Partial Axillary Lymph Node Dissection Research Articles

Tumor-infiltrating lymphocytes predict improved overall survival after post-mastectomy radiotherapy: a study of the randomized DBCG82bc cohort

Background The predictive value of tumor-infiltrating lymphocytes (TILs) on the benefit from radiotherapy (RT) remains unclear. Our aim was to investigate the association between TILs and post-mastectomy RT (PMRT) regarding the risk of recurrence and survival in a randomized cohort. Material and methods Stromal TILs were histologically estimated in 1011 tumors from high-risk breast cancer (BC) patients from the DBCG82bc trial. Patients were diagnosed between 1982 and 90, treated with total mastectomy and partial axillary lymph node dissection, randomized to ± PMRT followed by adjuvant systemic treatment. A competing risk model, Kaplan–Meier analysis and multivariate Cox regression analysis were used for correlating TILs and clinical outcome. Results 106 of 1011 patients (10.5%) showed high TILs using a 30% cut-off. In multivariate regression analysis, a high level of TILs was an independent factor associated with lower risk of distant metastasis (DM) and improved overall survival (OS), but without association with loco-regional control. High TILs were associated with a significantly greater OS after PMRT at 20 years compared to low TILs (8% improvement for low TILs (23% to 31%) vs. 22% for high TILs (26% to 48%), interaction-test: p = 0.028). The association between TILs and PMRT was more pronounced among estrogen-receptor negative (ER–) tumors, and patients having ER–/low TILs tumors showed no OS benefit from PMRT at 20 years (–4% improvement for low TILs (28% to 24%) vs. 23% for high TILs (20% to 43%). A similar trend in the association between high TILs and reduced risk of DM after PMRT was seen. Conclusion High TILs predict improved OS from PMRT in BC patients, and the association appeared especially strong for ER– tumors. A trend in the association between high TILs and reduced risk of DM after PMRT was seen. These findings may indicate that RT triggers an immune response inducing a systemic effect outside the treatment field.

Sentinel lymph node biopsy following previous axillary surgery in recurrent breast cancer

IntroductionIpsilateral breast recurrence or second primary breast cancer can develop in patients who have undergone breast conserving surgery (BCS) and axillary surgery. The purpose of this study was to examine the feasibility of a reoperative sentinel lymph node biopsy (SLNB) as a repeated axillary staging procedure. Patients and methodsFrom August 2014 through January 2017 patients with locally recurrent breast cancer or with BRCA mutation requiring risk reduction mastectomy as a second surgical procedure, underwent repeat SLNB in three Hungarian Breast Units with a radiocolloid (and blue dye) technique. ResultsHundred and sixty repeat SLNBs were analysed, 80 after previous SLNB and 80 after previous total or partial axillary lymph node dissection (ALND). SLN identification was successful in 106 patients (66%); 77/80 (77.5%) and 44/80 (55%) in the SLNB and ALND groups, respectively. (p < 0.003). Extra-axillary lymph drainage was more frequent in the ALND group (19/44, 43,2% versus 7/62, 11,3%; p < 0.001). Lymphatic drainage to the contralateral axilla was observed in 14 patients (11 in the ALND group, p = 0.025), isolated parasternal drainage was detected in 4 patients (p = 0.31). Only 9/106 patients with successful repeat SLNB (8,8%, all with 1 SLN removed) had SLN metastases ConclusionsRepeat SLNB is feasible in patients with ipsilateral breast tumor recurrence or new ipsilateral primary tumor after previous BCS and axillary staging. Repeat SLNB should replace routine ALND as the standard axillary restaging procedure in recurrent disease with a clinically negative axilla. Preoperative lymphoscintigraphy is important to explore extra-axillary lymphatic drainage in this restaging setting.

Partial axillary lymph node dissection inferior to the intercostobrachial nerves complements sentinel node biopsy in patients with clinically node-negative breast cancer

BackgroundThe practice of breast cancer diagnosis and treatment in China varies to that in western developed countries. With the unavailability of radioactive tracer technique for sentinel lymph nodes biopsy (SLNB), using blue dye alone has been the only option in China. Also, the diagnosis of breast malignant tumor in most Chinese centres heavily relies on intraoperative instant frozen histology which is normally followed by sentinel lymph nodes mapping, SLNB and the potential breast and axillary operations in one consecutive session. This practice appears to cause a high false negative rate (FNR) for SLNB. The present study aimed to investigate the impact of the current practice in China on the accuracy of SLNB, and whether partial axillary lymph node dissection (PALND), dissection of lymph nodes inferior to the intercostobrachial nerve (ICBN), was a good complementary procedure following SLNB using blue dye.Methods289 patients with clinically node-negative breast cancer were identified and recruited. Tumorectomy, intraoperative instant frozen histological diagnosis, SLNB using methylene blue dye, and PALND or complete axillary node dissection (ALND) were performed in one consecutive operative session. The choice of SLNB only, SLNB followed by PALND or by ALND was based on the pre-determined protocol and preoperative choice by the patient. Clinical parameters were analyzed and survival analysis was performed.Results37 % patients with clinically negative nodes were found nodes positive. 59 patients with positive SLN underwent ALND, including 47 patients with up to two positive nodes which were all located inferior to the ICBN. 9 patients had failed SLNB and underwent PALND. Among them, 3 (33.3 %) patients were found to have one metastatic node. 149 patients showed negative SLNB but chose PALND. Among them, 30 (20.1 %), 14 (9.4) and 1 (0.7 %) patients were found to have one, two and three metastatic node(s), respectively. PALND detected 48 (30.4 %) patients who had either failed SLNB or negative SLNB to have additional positive nodes. All the patients with up to two positive nodes had their nodes located inferior to the ICBN. The FNR of SLNB was 43 %. The accuracy rate was 58 %. The follow-up ranged 12–33 months. The incidence of lymphedema for SLNB, PALND, and ALND was 0 %, 0 %, and 25.4 %, respectively (P < 0.005). The disease-free survivals for SLNB, PALND, and ALND groups were 95.8 %, 96.8 %, and 94.9 %, respectively (p > 0.05).ConclusionsUnder the circumstances of current practice in China, PALND is a good complementary procedure following SLNB in clinically node-negative breast cancer.

Partial axillary dissection in early breast cancer

BackgroundIn order to reduce the probability of later clinical involvement of the axilla and at establishing a sound basis for adjuvant treatment planning axillary dissection is an important operative procedure. So, partial axillary dissection has been applied to decrease the morbidity and postoperative axillary complications.Aim of the work was to study the reliability of partial axillary lymph node dissection in patients with breast carcinoma with clinically negative axilla. MethodsEighteen patients underwent modified radical mastectomy, while the other two patients who were fulfilling the criteria for conservative breast surgery underwent lumpectomy. All patients did complete axillary lymph nodes dissection. Intraoperative leveling of the axilla was performed and level I axillary lymph nodes were identified according to their relation to pectoralis minor muscle; then they were subjected to intraoperative pathological examination by frozen section examination followed by complete axillary clearance. Then post operative histopathological examination of the tumor and all lymph nodes was done. ResultsBy intraoperative pathological examination; five patients (25%) were found positive for malignant invasion, while 15 patients (75%) were pathologically free. While paraffin section showed six patients (30%) with malignant invasion, and 14 patients (70%) were pathologically free. There was a false negative rate of 5% in level I axillary lymph nodes by intraoperative pathological examination which was positive for metastasis by paraffin section that revealed microinvasion in one lymph node out of 8 in level I. Only two cases out of 20 were found positive for metastasis in level II and III. ConclusionPartial axillary lymph node dissection is a minimally invasive, feasible and sufficient technique that can predict the axillary lymph node status.

Partial Lower Axillary Dissection for Patients with Clinically Node-negative Breast Cancer

To evaluate retrospectively the outcomes of partial lower axillary lymph node dissection caudal to the intercostobrachial nerve in patients with clinically node-negative (N(0)) breast cancer. Numbers of dissected and metastatic nodes, overall and disease-free survival rates, postoperative complication rates, and axillary recurrence were compared between patients who underwent breast cancer surgery with partial axillary node dissection (n = 1043) and historical controls who underwent conventional dissection (n = 1084). The 5-year overall and disease-free survival rates were 95.6% and 89.7%, and 94.9% and 88.4%, respectively, in the partial dissection and conventional dissection groups; the differences were not significant. Mean duration of surgery (41.6 min versus 60.9 min), intraoperative blood loss (28.0 ml versus 51.3 ml), volume of lymphatic drainage at 2 weeks postoperatively (488 ml versus 836 ml), and persistent arm lymphoedema (0.0% versus 11.8%) were significantly different between the partial and conventional dissection groups, respectively. Partial axillary lymph node dissection was associated with similar survival rates (but lower postoperative complication rates) compared with conventional axillary dissection and is recommended in patients with N(0) breast cancer.

Success treatment of post-irradiation morphoea with acitretin and narrowband UVB

Post-irradiation morphoea is a rare but under-recognised complication of radiotherapy treatment for breast cancer. Management of this condition is difficult, and many cases are recalcitrant to therapy. A 43-year-old woman with breast cancer received radiotherapy following a mastectomy and partial axillary lymph node dissection, shortly after which she developed a hot, tender, erythematous and indurated plaque at the mastectomy site. Subsequently the skin became retracted, depressed and hyperpigmented. The clinical features, along with histological findings, were consistent with post-irradiation morphoea. Treatment with narrowband ultraviolet B and acitretin 10 mg daily was commenced 5 years following radiotherapy. After 2 months of therapy the patient reported significant improvement in tenderness and range of left arm movement. Objectively the plaque was less indurated and softer to palpation. We propose that this treatment regimen is an option in the management of post-irradiation morphoea.

Axillary reverse mapping for preventing lymphedema in axillary lymph node dissection and/or sentinel lymph node biopsy

The Japanese Breast Cancer Society 2009 Axillary lymph node dissection (ALND) is a standard surgical treatment in patients with involved axillary lymph nodes. Unfortunately, arm lymphedema develops in 2.7– 5.0% of patients treated by partial ALND (level I and II), in 3.1–9.6% of those undergoing total ALND, and in 26– 38% of patients treated with ALND and radiotherapy [1]. The risk of lymphedema is often used as an argument against ALND. Currently, sentinel lymph node (SLN) biopsy has become a highly utilized and widely accepted method for surgical staging of axillary lymph nodes in breast cancer. It can avoid an unnecessary ALND in patients with node-negative breast cancer, thereby pre

Seroma Prevention Using Mytilus edulis Protein in a Rat Mastectomy Model

Seroma formation is common following mastectomy and autologous breast reconstruction and is a potential cause of significant morbidity in patients. For this reason, many methods have been investigated to prevent this complication. BD Cell-Tak is a tissue adhesive formulated from the proteins excreted by the marine mussel Mytilus edulis. The purpose of this study was to determine if Cell-Tak is able to prevent seroma formation in a rat mastectomy seroma model. Twenty Sprague-Dawley rats underwent unilateral radical mastectomy, partial axillary lymph node dissection, and disruption of the dermal lymphatics. The animals were randomly assigned to either control (n = 10) or experimental groups (n = 10). The experimental animals received 0.3 ml of the topical adhesive in the wound prior to closure, whereas control animals received no treatment. On postoperative day 7, seroma collections were aspirated and quantified and the tissue flaps were sent for histologic analysis. The control rats had a mean seroma volume of 5.3 +/- 2.6 ml, whereas the rats treated with Cell-Tak tissue adhesive had a mean seroma volume of 1.8 +/- 1.5 ml (p < 0.004). Histologic analysis revealed mild inflammation consistent with postoperative changes in both groups and no evidence of foreign body reaction to the adhesive. BD Cell-Tak tissue adhesive significantly reduces seroma formation in the rat mastectomy model. This tissue adhesive may prove beneficial in patients undergoing mastectomy with or without breast reconstruction.

Measurement of the Uncomplexed Fraction of Tissue Inhibitor of Metalloproteinases-1 in the Prognostic Evaluation of Primary Breast Cancer Patients*

Several studies have demonstrated an association between high tumor tissue levels of total tissue inhibitor of metalloproteinases-1 (TIMP-1) and a poor prognosis of primary breast cancer patients. In the present study we investigated whether measurements of the uncomplexed fraction of TIMP-1 added prognostic information to that already obtained from total TIMP-1. We measured the uncomplexed fraction of TIMP-1, using a thoroughly validated ELISA specific for this fraction, in 341 tumor tissue extracts obtained from patients with primary breast cancer. These measurements were related to previously performed measurements of total TIMP-1 as well as to patient outcome. The observation time was 8.3 years (range, 7.3-11.3 years). During this period 136 patients died, and 153 patients experienced recurrence of disease. Cox regression analysis of recurrence-free survival (RFS) suggested that a score based on both uncomplexed and total TIMP-1, reflecting the tumor level of TIMP-1/MMP complexes, would be a more precise estimate of prognosis than total TIMP-1 alone. Univariate survival analysis showed a highly significant relationship between high values of the score and poor outcomes for RFS (p = 0.0002; hazard ratio = 2.7; 95% confidence interval, 1.5-4.8). Similar results were found for overall survival (p = 0.0001; hazard ratio = 3.3; 95% confidence interval, 1.8-6.3). Multivariate analysis of RFS and overall survival demonstrated that the score was significant including the classical prognostic factors used in breast cancer (p < 0.0001). The present study raises the hypothesis that it is the tumor level of TIMP-1/MMP complexes (i.e. activated matrix metalloproteinases) rather than TIMP-1 itself that determines prognosis, supporting the use of the combined score and not only total TIMP-1 in stratification of breast cancer patients.