Axillary Management Research Articles

84 (PB-084) Poster - Quality of life and lymphedema incidence after axillary surgery in pN1 breast cancer patients: lymphadenectomy vs. Sentinel lymph node biopsy

Introduction: In the last decade, there has been a paradigm shift in axillary management in patients with breast cancer: the possibility of avoiding axillary lymph node dissection (ALND) in a specific group of breast cancer patients with axillary disease, to decrease the axillar surgery-related morbidity. Objectives: To Assess the impact on the quality of life (QoL) of ALND vs. Sentinel lymph node dissection (SLN) associated with radiotherapy for patients with node-positive breast cancer. To Appraise the incidence of lymphedema after axillary treatment in both groups. Methods: Retrospective observational study of surgery patients with node-positive breast cancer (pN1), at a university center from 2018 to 2019. In addition, a cross-sectional study was performed between May to July 2022 to assess the incidence of arm lymphedema measured by circometry and appraise QoL. We use the QLQ-BR23 questionnaire to assess the general QoL, and ULL-27 questionnaire to appraise the specific QoL scale in upper limb lymphedema, both for Spanish population. Results: 114 patients completed the questionnaires and measurements: 68 ALND patients and 46 SLN, with 40.8 months postoperative follow-up. The scores on both questionnaires were similar in all dimensions explored in both groups of patients, without significant clinical or statistical differences. In the lymphadenectomy group, the incidence of lymphedema was higher (32.4% vs 10.9%; p = 0.006). The QoL of lymphedema patients were globally similar than no lymphedema patients, but the QoL of symptomatic lymphedema was worse (BR-23: perspective dimension 56.9 vs 72.4, p = 0.002; sexual function 61.6 vs 77.9 p = 0.002 and ULL-27 (best 0 worse 100): physical dimension 37.8 vs 19.1 p = 0.003). Conclusions. The axillary node dissection does not produce a significant impact on the quality of life of patients with breast cancer and axillary involvement, despite developing lymphedema more frequently. The symptomatic lymphedema patients have worse quality of life. No conflict of interest.

58 (PB-058) Poster - Breast cancer in elderly patients in a Venezuelan breast center. How we manage the axilla

Objective: Axillary management in elderly patients with early breast cancer and clinically negative axillary nodes is controversial. This study aimed to evaluate clinico-histopathological and survival data in breast cancer patients aged 80 years or older with a negative axillary clinical and ultrasound examination not undergoing axillary lymph node investigation Patients and Method: A retrospective study of 36 patients who met the following inclusion criteria: aged 80 years or more, with a diagnosis of early breast cancer and clinically and ultrasound node negative breast cancer, and in a state of complete physical, mental well-being. The patients were treated surgically without axillary dissection. Clinico-histopathological, treatment and survival characteristics were evaluated. Results: A total of 36 patients were studied with an average age of 83.5 years (range, 80–91 years), and a median follow-up of 39.7 months (range: 0.5–168 months). Of these, 1 patient had bilateral breast cancer. Most patients were treated with partial mastectomy (64.9%). Almost all of the patients received adjuvant hormonal therapy (91.7%), almost one third received adjuvant radiotherapy (30.6%). Infiltrating ductal carcinoma represented 62% of the total. Average tumor size of 17.5 mm (range, 2– 50 mm). The most frequent molecular subtype was luminal A (54.1%). 8.3% of the patients had a relapse, none in axilla. Disease free survival was found to be a mean of 141.7 months, while five-year disease-free survival rate was 80.9%. The overall survival average time was 95.5months, while the five-year overall survival rate was 57%.Table 1:Clinical and Histopathological characteristicsAge (years) N = 36 (1 bilateral)80–8424 (66.7)85–9112 (33.3)Media (STD)83.5 (0.49)Tumor characteristicsTumor size (mm) N = 37≤2029 (78.4)<20 ≤ 508 (21.6)Media (STD) (range)17.5(1.52) (5–50)Histological type N = 37IDC23 (62.2)ILC4 (10.8)Others10 (27)Molecular Subtypes N = 37Luminal A20 (54.1)Luminal B10 (27)Luminal B-H5 (13.5)HER21 (2.7)Triple negative1 (2.7)Type of Surgery N = 37BCS24 (64.9)TM£1 patient with bilateral mastectomy13 (35.1)Treatment N = 36Adjuvant Hormonotherapy33 (91.7)Adjuvant Radiotherapy11 (30.6)Neoadjuvant Hormonotherapy9 (25)IDC: infiltrating ductal carcinoma, ILC: infiltrating lobullar carcinoma, Others: muninous carcinoma, papillary carcinoma, cribiform carcinoma, ductal carcinoma in situ. BCS: breast conservative surgery. TM: Total mastectomy.£ 1 patient with bilateral mastectomy Open table in a new tab IDC: infiltrating ductal carcinoma, ILC: infiltrating lobullar carcinoma, Others: muninous carcinoma, papillary carcinoma, cribiform carcinoma, ductal carcinoma in situ. BCS: breast conservative surgery. TM: Total mastectomy. Conclusion: Results from the present investigation suggest that axillary lymph node biopsy could be omitted in women 80 years or older with clinically node negative breast cancer treated with breast surgery and adjuvant therapy. No conflict of interest.

Surgical Management of the Axilla in Invasive Lobular Carcinoma in the Z1071 Era: A Propensity-Score Matched Analysis of the National Cancer Database.

In patients with invasive lobular carcinoma (ILC) and clinically positive nodes (cN1) who demonstrate an axillary clinical response to neoadjuvant-chemotherapy (NAC), the outcomes of sentinel lymph node biopsy (SLNB) compared to axillary lymph node dissection (ALND) are not well studied. We sought to evaluate axillary surgery practice patterns and the resultant impact on overall survival (OS) in cN1 ILC. The National Cancer Database (NCDB) was queried (2012-2017) for women with cN1 ILC who were treated with NAC followed by surgery. Propensity-score matching was performed between SLNB and ALND cohorts. Kaplan-Meier and Cox regression analyses were performed to identify predictors of OS. Of 1390 patients, 1192 were luminal A ILCs (85.8%). 143 patients (10.3%) had a complete axillary clinical response, while 1247 (89.7%) had a partial clinical response in the axilla. Definitive axillary surgery was SLNB in 211 patients (15.2%). Utilization of SLNB for definitive axillary management increased from 8% to 16% during the study period. Among 201 propensity-score matched patients stratified by SLNB vs. ALND, mean OS did not significantly differ (81.6 ± 1.8 vs. 81.4 ± 2.0 months; p = 0.56). Cox regression analysis of the entire cohort demonstrated that increasing age, grade, HER2+ and triple-negative tumors, and partial clinical response were unfavorable OS predictors (p &lt; 0.02 each). The definitive axillary operation and administration of adjuvant axillary radiation did not influence OS. In cN1 ILC patients with a clinical response to NAC in the axilla, SLNB vs. ALND did not affect OS. Further axillary therapy may be warranted with ypN+ disease.

An MRI-based Scoring System for Preoperative Prediction of Axillary Response to Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: A Multicenter Retrospective Study

To develop and validate a simplified scoring system by integrating MRI and clinicopathologic features for preoperative prediction of axillary pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) in clinically node-positive breast cancer. A total of 389 patients from three hospitals were retrospectively analyzed. To identify independent predictors for axillary pCR, univariable and multivariable logistic regression analyses were performed on pre- and post-NAC MRI and clinicopathologic features. Then, a simplified scoring system was constructed based on regression coefficients of predictors in the multivariable model, and its predictive performance was assessed with the receiver operating characteristic curve and calibration curve. The added value of the scoring system for reducing false-negative rate (FNR) of the sentinel lymph node biopsy (SLNB) was also evaluated. The simplified scoring system including seven predictors: progesterone receptor-negative (Three points), HER2-positive (Two points), post-NAC clinical T0-1 stage (Two points), pre-NAC higher ADC value of breast tumor (One point), absence of perinodal infiltration at pre-NAC (One point) and post-NAC MRI (Two points), and absence of enhancement in the tumor bed at post-NAC MRI (Two points), showed good calibration and discrimination, with AUCs of 0.835, 0.828 and 0.798 in the training, internal and external validation cohorts, respectively. The axillary pCR rates were increased with the total points of the scoring system, and patients with a score of ≥11 points had a pCR rate of 86%-100%. In test cohorts for simulating clinical application, the diagnostic accuracy for axillary pCR was 80%-90% among four different radiologists. Compared to standalone SLNB, combining the scoring system with SLNB reduced the FNR from 14.5% to 4.8%. The clinicopathologic-image scoring system with good predictive performance for axillary pCR in clinically node-positive breast cancer, may guide axillary management after NAC and improve patient selection for de-escalating axillary surgery to reduce morbidity.

ASO Author Reflections: The Evolution of Axillary Management in Breast Cancer.

ASO Author Reflections: The Evolution of Axillary Management in Breast Cancer.

Ultra-Hypofractionation for Whole-Breast Irradiation in Early Breast Cancer: Interim Analysis of a Prospective Study.

We report on the early clinical outcomes of a prospective series of early breast cancer (EBC) patients treated with ultra-hypofractionated post-operative whole-breast irradiation (WBI) after breast-conserving surgery (BCS) and axillary management. Primary endpoints were patient’s compliance and acute toxicity. Secondary endpoints included physician-rated cosmesis and ipsilateral breast tumour recurrence (IBTR). Acute toxicity was evaluated at the end of WBI, 3 weeks and 6 months thereafter, according to the Common Terminology Criteria for Adverse Events (v. 5.0). Patients were treated between September 2021 and May 2022. The treatment schedule for WBI consisted of either 26 Gy in 5 fractions over one week (standard approach) or 28.5 Gy in 5 fractions over 5 weeks (reserved to elders). Inverse planned intensity-modulated radiation therapy (IMRT) was used employing a static technique. A total of 70 patients were treated. Fifty-nine were treated with the 26 Gy/5 fr/1 w and 11 with the 28.5 Gy/5 fr/5 ws schedule. Median age was 67 and 70 in the two groups. Most of the patients had left-sided tumours (53.2%) in the 26 Gy/5 fr/1 w or right-sided lesions (63.6%) in the 28.5 Gy/5 fr/5 ws group. Most of the patients had a clinical T1N0 disease and a pathological pT1pN0(sn) after surgery. Ductal invasive carcinoma was the most frequent histology. Luminal A intrinsic subtyping was most frequent. Most of the patients underwent BCS and sentinel lymph node biopsy and adjuvant endocrine therapy. All patients completed the treatment program as planned. Maximum detected acute skin toxicities were grade 2 erythema (6.7%), grade 2 induration (4.4%), and grade 2 skin colour changes. No early IBTR was observed. Ultra-hypofractionated WBI provides favourable compliance and early clinical outcomes in EBC after BCS in a real-world setting.

Current trends in diagnostic and therapeutic management of the axilla in breast cancer patients receiving neoadjuvant therapy: results of the German-wide NOGGO MONITOR 24 survey

PurposeIn the last 2 decades, the optimal management of the axilla in breast cancer patients receiving neoadjuvant chemotherapy (NACT) has been one of the most frequently discussed topics. Little is known about the attitudes of surgeons/radiologists towards new developments such as targeted axillary dissection. Therefore, the NOGGO conducted a survey to evaluate the current approach to axillary management.MethodsA standardized digital questionnaire was sent out to > 200 departments in Germany between 7/2021 and 5/2022. The survey was supported by EUBREAST.ResultsIn total, 116 physicians completed the survey. In cN0 patients scheduled to receive NACT, 89% of respondents recommended sentinel lymph node biopsy (SLNB) after NACT. In case of ypN1mi(sn), 44% advised no further therapy, while 31% proposed ALND and 25% axillary irradiation. 64% of respondents recommended a minimally invasive axillary biopsy to cN + patients. TAD was used at the departments of 82% of respondents and was offered to all cN + patients converting to ycN0 by 57% and only to selected patients, usually based on the number of suspicious nodes at time of presentation, by 43%. The most common marking technique was a clip/coil. 67% estimated that the detection rate of their marker was very good or good.ConclusionThis survey shows a heterogenous approach towards axillary management in the neoadjuvant setting in Germany. Most respondents follow current guidelines. Since only two-thirds of respondents experienced the detection rate of the marker used at their department as (very) good, future studies should focus on the comparative evaluation of different marking techniques.

The Influence of Screening Mammography Cessation and Resumption on Breast Cancer Presentation and Treatment: A Multi-Hospital Health System Experience During the Early COVID-19 Pandemic.

To assess the impact of the coronavirus disease-2019 (COVID-19) pandemic screening restrictions on the diagnosis and treatment of breast cancer in a single health system. We performed a retrospective, cohort investigation of breast cancer patients at a multi-institution health system from March 1, 2019 to December 31, 2020 with two time periods related to the pandemic: "Early phase" (March 18 - June 7) reflecting the time of the screening mammography moratorium and "Late phase" (June 8 - December 31) to reflect the time once screening mammography resumed. 2020 was compared to 2019 to exclude potential differences from temporal or seasonal changes. Variables included demographics, COVID related-deferral, cancer specific data, method of detection, type of treatment recommended and received. Fewer patients presented with a breast cancer diagnosis during Early phase 2020 when compared to any other time period. Numbers increased significantly in Late phase 2020; total numbers of patients seen in 2020 approached but did not completely reach that of 2019. When compared to other time periods, patients who presented during the moratorium on screening were younger, more likely to be black, had a higher Body Mass Index, and were more likely to have a human epidermal growth factor receptor 2 positive tumor. There was a slight increase in size of presenting tumor and node positivity, although no differences in breast or axillary surgical management were identified. Despite an increase in tumor size and positive nodal status seen during the screening moratorium, surgical treatment was not negatively impacted.

AGO Recommendations for the Surgical Therapy of Breast Cancer: Update 2022.

The recommendations of the AGO Breast Committee on the surgical therapy of breast cancer were last updated in March 2022 (www.ago-online.de). Since surgical therapy is one of several partial steps in the treatment of breast cancer, extensive diagnostic and oncological expertise of a breast surgeon and good interdisciplinary cooperation with diagnostic radiologists is of great importance. The most important changes concern localization techniques, resection margins, axillary management in the neoadjuvant setting and the evaluation of the meshes in reconstructive surgery. Based on meta-analyses of randomized studies, the level of recommendation of an intraoperative breast ultrasound for the localization of non-palpable lesions was elevated to “++”. Thus, the technique is considered to be equivalent to wire localization, provided that it is a lesion which can be well represented by sonography, the surgeon has extensive experience in breast ultrasound and has access to a suitable ultrasound device during the operation. In invasive breast cancer, the aim is to reach negative resection margins (“no tumor on ink”), regardless of whether an extensive intraductal component is present or not. Oncoplastic operations can also replace a mastectomy in selected cases due to the large number of existing techniques, and are equivalent to segmental resection in terms of oncological safety at comparable rates of complications. Sentinel node excision is recommended for patients with cN0 status receiving neoadjuvant chemotherapy after completion of chemotherapy. Minimally invasive biopsy is recommended for initially suspect lymph nodes. After neoadjuvant chemotherapy, patients with initially 1 – 3 suspicious lymph nodes and a good response (ycN0) can receive the targeted axillary dissection and the axillary dissection as equivalent options.

Axillary lymph node dissection can be omitted in patients with limited clinically node-positive breast cancer: a National Cancer Database analysis.

De-escalation of axillary surgery in breast cancer has progressively taken place when appropriate. Data supporting surgical de-escalation in patients with clinically node-positive (cN+) disease remains scarce. Here, survival among patients with cN+ T1-2 tumours undergoing sentinel lymph node biopsy (SLNB) and regional nodal irradiation (RNI) was investigated and compared with that among patients undergoing axillary lymph node dissection (ALND) with or without RNI. The National Cancer Data Base was used to identify three groups of patients with cN+ tumours according to axillary management among those treated between 2010 and 2016: patients who underwent SLNB and RNI (cN+ SLNB/RNI group); those who had ALND and RNI (cN+ ALND/RNI group); and those who had ALND alone (cN+ ALND/no RNI group). Patients who underwent neoadjuvant chemotherapy, and those who had stage IV breast cancer or pN2-3 disease were excluded. A total of 12 560 patients met the inclusion criteria: 3030 in the cN+ SLNB/RNI, 5446 in the cN+ ALND/RNI, and 4084 in the cN+ ALND/no RNI group. The sizes of cN + SLNB/RNI and cN+ ALND/RNI groups increased over the study interval, whereas the cN+ ALND/no RNI group decreased in size (P < 0.001). There was a median of one positive node in the cN+ SLNB/RNI group and two nodes in the cN+ ALND/RNI and cN+ ALND/no RNI groups. The median number of nodes examined was three, 14, and 14, respectively (P < 0.001). Median follow-up was 57.9 (range 0.8-114) months. The overall survival rate was 97, 97, and 92 per cent respectively at two years, and 88, 86, and 78 per cent at five years (P < 0.001). Patients with limited cN+ T1-2 breast cancer undergoing upfront SLNB and RNI have favourable survival outcomes that are not inferior to those of patients undergoing ALND with or without RNI. Prospective studies are warranted to assess locoregional control and long-term outcomes.

Axillary Management after Neoadjuvant Chemotherapy; A Review of How and When?

Axillary Management after Neoadjuvant Chemotherapy; A Review of How and When?

Axillary management for early invasive breast cancer patients: Who will truly benefit?

BackgroundThe implementation of sentinel lymph node biopsy (SLNB) and further completion axillary lymph node dissection (cALND) after positive sentinel lymph nodes (SLNs) on early invasive breast cancer patients should be cautiously tailored. Identifying predictors for SLN and non-sentinel lymph node (nSLN) metastases can help surgeons make better surgical decisions.MethodsA retrospective case-control study was designed and a total of 560 eligible patients were enrolled consecutively. They were all diagnosed in our center and received appropriate medical care. According to the metastasis of SLN and nSLN, they were divided into metastatic and non-metastatic groups on two successive occasions to investigate the relationship between clinical factors, pathological factors, hematological factors and lymph node metastasis.ResultsIn total, 101 (18.04%) patients developed SLN metastases, including 98 patients with macro-metastases and 3 patients with micro-metastases. Out of 97 patients receiving further cALND, 20 patients (20.62%) developed nSLN metastases. Multivariate analysis revealed that “high expression of Ki-67” and “lymphatic invasion” predicted a higher risk of SLN metastasis; and “increased number of positive SLNs” and “increased systemic inflammation index (SII)” predicted a higher risk of nSLN metastasis.ConclusionSurgery for early invasive breast cancer patients should be more customized and precise. Appropriate axillary management is necessary for patients with the associated predictors.

The Role of Surgical Axillary Staging Prior to Immediate Breast Reconstruction in the Era of De-Escalation of Axillary Management in Early Breast Cancer.

Postmastectomy radiotherapy (PMRT) following immediate breast reconstruction (IBR) is associated with postoperative complications. Although the incidence of node-positive breast cancer is declining, a separate sentinel lymph node biopsy (SLNB) is still performed before mastectomy when IBR is planned, in order to evaluate nodal status and the need for PMRT. This study assessed the impact of staged SLNB on the breast reconstructive planning, and presents common clinicopathological characteristics of breast cancer with macrometastatic nodal spread where staged SLNB would be beneficial to indicate PMRT. Medical records of breast cancer patients scheduled for mastectomy and IBR at Skåne University Hospital, Sweden, from November 2014 to February 2020, were reviewed. Of 92 patients, node-positive disease was present in 15 (16%). Fifty-three patients underwent staged SLNB before mastectomy and IBR, and 10 (19%) presented with nodal metastasis. All patients with macrometastatic sentinel nodes were presented with palpable, multifocal, ER+ breast carcinoma of no special type with tumor size > 17.0 mm. Overall, four women received PMRT after verified metastasis by staged SLNB, and IBR was cancelled for three patients. These findings question the benefit of routine staged SLNB before mastectomy and IBR in breast cancer populations within established mammography screening programs with low risk of nodal metastasis.

Nodal Pathologic Complete Response Rates in Luminal Breast Cancer Vary by Genomic Risk.

Although an advantage of neoadjuvant chemotherapy (NAC) is eradication of axillary disease, nodal pCR rates are much lower for ER+/HER2- breast cancer than other subtypes. We sought to evaluate the association of genomic risk with nodal pCR in ER+/HER2- disease. Patients with ER+/HER2- clinically-node-positive (cT0-cT4d/cN1-cN3/cM0) breast cancer treated with NAC and surgery 2010-2018 in the National Cancer Database were identified. Low genomic risk was classified as Oncotype Dx Recurrence Score (RS) 0-25, or Mammaprint 70-gene or RS coded as "Low." High genomic risk included RS >25, or 70-gene or RS coded as "High." Nodal pCR was compared between patients with high versus low genomic risk by using chi-square tests and multivariable logistic regression. Of 15,698 patients, genomic risk was available for 692 of 15,698 (4.4%). High genomic risk was similar between patients aged <50 years versus 50+ (50.8% vs. 57.3%, p = 0.10). Nodal pCR was higher in high genomic risk (25.0%) than low genomic risk (10.4%, p < 0.001). This difference was observed both for patients aged <50 years (29.9% vs. 9.8%) and aged ≥50 years (22.7% vs. 10.8%). On multivariable analysis adjusted for potential confounding variables, including age, grade, and PR status, genomic risk was independently associated with decreased odds of residual nodal disease (odds ratio 0.49, p = 0.002). For patients with node-positive ER+/HER2- breast cancer treated with NAC, nodal pCR was highest in patients aged <50 years with high genomic risk tumors. In contrast, nodal pCR rates were low in patients with low genomic risk tumors, regardless of age. This information may help when counseling patients regarding axillary management.

Intraoperative sentinel lymph node evaluation in patients with node-positive breast cancer status post neoadjuvant systemic therapy - An institutional experience

Recent studies have shown the feasibility and utility of sentinel lymph node (SLN) biopsy in patients with biopsy proven node-positive breast cancer after neoadjuvant chemotherapy. We reviewed our experience in intraoperative SLN evaluation in such cases and its effect on axillary management. A retrospective analysis of breast cancer patients (2015–2018) with a biopsy-proven positive axillary lymph node, who received neoadjuvant systemic therapy and underwent intraoperative SLN assessment was performed. Intraoperative SLN assessment results were compared with final pathology. Its accuracy and effect on axillary management is summarized. We identified 106 patients with positive axillary lymph node and neoadjuvant systemic therapy between the ages of 28 and 75 years who had SLN biopsy and lumpectomy (33) or mastectomy (73). Three or more SLNs were identified in 91 cases (86 %). The previously biopsied lymph node was identified as one of the sentinel lymph nodes in 93 cases (88 %). There is a high concordance rate between frozen section diagnosis and final diagnosis on sentinel lymph nodes. No false positive case and seven false negative frozen section diagnosis cases (diagnosed as negative on frozen section and positive on permanent sections) were identified. False-negative frozen section diagnosis correlated with low-volume nodal disease and obscuring tumor bed changes. Almost half of the positive lymph nodes were converted to negative after neoadjuvant chemotherapy. SLN biopsy with intraoperative frozen section evaluation after neoadjuvant systemic therapy in node-positive patients is an effective way to minimize axillary surgery.

Non-invasive predictors of axillary lymph node burden in breast cancer: a single-institution retrospective analysis

PurposeAxillary 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.MethodsA 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.ResultsOne 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).ConclusionIdentifying 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.

Axillary surgery after neoadjuvant therapy in initially node-positive breast cancer: international EUBREAST survey.

There is no consensus on axillary management after neoadjuvant therapy (NAT) in patients with clinically node-positive (cN+) breast cancer. To investigate current clinical practice, an international survey was conducted among breast surgeons and radiation oncologists. The aim of the first part of the survey was to provide a snapshot of international discrepancies regarding axillary surgery in this context. The European Breast Cancer Research Association of Surgical Trialists (EUBREAST) developed a web-based survey containing 39 questions describing clinical scenarios in the setting of axillary management in patients with cN1 disease converting to ycN0 after NAT. The survey was then distributed to breast surgeons and radiation oncologists via 14 breast cancer societies between April and October 2021. Responses from 349 physicians in 45 countries were recorded. The most common post-NAT axillary surgery in patients with cN1 disease converting to ycN0 was targeted axillary dissection (54.2 per cent), followed by sentinel lymph node biopsy (SLNB) alone (20.9 per cent), level 1-2 axillary lymph node dissection (ALND) (18.4 per cent), level 1-3 ALND (4 per cent), and targeted lymph node biopsy (2.5 per cent). For SLNB alone, dual tracers were most commonly used (62.3 per cent). Management varied widely in patients with ambiguous axillary status before initiation of treatment or a residual metastatic burden in the axilla after NAT. In patients with ycN+ tumours, ALND was the preferred surgical approach for 66.8 per cent of respondents. These results highlight the wide heterogeneity in surgical approaches to the axilla after NAT. To standardize the guidelines, further data from clinical research are urgently needed, which underlines the importance of the ongoing AXSANA (EUBREAST-3) study.

Prediction of axillary lymph node metastasis in triple-negative breast cancer by multi-omics analysis and an integrated model.

BackgroundTo avoid unnecessary postoperative complications, it is essential to select breast cancer patients without axillary lymph node (LN) metastasis who might be eligible for exemption from sentinel lymph node biopsy (SLNB). However, the lymph node metastasis (LNM) of triple-negative breast cancer (TNBC) is difficult to predict if only considering clinical parameters. Hence, by investigating the difference between LN positive and LN negative patients, we aimed to build a multi-omics model able to better predict LNM in TNBC.MethodsA total of 445 TNBC patients with lymph node status and multi-omics data were enrolled and divided into training and validation sets. We analyzed both clinicopathological characteristics and multi-omics data to search for robust biomarkers, which were used to establish a multi-omics model.ResultsCompared with LN negative patients, LN positive patients had an increasing number of mutational events, while the frequencies of both amplification and deletion in somatic copy number alterations (SCNAs) were lower in LN positive cases. After analyzing upregulated gene-related pathways, neutrophil-related pathways were found to be enriched in LN positive patients. Based on these omics analyses, 5 predictors were utilized to build a multi-omics model, and the area under the receiver operating characteristic curve was 0.790 in the training set and 0.807 in the validation set, showing a better performance than models using individual omics data.ConclusionsAfter analyzing the largest TNBC multi-omics cohorts, we identified the potential clinical and molecular characteristics that are related to LNM. A multi-omics model was developed and performed robustly in predicting LNM, with the potential assistance of tailoring unnecessary axillary LN management among TNBC patients.

Sentinel node biopsy and regional recurrence following neoadjuvant chemotherapy in patients with isolated tumor cells: A rare event.

e12581 Background: Lack of consensus exists regarding the optimal surgical axillary management of breast cancer patients treated with neoadjuvant therapy followed by sentinel node biopsy (SNB) with only isolated tumor cells (ITCs) identified in the sentinel node (SN). Few studies with limited patients have addressed this. A prospectively maintained database was reviewed to identify residual nodal metastatic burden and outcomes for patients with SN ITCs. Methods: Operable breast cancer patients treated with neoadjuvant therapy followed by breast surgery with SNB were identified who had only ITCs in the SN. Patients were excluded who had recurrent breast cancer, metastatic disease at time of operation, or who had an operation performed at another institution. Residual burden of axillary metastatic disease in patients who underwent completion axillary dissection and locoregional recurrence were examined. All SNs were examined with both hematoxylin and eosin stains as well as well as immunohistochemical stains. Results: 875 patients underwent neoadjuvant therapy followed by breast surgery and SNB from July 2007 to November 2021. Seventeen patients (1.9%) had only ITCs in the SN. The mean patient age of these 17 patients was 55.6 years (range 31-83 years). The majority had invasive ductal carcinoma (n = 15, 88.2%). Fourteen patients (82.4%) had ER+ tumors, 11 (64.7%) PR+ tumors, 2 patients (11.7%) had HER2+, and 3 patients (17.6%) had triple negative cancers. All patients had clinical T1 to T3 tumors and clinical N0 (n = 11, 64.7%), N1 (n = 5, 29.4%), or N2 (n = 1, 5.9%) disease. Two patients had isolated tumor cells identified on frozen section. Both of these patients underwent axillary dissection during the index operation and had further nodal disease identified (1 patient with ITCs only and 1 patient with macrometastasis). Fourteen patients had SN tumor free frozen sections but ultimately had ITCs identified with H&amp;E. Five of these patients underwent a completion axillary dissection. Three of the 5 patients (60%) had additional ITCs identified after completion ALND. Fourteen patients had nodal irradiation. The three patients who did not receive irradiation did not undergo ALND. All patients with ER+ tumors received adjuvant endocrine therapy, the 2 patients with HER2+ cancers received adjuvant targeted HER2 therapy, and 4 patients received adjuvant chemotherapy. At a mean follow-up of 21.8 months (range 2-63 months), no locoregional recurrences occurred in any patient. Conclusions: ITCs in the SN after neoadjuvant therapy is a rare finding and are unlikely to be associated with regional recurrence.

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.

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. 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. 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. 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.