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Asian Pacific Journal of Cancer... Aug 2022Currently, the standard method for staging and treatment of axillary lymph nodes for early-stage breast cancer is sentinel lymph node biopsy (SLNB), while axillary lymph... (Meta-Analysis)
Meta-Analysis
Comparing Early-Stage Breast Cancer Patients with Sentinel Lymph Node Metastasis with and without Completion Axillary Lymph Node Dissection: A Systematic Review and Meta-Analysis.
BACKGROUND
Currently, the standard method for staging and treatment of axillary lymph nodes for early-stage breast cancer is sentinel lymph node biopsy (SLNB), while axillary lymph node dissection (ALND) is used in cases with palpable axillary lymph nodes or positive SLNB cases. The aim of this review was to compare overall survival (OS), disease-free survival (DFS), and axillary recurrence in early-stage breast cancer patients underwent SLNB or SLNB and completion ALND.
METHODS
The databases of PubMed, Scopus, and Cochrane Library were searched using the key words of "breast cancer", "axillary lymph node dissection", and "sentinel lymph node dissection". In addition, other sources were searched for ongoing studies (i.e., clinicaltrials.gov). The clinical trials were evaluated based on the Jadad quality criteria, and cohort studies were evaluated according to the STROBE criteria. At the end of the search, the articles were screened independently by two reviewers to check their eligibility to be included in the study. Afterwards, the data were extracted independently by two researchers.
RESULTS
After searching the databases, 169 papers were retrieved. However, after removing the duplicates and studying the titles and abstracts of these papers, only ten ones underwent further investigation. After reading full-text of each article, four studies were finalized. Following a manual search, 27 papers were entered into the study for the final evaluation, 11 of which were included in the meta-analysis based on the inclusion and exclusion criteria. The findings showed no significant differences in OS, DFS, and axillary recurrence in early-stage breast cancer patients underwent SLNB or SLNB and completion ALND.
CONCLUSION
The findings did not confirm that ALND improved OS, DFS, and axillary recurrence in patients who were clinically node-negative and positive SLNB.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 36037108
DOI: 10.31557/APJCP.2022.23.8.2561 -
Annals of Surgery Apr 2023To evaluate the impact of axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) on upper limb (UL) morbidity in breast cancer patients. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To evaluate the impact of axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) on upper limb (UL) morbidity in breast cancer patients.
BACKGROUND
Axillary de-escalation is motivated by a desire to reduce harm of ALND. Understanding the impact of axillary surgery and disparities in operative procedures on postoperative arm morbidity would better direct resources to the point of need and cement the need for de-escalation strategies.
METHODS
Embase, MEDLINE, CINAHL, and PsychINFO were searched from 1990 until March 2020. Included studies were randomized-controlled and observational studies focusing on UL morbidities, in breast surgery patients. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of UL morbidity comparing SLNB and ALND at <12 months, 12 to 24 months, and beyond 24 months were analyzed.
RESULTS
Sixty-seven studies were included. All studies reported a higher rate of lymphedema and pain after ALND compared with SLNB. The difference in lymphedema and pain prevalence between SLNB and ALND was 13.7% (95% confidence interval: 10.5-16.8, P <0.005) and 24.2% (95% confidence interval: 12.1-36.3, P <0.005), respectively. Pooled estimates for prevalence of reduced strength and range of motion after SLNB and ALND were 15.2% versus 30.9% and 17.1% versus 29.8%, respectively. Type of axillary surgery, greater body mass index, and radiotherapy were some of the predictors for UL morbidities.
CONCLUSIONS
Prevalence of lymphedema after ALND was higher than previously estimated. ALND patients experienced greater rates of lymphedema, pain, reduced strength, and range of motion compared with SLNB. The findings support the continued drive to de-escalate axillary surgery.
Topics: Humans; Female; Sentinel Lymph Node Biopsy; Breast Neoplasms; Lymph Node Excision; Morbidity; Lymphedema; Axilla; Pain; Lymph Nodes; Sentinel Lymph Node; Randomized Controlled Trials as Topic
PubMed: 35946806
DOI: 10.1097/SLA.0000000000005671 -
Scientific Reports Jun 2022Seroma or lymphocele remains the most common complication after mastectomy and lymphadenectomy for breast cancer. Many different techniques are available to prevent this... (Meta-Analysis)
Meta-Analysis
Seroma or lymphocele remains the most common complication after mastectomy and lymphadenectomy for breast cancer. Many different techniques are available to prevent this complication: wound drainage, reduction of the dead space by flap fixation, use of various types of energy, external compression dressings, shoulder immobilization or physical activity, as well as numerous drugs and glues. We searched MEDLINE, clinicaltrials.gov, Cochrane Library, and Web of Science databases for publications addressing the issue of prevention of lymphocele or seroma after mastectomy and axillary lymphadenectomy. Quality was assessed using Hawker's quality assessment tool. Incidence of seroma or lymphocele were collected. Fifteen randomized controlled trials including a total of 1766 patients undergoing radical mastectomy and axillary lymphadenectomy for breast cancer were retrieved. The incidence of lymphocele or seroma in the study population was 24.2% (411/1698): 25.2% (232/920) in the test groups and 23.0% (179/778) in the control groups. Neither modification of surgical technique (RR 0.86; 95% CI [0.72, 1.03]) nor application of a medical treatment (RR 0.96; 95% CI [0.72, 1.29]) was effective in preventing lymphocele. On the contrary, decreasing the drainage time increased the risk of lymphocele (RR 1.88; 95% CI [1.43, 2.48). There was no publication bias but the studies were of medium to low quality. To conclude, despite the heterogeneity of study designs, drainage appears to be the most effective technique, although the overall quality of the data is low.
Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphocele; Mastectomy; Postoperative Complications; Seroma
PubMed: 35705655
DOI: 10.1038/s41598-022-13831-9 -
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 -
Indian Journal of Plastic Surgery :... Feb 2022Several studies have proven prophylactic lymphovenous anastomosis (LVA) performed after lymphadenectomy can potentially reduce the risk of cancer-related lymphedema...
Several studies have proven prophylactic lymphovenous anastomosis (LVA) performed after lymphadenectomy can potentially reduce the risk of cancer-related lymphedema (CRL) without compromising the oncological treatment. We present a systematic review of the current evidence on the primary prevention of CRL using preventive lymphatic surgery (PLS). A comprehensive search across PubMed, Cochrane-EBMR, Web of Science, Ovid Medline (R) and in-process, SCOPUS, and ScienceDirect was performed through December 2020. A meta-analysis with a random-effect method was accomplished. Twenty-four studies including 1547 patients fulfilled the inclusion criteria. Overall, 830 prophylactic LVA procedures were performed after oncological treatment, of which 61 developed lymphedema. The pooled cumulative rate of upper extremity lymphedema after axillary lymph node dissection (ALND) and PLS was 5.15% (95% CI, 2.9%-7.5%; < 0.01). The pooled cumulative rate of lower extremity lymphedema after oncological surgical treatment and PLS was 6.66% (95% CI < 1-13.4%, p-value = 0.5). Pooled analysis showed that PLS reduced the incidence of upper and lower limb lymphedema after lymph node dissection by 18.7 per 100 patients treated (risk difference [RD] - 18.7%, 95% CI - 29.5% to - 7.9%; < 0.001) and by 30.3 per 100 patients treated (RD - 30.3%, 95% CI - 46.5% to - 14%; < 0.001), respectively, versus no prophylactic lymphatic reconstruction. Low-quality studies and a high risk of bias halt the formulating of strong recommendations in favor of PLS, despite preliminary reports theoretically indicating that the inclusion of PLS may significantly decrease the incidence of CRL.
PubMed: 35444756
DOI: 10.1055/s-0041-1740085 -
BJS Open Mar 2022Axillary lymph node status remains the most powerful prognostic indicator in invasive breast cancer. Ductal carcinoma in situ (DCIS) is a non-invasive disease and does... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Axillary lymph node status remains the most powerful prognostic indicator in invasive breast cancer. Ductal carcinoma in situ (DCIS) is a non-invasive disease and does not spread to axillary lymph nodes. The presence of an invasive component to DCIS mandates nodal evaluation through sentinel lymph node biopsy (SLNB). Quantification of the necessity of upfront SLNB for DCIS requires investigation. The aim was to establish the likelihood of having a positive SLNB (SLNB+) for DCIS and to establish parameters predictive of SLNB+.
METHODS
A systematic review was performed as per the PRISMA guidelines. Prospective studies only were included. Characteristics predictive of SLNB+ were expressed as dichotomous variables and pooled as odds ratios (o.r.) and associated 95 per cent confidence intervals (c.i.) using the Mantel-Haenszel method.
RESULTS
Overall, 16 studies including 4388 patients were included (mean patient age 54.8 (range 24 to 92) years). Of these, 72.5 per cent of patients underwent SLNB (3156 of 4356 patients) and 4.9 per cent had SLNB+ (153 of 3153 patients). The likelihood of having SLNB+ for DCIS was less than 1 per cent (o.r. <0.01, 95 per cent c.i. 0.00 to 0.01; P < 0.001, I2 = 93 per cent). Palpable DCIS (o.r. 2.01, 95 per cent c.i. 0.64 to 6.24; P = 0.230, I2 = 0 per cent), tumour necrosis (o.r. 3.84, 95 per cent c.i. 0.85 to 17.44; P = 0.080, I2 = 83 per cent), and grade 3 DCIS (o.r. 1.34, 95 per cent c.i. 0.80 to 2.23; P = 0.270, I2 = 0 per cent) all trended towards significance in predicting SLNB+.
CONCLUSION
While aggressive clinicopathological parameters may guide SLNB for patients with DCIS, the absolute and relative risk of SLNB+ for DCIS is less than 5 per cent and 1 per cent, respectively. Well-designed randomized controlled trials are required to establish fully the necessity of SLNB for patients diagnosed with DCIS.
REGISTRATION NUMBER
CRD42021284194 (https://www.crd.york.ac.uk/prospero/).
Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Carcinoma, Intraductal, Noninfiltrating; Female; Humans; Lymphatic Metastasis; Middle Aged; Prospective Studies; Sentinel Lymph Node Biopsy; Young Adult
PubMed: 35380620
DOI: 10.1093/bjsopen/zrac022 -
Archives of Gynecology and Obstetrics Oct 2022Management of regional lymph nodes in breast cancer recurrence has been heterogeneous. To facilitate clinical practice, this review aims to give an overview on the... (Review)
Review
PURPOSE
Management of regional lymph nodes in breast cancer recurrence has been heterogeneous. To facilitate clinical practice, this review aims to give an overview on the prognosis, staging and operative management of (inapparent) regional lymph nodes.
METHODS
Current national and international guidelines are reviewed and a structured search of the literature between Jan 1, 1999 and Feb 1, 2021 on the repeat sentinel node biopsy (re-SNB) procedure was performed.
RESULTS
Positive regional lymph nodes in recurrent breast cancer indicate a poorer outcome with axillary recurrences being the most favorable tumor site among all nodal regions. Most preferred staging method is ultrasound ± guided biopsy. PET-CT, scintimammography, SPECT-CT may improve visualization of affected lymph nodes outside the axilla. Concerning operative management 30 articles on re-SNB were identified with a mean harvesting rate of 66.4%, aberrant drainage and aberrant metastasis in 1/3 of the cases. Total rate of metastasis is 17.9%. After previous axillary dissection (ALND) the re-SNB has a significantly lower harvesting rate and higher aberrant drainage and aberrant metastasis rate. The prognostic outcome after re-SNB has been favorable.
CONCLUSION
Nodal status in recurrent disease has prognostic value. The choice of operative management of clinically inapparent regional lymph nodes during local recurrence should be based on the previous nodal staging method. Patients with previous ALND should be spared a second systematic ALND. Re-SNB or no axillary surgery at all are possible alternatives. Lymphoscintigraphy may be performed to identify extraaxillary drainage. However, for definite recommendations randomized controlled studies are heavily needed.
Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Neoplasm Recurrence, Local; Positron Emission Tomography Computed Tomography; Prognosis; Sentinel Lymph Node Biopsy
PubMed: 35122159
DOI: 10.1007/s00404-021-06352-9 -
Breast Cancer (Tokyo, Japan) Nov 20211. To systematically analyse studies comparing survival outcomes between axillary lymph-node dissection (ALND) and axilla observation (Obs), in women with low-risk,... (Comparative Study)
Comparative Study Meta-Analysis
PURPOSE
1. To systematically analyse studies comparing survival outcomes between axillary lymph-node dissection (ALND) and axilla observation (Obs), in women with low-risk, clinically node-negative breast cancer. 2. To consider results in the context of current axillary surgery de-escalation trials and studies.
METHODS
9 eligible studies were identified, 6 RCTs and 3 non-randomized studies (4236 women in total). Outcomes assessed: overall survival (OS) and disease-free survival (DFS). The logged (ln) hazard ratio (HR) was calculated and used as the statistic of interest. Data was grouped by follow-up.
RESULTS
Meta-analyses found no significant difference in OS at 5, 10 and 25-years follow-up (5-year ln HR = 0.08, 95% CI - 0.09, 0.25, 10-year ln HR = 0.33, 95% CI - 0.07, 0.72, 25-year ln HR = 0.00, 95% CI - 0.18, 0.19). ALND caused improvement in DFS at 5-years follow-up (ln HR = 0.16, 95% CI 0.03, 0.29), this was not demonstrated at 10 and 25-years follow-up (10-year ln HR = 0.07, 95% CI - 0.09, 0.23, 25-year ln HR = - 0.03, 95% CI - 0.21, 0.16). Studies supporting ALND for DFS at 5-years follow-up had greater relative chemotherapy use in the ALND cohort.
CONCLUSION
ALND does not cause a significant improvement in OS in women with clinically node-negative breast cancer. ALND may improve DFS in the short term by tailoring a proportion of patients towards chemotherapy. Our evidence suggests that when the administration of systemic therapy is balanced between the two arms, axillary de-escalation studies will likely find no difference in OS or DFS.
Topics: Aged; Breast Neoplasms; Disease-Free Survival; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Middle Aged; Progression-Free Survival; Watchful Waiting
PubMed: 34241800
DOI: 10.1007/s12282-021-01273-6 -
Cancers Apr 2021use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenectomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this... (Review)
Review
BACKGROUND
use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenectomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this finding applies to the axillary lymphadenectomy.
METHODS
randomized trials evaluating the efficacy of fibrin sealants in reducing axillary lymphatic complications were included. Lymphocele, drainage output, surgical-site complications, and hospital stay were considered as outcomes.
RESULTS
twenty-three randomized studies, including patients undergoing axillary lymphadenectomy for breast cancer, melanoma, and Hodgkin's disease, were included. Fibrin sealants did not affect axillary lymphocele incidence nor the surgical site complications. Drainage output, days with drainage, and hospital stay were reduced when fibrin sealants were applied ( < 0.0001, < 0.005, = 0.008).
CONCLUSION
fibrin sealants after axillary dissection reduce the total axillary drainage output, the duration of drainage, and the hospital stay. No effects on the incidence of postoperative lymphocele and surgical site complications rate are found.
PubMed: 33923153
DOI: 10.3390/cancers13092056 -
Breast Care (Basel, Switzerland) Feb 2021Breast cancer represents the most common type of cancer among women in the world. The presence and extent of axillary lymph node involvement represent an important...
INTRODUCTION
Breast cancer represents the most common type of cancer among women in the world. The presence and extent of axillary lymph node involvement represent an important prognostic factor. Sentinel lymph node biopsy (SLNB) is currently accepted for T1 and T2 with negative axillae (N0); however, many patients with T3-T4b tumors with N0 are often submitted to unnecessarily axillary lymph node dissection.
MATERIALS AND METHODS
This is a retrospective, observational study of patients treated for breast cancer between 2008 and 2015, with T3/T4b tumors and N0, who underwent SLNB. A systematic review of the literature was also carried out in 5 bases.
RESULTS
We analyzed 73 patients, and SLNB was negative for macrometastasis in 60.3% of the cases. With a mean follow-up of 45 months, no ipsilateral axillary local recurrence was observed. In the systematic review, only 7 articles presented data for analysis. Grouping these studies with the present series, the rate of N0 was 32.1% for T3 and 61.0% for T4b; grouping all studies (T3 and T4b = 431) the rate was 32.5%.
CONCLUSIONS
SLNB in T3/T4b tumors is a feasible and safe procedure from the oncological point of view, as it has not been associated with ipsilateral axillary relapse.
PubMed: 33716629
DOI: 10.1159/000504693