Across the four studies that evaluated preoperative CEUS-guided SLN biopsy, pooled sensitivity for identification of nodal metastases was 54% (95% confidence interval [CI]: 47-61) and pooled specificity 100% (95% CI: 99-100).
CONCLUSION
CEUS is a promising technique for preoperative staging of the axilla. CEUS-guided core biopsy has the potential to identify nodal metastases in over half (54%) of patients with normal axillary B-mode ultrasound. CEUS-guided identification and localisation of the SLN may offer a viable alternative to standard lymphatic mapping using isotope and blue dye; however, further prospective studies with larger samples are warranted.
Topics: Breast; Breast Neoplasms; Contrast Media; Humans; Image Enhancement; Preoperative Care; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Ultrasonography, Mammary
PubMed: 28774472
DOI: 10.1016/j.crad.2017.06.121 -
Journal of Advanced Nursing Sep 2010This article is a report of a review of the effectiveness of exercise programmes on shoulder mobility and lymphoedema in postoperative patients with breast cancer having... (Review)
Review
AIM
This article is a report of a review of the effectiveness of exercise programmes on shoulder mobility and lymphoedema in postoperative patients with breast cancer having axillary lymph node dissection, as revealed by randomized controlled trials.
BACKGROUND
Breast cancer is the most common malignancy in women. After surgery, the most common postoperative complications are reduced range of motion in the shoulder, muscle weakness in the upper extremities, lymphoedema, pain and numbness. To reduce these impairments, shoulder exercises are usually prescribed. However, conflicting results regarding the effect and timing of such exercises have been reported. Data sources. Studies were retrieved from a systematic search of published works over the period 2000-2009 indexed in the Cumulative Index to Nursing and Allied Health Literature, Ovid Medline, the British Nursing Index, Proquest, Science Direct, Pubmed, Scopus and the Cochrane Library, using the combined search terms 'breast cancer', 'breast cancer surgery', 'exercise', 'lymphoedema', 'shoulder mobility' and 'randomized controlled trials'.
METHODS
A quantitative review of effectiveness was carried out. Studies were critically appraised by three independent reviewers, and categorized according to levels of evidence defined by the Joanna Briggs Institute.
RESULTS
Six studies were included in the review. Early rather than delayed onset of training did not affect the incidence of postoperative lymphoedema, but early introduction of exercises was valuable in avoiding deterioration in range of shoulder motion.
CONCLUSION
Further studies are required to investigate the optimal time for starting arm exercises after this surgery. Nurses have an important role in educating and encouraging patients to practise these exercises to speed up recovery.
Topics: Arm; Axilla; Body Mass Index; Breast Neoplasms; Exercise Therapy; Female; Humans; Lymph Node Excision; Lymphedema; Middle Aged; Muscle Weakness; Randomized Controlled Trials as Topic; Range of Motion, Articular; Recovery of Function; Severity of Illness Index; Shoulder Joint; Time Factors; Treatment Outcome
PubMed: 20626480
DOI: 10.1111/j.1365-2648.2010.05374.x -
Breast (Edinburgh, Scotland) Oct 2020The axillary reverse mapping (ARM) technique, identify and preserve arm nodes during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), was... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The axillary reverse mapping (ARM) technique, identify and preserve arm nodes during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), was developed to prevent breast-cancer related lymphedema (BCRL) remains controversial.
METHODS
A comprehensive search of Medline Ovid, Pubmed, Web of Science and the Cochrane CENTRAL databases was conducted from the inception till January 2020. The key word including "breast cancer", "axillary reverse mapping", and "lymphedema". Stata 15.1 software was used for the meta-analysis.
RESULTS
As a result, twenty-nine related studies involving 4954 patients met our inclusion criteria. The pooled overall estimate lymphedema incidence was 7% (95% CI 4%-11%, I = 90.35%, P < 0.05), with SLNB showed a relatively lower pooled incidence of lymphedema (2%, 95% CI 1%-3%), I = 26.06%, P = 0.23) than that of ALND (14%, 95% CI 5%-26%, I = 93.28%, P < 0.05) or SLNB and ALND combined (11%, 95% CI 1%-30%). The ARM preservation during ALND procedure could significantly reduce upper extremity lymphedema in contrast with ARM resection (OR = 0.27, 95% CI 0.20-0.36, I = 31%, P = 0.161). Intriguingly, the result favored ALND-ARM over standard-ALND in preventing lymphedema occurrence (OR = 0.21, 95% CI 0.14-0.31, I = 43%, P = 0.153). The risk of metastases in the ARM-nodes was not significantly lower in the patients who had received neoadjuvant chemotherapy, as compared to those without neoadjuvant treatment (OR = 1.20, 95% CI 0.74-1.94, I = 49.4%, P = 0.095).
CONCLUSIONS
ARM was found to significantly reduce the incidence of BCRL. The selection of patients for this procedure should be based on their axillary nodal status. Preoperative neoadjuvant chemotherapy has no significant impact on the ARM lymph node metastasis rate.
Topics: Adult; Aged; Axilla; Breast Cancer Lymphedema; Breast Neoplasms; Female; Humans; Incidence; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Postoperative Complications; Risk Assessment; Sentinel Lymph Node Biopsy
PubMed: 32858404
DOI: 10.1016/j.breast.2020.08.007 -
Clinical Breast Cancer Feb 2018Lymphedema is not uncommon after axillary dissection for breast cancer. Improved survival of patients with breast cancer from advances in adjuvant therapy has resulted...
Lymphedema is not uncommon after axillary dissection for breast cancer. Improved survival of patients with breast cancer from advances in adjuvant therapy has resulted in increased awareness of the quality of life for long-term survivors. Air travel has been postulated as 1 of the risk factors of lymphedema exacerbation. In the present systematic review, we sought to critically evaluate the current data on this topic. The present study was registered in the Research Registry. A systematic review of lymphedema and air travel was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. The Medline, EMBASE, CINAHL, and Cochrane databases were searched for English-language studies up to June 2017 with a predefined strategy. The retrieved studies were independently screened and rated for relevance. Data were extracted by 2 of us. A total of 55 studies were identified using predefined keywords; 12 studies were included using the criteria stated in the study protocol. A pooled analysis of 2051 patients with a history of air travel revealed that ≤ 14.5% developed lymphedema after air flight. However, a subsequent analysis of 4 studies with a control arm showed that 107 of 1189 patients (9%) with a documented history of air travel developed lymphedema compared with 204 of 2356 patients (8.7%) who had not flown (χ test; P = .80). Two studies (1030 patients) evaluated the effect of lymphedema on patients' air travel patterns. Of the 1030 patients, 141 (13.7%) had totally avoided air travel after the development of lymphedema. However, air travel was not adversely associated with the development of lymphedema.
Topics: Air Travel; Breast Neoplasms; Cancer Survivors; Chemotherapy, Adjuvant; Disease Progression; Female; Humans; Lymphedema; Mastectomy; Postoperative Complications; Quality of Life; Sentinel Lymph Node Biopsy; Travel-Related Illness
PubMed: 29157874
DOI: 10.1016/j.clbc.2017.10.011 -
Annals of Surgical Oncology Feb 2021After the publication of the Z0011 trial, the American Society of Clinical Oncology published an updated clinical practice guideline stating that clinicians should not... (Meta-Analysis)
Meta-Analysis
Axillary Management in Women with Early Breast Cancer and Limited Sentinel Node Metastasis: A Systematic Review and Metaanalysis of Real-World Evidence in the Post-ACOSOG Z0011 Era.
BACKGROUND
After the publication of the Z0011 trial, the American Society of Clinical Oncology published an updated clinical practice guideline stating that clinicians should not recommend axillary lymph node dissection (ALND) for early-stage breast cancer patients with the involvement of one or two sentinel lymph nodes (SLNs). However, these recommendations have been challenged because they were mainly based on data from limited studies. The aim of the current study is to systematically compare the real-world outcomes of SLN biopsy (SLNB) alone and SLNB + ALND in patients with early-stage breast cancers and limited positive SLN metastasis in the post-Z0011 era PATIENTS AND METHODS: We searched articles in the PubMed, EMBASE, and Cochrane library databases. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were recurrence rate and the incidence of lymphedema.
RESULTS
One randomized controlled trial and six retrospective studies with 8864 patients were retrieved. For patients with early-stage breast cancer with one or two SLN metastases, receiving SLNB alone showed no significant difference in OS, DFS, and recurrence rate compared with receiving SLNB + ALND. The incidence of lymphedema in patients who received SLNB alone was significantly lower than those who received SLNB + ALND (odds ratio 1.95, 95% confidence interval 1.02-3.71).
CONCLUSIONS
Current real-world evidence proved that the Z0011 strategy is safe with respect to survival outcomes and effective in reducing the incidence of lymphedema. ALND should be avoided in patients with early-stage breast cancer with one or two SLN metastases in the post-Z0011 era.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Neoplasm Recurrence, Local; Randomized Controlled Trials as Topic; Retrospective Studies; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 32705512
DOI: 10.1245/s10434-020-08923-7 -
Cancer Medicine Nov 2022More initial clinical node-positive breast cancer patients achieve axillary pathological complete response (ax-pCR) after neoadjuvant systemic therapy (NST). Restaging... (Meta-Analysis)
Meta-Analysis Review
Diagnostic accuracy of de-escalated surgical procedure in axilla for node-positive breast cancer patients treated with neoadjuvant systemic therapy: A systematic review and meta-analysis.
BACKGROUND
More initial clinical node-positive breast cancer patients achieve axillary pathological complete response (ax-pCR) after neoadjuvant systemic therapy (NST). Restaging axillary status and performing de-escalated surgical procedures to replace routine axillary lymph nodes dissection (ALND) is urgently needed. Targeted axillary lymph node biopsy (TLNB) is a novel de-escalated surgical strategy marking metastatic axillary nodes before NST and targeted dissection and biopsy intraoperatively to tailor individual axillary management.
METHODS
This study provided a systematic review and meta-analysis to evaluate the feasibility and diagnosis accuracy of TLNB. Prospective and retrospective clinical trials on TLNB were searched from Pubmed, Embase, and Cochrane. Identification rate (IFR), false-negative rate (FNR), negative predictive value (NPV), and rate of ax-pCR were the outcomes of this meta-analysis.
RESULTS
One thousand nine hundred and twenty patients attempted TLNB, with an overall IFR of 93.5% (95% confidence interval [CI] 90.1%-96.2%). IFR of three nodal marking methods, namely iodine seeds, clips, and carbon dye, was 95.6% (95% CI 91.2%-98.7%), 91.7% (95% CI 87.3%-95.4%), and 97.1% (95% CI 89.1%-100.0%), respectively. Of them, 847 patients received ALND, with an overall FNR of 5.5% (95% CI 3.3%-8.0%), and NPV ranged from 90.1% to 96.1%. Regression analysis showed that the overlap of targeted and sentinel biopsied nodes might associate with IFRs and FNRs.
CONCLUSION
TLNB is a novel, less invasive surgical approach to distinguish initial node-positive breast cancer that achieves negative axillary conversion after NST. It yields an excellent IFR with a low FNR and a high NPV. A combination of preoperative imaging, intraoperative TLNB with SLNB, and postoperative nodal radiotherapy might affect the future treatment paradigm of primary breast cancer with nodal metastases.
Topics: Humans; Female; Axilla; Neoadjuvant Therapy; Breast Neoplasms; Sentinel Lymph Node Biopsy; Prospective Studies; Retrospective Studies; Lymphatic Metastasis; Lymph Node Excision; Lymph Nodes; Neoplasm Staging
PubMed: 35502768
DOI: 10.1002/cam4.4769 -
The British Journal of Surgery Mar 2014One-step nucleic acid amplification (OSNA) is a new rapid assay for detecting breast cancer metastases during surgery, saving a second procedure for patients requiring... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
One-step nucleic acid amplification (OSNA) is a new rapid assay for detecting breast cancer metastases during surgery, saving a second procedure for patients requiring an axillary clearance. Many centres in the UK and abroad have adopted OSNA in place of routine histopathology, despite no published meta-analysis. The aim of this systematic review and meta-analysis was to determine whether intraoperative OSNA for lymph node assessment is comparable to routine histopathology in the detection of clinically relevant metastases.
METHODS
PubMed, Embase, Web of Knowledge and regional databases were searched for relevant studies published before December 2012. Included studies compared OSNA and standard histology using fresh lymph nodes that were assessed in a clearly defined systematic manner in accordance with the index study.
RESULTS
Twelve eligible studies were identified that included 5057 lymph nodes from 2192 patients. Although meta-analysis using a random-effects model showed a similar overall proportion of macrometastases detected (429 of 3234 versus 432 of 3234; odds ratio 0·99, 95 per cent confidence interval 0·86 to 1·15), analysis of concordance showed that the pooled positive predictive value for detecting macrometastases was 0·79. This suggests that up to 21 per cent of patients found to have macrometastases using OSNA would have an axillary clearance when histology would have classified the deposits as non-macrometastases. Furthermore, analysis of data from the index publication showed that the range of cytokeratin 19 titres for tumours of a given volume is too wide to predict tumour size.
CONCLUSION
OSNA has an unacceptably low positive predictive value, leading to axillary clearances that would not be recommended if standard histology had been used to assess the sentinel node.
Topics: Breast Neoplasms; Female; Humans; Intraoperative Care; Keratin-19; Lymph Nodes; Lymphatic Metastasis; Nucleic Acid Amplification Techniques; Sensitivity and Specificity; Sentinel Lymph Node Biopsy
PubMed: 24536007
DOI: 10.1002/bjs.9386 -
British Medical Bulletin Dec 2021Winged scapula (WS) is a critical complication of axillary surgery in patients treated for breast cancer, and is associated with pain, impairment of the upper... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Winged scapula (WS) is a critical complication of axillary surgery in patients treated for breast cancer, and is associated with pain, impairment of the upper extremity's function and poor performance in daily activities.
SOURCES OF DATA
A systematic review and meta-analysis were performed following the PRISMA guidelines. Two independent reviewers searched PubMed, Embase and Virtual Health Library databases from January 1, 2000 to December 1, 2020. Clinical studies evaluating the diagnosis and epidemiology of WS among breast cancer surgery (BCS) patients were included.
AREAS OF AGREEMENT
The diagnosis of WS relies almost entirely on physical assessment. Studies have suggested a high variability in the report of the incidence of WS given the subjectivity of its diagnosis, and the different criteria used during clinical assessment.
AREAS OF CONTROVERSY
The diagnosis of WS in BCS patients remains a challenge given the lack of standardized diagnostic protocols. Physical examination cannot rely on one manoeuvre only, as it may overlook patients with subtle injuries or overweight and contributing to the underreporting of its incidence.
GROWING POINTS
BCS patients undergoing axillary lymph node dissection experience a significantly higher incidence of WS than those undergoing sentinel lymph node dissection. The global incidence of WS after BCS is 16.79%. Additionally, the anterior flexion test and the push-up test are the most commonly performed diagnostic manoeuvers.
AREAS TIMELY FOR DEVELOPING RESEARCH
Further studies should aim for objective diagnostic tests, especially when the condition is not evident.
Topics: Axilla; Breast Neoplasms; Female; Humans; Incidence; Lymph Node Excision; Scapula; Sentinel Lymph Node Biopsy
PubMed: 34471931
DOI: 10.1093/bmb/ldab021