Management of the axilla in postmenopausal patients with cN0 hormone receptor-positive/HER2-negative breast cancer treated with neoadjuvant endocrine therapy and its prognostic impact (original) (raw)
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Clinical Breast Cancer, 2013
Aims: The Hungarian National Institute of Oncology has just closed a single-centre randomized clinical study. The OTOASOR (Optimal Treatment of the Axilla-Surgery or Radiotherapy) trial compares completion axillary lymph node dissection (ALND) to regional nodal irradiation (RNI) in patients with sentinel lymph node-positive (SLN+) primary invasive breast cancer. In the investigational treatment arm patients received 50 Gy RNI instead of completion ALND. In these patients we had information only about the SLN status, but the further axillary nodal involvement remained unknown. The aim of this study was to investigate whether the result of completion ALND influenced the recommendation for adjuvant treatment in SLN+ breast cancer patients. Patients and methods: Patients with SLN+ primary breast cancer were randomized for completion ALND (arm A-standard treatment) or RNI (arm B-investigational treatment). Adjuvant systemic treatments was given according to the standard institutional protocol and patients were followed according to the actual institutional guidelines. Results: Between August 2002 and June 2009, 474 SLN+ patients were randomized to completion ALND (arm A-standard treatment, 244 patients) or RNI (arm B-investigational treatment, 230 patients). There were no significant differences in terms of major prognostic factors between the two arms. Two-hundred and fourty-two patients (99.6%) on arm A and 229 patients (99.6%) on arm B received adjuvant systemic treatments including chemotherapy and/or endocrine treatment (p=NS). One-hundred and ninety-four patients (79.5%) received adjuvant chemotherapy on arm A and 159 patients (69.1%) on arm B (p=0.031). Two-hundred and four patients (83.6%) received adjuvant endocrine treatment on arm A and 196 patients (85.2%) on arm B (p=NS). Six patients (2.5%) received adjuvant trastuzumab treatment on arm A and 13 patients (5.7%) on arm B (p=NS). Conclusions: The result of completion ALND after positive SLNB appears to have no major impact on the administration of adjuvant systemic therapy.
Medicine, 2020
The neoadjuvant chemotherapy (NAC) is the gold standard initial treatment of the locally advanced breast cancer (LABC). However, the reliability of methods that used to assess response the NAC is still controversial. In this study, patients with LABC who underwent NAC were evaluated retrospectively. The assessment of response to NAC and the effect of axillary approach were investigated on LABC course. The study comprised 94 patients who received NAC with an LABC diagnosis between 2008 and 2020. In our center, magnetic resonance imaging, ultrasonography, and 18 F-flouro deoxyglucose positron emission tomography/computed tomography, and, for some patients, fine-needle aspiration biopsy of suspicious axillary lymph nodes have been performed to assess the effects of NAC. Patients with positive hormone receptor status received adjuvant hormonotherapy, and those with human epidermal growth factor receptor 2 gene expression were treated with trastuzumab. Adjuvant radiotherapy was applied to all patients undergoing breast conserving surgery. Radiotherapy was applied to the peripheral lymphatic areas in the clinical N1 to N3 cases regardless of the response to NAC. The clinical response to the NAC was found that partial in 59% and complete in 19% of the patients. However, 21.2% of the patients were unresponsive. The mean of lymph nodes that excised with the procedure of sentinel lymph node biopsy (SLNB) was 2.4 (range 1-7). In 22 of the 56 patients who underwent SLNB, axillary dissection (AD) was added to the procedure upon detection of metastasis in frozen section examinations. There was no difference between the SLNB and AD groups regarding overall survival (OS; P = .472) or disease-free survival (DFS) rates (P = .439). However, there were differences in the OS (P < .05) and DFS (P = .05) rates on the basis of the LABC histopathological subtypes. The study found that a relationship between molecular subtypes and LABC survival. However, the post-NAC axillary approach had no effect on OS or DFS. Therefore, multiple imaging and interventional methods are needed for the evaluation of NAC response. In addition, morbidity can be avoided after AD by the use of SLNB in cN0 patients. Abbreviations: 18 F-FDG PET/CT = 18 F-flouro deoxyglucose Positron emission tomography/computed tomography, AD = axillary dissection, Adjht = adjuvant hormonotherapy, ADRT = adjuvant radiotherapy, ADRT = adjuvant radiotherapy, BCS = breast conserving surgery, CI = confidence interval, DFS = disease-free survival, ER = estrogen-receptor, FNAB = fine-needle aspiration biopsy, FNR = False negative rate, HER2 = human epidermal growth factor receptor 2, IHC = immunohistochemical, LABC = locally advanced breast cancer, LNs = lymph nodes, LRR = locoregional recurrence, MRI = magnetic resonance imaging, NAC = neoadjuvant chemotherapy, OS = overall survival, pCR = pathological complete response, PR = progesterone-receptor, RT = radiotherapy, SLNB = sentinel lymph node biopsy, TNBCs = triple negative breast cancers, US = ultrasonography.
Introduction: For patients with clinically negative axilla, sentinel lymph node biopsy (SLNB) is the standard method for axillary staging Because the SLBNs are the only positive nodes in approximately 40-70% of patients with pathologically proven positive axillae after completion axillary lymph node dissection (ALND), the treatment of patients with a positive SLBN has been reconsidered and the development of predictive tools that select the patients whom routine ALND could be avoided safely. Purpose: to characterize the patients in whom completion ALND can be avoided in spite of positive SLNB. Patients and methods: This retrospective study included all patients who had SLNB at The characteristics of the special group with positive SLNB and node-negative upon completion ALND were studied. Results: out of 66 patients with clinically negative axillae, SLNB was negative in 36 patients, with no more ALND, J Cancer Sci Clin Ther 2020; 4 (1): 001-014 Journal of Cancer Science and Clinical Therapeutics 2 and SLNB was positive in 30 patients for whom completion ALND was done, and revealed that 63.4% (19 out of 30 patients) had no other positive nodes after completion ALND. Conclusion: In patients with clinically negative axillae and positive sentinel SLNB, A combination of multiple predictive parameters as, the number of positive SLNs, the ratio between metastatic SLNs and total number of SLN retrieved, extracapsular invasion, and lymphovascular invasion were significant predictors for the risk of non-SLN involvement and can identify the patients with positive SLNB for whom routine ALND could be safely avoided.
Annali Italiani Di Chirurgia, 2010
AIM: The aim of this study was to determine factors that predict non-sentinel axillary lymph nodes (NSLNs) metastases in breast cancer patients with positive sentinel node biopsy (SLNB). MATERIAL OF STUDY: We reviewed the records of a consecutive series of 176 breast cancer patients who underwent SLNB at our institution. From the database we analysed those cases with one or more positive sentinel lymph nodes (SLNs) in order to determine factors predicting NSLN metastases. RESULTS: From a series of 176 consecutive patients, we evaluated 41 cases (23.3%) with positive SLNB. Subsequent completion axillary lymph node dissection (CALND) revealed NSLN metastases in 15 cases (36.6%). The significant variables predictive of NSLN involvement were the presence of macrometastases with extranodal extension (p=0.048), the presence of more than one positive SLN (p=0.08) and a ratio between positive SLN and SLNs globally dissected higher than 0.5 (p=0.05). DISCUSSION: CALND is the gold standard for patients with positive SLNB, but results, in almost 40-70% of cases, in no additional positive nodes and its therapeutic benefit remains controversial. Clinicopathologic factors predictive of NSLN metastases may be useful in identifying a subset of patients with lower risk of further axillary involvement. CONCLUSIONS: In patients with early breast carcinoma and a positive SLNB, the size of SLN metastases, the presence of extranodal extension, more than one positive SLN and a nodal ratio higher than 0.5 are the factors that significantly increase the frequency of additional axillary positive lymph nodes.
European Journal of Surgical Oncology (EJSO), 2007
Aim: Sentinel lymph node biopsy (SLNB) without completion axillary lymph node dissection (ALND) is replacing ALND as the axillary staging procedure of choice in breast cancer patients with a clinically negative axilla even though it is unclear whether this influences patient survival. Our aim was to compare the survival of breast cancer patients with a negative SLNB without completion ALND to that of extensive ALND-negative patients. Methods: Eindhoven Cancer Registry data on breast cancer patients diagnosed between 1989 and 2002 with follow-up to 1 January 2005 was used. Survival was compared between 880 SLNB-negative women (median follow-up 3.6 years) without completion ALND and 1681 ALND-negative women (median follow-up 7.7 years) with at least 10 axillary nodes removed. Conclusions were made after correcting for age, tumour size, tumour location, tumour histology, tumour grade, mitotic activity index (MAI), hormone receptor status, and local and systemic treatment in uni-and multivariate analyses. Results: Crude 5-year survival rates were 85% for ALND-negative and 89% for SLNB-negative breast cancer patients ( p ¼ 0.026). After correction for potential confounders in a multivariate Cox regression analyses, the hazard ratio for overall mortality of ALND-negative compared to SLNB-negative patients without completion ALND was 1.23 (95% confidence interval: 0.93e1.64). Conclusion: Survival after a SLNB without completion ALND is at least equivalent to after an extensive ALND in node-negative breast cancer patients. This means that the SLNB only can safely replace ALND as the procedure of choice for axillary staging in breast cancer patients with a clinically negative axilla.
Advances in Radiation Oncology
Current standard of care for patients with breast cancer with a positive node on sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy is axillary dissection with irradiation of the regional nodes, but it is unknown whether axillary lymph node dissection (ALND) can be safely omitted if complete axillary radiation is delivered instead. Methods and Materials: We identified 161 patients found to have a positive sentinel lymph node on SLNB after neoadjuvant chemotherapy for breast cancer between December 2006 and October 2017, who were treated with or without completion ALND. Local, regional, and distant recurrence and overall survival were analyzed using the Kaplan-Meier method. Patient, disease, and treatment factors potentially predictive of each outcome were entered into Cox regression analysis. Results: Median follow-up was 28.8 months (range, 2.5-137.0). The 3-year regional control rate did not differ according to extent of axillary surgery (92.6% for SLNB alone vs 96.4% for SLNB with ALND, P Z .616). Regional recurrence occurred as part of first recurrence in 9 patients (5.6%). Five patients failed in axillary levels 1 or 2, 6 failed in axillary level 3 or supraclavicular nodes, and 2 failed in internal mammary nodes, with some patients failing in multiple regional nodal areas. Extent of axillary dissection (SLNB only vs SLNB plus ALND) did not predict for disease control or survival. Patients who underwent ALND were significantly more likely to have lymphedema (25.0% vs 9.4%, P Z .021). Conclusions: Careful selection of patients with a positive sentinel node on SLNB after neoadjuvant chemotherapy for omission of completion ALND in favor of irradiation of the undissected axilla does not compromise local, regional, or distant control or overall survival and results in lower rates of lymphedema.
Breast Diseases: A Year Book Quarterly, 2011
The prognostic value of lymph node involvement after neoadjuvant chemotherapy for breast cancer is not straightforward. We evaluated whether lymph node involvement is associated with overall survival in patients treated with neoadjuvant chemotherapy and whether Lymph Node Ratio (LNR--ratio of the positive to excised axillary lymph nodes) is a superior prognosticator when compared to ypN status (according to the pTNM classification). Three hundred and fourteen patients receiving neoadjuvant chemotherapy in Geneva, Singapore or Kuala Lumpur were pooled for analysis. We evaluate the prognostic value of the LNR [zero, low (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;0 and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.2), intermediate (0.2-0.65) and high risk (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;0.65)] and ypN staging [ypN0, ypN1, ypN2 and ypN3] with multivariate Cox regression analysis. When using the LNR classification, 88 patients were categorised as zero, 91 as low, 82 as intermediate and 53 as high risk. For classic ypN staging, 88 were ypN0, 126 ypN1, 58 ypN2 and 42 ypN3. Compared to the low risk category, LNR zero corresponded to an adjusted hazard ratio [HRadj] of 0.4 (95%CI, 0.2-0.9), intermediate risk LNR to a HRadj of 1.2 (0.7-2.2) and high risk LNR to a HRadj of 2.7 (1.5-5.0). Similarly, the ypN0 category corresponded to a HRadj of 0.3 (0.2-0.7), ypN2 to a HRadj 1.1 (0.6-2.0) and ypN3 to a HRadj 2.2 (1.3-3.8) compared to ypN1 patients. Lymph node status after neoadjuvant chemotherapy predicts overall survival. In patients treated with neoadjuvant chemotherapy, LNR does not seem to be superior to classic ypN staging.
European Journal of Surgical Oncology (EJSO), 1998
Aims. Clinical records of patients undergoing surgery for breast cancer were reviewed in order to evaluate the prognostic role of lymph-node level involvement. Methods. From 1982 to 1991, 1143 patients had radical mastectomy or conservative surgery with total axillary dissection: 461 patients of mean age 57.1 years (range: 25-89 years) were lymph-node positive (pNl); 369 patients (80%) had radical mastectomy; and 92 patients (20%) had conservative treatment plus post-operative radiotherapy, with the same mean number (n = 16) of lymph nodes collected in the surgical specimen. Data were analysed for the number of positive lymph nodes and level of involvement. Results. Level I, Levels I+II and Levels I+II+III were involved in 44.9, 18 and 21.4% of patients, respectively; 'skip metastases' occurred in 72 of 461 pNl patients (15.5%). A univariate analysis showed that prognosis was directly related to the number of levels involved (P<0.001), and skip metastases had the same prognostic role as Level I involvement. The numbers of involved lymph-node levels and metastatic lymph nodes were well correlated; multivariate analysis showed that involvement of Levels I and III was independently correlated with prognosis. After adjustment for age and number of positive lymph nodes, the number of involved lymph-node levels was an independent prognostic factor, with highest predictability when all three lymph-node levels were positive (P=0.009). Conclusions. The prognostic value of lymph-node status should be defined not only by the number of metastatic lymph nodes, but also by the number of levels of involvement.
Annals of Surgical Oncology, 2010
Background. Completion axillary lymph node dissection (CALND) is routinely performed in breast cancer patients with positive sentinel lymph nodes (SLN). We sought to determine the sociodemographic, pathologic, and therapeutic variables that were associated with CALND. Methods. From 7/1997 to 7/2003, 1,470 patients with invasive breast cancer were SLN positive by intraoperative frozen section or final pathologic exam by hematoxylineosin and/or immunohistochemistry (IHC). A comorbidity score was assigned using Adult Comorbidity Evaluation-27 system. Fisher's exact, Wilcoxon tests, and multivariate logistic regression analysis were used. Results. CALND was performed less often in patients with age C 70 years compared with age \ 70 years, moderate or severe comorbidities compared with no or mild, IHC-only positive SLN and breast conservation therapy (BCT compared with mastectomy. Patients who did not undergo CALND were less likely than CALND patients to have grade III disease, lymphovascular invasion multifocal disease, tumor size [ 2 cm or to receive adjuvant chemotherapy. However, they were more likely to undergo axillary radiotherapy (RT). On multivariate analysis, age C 70 years [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.26-0.63], IHC-only positive SLN (OR 0.13, 95%CI 0.09-0.19), presence of moderate to severe comorbidities (OR 0.64, 95%CI 0.41-0.99), tumor size B 2 cm (OR 0.44, 95%CI 0.29-0.66), axillary RT (OR 0.39, 95%CI 0.20-0.78), and BCT (OR 0.54, 95%CI 0.37-0.79) were all independently associated with lower odds of CALND.