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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 -
JAMA Surgery Aug 2020Overtreatment of early-stage breast cancer results in increased morbidity and cost without improving survival. Major surgical organizations participating in the Choosing...
IMPORTANCE
Overtreatment of early-stage breast cancer results in increased morbidity and cost without improving survival. Major surgical organizations participating in the Choosing Wisely campaign identified 4 breast cancer operations as low value: (1) axillary lymph node dissection for limited nodal disease in patients receiving lumpectomy and radiation, (2) re-excision for close but negative lumpectomy margins for invasive cancer, (3) contralateral prophylactic mastectomy in patients at average risk with unilateral cancer, and (4) sentinel lymph node biopsy in women 70 years or older with hormone receptor-positive cancer.
OBJECTIVE
To evaluate the extent to which these procedures have been deimplemented, determine the implications of decreased use, and recognize possible barriers and facilitators to deimplementation.
EVIDENCE REVIEW
A systematic review of published literature on use trends in breast surgery was performed in accordance with PRISMA guidelines. The Ovid, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for original research with relevance to the Choosing Wisely recommendations of interest. Eligible studies were examined for data about use, and any patient-level, clinician-level, or system-level factors associated with use.
FINDINGS
Concordant with recommendations, national rates of axillary lymph node dissection for patients with limited nodal disease have decreased by approximately 50% (from 44% in 2011 to 30% to 34% in 2012 and 25% to 28% in 2013), and national rates of lumpectomy margin re-excision have decreased by nearly 40% (from 16% to 34% before to 14% to 18% after publication of a consensus statement). Conversely, national rates of contralateral prophylactic mastectomy continue to rise each year, accounting for up to 30% of all mastectomies for breast cancer (range in all mastectomy cases: 2010-2012, 28%-30%; 1998, <2%), and rates of sentinel lymph node biopsy in women 70 years or older with low-risk breast cancer are persistently greater than 80% (range, 80%-88%). Factors associated with high rates of contralateral prophylactic mastectomy use are younger age, white race, increased socioeconomic status, and the availability of breast reconstruction; limited data exist on factors associated with high rates of sentinel lymph node biopsy in women 70 years or older. Successful deimplementation of axillary lymph node dissection and lumpectomy margin re-excision were associated with decreased costs and improved patient-centered outcomes.
CONCLUSIONS AND RELEVANCE
This review demonstrates variable deimplementation of 4 low-value surgical procedures in patients with breast cancer. Addressing specific patient-level, clinician-level, and system-level barriers to deimplementation is necessary to encourage shared decision-making and reduce overtreatment.
Topics: Breast Neoplasms; Clinical Decision-Making; Female; Humans; Mastectomy; Practice Guidelines as Topic; Procedures and Techniques Utilization; Value-Based Health Insurance
PubMed: 32492121
DOI: 10.1001/jamasurg.2020.0322 -
Cirugia Espanola Nov 2020Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in... (Comparative Study)
Comparative Study
Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence.
Topics: Axilla; Biomarkers, Tumor; Breast Neoplasms; Dissection; Female; Humans; Iodine Radioisotopes; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Monitoring, Intraoperative; Neoadjuvant Therapy; Neoplasm Staging; Non-Randomized Controlled Trials as Topic; Observational Studies as Topic; Sentinel Lymph Node Biopsy; Ultrasonography
PubMed: 32386728
DOI: 10.1016/j.ciresp.2020.03.012 -
The Breast Journal Jul 2020
Meta-Analysis
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphoscintigraphy; Radiopharmaceuticals; Sentinel Lymph Node Biopsy
PubMed: 32091643
DOI: 10.1111/tbj.13791 -
European Journal of Surgical Oncology :... Jun 2020Chyle leaks following surgery to the axilla are seldom encountered with an incidence <0.7%. Management varies with no consensus in the literature. Injury to branching...
INTRODUCTION
Chyle leaks following surgery to the axilla are seldom encountered with an incidence <0.7%. Management varies with no consensus in the literature. Injury to branching tributaries of the thoracic duct may require lengthy management at significant cost to patient and clinical team. This paper aims to provide an up-to-date review to support clinical management.
METHODS
The term 'chyle' was combined with 'breast' or 'axilla.' EMBASE, Medline and PubMed database searches were conducted. All papers published in English were included with no exclusion date limits.
RESULTS
51 cases from 31 papers. All were female (mean age = 53.3yrs). 47/51 leaks were left-sided. 5/51 underwent sentinel node biopsy, 19/51 level II axillary node clearance (ANC), 23/51 level III ANC, 5/51 not specified. 59% (30/51) of leaks were identified within 2 postoperative days (mean = 3.3days). 96% initially managed conservatively: Drain = 38/51; low-fat diet = 34/51; compression bandaging = 20/51; Aspiration = 6/51. 40/51 (78%) were successfully managed conservatively, 11 patients returned to theater for secondary management. 7/11 recorded volumes >500mls/24 hrs before secondary surgery. Mean resolution time from initial surgery was 17.3days (range = 4-64days). No statistically significant difference (p = 0.72) in time to resolution between conservatively and surgically managed patients.
CONCLUSIONS
Chyle leaks are rarely seen following axillary surgery. Aberrant thoracic duct anatomy represents the likeliest aetiology. We advocate early recognition and tailored individual management. Conservative management with non-suction drainage, low-fat diet and axillary compression bandaging appear effective where output <500ml/24 hrs. Secondary surgical management should be considered in high chylous output (<500mls/24 hrs) patients unresponsive to conservative measures. We propose a management algorithm to aide clinicians.
Topics: Chylous Ascites; Disease Management; Drainage; Global Health; Humans; Incidence; Lymph Node Excision; Postoperative Complications; Thoracic Duct
PubMed: 32033823
DOI: 10.1016/j.ejso.2020.01.029 -
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 -
Plastic and Reconstructive Surgery Feb 2020Injuries to the upper extremity lymphatic system from cancer may require measures to prevent secondary lymphedema. Guidelines were established relating to the use of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Injuries to the upper extremity lymphatic system from cancer may require measures to prevent secondary lymphedema. Guidelines were established relating to the use of tourniquet and elective hand and upper extremity surgery. However, reports in the setting of hand surgery have indicated that prior guidelines may not be protective to the patient.
METHODS
The study systematically reviewed the current literature evaluating elective hand surgery in breast cancer patients. The authors evaluated the risk of complications, including new or worsening lymphedema and infection.
RESULTS
One hundred ninety-eight abstracts were identified, and a bibliographic review was performed. Nine studies pertained to our subject, and four were included for final review. All studies included patients with prior breast cancer treatment involving breast surgery and axillary lymph node dissection. Pneumatic tourniquets were used during nearly all operations. Patients without presurgery ipsilateral lymphedema had a 2.7 percent incidence of developing new lymphedema and a 0.7 percent rate of postoperative infection. Patients with presurgery lymphedema had a 11.1 percent incidence of worsening lymphedema and a 16.7 percent rate of infection. However, all cases of new or exacerbated lymphedema resolved within 3 months. Tourniquet use was not found to increase rates of lymphedema.
CONCLUSIONS
Based on the available evidence, there is no increased risk of complications for elective hand surgery in patients with prior breast cancer treatment. Breast cancer patients with preexisting ipsilateral lymphedema carry slightly increased risk of postoperative infection and worsening lymphedema. It is the authors' opinion and recommendation that elective hand surgery with a tourniquet is not a contradiction in patients who have received previous breast cancer treatments.
Topics: Breast Neoplasms; Carpal Tunnel Syndrome; Elective Surgical Procedures; Female; Hand; Humans; Lymph Node Excision; Lymphedema; Mastectomy; Patient Safety; Postoperative Complications; Retrospective Studies; Second-Look Surgery; Sentinel Lymph Node Biopsy; Surgical Wound Infection; Tourniquets; Treatment Outcome
PubMed: 31985641
DOI: 10.1097/PRS.0000000000006438 -
Archives of Gynecology and Obstetrics Feb 2020Data on the optimal treatment strategy for patients undergoing neoadjuvant therapy (NAT) who initially presented with metastatic nodes and convert to node-negative...
Axillary ultrasound for prediction of response to neoadjuvant therapy in the context of surgical strategies to axillary dissection in primary breast cancer: a systematic review of the current literature.
PURPOSE
Data on the optimal treatment strategy for patients undergoing neoadjuvant therapy (NAT) who initially presented with metastatic nodes and convert to node-negative disease (cN+ → ycN0) are limited. Since NAT leads to axillary downstaging in 20-60% of patients, the question arises whether these patients might be offered less-invasive procedures than axillary dissection, such as sentinel node biopsy or targeted removal of lymph nodes marked before therapy.
METHODS
We performed a systematic review of clinical studies on the use of axillary ultrasound for prediction of response to NAT and ultrasound-guided marking of metastatic nodes for targeted axillary dissection.
RESULTS
The sensitivity of ultrasound for prediction of residual node metastasis was higher than that of clinical examination and MRI/PET in most studies; specificity ranged in large trials from 37 to 92%. The diagnostic performance of ultrasound after NAT seems to be associated with tumor subtype: the positive predictive value was highest in luminal, the negative in triple-negative tumors. Several trials evaluated the usefulness of ultrasound for targeted axillary dissection. Before NAT, nodes were most commonly marked using ultrasound-guided clip placement, followed by ultrasound-guided placement of a radioactive seed. After chemotherapy, the clip was detected on ultrasound in 72-83% of patients; a comparison of sonographic visibility of different clips is lacking. Detection rate after radioactive seed placement was ca. 97%.
CONCLUSION
In conclusion, ultrasound improves prediction of axillary response to treatment in comparison to physical examination and serves as a reliable guiding tool for marking of target lymph nodes before the start of treatment. High quality and standardization of the examination is crucial for selection of patients for less-invasive surgery.
Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Ultrasonography
PubMed: 31897672
DOI: 10.1007/s00404-019-05428-x -
Breast (Edinburgh, Scotland) Dec 2019PAST: The role of post-mastectomy radiotherapy (PMRT) in patients with tumor <5 cm and one to three positive lymph nodes after axillary dissection (ALND) is vigorously... (Meta-Analysis)
Meta-Analysis
PAST: The role of post-mastectomy radiotherapy (PMRT) in patients with tumor <5 cm and one to three positive lymph nodes after axillary dissection (ALND) is vigorously debated. Initial doubts over the efficacy and safety of PMRT in these patients were partially overcome by improvement in technology and systemic treatments. Several randomized controlled clinical trials confirmed benefit of PMRT in N1 patients, which were meta-analyzed by the Early Breast Cancer Trialists' Collaborative Group (EBCTCG). This meta-analysis provides the sole high-level evidence to guide clinical decision-making. PRESENT: Nevertheless, concerns have been evoked around these results, most notably concerning the patient selection bias and the era in which the patients were treated. More recent studies, albeit retrospective, are in contrast with this level I evidence, unequivocally reporting inferior recurrence rates in control arms than those of the EBCTCG meta-analysis. Taken together, these results suggest that one solution would not fit all N1 patients and that patient selection for PMRT shall be stratified upon risks factors. Most prominent of such factors identified are: patient age; number and ratio of positive lymph nodes; histological features such as lymphovascular invasion; and hormone receptor expression. FUTURE: A prospective randomized controlled trial SUPREMO will release its final results in 2023 and shed light onto the subject. Genomic tumor cell profiling will likely provide further guidelines in terms of risk stratification. SUPREMO translational sub-study will also offer material for genomic analyses. A cross-field tendency to forgo nodal dissection in favor of sentinel lymph node biopsy followed by nodal irradiation might eventually render the question of PMRT indication after ALND irrelevant.
Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Mastectomy; Radiotherapy, Adjuvant
PubMed: 31561088
DOI: 10.1016/j.breast.2019.09.008 -
World Journal of Surgical Oncology Aug 2019Results from studies of internal mammary lymph node sentinel biopsy are inconsistent. (Meta-Analysis)
Meta-Analysis
PURPOSE
Results from studies of internal mammary lymph node sentinel biopsy are inconsistent.
METHODS
A comprehensive literature search was conducted in MEDLINE, EMBASE, Scopus, Cochrane database, and Clinical Trials. Studies reporting the rate of internal mammary lymph node sentinel biopsy (IMN-SLNB) positivity were identified. We performed pooled proportion meta-analysis using random-effects meta-analyses. The correlation of IMN and axillary lymph node (AXN) metastasis was also investigated.
RESULTS
After application of inclusion and exclusion criteria, a total of 18 articles (total number of patients = 2427) were included. The pooled estimate for IMN-SLNB positivity rate was 15% (95% confidence interval (CI) 12-17%). Significant between-study heterogeneity was observed. Our results indicate that axillary lymph node metastasis is a strong predictor of IMN involvement (OR 6.01, 95% CI, 3.49, 10.34).
CONCLUSION
Internal mammary lymph nodes metastasis might be underestimated. Patients with positive axillary lymph nodes have a higher risk of internal lymph nodes metastasis. As a result, IMN-SLNB might be considered in these patients. Future work needs to be done to assess whether pathological confirmed IMN metastasis can affect patients' survival.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymphatic Metastasis; Sentinel Lymph Node Biopsy
PubMed: 31382973
DOI: 10.1186/s12957-019-1683-8