Axillary Surgery In Patients Research Articles

Extent of regional lymph node surgery and impact on outcomes in patients with early-stage breast cancer and limited axillary disease undergoing mastectomy.

Management of the axilla in patients with early-stage breast cancer (ESBC) has evolved. Recent trials support less extensive axillary surgery in patients undergoing mastectomy. We examine factors affecting regional lymph node (RLN) surgery and outcomes in patients with ESBC undergoing mastectomy. Women with clinical T1/2 N0 M0 invasive BC who underwent mastectomy with 1-2 positive nodes were selected from the National Cancer Database (2004-2015). Axillary surgery was defined by number of RLNs examined: 1-5 sentinel LN dissection (SLND), and ≥ 10 axillary LND (ALND). Binary logistic regression and survival analyses were performed to assess the association between axillary surgery and clinical characteristics, and overall survival (OS), respectively. 34,243 patients were included: 13,821 SLND (40%) and 20,422 ALND (60%). SLND significantly increased from 21% (2004) to 45% (2015) (p < .001). Independent factors associated with SLND were treatment year, non-Academic centers, geographic region, tumor histology, and postmastectomy radiotherapy (PMRT). Multivariable survival analysis showed that ALND was associated with better OS (HR 0.78, 95% CI 0.72-0.83, p < .001) relative to SLND; however, there was no difference in patients with LN micrometastases treated without RT (HR 0.87, 95% CI 0.73-1.05, p = .153) or patients receiving PMRT (HR 0.92, 95% CI 0.76-1.13, p = .433). SLND has significantly increased in patients undergoing mastectomy with limited axillary disease and is influenced by patient, tumor, and treatment factors. Survival outcomes did not differ by axillary treatment for patients with LN micrometastases treated without RT or patients who received PMRT. SLND may be considered in select patients with ESBC and limited axillary disease undergoing mastectomy.

Pre-operative and intra-operative detection of axillary lymph node metastases in 108 patients with invasive lobular breast cancer undergoing mastectomy

BackgroundDespite the recent changes in the treatment of the axilla in selected breast cancer patient, positive sentinel lymph node (SLN) in patients undergoing mastectomy still necessitates axillary lymph node dissection (ALND). In invasive lobular carcinoma (ILC), pre-operative detection of the lymph node metastasis may be demanding due to its unique morphology. The aim of this study was to examine the benefit of preoperative axillary ultrasound (AUS), ultrasound-guided fine-needle aspiration biopsy (US-FNAB), and intra-operative imprint cytology (IIC), in order to avoid two-stage axillary surgery in patients with ILC undergoing mastectomy.MethodsThe object of this study were 102 patients (median age 52, range 34–73 years) with clinically non-suspicious axilla in whom 108 mastectomies were performed after a pre-operative AUS investigation. Whenever a metastasis was detected in a sentinel lymph node, ALND was done. Reports of the pre-operative AUS investigation, US-FNAB, and IIC were compared with definitive histopathological reports of surgical specimens.ResultsIn 46 cases lymph node metastases were diagnosed. AUS suspicious lymph nodes were found in 29/108 cases and histopathology confirmed metastases in 22/30 cases. US-FNAB was performed in 29 cases with AUS suspicious lymph nodes. Cytology proved metastases in 11/29 cases. Histopathology confirmed metastases in 10/11 cases with only isolated tumor cells found in one case. IIC investigation was performed in 63 cases and in 10/27 cases metastases were confirmed by histopathology. Pre-operative AUS, US-FNAB, and/or IIC investigation enabled ALND during a single surgical procedure in 20/46 patients with metastases in lymph nodes.ConclusionPre-operative AUS, US-FNAB, and/or IIC are/is beneficial in patients with ILC planned for mastectomy in order to decrease the number of two stage axillary procedures.

Abstract OT2-04-02: Comparison of axillary sentinel lymph node biopsy versus no axillary surgery in patients with early-stage invasive breast cancer and breast-conserving surgery: A randomized prospective surgical trial. The Intergroup-Sentinel-Mamma (INSEMA)-trial

Abstract Background: Currently, axillary surgery for breast cancer is considered as staging procedure that does not seem to influence breast cancer mortality, since the risk of developing metastasis depends mainly on the biological behaviour of the primary. Based on this, the postsurgical therapy should be considered on the basis of biologic tumor characteristics rather than nodal involvement. Trial design: The goal of INSEMA is to show that early-stage breast cancer patients with reduced extent of axillary surgery are not inferior regarding invasive disease-free survival (IDFS) outcome. Patients with planned breast-conserving surgery (BCS) will be first randomized (1:4 ratio) to either no axillary surgery or axillary sentinel lymph node biopsy (SLNB). Patients with SLNB and pN+(sn) status will be secondly randomized (1:1 ratio) to either SLNB alone or completion axillary lymph node dissection (ALND) in cases with less than three involved nodes (one or two macrometastases). Primary objective: -IDFS after BCS (non-inferiority question) Inclusion criteria: -Written informed consent -Histologically confirmed unilateral primary invasive carcinoma of the breast (core biopsy) -Age at least 35 years -Preoperative imaging techniques with estimated tumor size of maximal 5 cm (iT1/iT2 irrespective of hormone sensitivity or HER2 status) -Clinically and sonographically tumor-free axilla prior to core biopsy -In cases with cN0 and iN+, a negative core biopsy or fine needle aspiration biopsy of the suspected lymph node is required -No clinical evidence for distant metastasis (M0) -Planned breast-conserving surgery (R0 resection) with postoperative external whole-breast irradiation (conventional fractionation or hypofractionation) Statistics: The calculated total case number for per-protocol analyses is 6,740 (5,940 German and 800 Austrian patients), the expected total number of randomized patients is 7,095. Time lines: -First patient in: September 2015 -Last patient in: August 2019 -Final analysis: End of 2024 Present accrural: In June 2016, more than 1.000 patients were recruited in Germany and Austria. Citation Format: Reimer T, von Minckwitz G, Loibl S, Hildebrandt G, Nekljudova V, Schneider-Schranz C, Gerber B. Comparison of axillary sentinel lymph node biopsy versus no axillary surgery in patients with early-stage invasive breast cancer and breast-conserving surgery: A randomized prospective surgical trial. The Intergroup-Sentinel-Mamma (INSEMA)-trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-04-02.

Abstract P2-01-21: Preoperative axillary ultrasound guided needle sampling in breast cancer: Comparing the sensitivity of fine needle aspiration cytology and core needle biopsy

Abstract Background: Preoperative axillary ultrasound (US) combined with selective US-guided needle sampling (UNS) can be used to identify lymph node metastases. This can inform decisions about neoadjuvant chemotherapy and allow a patient to proceed immediately to axillary lymph node dissection (ALND) thus avoiding an extra sentinel node biopsy (SNB) procedure. We acknowledge the landmark ACOSOG Z0011 trial showing a subgroup of patients (T1-2) undergoing breast conserving surgery and whole-breast radiotherapy in which ALND can safely be omitted if they have minimal nodal disease burden. For these patients the utility of UNS may be limited if the surgeon has modified their practice according to the trial. For patients not fitting the Z0011 trial criteria, preoperative UNS remains important. Previous studies comparing the sensitivity of axillary US-guided fine needle aspiration cytology (FNA) and core needle biopsy (CNB) have been small and a meta-analysis has not shown a difference in sensitivity1. Our aim was to directly compare the sensitivity of the two techniques. Method: Patients with macrometastatic nodal involvement that were treated at a tertiary referral centre between January 2013 and December 2014 were retrospectively identified from pathology records. Preoperative UNS had been performed by one of eight Consultant Radiologists with the sampling method being according to each individual radiologist's preference. The result of the first UNS performed on each patient was compared to post-operative histopathology results. Patients who had undergone previous axillary surgery or any part of their investigations/treatment at another unit were excluded. Results: A total of 101 CNBs and 181 FNAs were performed in 282 patients. There were 78 true positive CNBs and 96 true positive FNAs. US-guided CNB was therefore more sensitive than US-guided FNA (77.2% vs. 53.0%, p=&amp;lt;0.001). Two non-diagnostic CNBs and eight non-diagnostic FNAs were performed. Five patients in the CNB group were correctly identified preoperatively as having isolated tumour cells (ITCs) or micrometastatic disease only in their axillary lymph nodes and were therefore triaged to SNB rather than ALND. A single haematoma requiring non-operative management was recorded in the CNB group. Conclusion: US-guided CNB of the axilla is more sensitive than US-guided FNA and is a safe technique in experienced hands. We also highlight the additional potential benefit (whilst accepting the possibility of sampling error) of CNB over FNA in assisting the multidisciplinary planning of axillary surgery in patients who are found to have ITCs or micrometastatic disease only during their preoperative axillary staging.

A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Lymph Node Dissection on Axillary Surgery in Patients with Breast Cancer.

Evidence from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial suggests completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy (+SLNB) does not improve outcomes in select patients, leading to practice variation. A multidisciplinary group of surgeons, oncologists, and pathologists developed a regional guideline for cALND which was disseminated in August 2012. We assessed the impact of Z0011 and the regional guideline on cALND rates. Consecutive invasive breast cancer cases undergoing SLNB were reviewed at 12 hospitals. Patient, tumor, and process measures were collected for three time periods: TP1, before publication of Z0011 (May 2009-August 2010); TP2, after publication of Z0011 (March 2011-June 2012); and TP3, after guideline dissemination (January 2013-April 2014). Cases were categorized by whether they met the guideline criteria for cALND (i.e. ≤50years, mastectomy, T3 tumor, three or more positive sentinel lymph nodes [SLNs]) or not (e.g. age>50 years, breast-conserving surgery, T1/T2 tumor, and one to two positive SLNs). The SLNB rate increased from 56% (n=620), to 70% (n=774), to 78% (n=844) in TP1, TP2, and TP3, respectively. Among cases not recommended for cALND using the guideline criteria, cALND rates decreased significantly over time (TP1, 71%; TP2, 43%; TP3, 17%) [p<0.001]. The cALND rate also decreased over time among cases recommended to have cALND using the guideline criteria (TP1, 92%; TP2, 69%; TP3, 58%) [p<0.001]. Based on multivariable analysis, age and nodal factors appeared to be significant factors for cALND decision making. Publication of ACOSOG Z0011 and regional guideline dissemination were associated with a marked decrease in cALND after +SLNB, even among several cases in which the guideline recommended cALND.

Nomograms for Predicting Axillary Response to Neoadjuvant Chemotherapy in Clinically Node-Positive Patients with Breast Cancer.

Many patients with clinically node-positive breast cancer receive neoadjuvant chemotherapy (NAC). Recent trials suggest the potential for limiting axillary surgery in patients who convert to pathologically node-negative disease. The authors developed a nomogram to predict axillary response to NAC in patients with cN1 disease that can assist clinicians in treatment planning. Patients with cT1-4N1M0 breast cancer who received NAC and underwent axillary lymph node dissection from 2001 through 2013 were identified (n=584). Uni- and multivariate logistic regression analyses were performed to determine factors predictive of nodal conversion. A nomogram to predict the likelihood of nodal pathologic complete response (pCR) was constructed based on clinicopathologic variables and validated using an external dataset. Axillary pCR was achieved for 217 patients (37%). Patients presenting with high nuclear grade [grade 3 vs. 1, odds ratio (OR) 13.4], human epidermal growth factor receptor 2-positive (OR 4.7), estrogen receptor (ER)-negative (OR 3.5), or progesterone receptor-negative (OR 4.3) tumors were more likely to achieve nodal pCR. These factors, together with clinically relevant factors including presence of multifocal/centric disease, clinical T stage, and extent of nodal disease seen on regional nodal ultrasound at diagnosis were used to create nomograms predicting nodal conversion. The discrimination of the nomogram using ER+ status (>1% staining) versus ER- status [area under the curve (AUC) 78%] was improved slightly using the percentage of ER staining (AUC 78.7%). Both nomograms were validated using an external cohort. Nomograms incorporating routine clinicopathologic parameters can predict axillary pCR in node-positive patients receiving NAC and may help to inform treatment decisions.

Avoidance of axillary surgery in patients with invasive breast cancer. Long term follow-up of a cohort of 194 patients

Avoidance of axillary surgery in patients with invasive breast cancer. Long term follow-up of a cohort of 194 patients

Abstract OT2-02-01: Comparison of axillary sentinel lymph node biopsy versus no axillary surgery in patients with early-stage invasive breast cancer and breast-conserving surgery: A randomized prospective surgical trial. The intergroup-sentinel-mamma (INSEMA)-trial

Abstract Background: Currently, axillary surgery for breast cancer is considered as staging procedure that does not seem to influence breast cancer mortality, since the risk of developing metastasis depends mainly on the biological behaviour of the primary. Based on this, the postsurgical therapy should be considered on the basis of biologic tumor characteristics rather than nodal involvement. Trial design: The goal of INSEMA is to show that early-stage breast cancer patients with reduced extent of axillary surgery are not inferior regarding invasive disease-free survival (IDFS) outcome. Patients with planned breast-conserving surgery (BCS) will be first randomized (1:4 ratio) to either no axillary surgery or axillary sentinel lymph node biopsy (SLNB). Patients with SLNB and pN+(sn) status will be secondly randomized (1:1 ratio) to either SLNB alone or completion axillary lymph node dissection (ALND) in cases with less than three involved nodes (one or two macrometastases). Primary objective: -IDFS after BCS (non-inferiority question) Inclusion criteria: -Written informed consent -Histologically confirmed unilateral primary invasive carcinoma of the breast (core biopsy) -Age at least 35 years -Preoperative imaging techniques with estimated tumor size of maximal 5 cm (iT1/iT2 irrespective of hormone sensitivity or HER2 status) -Clinically and sonographically tumor-free axilla prior to core biopsy -In cases with cN0 and iN+, a negative core biopsy or fine needle aspiration biopsy of the suspected lymph node is required -No clinical evidence for distant metastasis (M0) -Planned breast-conserving surgery (R0 resection) with postoperative external whole-breast irradiation (conventional fractionation or hypofractionation) Statistics: Assumptions for first randomization: -The 5-year IDFS for women with cN0/iN0 axillary lymph nodes and T1/T2 disease is considered to be 88% -Clinical non-inferiority is defined as the non-SLNB group having a 5-year IDFS of not less than 85% and if the hazard ratio (HR) is less than 1.271 when compared with the SLNB group The total number of patients in the per-protocol set of the first randomization must be increased from 3,796 to 5,940 (936 events) due to unequal-sample-size design. Assumptions for second randomization: -The 5-year IDFS for women with pN+(sn) axillary lymph nodes (1-2 macrometastases) and T1/T2 disease is considered to be 81% -Clinical non-inferiority is defined as the SLNB alone group having a 5-year IDFS of not less than 76.5% and if the hazard ratio (HR) is less than 1.271 when compared with the completion ALND group The total number of patients to be included into the per-protocol set for the second randomization will be approximately 1,968. Finally, the calculated total case number for per-protocol analyses is 6,740 (5,940 German and 800 Austrian patients), the expected total number of randomized patients is 7,095. Time lines: -First patient in: September 2015 -Last patient in: August 2019 -Final analysis: End of 2024 Funding by Deutsche Krebshilfe (grant no. 110580). Citation Format: Reimer T, von Minckwitz G, Loibl S, Hildebrandt G, Denkert C, Nekljudova V, Kundt G, Becker D, Gerber B. Comparison of axillary sentinel lymph node biopsy versus no axillary surgery in patients with early-stage invasive breast cancer and breast-conserving surgery: A randomized prospective surgical trial. The intergroup-sentinel-mamma (INSEMA)-trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT2-02-01.

Axillary surgery in women with sentinel node-positive operable breast cancer: a systematic review with meta-analyses.

Traditionally, women with node-positive operable breast cancer have received complete axillary lymph node dissection (ALND), which is associated with significant morbidity, but recently less invasive alternatives have been explored. We conducted a systematic review of randomised controlled trials assessing alternative approaches to axillary surgery in patients with pathologically-confirmed sentinel node-positive operable breast cancer. We searched on 16/3/15 the Specialized Register of the Cochrane Breast Cancer group; CENTRAL; MEDLINE; PreMEDLINE; EMBASE; WHO International Clinical Trials Registry Portal; ClinicalTrials.gov; conference proceedings from ASCO and the San Antonio Breast Cancer meetings; checked reference lists and contacted authors to identify relevant studies. Double, independent study sifting, extraction, appraisal and summarising were undertaken using standard Cochrane Collaboration methodology. We included three studies (2020 patients) comparing ALND with sentinel lymph node dissection (SLND) to SLND alone, and two studies (1899 patients) comparing ALND to axillary radiotherapy (aRT). No differences in survival or recurrence were observed between ALND and SLND or aRT, but morbidity may have been increased in ALND, and all the results were subject to different biases, such as recruitment bias, performance bias, and outcome-reporting bias. Whilst it is encouraging that there appears to be no adverse effect on recurrence or survival, it will be appropriate to confirm these findings and provide additional data confirming quality of life effects and long term outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-016-1712-9) contains supplementary material, which is available to authorized users.

Re: Predictive value of fine needle aspiration biopsy of axillary lymph nodes in preoperative breast cancer staging.

Axillary management in breast cancer has evolved tremendously in the last decades. Sentinel lymph node biopsy (SLNB) has replaced axillary dissection in patients without any clinical and radiological involvement in the axilla. Although the complication rate of SLNB is lower than axillary dissection, the search for an accurate method to determine the axillary status in breast cancer with even lower complication rate is continuing. Fine needle aspiration biopsy (FNAB) is performed under ultrasonography guidance in case of suspicious lymph nodes in the axilla, especially in those with cortical thickening or decreased echogenecity in the hilum in addition to changes in size and shape of the lymph node. The accuracy of FNAB in predicting the status of the axilla is investigated in recent studies. Fine needle aspiration biopsy of the axilla helps the clinician in determining surgical approach and neoadjuvant chemotherapy. Nowadays, extent of axillary surgery has almost no definitive role in deciding the mode of adjuvant treatment. Obtaining information about the presence of metastatic disease in the axilla is enough to determine the prognosis of the patient. However, 30% of axillary metastases were detected with FNAB under ultrasonography guidance and additional 30% with SLNB whereas the axillary status of the remaining patients were determined by histopathologic examination (1). In addition to the information about the axilla, FNAB enables us to place clips into the metastatic lymph nodes to follow the results of neoadjuvant treatment. Akinci et al. investigated this topic in the article entitled “Predictive value of fine needle aspiration biopsy of axillary lymph nodes in preoperative breast cancer staging” (2). This study aimed to determine the role of ultrasound-guided FNAB in axillary staging. Sensitivity, specificity, positive and negative predictive value, and accuracy of FNAB were studied. Sensitivity and negative predictive value showed moderate values (60%) whereas specificity and positive predictive values were 100%. Overall accuracy of axillary FNAB was reported as 76.1%. These results are in accordance with the results of the previous studies. Sensitivity of FNAB under ultrasound guidance changes between 45–95% and the specificity is almost 100% (3, 4). Microbiopsies using larger needles and addition of immunohistochemical examination increase the sensitivity and presence of micrometastases in the lymph node contributes to the false negative results (5). Small number of patients included in the study may be its limitation, however, prospective design of the study supports the results with higher reliability. Finally, this study encourages the clinicians to utilize ultrasound-guided FNAB more frequently to avoid unnecessary SLNB in breast cancer. As a conclusion, randomized controlled trials including large enough number of patients are required to establish the value of FNAB in axillary staging of breast cancer. Sentinel node vs. observation after axillary ultrasound (SOUND) trial is an ongoing prospective randomized trial comparing SLNB and no axillary surgery in patients with normal axillary ultrasound (6). If a high predictive power of FNAB for axillary lymph node metastases could be proven, SLNB might be replaced by this method in the future. Detection of axillary metastases with FNAB might avoid performing SLNB and frozen section study decreasing time spent during surgery and total expenses in treatment.

Normal Axillary Ultrasound Excludes Heavy Nodal Disease Burden in Patients with Breast Cancer.

Axillary lymph node stage is important in guiding adjuvant treatment for breast cancer. The role of axillary ultrasound (AUS) in axillary staging is uncertain. From an institutional database, all newly diagnosed invasive breast carcinomas from February 1, 2011 to October 31, 2014 were identified; exclusions were for stage IV disease, palpable adenopathy, or receipt of neoadjuvant chemotherapy. AUS findings, categorized as suspicious versus not suspicious, were correlated with the number of nodal metastasis from surgical pathology. The false-negative rate of nonsuspicious AUS for identifying ≥3 lymph nodes positive on final pathology was calculated. A total of 513 cancers were included. Overall, 400 AUSs were not suspicious (78%), and 113 were suspicious (22%). The sensitivity and specificity of AUS for predicting ≥3 nodal metastasis were 71 and 83%, respectively. The false-negative rate for detecting ≥3 nodal metastasis was 4%. False-negative rate was higher for lobular versus nonlobular carcinomas (12.0 vs. 2.3%, p = 0.004) and for pT2-pT4 tumors versus pT1 tumors (8.2 vs. 1.7 %, p = 0.005). Patients with normal axillary physical exam and ultrasound rarely harbor a large nodal disease burden. Randomized trials of sentinel lymph node biopsy versus no axillary surgery in patients with normal AUS must be powered for subgroup analysis of patients with invasive lobular carcinoma and pT2-pT4 tumors. Preoperative identification of nodal metastasis may decrease the need for second surgeries and identify candidates for neoadjuvant chemotherapy. AUS is a noninvasive means of predicting disease burden preoperatively and as such is a powerful tool to individualize treatment plans.

Syndrome de la corde axillaire après chirurgie ganglionnaire dans un contexte de mélanome : 5 cas

Axillary web syndrome is a rare disease similar to Mondor's disease and is usually seen after axillary surgery. Herein, we describe five new cases, all of which occurred in a setting of melanoma. Five patients presented axillary web syndrome following sentinel node surgery, adenectomy or axillary curettage in a setting of melanoma. Therapy involving analgesics and physiotherapy to snap the cord-like structure helped accelerate resolution. Some debate continues to surround the physiopathology of axillary web syndrome in the literature, particularly regarding its relationship with Mondor's disease, which is considered to result from superficial venous thrombosis. The lymphatic and myofascial explanation for the syndrome appears to us to be more coherent and justifies the non-aggressive therapeutic approach we adopt for our patients, who receive assurances about the benign nature of their condition and the absence of sequelae. Axillary surgery in patients presenting melanoma appears to be a risk factor for axillary web syndrome. No relationship has as yet been demonstrated between this syndrome and the presence of axillary metastases.

Axillary lymph node dissection versus no dissection in patients with T1N0 breast cancer: A randomized clinical trial (INT09/98)

Although axillary surgery is still considered to be a fundamental part of the management of early breast cancer, it may no longer be necessary either as treatment or as a guide to adjuvant treatment. The authors conducted a single-center randomized trial (INT09/98) to determine the impact of avoiding axillary surgery in patients with T1N0 breast cancer and planning chemotherapy based on biological factors of the primary tumor on long-term disease control. From June 1998 to June 2003, 565 patients aged 30 years to 65 years with T1N0 breast cancer were randomized to either quadrantectomy with (QUAD) or without (QU) axillary lymph node dissection; a total of 517 patients finally were evaluated. All patients received radiotherapy to the residual breast only. Chemotherapy for patients in the QUAD treatment arm was determined based on lymph node status, estrogen receptor status, and tumor grade. Chemotherapy for patients in the QU treatment arm was based on estrogen receptor status, tumor grade, and human epidermal growth factor receptor 2 and laminin receptor status. Overall survival (OS) was the primary endpoint. Disease-free survival (DFS) and rate and time of axillary lymph node recurrence in the QU treatment arm were the secondary endpoints. After a median follow-up of >10 years, the estimated adjusted hazards ratio of the QUAD versus QU treatment arms for OS was 1.09 (95% confidence interval, 0.59-2.00; P = .783) and was 1.04 (95% confidence interval, 0.56-1.94; P = .898) for DFS. Of the 245 patients in the QU treatment arm, 22 (9.0%) experienced axillary lymph node recurrence. The median time to axillary lymph node recurrence from breast surgery was 30.0 months (interquartile range, 24.2 months-73.4 months). Patients with T1N0 breast cancer did not appear to benefit in terms of DFS and OS from immediate axillary lymph node dissection in the current randomized trial. The biological characteristics of the primary tumor appear adequate for guiding adjuvant treatment.

Assessment of ultrasound features predicting axillary nodal metastasis in breast cancer

Purpose: In preparation of a planned study to compare axillary sentinel lymph node biopsy (SLNB) versus no axillary surgery in patients with early breast cancer (Intergroup-Sentinel-Mamma-Trial) we evaluated the accuracy of axillary ultrasound (AUS) in detecting axillary nodal metastasis. The aim was to identify ultrasound features with high predictive power and to create a suitable clinical flow chart.

Axillary Node Interventions in Breast Cancer

Recent data from clinical trials have challenged traditional thinking about axillary surgery in patients with breast cancer. To summarize evidence regarding the role of axillary interventions (surgical and nonsurgical) in breast cancer treatment and to review the association of these axillary interventions with recurrence of axillary node metastases, mortality, and morbidity outcomes in patients with breast cancer. Ovid MEDLINE (1946-July 2013), Cochrane Database of Systematic Reviews (2005-July 2013), Cochrane Database of Abstracts of Reviews of Effects (1994-July 2013), and Cochrane Central Register of Controlled Trials (1989-July 2013) were searched for publications on axillary interventions in breast cancer. Clinical trials, observational studies, and meta-analyses with at least 2-year follow-up were included. A total of 1070 publications were reviewed, 17 of which met final inclusion criteria. Partial mastectomy followed by whole breast radiation is breast-conserving therapy. For women with no suspicious, palpable axillary nodes who undergo breast-conserving therapy, there is little evidence of benefit from surgical complete axillary node dissection compared with sentinel node biopsy alone. Complete axillary node dissection in patients with no palpable lymph nodes, compared with sentinel node biopsy, provides no survival benefit and is associated with a 1% to 3% reduction in recurrence of axillary lymph node metastases, but is associated with a 14% risk of lymphedema. Surgical axillary staging via sentinel node biopsy in patients with benign axillary nodes on radiological and clinical examination helps to inform decisions regarding adjuvant systemic and radiation therapy. Patients and physicians should tailor axillary lymph node interventions to maximize regional disease control and minimize morbidity. Complete axillary lymph node dissection is indicated in patients who present with palpable or needle biopsy-proven axillary metastases, patients with positive sentinel nodes undergoing mastectomy (who do not, as a standard, receive adjuvant radiation), patients with more than 3 positive sentinel nodes undergoing breast-conserving therapy, and patients not meeting eligibility criteria for recent trials establishing the safety of sentinel node biopsy alone in patients with breast cancer and metastases in their sentinel nodes. Available evidence suggests that axillary node dissection is associated with more harm than benefit in women undergoing breast-conserving therapy who do not have palpable, suspicious lymph nodes, who have tumors 3.0 cm or smaller, and who have 3 or fewer positive nodes on sentinel node biopsy.

Lymphatic Mapping With Fluorescence Navigation Using Indocyanine Green and Axillary Surgery in Patients With Primary Breast Cancer

The indocyanine green fluorescence (ICGf) navigation method provides real-time lymphatic mapping and sentinel lymph node (SLN) visualization, which enables the removal of SLNs and their associated lymphatic networks. In this study, we investigated the features of the drainage pathways detected with the ICGf navigation system and the order of metastasis in axillary nodes. From April 2008 to February 2010, 145 patients with clinically node-negative breast cancer underwent SLN surgery with ICGf navigation. The video-recorded data from 79 patients were used for lymphatic mapping analysis. We analyzed 145 patients with clinically node-negative breast cancer who underwent SLN surgery with the ICGf navigation system. Fluorescence-positive SLNs were identified in 144 (99%) of 145 patients. Both single and multiple routes to the axilla were identified in 47% of cases using video-recorded lymphatic mapping data. An internal mammary route was detected in 6% of the cases. Skip metastasis to the second or third SLNs was observed in 6 of the 28 node-positive patients. We also examined the strategy of axillary surgery using the ICGf navigation system. We found that, based on the features of nodal involvement, 4-node resection could provide precise information on the nodal status. The ICGf navigation system may provide a different lymphatic mapping result than computed tomography lymphography in clinically node-negative breast cancer patients. Furthermore, it enables the identification of lymph nodes that do not accumulate indocyanine green or dye adjacent to the SLNs in the sequence of drainage. Knowledge of the order of nodal metastasis as revealed by the ICGf system may help to personalize the surgical treatment of axilla in SLN-positive cases, although additional studies are required.

Factors Affecting Nodal Status in Invasive Breast Cancer: A Retrospective Analysis of 623 Patients

With increasing numbers of early, screen-detected breast cancers and the emergence of sentinel-node biopsy, surgical management of the axilla is evolving. In recent years many authors have searched for favorable subcategories of tumors in which it may be possible to avoid axillary lymph node clearance. The aim of this study is to determine preoperative factors that might predict lymph node negative axillae. A retrospective analysis of 623 patients with invasive breast cancer was performed. A number of clinical and pathological variables were analyzed. Uni- and multivariate analysis was carried out to determine factors predictive for lymph node metastases. Age, tumor size, grade, histology and lymphovascular invasion were found to be independent predictors of nodal positivity but, contrary to other recent studies, we found no effect of ER/PR (estrogen-receptor/progesterone-receptor) or HER-2 status. The strongest predictor of lymph node metastases was tumor size >50 mm (OR 2.33), followed by the presence of lymphovascular invasion (OR 1.33). Our results could be used for preoperative counseling and planning axillary surgery in patients with invasive breast cancer. We propose that the predictive factors identified in this study could be used in combination with axillary ultrasound to selectively target patients for sentinel-node biopsy or to target the use of ultrasonographic assessment of the axilla. However, no consistent and reliable markers have been identified to predict patients that can safely avoid axillary surgery.

Pre and intra-operative strategies to avoid unnecessary axillary surgery in patients with early breast cancer

Pre and intra-operative strategies to avoid unnecessary axillary surgery in patients with early breast cancer

Indications for the sentinel node: multicentric, size of tumor, prior surgery

AbstractSentinel lymph node biopsy (SLNB) has been adopted as an applicable alternative to the standard axillary lymph node dissection (ALND) level I and II. It makes possible a less extensive axillary surgery in patients with early breast cancer with negative lymph node, who would not benefit from further dissection, in order to prevent unnecessary morbidity. On the other hand, SLNB is not appropriate in every clinical circumstance. In some clinical situations like tumor size T1 and T2, SLNB is, meanwhile, regarded as a standard procedure. In other settings like increased age and body mass index, pregnancy, ductal carcinoma in situ (DCIS), neoadjuvant chemotherapy, advanced disease (T3 and T4), prior surgery and multifocal/multicentric disease, there is a controversial debate about the importance of SLNB. This article reviews the absolute and relative contraindications of this procedure in respect to the latter three clinical situations.For the advanced breast cancers T3 and T4, there seems to be an increasing evidence of an acceptable accuracy, although it should be further evaluated in randomized clinical trials (RCT). The indication of SLNB in previously operated patients depends on the type of prior surgery. A diagnostic biopsy does not represent a contraindication, whereas the sentinel node biopsy should not be used after an extensive breast surgery neither in the context of oncologic nor non-oncologic purposes. In the context of multicentric disease, there is growing evidence that SLNB is suitable, but actually it should be restricted to RCT. However, the multifocal disease is only a relative contraindication, that is it could be applied in well-selected patients.

O-67 Prediction of axillary lymph node metastasis by size and grade of tumour an aid for the discussion of axillary surgery in patients with operable breast cancer

Recent literature has suggested that completion axillary lymph node dissection (ALND) in breast carcinoma patients with positive SLN may not be necessary. However, a method for determining the risk of non-SLN or extranodal disease remains to be established.To determine if pathological variables from primary tumors and sentinel lymph node (SLN) metastases could predict the probability of non-sentinel lymph node (NSLN) metastases and extranodal disease in patients with breast carcinoma and SLN metastases.84 women with T1-3 breast cancer and clinically-negative axillae underwent completion ALND. Maximum diameter and width of SLN metastases were measured to calculate metastatic area. When multiple SLNs contained metastases, areas were summed to calculate the Total Metastatic Area (TMA). Multiple linear regression models were used to identify predictive factors.Her-2/neu over-expression increased the odds of NSLN metastases (OR 4.3, p = 0.01) and extranodal disease (OR 7.9, p < 0.001). Independent SLN predictors were ≥1 positive SLN (OR, 7.35), maximum diameter and area of SLN metastases (OR 2.26, 1.85 respectively) and TMA (OR, 2.12). Maximum metastatic diameter/SLN diameter (OR 3.71, p = 0.04) and the area of metastases/SLN area (OR 3.4, p = 0.04) were predictive. For every 1 mm increase in diameter of SLN metastases, the odds of NSLN extranodal disease increased by 8.5% (p = 0.02). TMA >0.40 cm2 was an independent predictor for NSLN metastases and extranodal disease.Her-2/neu over-expression and parameters assessing metastatic burden in the SLN, particularly TMA, predicted the presence of NSLN involvement and extranodal disease in patients with breast carcinoma and SLN metastases.