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Breast (Edinburgh, Scotland) Apr 2023To explore the risk factors for breast cancer-related lymphedema (BCRL) and upper extremity dysfunction (UED) in patients with early breast cancer after modern...
PURPOSE
To explore the risk factors for breast cancer-related lymphedema (BCRL) and upper extremity dysfunction (UED) in patients with early breast cancer after modern comprehensive treatment and to compare the toxicity of different treatment strategies.
METHODS
From 2017 to 2020, a total of 1369 female patients with pT1-3N0-1M0 breast cancer who underwent adjuvant radiotherapy in our centre were retrospectively reviewed. BCRL and UED were identified by the Norman and QuickDASH questionnaires. The incidence, severity and risk factors for BCRL and UED were evaluated.
RESULTS
After a median follow-up of 25 months, a total of 249 patients developed BCRL; axillary lymph node dissection (ALND), increased number of dissected nodes, right-sided and hypofractionated radiotherapy containing RNI were found to be significant risk factors (all p values < 0.05). The sentinel lymph node biopsy (SLNB)+ regional nodal irradiation (RNI) group had a significantly lower BCRL risk than the ALND + RNI group (10.8% vs. 32.5%, HR = 0.426, p = 0.020), while there was no significant difference between ALND vs. ALND + RNI or SLNB vs. SLNB + RNI. A total of 193 patients developed UED, and ALND (p = 0.02) was the only significant risk factor. The SLNB + RNI group had a significantly decreased risk of UED compared with the ALND + RNI group (7.5% vs. 23.9%, HR = 0.260, p = 0.001), and there was no significant difference between SLNB vs. SLNB + RNI or ALND vs. ALND + RNI.
CONCLUSION
Aggressive ALND remains the primary risk factor for BCRL and UED while RNI does not. Thus, replacing ALND with tailored radiotherapy would be an effective preventive strategy in early breast cancer patients.
Topics: Humans; Female; Breast Neoplasms; Retrospective Studies; Lymph Node Excision; Sentinel Lymph Node Biopsy; Lymph Nodes; Lymphedema; Axilla; Breast Cancer Lymphedema
PubMed: 36764019
DOI: 10.1016/j.breast.2023.02.001 -
Breast Cancer Research and Treatment Sep 2022Axillary staging is an important prognostic factor in breast cancer. Sentinel lymph node biopsy (SNB) is currently used to stage patients who are clinically and...
PURPOSE
Axillary staging is an important prognostic factor in breast cancer. Sentinel lymph node biopsy (SNB) is currently used to stage patients who are clinically and radiologically node-negative. Since the establishment that axillary node clearance (ANC) does not improve overall survival in breast-conserving surgery for patients with low-risk biological cancers, axillary management has become increasingly conservative. This study aims to identify and assess the clinical predictive value of variables that could play a role in the quantification of axillary burden, including the accuracy of quantifying abnormal axillary nodes on ultrasound.
METHODS
A retrospective analysis was conducted of hospital data for female breast cancer patients receiving an ANC at our centre between January 2018 and January 2020. The reference standard for axillary burden was surgical histology following SNB and ANC, allowing categorisation of the patients under 'low axillary burden' (2 or fewer pathological macrometastases) or 'high axillary burden' (> 2). After exploratory univariate analysis, multivariate logistic regression was conducted to determine relationships between the outcome category and candidate predictor variables: patient age at diagnosis, tumour focality, tumour size on ultrasound and number of abnormal lymph nodes on axillary ultrasound.
RESULTS
One hundred and thirty-five patients were included in the analysis. Logistic regression showed that the number of abnormal lymph nodes on axillary ultrasound was the strongest predictor of axillary burden and statistically significant (P = 0.044), with a sensitivity of 66.7% and specificity of 86.8% (P = 0.011).
CONCLUSION
Identifying the number of abnormal lymph nodes on preoperative ultrasound can help to quantify axillary nodal burden and identify patients with high axillary burden, and should be documented as standard in axillary ultrasound reports of patients with breast cancer.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Retrospective Studies; Sentinel Lymph Node Biopsy
PubMed: 35864309
DOI: 10.1007/s10549-022-06672-7 -
CA: a Cancer Journal For Clinicians 2015This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site... (Review)
Review
This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.
Topics: Axilla; Breast Neoplasms; Female; Head and Neck Neoplasms; Humans; Inguinal Canal; Lymph Node Excision; Lymphedema; Male; Melanoma; Neck Dissection; Neoplasms; Sentinel Lymph Node Biopsy; Skin Neoplasms; Urogenital Neoplasms
PubMed: 25410402
DOI: 10.3322/caac.21253 -
JAMA Oncology Aug 2022Risk factors for breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND) are poorly understood.
IMPORTANCE
Risk factors for breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND) are poorly understood.
OBJECTIVE
To evaluate rates of and risk factors associated with BCRL in a prospective cohort of women treated with ALND.
DESIGN, SETTING, AND PARTICIPANTS
This prospective BCRL screening study performed at a tertiary cancer center enrolled women with breast cancer 18 years and older undergoing breast surgery and unilateral ALND in the primary setting or after sentinel lymph node biopsy.
EXPOSURES
Risk of BCRL during the first 2 years after ALND and radiotherapy.
MAIN OUTCOMES AND MEASURES
Patients were prospectively evaluated with arm volume (perometer) measurements, and BCRL was defined as a relative volume change of 10% or greater from baseline. Cumulative incidence of BCRL was assessed using competing risk analysis. Risk factors for BCRL were assessed on univariate and multivariable analyses.
RESULTS
From November 2016 to March 2020, 304 patients were enrolled; 276 had at least 1 longitudinal measurement. Median (IQR) age was 48 (40-57) years; median (IQR) body mass index, calculated as weight in kilograms divided by height in meters squared, was 26.4 (22.5-31.2). Of the 276 patients included in the analysis, 29 (11%) self-identified as Asian, 55 (20%) as Black, 16 (6%) as Hispanic, 166 (60%) as White, and 10 (3%) as unknown race and ethnicity; 70% received neoadjuvant chemotherapy (NAC); 93% received nodal irradiation. The 24-month BCRL rate was 23.8% (95% CI, 17.9%-29.8%), with significant variation by race and ethnicity (24-month rate: 37.2% [Black], 27.7% [Hispanic], 22.5% [Asian], and 19.8% [White]; P = .004). The BCRL rates were also higher among patients receiving NAC vs up-front surgery (24-month rate: 29.3% vs 11.1%; P = .01). On multivariable analysis, Black race and Hispanic ethnicity (compared with White race) (odds ratio [OR], 3.88; 95% CI, 2.14-7.08 and OR, 3.01; 95% CI, 1.10-7.62, respectively; P < .001 for each), receipt of NAC (compared with up-front surgery) (OR, 2.10; 95% CI, 1.16-3.95; P = .01), older age (OR, 1.04; 95% CI, 1.02-1.07 per 1-year increase; P = .001), and a longer follow-up interval (OR, 1.57; 95% CI, 1.30-1.90 per 6-month increase; P < .001) were independently associated with an increased risk of BCRL, while ERBB2-positive subtype was associated with a decreased risk of BCRL (compared with hormone receptor positive/ERBB2 negative): OR, 0.50; 95% CI, 0.23-0.99; P = .04).
CONCLUSION AND RELEVANCE
In this cohort study, Black race, Hispanic ethnicity, NAC receipt, older age, and longer follow-up were independently associated with risk of BCRL. Studies are warranted to evaluate the biologic mechanisms behind racial and ethnic disparities in BCRL development and alternatives to NAC to avoid ALND in tumor subtypes unlikely to achieve nodal pathologic complete response.
Topics: Adult; Axilla; Breast Neoplasms; Cohort Studies; Ethnicity; Female; Humans; Lymph Node Excision; Lymphedema; Prospective Studies; Risk Factors; Sentinel Lymph Node Biopsy
PubMed: 35679026
DOI: 10.1001/jamaoncol.2022.1628 -
Lymphatic Research and Biology Dec 2022Lymphedema may develop when axillary lymph node dissection (ALND) injures and obstructs the lymph ducts in the upper limb. In patients with breast cancer, lymphedema is...
Lymphedema may develop when axillary lymph node dissection (ALND) injures and obstructs the lymph ducts in the upper limb. In patients with breast cancer, lymphedema is difficult to treat and can cause arm swelling, heaviness, and restricted movement. We aimed to identify the prevalence and risk factors for lymphedema after ALND in patients with breast cancer. This retrospective study included 175 patients with breast cancer who underwent ALND in the Nagasaki University Hospital, Japan, between 2005 and 2018. Lymphedema was defined as symptomatic arm swelling with a >2-cm difference in the arm circumference between the affected and contralateral arms. Patients were divided into two groups according to the presence or absence of lymphedema. Surgical and pathological findings were compared between the two groups. Univariate and multivariate analyses were performed, including the chi-square test, Student's -test, and logistic regression analysis. Lymphedema was prevalent in 20% of the study participants, and the mean time interval from surgery to development of lymphedema was 479 days. In the univariate analysis, a body mass index of >26 kg/m, smoking, radiotherapy (RT), and dissection of >18 axillary lymph nodes (ALNs) significantly increased the risk of lymphedema. In the multivariate analysis, smoking, RT, and dissection of >18 ALNs significantly increased the risk of lymphedema. The prevalence of lymphedema in our study was 20%. Our findings suggest that smoking, RT, and dissection of >18 ALNs are risk factors for lymphedema. Aggressive and empiric ALND might be associated with axillary lymph duct damage.
Topics: Humans; Female; Breast Neoplasms; Retrospective Studies; Sentinel Lymph Node Biopsy; Prevalence; Lymph Node Excision; Lymph Nodes; Lymphedema; Risk Factors; Axilla
PubMed: 35357959
DOI: 10.1089/lrb.2021.0033 -
Current Treatment Options in Oncology May 2020As the use of neoadjuvant systemic therapy (NAST) increases, the optimal management of the axilla has become increasingly complex. Consensus among professional... (Review)
Review
As the use of neoadjuvant systemic therapy (NAST) increases, the optimal management of the axilla has become increasingly complex. Consensus among professional organizations is that those patients with clinically negative axillary nodes who are being considered for NAST should undergo a sentinel lymph node (SLN) biopsy following NAST. If a positive SLN is subsequently identified, an axillary lymph node dissection (ALND) is the current standard of care. For patients with clinically node-positive disease, SLN biopsy is a reasonable option for those with a good response to NAST. Patients should undergo SLN mapping with a dual dye technique. Additionally, at least 2 lymph nodes should be removed, including the previously biopsied and marked lymph node with cancer. In this setting, the identification and false negative rates are acceptable. Patients found to have a negative SLN at this time may be spared the morbidity associated with ALND. Patients found to have persistently positive lymph nodes following NAST, either clinically or pathologically, should undergo a complete ALND.
Topics: Axilla; Breast Neoplasms; Clinical Decision-Making; Clinical Trials as Topic; Disease Management; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoadjuvant Therapy; Sentinel Lymph Node Biopsy; Treatment Outcome
PubMed: 32462230
DOI: 10.1007/s11864-020-00755-7 -
BMC Surgery 2013Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce...
BACKGROUND
Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results.
METHODS
Thirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel.
RESULTS
Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group.
CONCLUSIONS
Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.
Topics: Axilla; Breast Neoplasms; Female; Fibrin Tissue Adhesive; Humans; Lymph Node Excision; Mastectomy; Middle Aged; Postoperative Complications; Prospective Studies; Seroma
PubMed: 24266959
DOI: 10.1186/1471-2482-13-S2-S8 -
Chirurgia (Bucharest, Romania : 1990) 2021The identification and biopsy of the sentinel lymph node (SLNB) in breast cancer patients requiring neoadjuvant cytostatic treatment (NAC), with clinically negative...
The identification and biopsy of the sentinel lymph node (SLNB) in breast cancer patients requiring neoadjuvant cytostatic treatment (NAC), with clinically negative lymph nodes following treatment, may be an effective method of de-escalation of axillary surgery. Materials and methods: This prospective study includes 47 cases of breast cancer stage IIB-IIIA, with NAC treatment and complete axillary clinical and imaging response, surgeries performed at Prof. Dr. Alexandru Trestioreanu Oncological Institute in Bucharest (IOB) by the same team. In all the cases, SLNB was employed using the radioactive tracer method. The SLNB technique with Tc99 radioactive tracer involves: - injection of the radioactive tracer and preoperative lymphoscintigraphy, - intraoperative identification of the sentinel node/ lymph nodes and their excisional biopsy, - intraoperative histopathological examination, in paraffin blocks, and immunohistochemistry of the lymph node (SLN). SLN was identified in 46 of 47 cases. In 19 cases SLN was positive, and in 2 cases we recorded false negative results. All patients underwent standard axillary lymphadenectomy (back-up lymphadenectomy). The correlation between the intraoperative and paraffin histopathological examination of SLN with the paraffin and immunohistochemical examination of the rest of the axillary nodes (N-SLN) led to the following results: sensitivity 91% (19/ 21), specificity 100% (25/ 25), positive predictive value 100% (19/ 19), negative predictive value 93% (25/ 27). The accuracy of the method was 96% (44/ 46). SLN invasion was more common in patients with residual tumor 2 cm (vs T 2 cm) (p = 0.01), positive N-SLN (vs non-invaded N-SLN) (p = 0.003). N-SLNs were more frequently invaded when there was peritumoral lymphocyte invasion (vs. no invasion) (p = 0.01). SLNB in patients with breast cancer who require NAC, with clinically and imaging negative lymph nodes following treatment, has a high rate of specificity and an acceptable number of false negative results. Node invasion is more common in patients with residual tumors 2 cm, with lymphovascular invasion or with multicenter/ multifocal disease.
Topics: Axilla; Breast Neoplasms; Humans; Lymph Node Excision; Lymphatic Metastasis; Multicenter Studies as Topic; Neoadjuvant Therapy; Prospective Studies; Sentinel Lymph Node Biopsy; Treatment Outcome
PubMed: 33950813
DOI: 10.21614/chirurgia.116.2.178 -
Annals of Surgical Oncology Oct 2021Surgical axillary staging demonstrating positive nodal disease before neoadjuvant chemotherapy (NAC) necessitates axillary lymph node dissection (ALND) post-NAC. Despite...
BACKGROUND
Surgical axillary staging demonstrating positive nodal disease before neoadjuvant chemotherapy (NAC) necessitates axillary lymph node dissection (ALND) post-NAC. Despite evidence supporting post-NAC surgical staging, we hypothesized that there is persistent use of pre-NAC staging and that it is associated with aggressive clinicopathologic features and a higher rate of subsequent ALND.
PATIENTS AND METHODS
Stage I-III breast cancer patients who underwent lymph node staging surgery and received NAC between 2013 and 2017 in the National Cancer Database were included. Sequence of staging surgery and chemotherapy administration was determined. Multivariable regression was used to assess characteristics associated with pre-NAC staging. Rate of ALND was compared between those who had pre- and post-NAC surgical axillary staging.
RESULTS
In total, 120,538 met inclusion; 68% received NAC first and 32% had pre-NAC staging. Pre-NAC staging surgery was associated with younger age (age < 30 versus 40-49 years, HR 1.1) and decreased with older age (ages 70-79/80+ versus 40-49 years, HR 0.86 and 0.73). Advancing clinical T stage, lobular subtype, higher grade, and HR+/HER2- subtype were also associated with pre-NAC surgical staging. Women who underwent pre-NAC surgical staging were more likely to undergo ALND.
CONCLUSIONS
Over 30% of women underwent surgical axillary staging prior to NAC, resulting in higher rates of ALND in this cohort. While certain features suggestive of aggressive behavior (grade and T stage) were associated with pre-NAC surgical axillary staging, women with more aggressive tumor subtypes (triple negative/HER2+) were less likely to undergo pre-NAC surgical axillary staging. Pre-NAC surgical axillary staging should be performed only in rare circumstances to avoid unnecessary ALND.
Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Sentinel Lymph Node Biopsy
PubMed: 34379251
DOI: 10.1245/s10434-021-10628-4 -
Cancer Treatment Reviews Dec 2021Introduction of sentinel lymph node biopsy, initially in clinically node-negative and subsequently in patients presenting with involved axilla and downstaged by primary... (Review)
Review
Introduction of sentinel lymph node biopsy, initially in clinically node-negative and subsequently in patients presenting with involved axilla and downstaged by primary systemic therapy, allowed for significant decrease in morbidity compared to axillary lymph node dissection. Concurrently, regional nodal irradiation was demonstrated to improve outcomes in most node-positive patients. Additionally, over the last decades, introduction of more effective systemic therapies has resulted in improvements not only at distant sites, but also in locoregional control, creating space for de-escalation of locoregional treatments. We discuss the data on de-escalation in axillary surgery and irradiation, both in patients undergoing upfront surgery and primary systemic therapy, with special emphasis on the feasibility of omission of nodal irradiation in patients undergoing primary systemic therapy. In view of the accumulating evidence, omission of axillary irradiation may be considered in clinically node-positive patients converting after primary systemic therapy to pathologically negative nodes on sentinel lymph node biopsy (preferably also with in-breast pCR), presenting with lower initial nodal stage, older age and were treated with breast-conserving surgery followed by whole breast irradiation. Omission of regional nodal irradiation in patients with aggressive tumor phenotypes achieving a pCR is under investigation. In patients undergoing preoperative endocrine therapy the adoption of axillary management strategies utilized in case of upfront surgery seems more suitable than those used in post chemotherapy-based primary systemic therapy setting.
Topics: Antineoplastic Protocols; Axilla; Breast Neoplasms; Combined Modality Therapy; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Irradiation; Neoplasm Staging; Sentinel Lymph Node Biopsy
PubMed: 34656018
DOI: 10.1016/j.ctrv.2021.102297