Management Of Axillary Nodes Research Articles

The surgical management of axillary lymph node disease in breast cancer patients

The precise assessment and management of the axillary lymph nodes in breast cancer is crucial for regional control, disease staging, selection of adjuvant chemotherapy strategies, and prediction of prognosis, with a general downward trend in surgical management. For early breast cancer with negative axillary lymph node metastases, sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) as the criterion for axillary status measurement. Patients can be exempted from ALND if they have negative SLNB results. However, it remains to be carefully decided in China whether patients with one or two positive nodes in SLNB can be spared from ALND. However, consensus has been met that patients who meet the criteria of the Z0011 study can be exempted from ALND. For breast cancer patients with positive axillary lymph nodes metastases at the beginning of treatment, the clearance of lymph node disease can be achieved by neoadjuvant therapy, with a reduced rate of complications related to ALND. In particular, there are still many debates associated with SLNB after neoadjuvant therapy, such as whether patients who remain axillary lymph node positive can be spared from ALND. Exploratory and validation studies related to the SLNB avoidance criteria are still controversial. In the future, clinicians should consider the characteristics of patients, the risk of recurrence, and adjuvant treatment regimens to develop individualized axillary lymph node management.

Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy.

The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.

Receptor Positive Breast Lesions and Status of Axillary Lymph Node.

Objective This study aimed to examine the axillary pathological condition through the development of an assessment framework for hormone receptor-positive breast cancer subsequent to neoadjuvant chemotherapy (NAC). Furthermore, the primary objective of this study was to examine the association between axillary status and breast tumors that are positive for hormone receptors following neoadjuvant chemotherapy. Methodology The present retrospective investigation encompassed a cohort including 300 individuals who were administered neoadjuvant chemotherapy before receiving surgical intervention. The data collection period for this study was from September 2021 to December 2022. All patients received neoadjuvant chemotherapy, per the guidelines established by the National Comprehensive Cancer Network (NCCN). We divided patients into two distinct groups: a test set of 250 patients and a validity set of 50 patients. Patients with no evidence of lymphoid involvement underwent a biopsy of sentinel lymph nodes (SLNB) and would have undergone axillary dissection if the biopsy results had indicated positive findings. A logistic regression analysis was employed to investigate the variables linked to the presence of residual positive axillary lymph nodes in the test set. Subsequently, a multivariate analysis was conducted on the variables that exhibited a p-value below 0.2 in the univariate study. In addition, a value of 1 was assigned to all risk factors to construct a comprehensive correlation prediction model. Results The participants included in this study had a mean age and body mass index (BMI) of 46.24 ± 9.1 years and 25.8 ± 2.5 kg, respectively. The present investigation examined the presence of pathological axillary metastases in a cohort of 188 patients, which accounted for 62.55% of the total sample, by utilizing core-needle biopsy. Furthermore, the incidence rates of individuals presenting with clinical T1 were reported as 14.6%, while 55.2% cases of T2, 17.8% cases of T3, and 13% cases of T4 tumors were reported, respectively. Of the overall occurrences, the prevailing histological subtype was invasive ductal carcinoma, accounting for 91.4% (222 out of 243) of the cases. Multiple criteria were identified as independent predictors of the presence of residual positive axillary lymph nodes. The factors under consideration encompass lymphovascular invasion (odds ratio= 7.108; 95% breast cancer stage (odd ratio = 5.025; 95%, HER2 negativity (odd ratio= 2.997), low Ki-67 expression (odd ratio = 4.231), and suspected positive axillary lymph nodes before surgical intervention. Conclusion The present study presents a novel prediction model that integrates imaging and pathology data, aiming to assist patients and healthcare practitioners in evaluating the efficacy of NACfor hormone-receptor-positive breast tumors. The model holds particular significance for individuals who exhibit clinical positivity in their lymph nodes (LNs). Consequently, the model has the potential to provide guidance for the management of axillary lymph nodes and prevent unnecessary dissection.

A prospective comparison of a modified miniaturised hand-held epifluorescence microscope and touch imprint cytology for evaluation of axillary sentinel lymph nodes intraoperatively in breast cancer patients.

The management of axillary lymph nodes in early-stage breast cancer patients has changed considerably, with the primary focus shifting from the examination of sentinel lymph nodes (SLNs) to toward the detection of all macro-metastases. However, current methods, such as touch imprint cytology (TIC) and frozen sections, are inadequate for clinical needs. To address this issue, we proposed a novel miniaturised epifluorescence widefield microscope (MEW-M) to assess SLN status intraoperatively for improved diagnostic efficiency. A prospective, side-by-side comparison of intraoperative SLN evaluation between MEW-M and TIC was performed. A total of 73 patients with 319 SLNs consecutive enrolled in this study. MEW-M showed significantly superior image quality compared to TIC (median score 3.1 vs 2.1, p < 0.0001) and had a shorter time to issue results (10.3 vs 19.4 min, p < 0.0001). Likelihood ratio analysis illustrated that the positive likelihood ratio value of MEW-M compared with TIC was infinitely great vs 52.37 (95% CI, 21.96-124.90) in model 1 (classifying results into negative/positive), infinitely great vs 52.37 (95% CI, 21.96-124.90) in model 2 (classifying results into macro-metastasis/others, and TIC results followed the same classification as model 1), respectively. Similarly, the negative likelihood ratio values of MEW-M compared with TIC were 0.055 (95% CI, 0.018-0.160) and 0.074 (95% CI, 0.029-0.190) in model 1; and 0.019 (95% CI, 0.003-0.130) vs 0.020 (95% CI, 0.003-0.140) in model 2, respectively. MEW-M is a promising technique that can be utilised to provide a rapid and accurate intraoperative assessment of SLN in a clinical setting to help improve decision-making in axillary surgery.

The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus.

Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy (±targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.

Nomogram for predicting axillary upstaging in clinical node-negative breast cancer patients receiving neoadjuvant chemotherapy.

The prediction of axillary lymph node status after neoadjuvant chemotherapy (NAC) becoming critical because of the advocation of the de-escalation of axillary management. We investigate associated factors of axillary upstaging in clinical node-negative (cN0) breast cancer patients receiving NAC to develop and validate an accurate prediction nomogram. We retrospectively analyzed 1892 breast cancer patients with stage of cT1-3N0 treated by NAC and subsequent surgery between 2010 and 2020 in twenty hospitals across China. Patients randomly divided into a training set and validation set (3:1). Univariate and multivariate logistic regression analysis were performed, after which a nomogram was constructed and validated. In total, pathologic node negativity (ypN0) achieved in 1406 (74.3%) patients and another 486 (25.7%) patients upstaged to pathologic node positive (ypN+). Breast pathologic complete response (bpCR) was achieved in 445 (23.5%) patients and non-bpCR in 1447 (76.5%) patients. A nomogram was established by ER, tumor histology, HER2 status, cycle of NAC treatment, and the bpCR, which were confirmed by multivariate logistic analysis as independent predictors of nodal upstaging in the training cohort (n = 1419). The area under the receiver operating characteristic curve (AUC) of the training cohort and validation cohort (n = 473) were 0.73 (95% CI 0.693-0.751) and 0.77 (95% CI 0.723-0.812) respectively. We present a nomogram with a nationwide large sample data which can effectively predict axillary upstaging after neoadjuvant chemotherapy to give better advice for individualized axillary lymph node management of breast cancer.

Development and Validation of a Nomogram for Predicting Axillary Lymph Node Metastasis in Breast Cancer

BackgroundAxillary lymph node (ALN) status is a key prognosis indicator for breast cancer patients. To develop an effective tool for predicting axillary lymph node metastasis in breast cancer, a nomogram was established based on mRNA expression data and clinicopathological characteristics. Materials and MethodsA 1062 breast cancer patients with mRNA data and clinical information were obtained from The Cancer Genome Atlas (TCGA). We first analyzed the differentially expression genes (DEGs) between ALN positive and ALN negative patients. Then, logistic regression, least absolute shrinkage and selection operator (Lasso) regression, and backward stepwise regression were performed to select candidate mRNA biomarkers. The mRNA signature was constructed by the mRNA biomarkers and corresponding Lasso coefficients. The key clinical factors were obtained by Wilcoxon-Mann-Whitney U test or Pearson's χ2 test. Finally, the nomogram for predicting axillary lymph node metastasis was developed and evaluated by concordance index (C-index), calibration curve, decision curve analysis (DCA), and receptor operating characteristic (ROC) curve. Furthermore, the nomogram was externally validated using Gene Expression Omnibus (GEO) dataset. ResultsThe nomogram for predicting ALN metastasis yielded a C-index of 0.728 (95% CI: 0.698-0.758) and an AUC of 0.728 (95% CI: 0.697-0.758) in the TCGA cohort. In the independent validation cohort, the C-index and AUC of the nomogram were up to 0.825 (95% CI: 0.695-0.955) and 0.810 (95% CI: 0.666-0.953), respectively. ConclusionThis nomogram could predict the risk of axillary lymph node metastasis in breast cancer and may provide a reference for clinicians to design individualized axillary lymph node management strategies.

Image-Guided Localization Techniques for Metastatic Axillary Lymph Nodes in Breast Cancer; What Radiologists Should Know.

Targeted axillary dissection (TAD) is an axillary staging technique after NACT that involves the removal of biopsy-proven metastatic lymph nodes in addition to sentinel lymph node biopsy (SLNB). This technique avoids the morbidity of traditional axillary lymph node dissection and has shown a lower false-negative rate than SLNB alone. Therefore, marking positive axillary lymph nodes before NACT is critical in order to locate and remove them in the subsequent surgery. Current localization methods include clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive tracer-based localizers, magnetic seeds, radar reflectors, and radiofrequency identification devices. The aim of this paper is to illustrate the management of axillary lymph nodes based on current guidelines and explain the features of axillary lymph node markers, with relative advantages and disadvantages.

Evaluation of the Role of Axillary Lymph Node Fine-Needle Aspiration Cytology in Early Breast Cancer With or Without Neoadjuvant Chemotherapy.

Fine-needle aspiration cytology (FNAC) of axillary lymph nodes (AxLNs) is performed to diagnose nodal metastasis in patients with breast cancer. Although the sensitivity of ultrasound-guided FNAC for identifying AxLN metastasis is in the range of 36%-99%, whether sentinel lymph node biopsy (SLNB) should be performed for neoadjuvant chemotherapy (NAC) patients with negative FNAC results is uncertain. This study aimed to determine the role of FNAC before NAC in the evaluation and management of AxLN in early breast cancer patients. We retrospectively analyzed 3,810 clinically node-negative (a lymph node with no clinical metastasis without FNAC or radiological suspicion of metastasis with negative FNAC results) patients with breast cancer who underwent SLNB between 2008 and 2019. We compared the positivity rate of sentinel lymph nodes (SLNs) between patients who received and those who did not receive NAC with negative FNAC results or without FNAC and axillary recurrence rate in the neoadjuvant group with negative SLNB results. In the non-neoadjuvant (primary surgery) group, the positivity rate of SLNs in patients with negative FNAC results was higher than that in patients without FNAC (33.2% vs. 12.9%; p < 0.001). However, the SLN positivity rate of patients with negative FNAC results (false-negative rate for FNAC) in the neoadjuvant group was lower than that in the primary surgery group (3.0% vs. 33.2%; p < 0.001). After a median follow-up of 3 years, one axillary nodal recurrence was observed, which was a case from the neoadjuvant non-FNAC group. None of the patients in the neoadjuvant group with negative FNAC results had axillary recurrence. The false-negative rate for FNAC in the primary surgery group was high; however, SLNB was the proper axillary staging procedure for NAC patients who have clinically suspicious AxLN metastases on radiologic examination but negative FNAC results.

Recognising and interpreting reactive changes due to COVID-19 vaccinations: A multi-modality pictorial series

Category: OtherOutline of submission:In order to combat the spread of novel coronavirus disease, many countries have started mass immunisation programmes. In the UK, the first vaccine was administered on 8 December 2020. Some vaccinations are known to cause transient inflammation and avidity on 18F-fluorodeoxyglucose positron emission tomography (18 F-FDG PET/CT). COVID-19 vaccination also causes ipsilateral reactive lymphadenopathy. This can pose a diagnostic challenge in imaging. It is important for radiologists and nuclear medicine physicians to consider vaccination in the differential diagnosis of such cases to avoid misinterpretation. Recording of recent vaccinations in patient documentations is important to aid appropriate interpretation. Guidelines on management of axillary nodes may need adopting to include findings of vaccination-related changes.Educational objectives:•To present ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), FDG and 68Ga DOTATATE PET-CT pictorial examples of the spectrum and pattern of reactive nodes and tracer uptake that are seen in recently COVID-19 vaccinated individuals.•To discuss features of reactive lymph nodes (eg normal size and morphology in a ipsilateral tracer avid node).•To highlight the requirement for patient vaccination history to be recorded and available at the time of reporting.•Suggestions on follow up in equivocal cases. Category: Other Outline of submission: In order to combat the spread of novel coronavirus disease, many countries have started mass immunisation programmes. In the UK, the first vaccine was administered on 8 December 2020. Some vaccinations are known to cause transient inflammation and avidity on 18F-fluorodeoxyglucose positron emission tomography (18 F-FDG PET/CT). COVID-19 vaccination also causes ipsilateral reactive lymphadenopathy. This can pose a diagnostic challenge in imaging. It is important for radiologists and nuclear medicine physicians to consider vaccination in the differential diagnosis of such cases to avoid misinterpretation. Recording of recent vaccinations in patient documentations is important to aid appropriate interpretation. Guidelines on management of axillary nodes may need adopting to include findings of vaccination-related changes. Educational objectives:•To present ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), FDG and 68Ga DOTATATE PET-CT pictorial examples of the spectrum and pattern of reactive nodes and tracer uptake that are seen in recently COVID-19 vaccinated individuals.•To discuss features of reactive lymph nodes (eg normal size and morphology in a ipsilateral tracer avid node).•To highlight the requirement for patient vaccination history to be recorded and available at the time of reporting.•Suggestions on follow up in equivocal cases.

242P Patterns of management of positive sentinel lymph nodes in breast cancer patients after the American College of Surgeons Oncology Group Z0011 trial: A retrospective cohort

The management of axillary lymph nodes in breast cancer patients has changed over the past years. The ACOSOG-Z0011 clinical trial introduced drastic changes to the traditional surgical practice for early breast cancer with positive sentinel lymph nodes (SLNs). This study evaluates how these changes have affected the surgical management of early breast cancer at our institution.

113P Axillary lymph node management in early breast cancer patients with positive sentinel lymph node: A systematic review and meta-analysis of randomized trials

Omitting axillary lymph node dissection (ALND) in patients with early breast cancer and 1 or 2 positive sentinel lymph nodes (SLNs) is still debated especially in those undergoing mastectomy. We aim to provide updated evidence on this topic.

Efficacy of the Management of Node Negative Early Stage Breast Cancer Using 1% Methylene Blue in Sentinel Lymph Node Biopsy:prospective study, kasrAlaini University Hospital

Background:Accurate staging and proper management of axillary lymph nodes are important for the treatment of breast cancer. Sentinel lymph node biopsy (SLNB) provides accurate assessment of nodal status.Aimof work:Evaluation the safety, the accuracy and the cost of the application of SLNB using methylene blue 1% (MB 1%) in cases of node negative early stage breast cancer.Patients and methods:This study was conducted at Kasr Al-Ainy university Hospitals, Faculty of Medicine, Cairo University. Fifty-two female patients with node negative early stage breast cancer who agreed on undergoing breast conservative surgery( BCS), SLNB using 1% methylene blue and frozen section examination then managed according to ACOSOG Z0011 criteria .Results:Identification in 50 surgical specimens (identification rate 96.15%). By evaluating frozen section examination of the lymph nodes in relation to paraffin section examination we found that the sensitivity of the frozen section examination was 100% and specificity was 97.5% with positive predictive value 90.9%, negative predictive value 100% and overall accuracy was 98%.Conclusion:One % MB dye is very effective as a single agent in SLNB in node negative early stage breast cancer with very high identification rate compared to patent blue and radiocolloids. Implementation of ACOSOG Z0011 criteria proved its validity throughout our study as average 12 months follow up showed no locoregional recurrence

A National Survey of Breast Surgeons and Radiation Oncologists on Contemporary Axillary Management in Mastectomy Patients.

Management of axillary lymph nodes in breast cancer has undergone significant change over the past decade through landmark clinical trials. This study aimed to assess national practice patterns in axillary management in patients undergoing upfront mastectomy and examines what guides provider recommendations. A national case-based survey study was performed of surgeons and radiation oncologists from July to August 2020. Surgeons were identified through the American Society of Breast Surgeons (ASBrS) after review and approval by the ASBrS Research Committee, and radiation oncologists were identified through an institutional database. Both descriptive and comparative statistical analyses were performed. Overall, 994 providers responded-680 surgeons and 314 radiation oncologists. Surgeons were older and in practice longer (p<0.05) and treated a higher percentage of breast patients (81% vs. 40%, p<0.001). Most surgeons were hospital-employed (43%), whereas most radiation oncologists were in private practice (40%; p<0.001). Fifty-two percent of surgeons routinely send sentinel lymph nodes (SLNs) for frozen section (52%) during mastectomy, of which 78% proceed directly to axillary lymph node dissection (ALND) if positive. There was significant variability in treatment recommendations between the two groups among the hypothetical cases (p<0.001). In the setting of low disease burden in the SLNs, > 30% of surgeons recommended ALND, while radiation oncologists recommend axillary radiotherapy over axillary clearance (p<0.001). There is significant heterogeneity in the management of the axilla in mastectomy patients with pathologically positive SLNs, both between and among surgeons and radiation oncologists. Efforts should be made to assist both groups in identifying de-escalation opportunities to ensure that mastectomy patients with positive SLNs are treated appropriately.

How Do Pathologists in Academic Institutions Across the United States and Canada Evaluate Sentinel Lymph Nodes in Breast Cancer? A Practice Survey.

There are little data on how changes in the clinical management of axillary lymph nodes in breast cancer have influenced pathologist evaluation of sentinel lymph nodes. A 14-question survey was sent to Canadian and US breast pathologists at academic institutions (AIs). Pathologists from 23 AIs responded. Intraoperative evaluation (IOE) is performed for selected cases in 9 AIs, for almost all in 10, and not performed in 4. Thirteen use frozen sections (FSs) alone. During IOE, perinodal fat is completely trimmed in 8, not trimmed in 9, and variable in 2. For FS, in 12 the entire node is submitted at 2-mm intervals. Preferred plane of sectioning is parallel to the long axis in 8 and perpendicular in 12. In 11, a single H&E slide is obtained, whereas 12 opt for multiple levels. In 11, cytokeratin is obtained if necessary, and immunostains are routine in 10. Thirteen consider tumor cells in pericapsular lymphatics as lymphovascular invasion (LVI), and 10 consider it isolated tumor cells (ITCs). There is dichotomy in practice with near-equal support for routine vs case-by-case multilevel/immunostain evaluation, perpendicular vs parallel sectioning, complete vs incomplete fat removal, and tumor in pericapsular lymphatics as LVI vs ITCs.

Can intraoperative ultrasound replace the frozen section in the assessment of ex vivo sentinel lymph node biopsy in early breast cancer in countries with limited resources?

BackgroundAccurate staging and proper management of axillary lymph nodes (ALNs) in breast cancer patients are important for treatment. Surgical management of the axilla has evolved greatly in the last 20 years. Sentinel lymph node biopsy (SLNB), which was first investigated in the early 1990s, has replaced routine axillary lymph node dissection. This study evaluates the capability of using an ultrasound (US) as an alternative tool for the frozen section in the assessment of the ex vivo sentinel lymph node biopsy in countries with limited resources.ResultsThe study is a prospective study that included 216 female patients with early breast cancer and negative axillary lymph nodes. All excised lymph nodes were examined by the intraoperative US and frozen section examinations. All the results were correlated with the final histopathological results. The number of negative nodes by US, frozen, and paraffin section examination was 58.30%, 69.40%, and 69.40%, respectively. The number of positive nodes by the US, frozen, and paraffin section examinations was 41.70%, 30.60%, and 30.60% respectively. The sensitivity, specificity, PPV, NPV, and accuracy of US in the detection of positive lymph nodes were 95.45%, 82%, 70%, 97.62%, and 86.11%, respectively, and the sensitivity, specificity, PPV, NPV, and accuracy of frozen examination in the detection of positive lymph nodes were 90.91%, 96%, 90.91%, 96%, and 94.44%, respectively.ConclusionIntraoperative US is a good negative test in the assessment of ex vivo SLNB, but it is not a good positive test, so it cannot replace the intraoperative frozen section in the assessment of SLNs.

Less Axillary Lymphadenectomy is More Beneficial: 27-Year Follow-up of Patients with Breast Cancer

Background: One of the most important alterations in breast cancer treatment is the change of view in axillary lymph node management. At the moment, sentinel lymph node biopsy (SLNB) is the standard care in axillary lymph node management. However, in patients with clinically positive lymph nodes or in patients, who have no willingness to receive radioactive drugs, axillary lymph node dissection (ALND) must be done. To the best of our knowledge, there is no overall survival (OS) benefit in ALND, especially at the early stage of breast cancer, during which this procedure is not justified. Objectives: Herein, we have reported the results of 27 years of experiments in limited axillary lymph node dissection (LALND) in comparison to ALND as well as the relationship among the number of removed lymph nodes, OS, and disease-free survival (DFS) at the early stage of breast cancer. Methods: OS and DFS for 588 cases, who were at the early stage of breast cancer and treated by LALND between 1984 and 2019, were compared with 1026 patients, who were treated by ALND during the same interval in this study. Notably, SLNB cases were excluded. Results: The results revealed no significant difference among the groups in terms of DFS (P = 0.268, 0.123, and 0.333). Also, there was no difference in terms of OS between the LALND group (1 - 4 nodes, 5 - 6 nodes, and 7 - 8 nodes) and ALND group (≥ 9 nodes) in patients without lymph node involvement (AHR less than 2). However, in the patients with axillary lymph node metastasis (N1, N2), similar results were obtained. Correspondingly, in this group, the best results were observed in those patients, whose 7 - 8 lymph nodes were removed. Conclusions: Regarding the results of the current study; it can be concluded that performing the LALND in the defined anatomic range and removing 7 - 8 lymph nodes instead of removing 10 lymph nodes are not inferior when it is not possible to do SLNB (there is no access to it) and/or being a contraindication to do it for evaluating the status of axillary lymph nodes in the patients at the early stage of breast cancer.

The Management of Axillary Lymph Nodes in Breast Cancer - A Retrospective Single-Centre Study.

Introduction: We are presenting the experience of our centre with the surgical treatment of breast cancer, by comparing the use of axillary node dissection with sentinel lymph node biopsy (SNLB). Methods: We have made a retrospective analysis of breast cancer cases in the Surgical Oncology Clinic no. 1, "Alexandru Trestioreanu" Oncology Institute, Bucharest, in the period between December 2019 and December 2020. We are presenting the situations in which axillary node dissection can be replaced with SNLB and the limitations of this method. Results: Although the use of SNLB has advantages compared to axillary node dissection, it is limited by the early detection of breast cancer and by the necessity of adding axillary dissection to surgical treatment in the case of positive SNLB. Conclusions: The replacement of axillary node dissection with SNLB is a desideratum for the following decades in view of an optimal treatment of early-stage breast cancer, with fewer postoperative complications and a better life quality.

PET-CT and MR Imaging in the Management of Axillary Nodes in Early Stage Breast Cancer.

To discriminate between malignant or benign axillary lymph nodes in breast cancer using MRI, PET-CT, and sentinel lymph node biopsy. Observational study. Department of General Surgery, Recep Tayyip Erdogan University School of Medicine, from January 2014 to March 2019. Sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) was carried out on 102 patients, who had locally advanced cases and had not previously received neoadjuvant therapy. Axillary lymph nodes pathology results were evaluated and compared with PET-CT and MRI findings. PET-CT specificity was 93.18%, MRI specificity was 93.75%, and combined PET-CT and MRI specificity was 97.67%. PET-CT sensitivity was 81.03%, MRI sensitivity was 68.57%, and combined PET-CT and MRI sensitivity was 83.05%. For detecting the presence of axillary lymph node metastasis, there was a good correlation between histopathological results and the combined evaluation with PET-CT and MRI (kappa: 0.785, p <0.001). In combined PET-CT and MRI, short diamater mean values of lymph nodes in 10 patients, which could not detect lymph node metastases, were determined to be 5.2 ±0.9 mm. Combining PET-CT and MRI is superior to PET-CT or MRI imaging alone in distinguishing benign and malignant axillary lymph node; and contributes to deciding the approach to axillary lymph node surgery. Lymph node size is also important for this imaging method to determine benign and malignant nodes correctly. Key Words: Breast cancer, PET-CT, MRI, Sentinel lymph node biopsy, Axilla.

Proteomics of Sentinel Lymph Nodes in Early Breast Cancer for Identification of Thymidylate Synthase as a Potential Biomarker to Flag Metastasis: A Preliminary Study.

IntroductionBreast cancer is the second most common cancer in women across the world. Some of the patients who present in the early stage of disease are affected by metastasis to the axillary group of lymph nodes. The first among this group that is affected is called as sentinel lymph node, and its diagnosis is crucial for the staging of cancer thereby dictating the type of surgical therapy. Therefore, the sentinel lymph node status provides the most relevant information to the surgeon and patient prognosis. The expanded utilization of breast conservation surgery has declined the morbidity associated with mastectomy and axillary lymph node surgery. Recent interest is, therefore, centered on techniques that allow accurate assessment of the sentinel lymph node metastasis. A current procedure such as sentinel lymph node biopsy (SLNB) that is used to assess axillary lymph node metastasis is neither specific nor sensitive, and besides, it is time-consuming.ObjectiveTo compare the protein profiles between metastatic and non-metastatic lymph nodes to identify a biomarker that can flag lymph node metastasis.Materials and MethodsWomen with early breast cancer were screened using mammography imaging and recruited to the study. Surgical resection was done to remove the breast tissue, and sentinel lymph node was identified using fluorescein and methylene blue tracer. Lymph node was sliced, and one set was sent for histopathology, which was considered the gold standard to assess the metastatic status of the lymph node. One set of slices was taken for proteomic experiments. Proteins were labelled with fluorescent cyanine tags and were subjected to difference gel electrophoresis experiment. Differentially expressed spots that had at least a twofold relative ratio and consistent pattern across three sets of biological replicate experiments were marked. Gel spots were trypsin digested and identified on mass spectrometry machine. Validation study was done by Western blot experiment on the same set of samples.ResultsThymidylate synthase has a twofold higher expression in the metastatic sentinel lymph nodes as compared to non-metastatic lymph nodes in early breast cancer patients.ConclusionDifferential in gel expression proteomics is an ideal platform for the identification of potential protein biomarker candidates that can differentiate metastatic from non-metastatic lymph nodes in early breast cancer. The identification of thymidylate synthase offers a scope to develop an on-table diagnostic kit to assess the status of sentinel lymph nodes during mastectomy procedure to guide surgical management of axillary lymph nodes in early breast cancer.