-
Annals of Plastic Surgery May 2024Supermicrosurgical advances such as lymphovenous bypass (LVB) have enabled effective physiologic treatment of lymphedema affecting the extremities. Reports of surgical...
BACKGROUND
Supermicrosurgical advances such as lymphovenous bypass (LVB) have enabled effective physiologic treatment of lymphedema affecting the extremities. Reports of surgical treatment for breast lymphedema (BL) are sparse, consisting of case reports and almost exclusively LVB. We report our experience with BL, including a case of mastectomy and breast reconstruction with abdominal free flap and inguinal vascularized lymph node transfer (VLNT) for BL. We compare our series with the surgical literature to discern unique characteristics and treatment limitations inherent to this disease.
METHODS
A database was prospectively maintained from September 2020 to May 2023 including all patients diagnosed with BL who were referred to our institution. Breast lymphedema was diagnosed using clinical criteria, and relevant patient data were recorded. Patients interested in surgical management underwent indocyanine green lymphography to determine candidacy for LVB or other interventions. All patients, including those surgically managed, were treated with complex decongestive therapy.
RESULTS
Nine patients with BL were included. Eight had undergone breast-conserving therapy for breast cancer with whole breast irradiation. One patient was treated for Hodgkin lymphoma with axillary lymphadenectomy and axillary radiation. Indocyanine green lymphography was performed in 6 patients, of which 4 patients had diffuse dermal backflow. Two patients had lymphatic targets suitable for LVB, including the patient without breast irradiation. Three patients were managed surgically. One patient without bypass targets underwent breast reduction with partial symptomatic relief, later followed by a mastectomy with abdominal free flap reconstruction and VLNT. Two patients with suitable bypass targets underwent LVB, with resolution of breast swelling and subjective symptoms.
CONCLUSIONS
The diffuse lymphatic obliteration due to radiation field effect in BL results in a distinct pathophysiology compared with extremity lymphedema. Although published reports of surgical BL treatment almost exclusively describe LVB, other surgical options may be more frequently required. Ablative strategies such as mastectomy and regenerative techniques such as VLNT should be considered potential first-line treatment options for these patients.
Topics: Humans; Female; Middle Aged; Adult; Lymphedema; Mammaplasty; Mastectomy; Breast Neoplasms; Aged; Lymphography; Free Tissue Flaps
PubMed: 38689412
DOI: 10.1097/SAP.0000000000003817 -
La Radiologia Medica Jun 2024Data from recently trials have provided practice-changing recommendations in management of the axilla in early breast cancer (eBC). However, further controversies have... (Review)
Review
PURPOSE
Data from recently trials have provided practice-changing recommendations in management of the axilla in early breast cancer (eBC). However, further controversies have been raised, resulting in heterogeneous diffusion of these recommendations. Our purpose was to obtain a better homogeneity.
MATERIAL AND METHODS
In 2021, the Tuscan Breast Network (TBN) established a consensus with the aim to update recommendations in this area. We performed a literature review on axillary management in eBC patients which led to an expert Delphi consensus aiming to explore the gray areas, build consensus and propose evidence-based suggestions for an appropriate management. Thereafter, we investigate their implementation in clinical practice.
RESULTS
(1) DCIS patients should have SLN biopsy only in case of mastectomy or in conservative surgery if tumor is in a location that would preclude future nodal sampling or in case of a mass; (2) ALND may be omitted for 1-2 positive SLN patients undergoing BCS in T1-2 tumors with 1-2 SLN positive, eligible for whole-breast irradiation and adjuvant systemic therapies; (3) consider the option of RNI in patients with 1-3 positive lymph nodes and one or more high-risk characteristics; (4) the population identified in 2) should NOT undergo lymph node irradiation as an alternative to axillary surgery and (5) patients with clinically (pre-operatively) positive axilla, or undergoing primary systemic therapy, or outside the criteria reported in 2) must receive additional ALND and/or RT as per local policy.
CONCLUSION
This consensus provided a practical tool to stimulate local and national breast surgical and radiotherapy protocols.
Topics: Humans; Breast Neoplasms; Axilla; Female; Delphi Technique; Sentinel Lymph Node Biopsy; Italy; Lymph Node Excision; Consensus; Lymphatic Metastasis; Mastectomy
PubMed: 38683499
DOI: 10.1007/s11547-024-01818-7 -
Anticancer Research May 2024In the context of surgical de-escalation in early breast cancer (EBC), this study aimed to evaluate the contrast enhancement ultrasound (CEUS) sentinel lymph node (SLN)...
BACKGROUND/AIM
In the context of surgical de-escalation in early breast cancer (EBC), this study aimed to evaluate the contrast enhancement ultrasound (CEUS) sentinel lymph node (SLN) procedure as a non-invasive axillary staging procedure in EBC in comparison with standard SLN biopsy (SLNB).
PATIENTS AND METHODS
A subanalysis of the AX-CES study, a prospective single-arm, monocentric phase 3 study was performed (EudraCT: 2020-000393-20). The study included patients with EBC undergoing upfront surgery and SLN resection, with no prior history of locoregional treatment, and weighing between 40-85 kg. All patients underwent the CEUS SLN procedure as a non-invasive axillary staging procedure, with CEUS SLN accumulation marked using blue dye. After the CEUS SLN procedure, all patients underwent the standard mapping procedure. Data on success rate, systemic reactions, mean procedure time, mean surgical procedure, mean procedure without axillary staging, CEUS SLN appearance (normal/pathological), SLN number, and concordance with standard mapping procedure were collected.
RESULTS
After the CEUS SLN procedure, 29 LNs among 16 patients were identified and marked. In all cases, CEUS SLN revealed at least one LN enhancement. Six (37.50%) LNs were defined as pathological after the CEUS SLN procedure. Definitive staining of CEUS SLN pathology revealed metastatic involvement in four (66.67%) of the cases. Two SLNs were identified during the CEUS SLN procedure; however, owing to the low disease burden, no change in the surgical plan was reported.
CONCLUSION
The CEUS SLN procedure shows promise as a technique for non-invasive assessment of the axilla, potentially enabling safe axillary de-escalation in EBC by estimating the axillary disease burden.
Topics: Humans; Breast Neoplasms; Female; Contrast Media; Axilla; Neoplasm Staging; Middle Aged; Aged; Prospective Studies; Sentinel Lymph Node Biopsy; Sulfur Hexafluoride; Ultrasonography; Microbubbles; Lymphatic Metastasis; Sentinel Lymph Node; Adult
PubMed: 38677765
DOI: 10.21873/anticanres.17005 -
Anticancer Research May 2024Sentinel lymph node biopsy (SLNB) is effective in patients with breast cancer (BC) and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAC). However,...
BACKGROUND/AIM
Sentinel lymph node biopsy (SLNB) is effective in patients with breast cancer (BC) and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAC). However, the frequency with which axillary lymphadenectomy (ALND) can be avoided remains debated. This study aimed to identify patient populations that can benefit from this approach.
PATIENTS AND METHODS
The data of 195 consecutive patients with BC and positive axillary lymph nodes at diagnosis who underwent NAC were retrospectively analyzed. In all cases, the positivity of the lymph nodes was confirmed by cytological examination. Patients converted to ycN0 after NAC were considered eligible for SLNB. Indications for ALND were failed mapping, fewer than three SLNs recovered, and positive SLNs.
RESULTS
Of 195 cN1 patients potentially eligible for SLNB, 71 (36.4%) remained clinically ycN+ after NAC and underwent elective ALND, while 124 (83.7%) converted to ycN0 after NAC and SLNB. The lymph node identification rate was 95.9% (119/124 patients) with three or more SLNs recovered in 83 cases (89.8%). One or two lymph nodes were recovered in 36 cases (30.2%). Nodal pathologic complete response (pCR) was found in 34/83 (40.9%) patients with three or more SLNs recovered. Considering all 195 patients initially included in the study, 55 patients (28.2%) achieved lymph node pCR after NAC. Nodal pCR varied based on hormone receptor and HER2 status, with rates ranging from 20.7% for ER+/- patients to 95.3% for -/HER2+ patients (p<0.001).
CONCLUSION
More than 80% of cN1 patients in our study were eligible for SLNB after NAC. ALND could be avoided in approximately 30% of cases, supporting the role of NAC in reducing the need for ALND among patients with lymph node metastases.
Topics: Humans; Breast Neoplasms; Female; Neoadjuvant Therapy; Middle Aged; Axilla; Sentinel Lymph Node Biopsy; Aged; Adult; Lymph Node Excision; Lymph Nodes; Retrospective Studies; Lymphatic Metastasis
PubMed: 38677748
DOI: 10.21873/anticanres.17008 -
Scientific Reports Apr 2024We aimed to analyze the risk factors and construct a new nomogram to predict non-sentinel lymph node (NSLN) metastasis for cT1-2 breast cancer patients with positivity...
We aimed to analyze the risk factors and construct a new nomogram to predict non-sentinel lymph node (NSLN) metastasis for cT1-2 breast cancer patients with positivity after sentinel lymph node biopsy (SLNB). A total of 830 breast cancer patients who underwent surgery between 2016 and 2021 at multi-center were included in the retrospective analysis. Patients were divided into training (n = 410), internal validation (n = 298), and external validation cohorts (n = 122) based on periods and centers. A nomogram-based prediction model for the risk of NSLN metastasis was constructed by incorporating independent predictors of NSLN metastasis identified through univariate and multivariate logistic regression analyses in the training cohort and then validated by validation cohorts. The multivariate logistic regression analysis revealed that the number of positive sentinel lymph nodes (SLNs) (P < 0.001), the proportion of positive SLNs (P = 0.029), lymph-vascular invasion (P = 0.029), perineural invasion (P = 0.023), and estrogen receptor (ER) status (P = 0.034) were independent risk factors for NSLN metastasis. The area under the receiver operating characteristics curve (AUC) value of this model was 0.730 (95% CI 0.676-0.785) for the training, 0.701 (95% CI 0.630-0.773) for internal validation, and 0.813 (95% CI 0.734-0.891) for external validation cohorts. Decision curve analysis also showed that the model could be effectively applied in clinical practice. The proposed nomogram estimated the likelihood of positive NSLNs and assisted the surgeon in deciding whether to perform further axillary lymph node dissection (ALND) and avoid non-essential ALND as well as postoperative complications.
Topics: Humans; Breast Neoplasms; Nomograms; Female; Lymphatic Metastasis; Middle Aged; Sentinel Lymph Node Biopsy; Sentinel Lymph Node; Retrospective Studies; Aged; Adult; Risk Factors; ROC Curve; Lymph Nodes
PubMed: 38671007
DOI: 10.1038/s41598-024-60198-0 -
Breast Cancer Research and Treatment Jul 2024Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS)-guided SLNB. This systematic review and meta-analysis evaluate the diagnostic performance of FS-guided SLNB in early breast cancer.
OBJECTIVES
The objective was to evaluate the diagnostic performance of FS for sentinel lymph node biopsy.
METHODS
Eligibility criteria: Studies where SLNB was performed using FS.
INFORMATION SOURCES
PubMed, EMBASE, Cochrane library and online clinical trial registers. Risk of bias: Articles were assessed for risk of bias using the QUADAS-2 tool.
SYNTHESIS OF RESULTS
The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random-effects model.
RESULTS
A total of 45 articles were retrieved by the initial systematic search. 7 out of the 45 studies comprising a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87-0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9-9.07).
CONCLUSION
Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis.
Topics: Humans; Sentinel Lymph Node Biopsy; Breast Neoplasms; Female; Fluorescein; Lymphatic Metastasis; Sentinel Lymph Node; Axilla; Image-Guided Biopsy
PubMed: 38668856
DOI: 10.1007/s10549-024-07310-0 -
JAMA Oncology Jun 2024Data on oncological outcomes after omission of axillary lymph node dissection (ALND) in patients with breast cancer that downstages from node positive to negative with...
IMPORTANCE
Data on oncological outcomes after omission of axillary lymph node dissection (ALND) in patients with breast cancer that downstages from node positive to negative with neoadjuvant chemotherapy are sparse. Additionally, the best axillary surgical staging technique in this scenario is unknown.
OBJECTIVE
To investigate oncological outcomes after sentinel lymph node biopsy (SLNB) with dual-tracer mapping or targeted axillary dissection (TAD), which combines SLNB with localization and retrieval of the clipped lymph node.
DESIGN, SETTING, AND PARTICIPANTS
In this multicenter retrospective cohort study that was conducted at 25 centers in 11 countries, 1144 patients with consecutive stage II to III biopsy-proven node-positive breast cancer were included between April 2013 and December 2020. The cumulative incidence rates of axillary, locoregional, and any invasive (locoregional or distant) recurrence were determined by competing risk analysis.
EXPOSURE
Omission of ALND after SLNB or TAD.
MAIN OUTCOMES AND MEASURES
The primary end points were the 3-year and 5-year rates of any axillary recurrence. Secondary end points included locoregional recurrence, any invasive (locoregional and distant) recurrence, and the number of lymph nodes removed.
RESULTS
A total of 1144 patients (median [IQR] age, 50 [41-59] years; 78 [6.8%] Asian, 105 [9.2%] Black, 102 [8.9%] Hispanic, and 816 [71.0%] White individuals; 666 SLNB [58.2%] and 478 TAD [41.8%]) were included. A total of 1060 patients (93%) had N1 disease, 619 (54%) had ERBB2 (formerly HER2)-positive illness, and 758 (66%) had a breast pathologic complete response. TAD patients were more likely to receive nodal radiation therapy (85% vs 78%; P = .01). The clipped node was successfully retrieved in 97% of TAD cases and 86% of SLNB cases (without localization). The mean (SD) number of sentinel lymph nodes retrieved was 3 (2) vs 4 (2) (P < .001), and the mean (SD) number of total lymph nodes removed was 3.95 (1.97) vs 4.44 (2.04) (P < .001) in the TAD and SLNB groups, respectively. The 5-year rates of any axillary, locoregional, and any invasive recurrence in the entire cohort were 1.0% (95% CI, 0.49%-2.0%), 2.7% (95% CI, 1.6%-4.1%), and 10% (95% CI, 8.3%-13%), respectively. The 3-year cumulative incidence of axillary recurrence did not differ between TAD and SLNB (0.5% vs 0.8%; P = .55).
CONCLUSIONS AND RELEVANCE
The results of this cohort study showed that axillary recurrence was rare in this setting and was not significantly lower after TAD vs SLNB. These results support omission of ALND in this population.
Topics: Humans; Female; Middle Aged; Breast Neoplasms; Lymph Node Excision; Neoadjuvant Therapy; Axilla; Retrospective Studies; Neoplasm Staging; Adult; Sentinel Lymph Node Biopsy; Lymphatic Metastasis; Neoplasm Recurrence, Local; Aged; Lymph Nodes
PubMed: 38662396
DOI: 10.1001/jamaoncol.2024.0578 -
Breast Cancer Research and Treatment Aug 2024To select patients who would benefit most from sentinel lymph node biopsy (SLNB) by investigating the characteristics and risk factors of axillary lymph node metastasis...
PURPOSE
To select patients who would benefit most from sentinel lymph node biopsy (SLNB) by investigating the characteristics and risk factors of axillary lymph node metastasis (ALNM) in microinvasive breast cancer (MIBC).
METHODS
This retrospective study included 1688 patients with MIBC who underwent breast surgery with axillary staging at the Asan Medical Center from 1995 to 2020.
RESULTS
Most patients underwent SLNB alone (83.5%). Seventy (4.1%) patients were node-positive, and the majority had positive lymph nodes < 10 mm, with micro-metastases occurring frequently (n = 37; 55%). Node-positive patients underwent total mastectomy and axillary lymph node dissection (ALND) more than breast-conserving surgery (BCS) and SLNB compared with node-negative patients (p < 0.001). In the multivariate analysis, independent predictors of ALNM included young age [odds ratio (OR) 0.959; 95% confidence interval (CI) 0.927-0.993; p = 0.019], ALND (OR 11.486; 95% CI 5.767-22.877; p < 0.001), number of lymph nodes harvested (≥ 5) (OR 3.184; 95% CI 1.555-6.522; p < 0.001), lymphovascular invasion (OR 6.831; 95% CI 2.386-19.557; p < 0.001), presence of multiple microinvasion foci (OR 2.771; 95% CI 1.329-5.779; p = 0.007), prominent lymph nodes in preoperative imaging (OR 2.675; 95% CI 1.362-5.253; p = 0.004), and hormone receptor positivity (OR 2.491; 95% CI 1.230-5.046; p = 0.011).
CONCLUSION
Low ALNM rate (4.1%) suggests that routine SLNB for patients with MIBC is unnecessary but can be valuable for patients with specific risk factors. Ongoing trials for omitting SLNB in early breast cancer, and further subanalyses focusing on rare populations with MIBC are necessary.
Topics: Humans; Breast Neoplasms; Female; Middle Aged; Lymphatic Metastasis; Axilla; Retrospective Studies; Risk Factors; Sentinel Lymph Node Biopsy; Adult; Aged; Lymph Nodes; Lymph Node Excision; Neoplasm Invasiveness; Mastectomy; Aged, 80 and over
PubMed: 38658448
DOI: 10.1007/s10549-024-07305-x -
World Journal of Surgery Jun 2024Excess and prolonged axillary drainage is a frequent nuisance following axillary lymph node dissection (ALND) in breast cancer patients. No consensus exists about the... (Randomized Controlled Trial)
Randomized Controlled Trial
Efficacy of perioperative systemic tranexamic acid along with topical hemocoagulase in decreasing axillary drain output in breast cancer patients undergoing axillary lymph node dissection: A randomized, double-blind, placebo-controlled, superiority trial.
BACKGROUND
Excess and prolonged axillary drainage is a frequent nuisance following axillary lymph node dissection (ALND) in breast cancer patients. No consensus exists about the best method to prevent this consistently and reliably. Tranexamic acid (TA) has been found to reduce the amount and duration of drainage, but the reduction is not optimal. We hypothesized that systemic administration of TA along with the topical application of hemocoagulase (H) to the axillary dissection bed may decrease the cumulative axillary drain output and shorten the requirement of drainage after ALND as compared to placebo.
PATIENT AND METHODS
Seventy women undergoing ALND for breast carcinoma were randomized into two groups, the intervention (TA + H) group and the control (C) group. The cumulative drain output (primary objective), duration of drainage, incidence of seroma formation after drain removal, number of seroma aspirations required, volume of seroma aspirated, and incidence of surgical site infection (SSI) were compared.
RESULTS
The mean cumulative output in the TA + H group was significantly lower than the C group (290 ± 200 mL vs. 552 ± 369 mL, p < 0.001). Axillary drains were removed significantly earlier in the TA + H group (6.6 ± 2.2 vs. 11.7 ± 6.0 days, p < 0.001), but the incidence of seroma formation (p = 0.34), number of aspirations required (p = 0.33), volume of seroma aspirated (p = 0.47), and the incidence of SSI (p = 0.07) were similar.
CONCLUSIONS
Perioperative systemic administration of tranexamic acid along with topical application of H to the axillary dissection bed is effective in reducing cumulative axillary drain output after ALND. This strategy may also facilitate earlier removal of suction drains.
Topics: Humans; Female; Tranexamic Acid; Lymph Node Excision; Breast Neoplasms; Axilla; Middle Aged; Double-Blind Method; Antifibrinolytic Agents; Drainage; Administration, Topical; Adult; Batroxobin; Seroma; Aged; Treatment Outcome; Perioperative Care; Hemostatics
PubMed: 38658165
DOI: 10.1002/wjs.12189 -
European Journal of Surgical Oncology :... Jun 2024To clarify how body mass index (BMI) affects the development and temporal trend of breast cancer-related lymphedema (BCRL).
PURPOSE
To clarify how body mass index (BMI) affects the development and temporal trend of breast cancer-related lymphedema (BCRL).
METHODS
This is a prospective study in which patients with operable breast cancer were registered in a single institute between November 2009 and July 2010. The incidence of lymphedema at 1, 3, and 5 years after surgery was assessed according to BMI, and the trend of newly developed BCRL was examined. Obesity was defined as BMI ≥25 in accordance with the Japan Society for the Study of Obesity.
RESULTS
A total of 368 patients were included in this study. The multivariate analysis of the whole population showed that high BMI, axillary dissection, and radiotherapy remained as risk factors for BCRL. Patients with high BMI showed a significantly higher incidence of new lymphedema than those with low BMI at 1 year (p < 00.001) regardless of axillary procedures (39.1 % vs 16.3 % for axillary dissection; 15.6 % vs 1.5 % for sentinel lymph node biopsy) but not at 3 and 5 years. Once BCRL developed, patients with high BMI showed slow recovery and 50.0 % of the patients retained edema at 5 years while patients with low BMI showed rapid recovery and 26.7 % retained after 3 years (p = 0.04).
CONCLUSION
The preoperative BMI affected the incidence and temporal trend of BCRL regardless of axillary procedures or radiotherapy. Patients with high BMI should be given appropriate information about BCRL before surgery with careful follow-up for BCRL after treatment.
Topics: Humans; Female; Body Mass Index; Middle Aged; Breast Neoplasms; Prospective Studies; Lymph Node Excision; Aged; Incidence; Axilla; Risk Factors; Adult; Breast Cancer Lymphedema; Sentinel Lymph Node Biopsy; Obesity; Time Factors; Lymphedema; Mastectomy; Japan
PubMed: 38653160
DOI: 10.1016/j.ejso.2024.108350