Previous Axillary Surgery Research Articles

A systematic review of the complications of skin puncturing procedures in the upper limbs of patients that have undergone procedures on the axilla or breast.

The increasing incidence and prevalence of breast malignancies have led to increasing numbers of surgical interventions performed on the axilla and breast, including axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), and mastectomy. The risk of postoperative complications, like breast cancer-related lymphoedema (BCRL), can have significant deleterious cosmetic and quality of life effects. National guidelines and cancer councils publish recommendations to avoid skin puncturing procedures, such as venepuncture and intravenous (IV) cannulation, on arms ipsilateral to the surgical site to prevent BCRL occurrence. The initial trials that established a link between BCRL and skin puncture were conducted in the 1950s and 1960s; the evolution of surgical management of breast cancer has likely led to large decreases in complication rates. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, four databases were systematically searched for relevant articles. Eleven relevant articles were identified for inclusion in the final analysis. Updated Australian and New Zealand College of Anaesthetists & Faculty of Pain Medicine (ANZCA) guidelines were included in the analysis following their publication after the initial search had been completed. The overall quality and quantity of evidence in this field is sufficient to conclude that skin puncturing procedures on ipsilateral arms should not be avoided in patients with previous breast or axillary surgery. The highest-quality and most recent available evidence does not support an association between BCRL and skin puncturing procedures. Policies and practices that advocate avoiding skin puncture procedures to prevent BCRL may lead to delays in clinical care. The 2023 ANZCA guidelines recommend against avoiding affected arms for peripheral access and suggest the removal of institutional policies preventing this practice. In patients that have undergone breast surgery or axillary procedures, venous access procedures can be safely performed on the ipsilateral arm. The evidence does not support overarching restrictions on using the ipsilateral arm without pre-existing lymphoedema.

Abstract PO1-22-11: Use of magnetic tracer and magnetic resonance imaging for sentinel lymph node detection after breast cancer recurrence and previous axillary surgery: The SentiRecur feasibility study

Abstract Background: Preoperative imaging increases the chance of finding the sentinel lymph node (SLN) in patients with previous axillary surgery. Current clinical routine for preoperative localization is Technetium (Tc99) and lymphoscintigraphy. An alternative method has been proposed using superparamagnetic iron oxide nanoparticles (SPIO) and non-contrast enhanced magnetic resonance imaging (MRI) of the axillae. In this feasibility study, SPIO+MRI was used in parallel with Tc99+scintigraphy for SLN localization. Methods: Twenty patients with recurrent breast cancer and previous axillary surgery at Sahlgrenska and Linkoping University Hospitals scheduled for SLN-biopsy will be included. All patients received Tc99+scintigraphy as per standard practice. In addition, a SPIO injection and bilateral axillary MRI was performed up to four weeks before surgery. Both preoperative and perioperative SLN-detection rates were studied. Rates and number of concordant SLNs were presented as percentages. Results: So far, ten patients received both SPIO+MRI and Tc99+scintigraphy. The SLN-detection rates per patient were 70% (7/10) for SPIO+MRI and 50% (5/10) for Tc99+scintigraphy, respectively. The perioperative SLN-detection rates per patient were 60% (6/10) for SPIO using the magnetic probe (SentiMagTM) and 30% (3/10) for Tc99 using a gamma-probe. In total, eleven SLNs were detected with SentiMag and four with gamma-probe. Of all SLNs, only four (36%) contained both SPIO and Tc99. Conclusion(s): Although preliminary, the results suggest that Tc99+scintigraphy may be replaced by the magnetic technique for detecting SLNs after earlier axillary surgery. The magnetic technique enables logistic advantages as tracer injection and SLN identification during a wider time frame. Table 1. Sentinel lymph node detection in patients with recurrent breast cancer Table 1. Sentinel lymph node detection in patients with recurrent breast cancer Citation Format: Eva VikhePatil, Kian Chin, Amalia SegerbardPlanoudis, Carlos Dussan, Henrik Leonhardt, Pontus Zaar, Pantelis Gialis, Fredrik Wärnberg. Use of magnetic tracer and magnetic resonance imaging for sentinel lymph node detection after breast cancer recurrence and previous axillary surgery: The SentiRecur feasibility study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-22-11.

Abstract PO4-19-10: Selective Avoidance of Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy In HER-2 Positive/Triple Negative Breast Cancer Patients With Excellent Radiologic Response to the Breast and Axilla

Abstract Background Neoadjuvant chemotherapy (NACT) for breast cancer (BC) is downstaging inoperable tumors into operable tumors and de-escalating breast/axillary surgery. According to advanced NACT, dual human epidermal growth factor-2 (HER2) blockage in HER2-positive BC, carboplatin, and immunotherapy in triple-negative breast cancer (TNBC) revealed pathologic complete response (ypCR) rates of up to 68% and 80%, the indications for NACT have expanded to early BC and the expected ypCR rate has increased. Therefore, it may be reasonable to consider omitting surgery in cases with excellent responses to NACT. Although sentinel lymph node biopsy (SLNB) is minimally invasive, some patients still experience complications such as lymphedema, pain, sensory loss, and axillary web syndrome. Several recent retrospective studies and pilot prospective studies have reported axillary pathologic complete response (ApCR) is highly correlated with breast pathologic complete response (BpCR). In cN0 with HER2+ BC and TNBC, the ApCR rate in BpCR after NACT was reported up to 100%, and in cN1 with HER2+ BC and TNBC, the ApCR rate in BpCR after NACT was reported about 85%. There are many studies predicting BpCR using radiologic imaging such as breast mammography (MMG), ultrasonography (USG), and magnetic resonance imaging (MRI). However, the combination of tri-modality (MMG, USG, MRI) could not confirm BpCR. The current study is screened in cT1-3N0-1M0, HER2+ or TNBC, and planned breast-conserving surgery (BCS) patients after NACT with excellent response at the combination of tri-modality imaging (breast MMG, breast USG, breast MRI) and with expected BpCR at physical examination. Methods Trial design The ASLAN trial is a prospective, multicenter, single-arm, clinical study. The five tertiary care hospitals in South Korea are participating which are members of the Korean Breast Cancer Study Group (KBCSG). Eligibility Inclusion criteria: women aged 20-69; cT1-3N0-1M0; HER2+ or TNBC (defined by ER-negative (< 10% positive cells in IHC) and PR-negative (< 10% positive cells in IHC)); expected complete remission at physical examination and radiological expected Tumor size ≤ 2cm or non-mass enhancement ≤ 4cm at breast MRI after standard NACT; planned breast-conserving surgery (BCS) with whole-breast irradiation; ECOG performance status 0-1. Exclusion criteria: SLNB before NACT; previous axillary surgery; bilateral BC; pregnancy. Intervention In eligible patients, BCS was performed. After BCS, patients who showed BpCR are enrolled with the omission of SLNB. Patients with no BpCR proceed with routine axillary surgery. Sample size calculation The assumption for an acceptable 5-year RFS ≥84% is based on previous study findings. The calculated total case number for per-protocol analysis is N=178. By Jun 2023, 153 patients had been enrolled and the target accrual of 178 patients is expected to be complete by Dec 2023. Study outcomes Primary endpoint: 5-year recurrence-free survival. Secondary endpoint: local recurrence-free survival, breast cancer-specific survival, overall survival, ipsilateral axillary recurrence interval, distant metastasis-free survival, contralateral breast-free survival, re-operation rate according to breast biopsy after NACT, adverse event, and quality of life. Accrual Plans The first patient was enrolled on Sep 2021. Among 223 patients who were screened, 153 patients have been enrolled in Jun 2023. We plan to complete the target accrual by Dec 2023. Conclusion The primary aim of the ASLAN trial is to demonstrate the oncologic safety of omitting axillary surgery for the excellent response after NACT in HER2+ or TNBC, early breast cancer patients undergoing BCS and adjuvant RT ASLAN trial, altogether with the EUBREAST-01 and ASCIS trials, will answer the very important question that may alter the axillary surgery in highly selected patients after NACT Citation Format: Jai Min Ryu, Wonshik Han, Han-Byoel Lee, Sung Gwe Ahn, Hee Jeong Kim, Hyung Seok Park, Ji Soo Choi, Hyunjun Lee, Hae Young Kim, Jeong Eon Lee. Selective Avoidance of Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy In HER-2 Positive/Triple Negative Breast Cancer Patients With Excellent Radiologic Response to the Breast and Axilla [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-19-10.

Selective avoidance of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with HER-2 positive/triple negative breast cancer: Prospective, multi-center, single-arm study (ASLAN).

TPS624 Background: According to advanced neoadjuvant chemotherapy (NACT), which dual HER2 blockage in HER2+ BC and adding carboplatin or immunotherapy in triple-negative breast cancer (TNBC) increased pathologic complete response (ypCR) rates up to 68% and 80%. Because ypCR patients showed better survival, the indications for NACT have expanded to early BC and the expected ypCR rate has increased. Therefore, it may be reasonable to consider omitting surgery in cases with excellent responses to NACT. Several recent retrospective studies and pilot prospective studies have reported axillary pathologic complete response (ApCR) is highly correlated with breast pathologic complete response (BpCR) in HER2+ or TNBC after NACT. The current report describes the design of omission of sentinel lymph node biopsy (SLNB) after NACT in HER2+ or TNBC patients with excellent response. Similarly, EUBREAST-01 (NCT04101851) study is ongoing omission of sentinel lymph node biopsy (SLNB) after NACT in HER2+/TNBC with radiologic complete remission and a BpCR. Methods: The ASLAN trial is a prospective, multicenter, single-arm, clinical study. Five tertiary care hospitals in South Korea are participating. Inclusion criteria: women aged 20-69; cT1-3N0-1M0; HER2+ or TNBC (defined by ER-negative (< 10% positive cells in IHC) and PgR-negative (< 10% positive cells in IHC)); expected complete remission at physical examination and radiological expected Tumor size ≤ 2cm or non-mass enhancement ≤ 4cm at breast MRI after standard NACT; planned breast conserving surgery (BCS) with whole-breast irradiation; ECOG performance status 0-1. Exclusion criteria: SLNB before NACT; previous axillary surgery; bilateral BC. Patients who are eligible proceed BCS. After BCS, patients who showed BpCR are enrolled with omission of SLNB. Patients with no BpCR proceed with routine axillary surgery. The assumption for acceptable 5-year RFS ≥84% is based on previous study findings. The calculated total case number for per- protocol analysis is N=178. Primary endpoint: 5-year recurrence free survival. Secondary endpoint: local recurrence free survival, breast cancer specific survival, overall survival, ipsilateral axillary recurrence interval, distant metastasis free survival, contralateral breast free survival, re-operation rate according to breast biopsy after NACT, adverse event, and quality of life. The first patient was enrolled on September 2021. Among 147 patients who screened, 106 patients have been enrolled in January 2022. We plan to complete the target accrual by December 2025. Clinical trial information: NCT04993625 .

Abstract P5-01-08: Steps toward noninvasive lymph node staging (NILS) in clinically node negative patients: Artificial neural network model to preoperatively predict lymphovascular invasion

Abstract Background: Lymphovascular invasion (LVI) is one of the most important predictors for nodal status in breast cancer patients [1]. Multiple models have been published for prediction of preoperatively disease-free axillary using i.a. LVI [1-2]. However, LVI detection in preoperative core needle biopsy has been reported with a failure rate of 30% [3] and the analysis is not routinely performed in Sweden. Thus, a preoperative model of LVI status would be useful in prediction models for noninvasive lymph node staging (NILS). The purpose of this study was to develop an artificial neural network (ANN) model for LVI prediction using only clinicopathological variables that are routinely available in the preoperative setting. Methods: Data gathered prospectively during 2009-2012 in Lund, Sweden from 761 clinically node negative breast cancer patients were retrospectively extracted. Inclusion criteria were female sex, primary breast cancer and that each patient was scheduled for primary surgery. Patients with metastatic disease, bilateral cancer, tumor size greater than 50 mm, previous ipsilateral breast or axillary surgery, patients omitted of standard axillary staging procedure by SLNB or ALND, and those who had neoadjuvant treatment were excluded. LVI was assessed on surgical breast specimens and was defined as the presence of tumor cells within endothelium-lined vascular channels. Out of the 761 patients in the cohort, 613 patients were documented with LVI status. The LVI full case dataset was split 80/20 for training and validation. The remaining 148 patients were set aside for model testing. Since the test dataset did not contain information on LVI status, it was used to compare the predicted fraction of LVI positive patients to that of the development dataset. Only variables possible to obtain in the preoperative setting were included in the prediction models, comprising age, menopausal status, mode of detection (mammography screening or symptomatic representation), tumor size, multifocality (yes/no), histopathological type, histological grade, ki-67 percentage, estrogen receptor status, progesterone receptor status, and human epidermal growth factor receptor 2 status. An ensemble approach was used, where each ensemble constituted 30 ANNs that were trained and validated using 5-fold cross validation. For every ensemble model, different model parameters, such as L2-regularization and the number of hidden nodes, were tested. Model selection was based on validation AUC. Results: The study cohort included female clinically node negative breast cancer patients scheduled for primary surgery. Data from 613 patients (lymph node stages N0: 67.4%, N1: 26.9%, N2+: 5.7%) were used to develop the model, and 148 patients (N0: 56.8%, N1: 35.8%, N2+: 7.4%) constituted the internal test cohort. Fifteen percentage of the patients in the development dataset were LVI positive. The selected ensemble model achieved a validation AUC of 0.80 (CI 0.75-0.85). This model predicted an LVI positive rate of 16.2% in the test dataset. Conclusion: LVI was predicted with high accuracy using an ANN model based on routine preoperative clinicopathological variables. The result of validation AUC 0.80 (CI 0.75-0.85) indicates a potential for preoperative prediction of LVI, and the model can putatively be useful when applying preoperative nodal prediction models in patients without known LVI status. To confirm these results, verification in an external dataset is needed. Validation of the LVI-model in an independent dataset from the National Breast Cancer Registry will be performed, as well as an evaluation of the usefulness of the LVI-model as an imputation in a nodal prediction model. [1] Dihge, L. et al. BMC Cancer (2019). PMID: 31226956 [2] Bevilacqua, J. L. et al. J Clin Oncol. (2007). PMID: 17664461 [3] Harris, G. C. et al. Am J Surg Pathol. (2003). PMID: 12502923 Citation Format: Malin Hjärtström, Looket Dihge, Pär-Ola Bendahl, Mattias Ohlsson, Lisa Rydén. Steps toward noninvasive lymph node staging (NILS) in clinically node negative patients: Artificial neural network model to preoperatively predict lymphovascular invasion [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-01-08.

The Role of redo-Sentinel Lymph Node Biopsy in Patients With Prior Ipsilateral Breast Cancer Surgery

BackgroundSentinel Lymph Node Biopsy (SLNB) is used to stage the axilla, but there is limited data in patients with prior ipsilateral breast cancer. This study compares redo-SLNB (reSLNB) and Axillary node sample (ANS) in this sub-cohort of patients. Materials and MethodsThis is a retrospective study looking at patients with a new ipsilateral primary or recurrence with history of breast-conserving surgery. Planned and performed surgery, patient demographics and previous treatments were recorded. Node positivity and success rate of reSLNB was analyzed. ResultsA total of 86 patients were identified that had mastectomy for ipsilateral recurrent disease with radiologically negative axilla. Out of the 48 that had reSLNB, 35(72.9%) were successful. Nineteen percent of the reSLNB had positive axillae and 20% of the ANS patients. reSLNB success rate was significantly lower amongst patients with previous axillary surgery (P = .014) and previous positive nodes(P = .001). ConclusionreSLNB should be considered to restage the axilla in patients with previous history of ipsilateral cancer especially that there is growing evidence showing good identification rate.

Pre-pectoral breast reconstruction: early and long-term safety evaluation of 146 unselected cases of the early pre-pectoral era of a single-institution, including cases with previous breast irradiation and post-mastectomy radiation therapy.

We re-evaluated acute and early-late toxicity-related factors among pre-pectoral immediate tissue expander/implant (TE/I) breast reconstruction (BR) unselected, first-era, cases, including previous breast radiation treatment and post-mastectomy radiation therapy (PMRT). A retrospective analysis of 146 (117 therapeutic and 29 prophylactic) pre-pectoral reconstructions, between 2012 and 2016, considered patient-related (age, body mass index [BMI], smoke-history, comorbidity, BRCA mutation), and treatment-related characteristics (previous irradiation, axillary surgery, PMRT, pre- and postoperative chemotherapy, endocrine therapy, and target-therapy). Safety was evaluated as acute and early-late complications, and TE/I failures. At multivariate analysis of the 146 cases (117 patients submitted to BR) a significant factor related to acute toxicity was: BMI ≥ 25 (31.3% [≥ 25] vs 8.8% [< 25]; OR 4.44, 95% CI 1.56-12.6; p = 0.003), while previous breast surgery on ipsilateral side presented a borderline significance (31.6% [previous surgery] vs 7.4% [no previous surgery]; OR 3.74, 95% CI 0.97-14.40; p = 0.055). Factors significantly related to TE/I failure were: current or previous smoking exposition (13.8% [smokers] vs 2.6% [non-smokers]; OR 7.32, 95% CI 1.37-39.08; p = 0.02) and preoperative chemotherapy (18.8% [yes] vs 3.5% [no]; OR 8.16, 95% CI 1.29-51.63; p = 0.026). At 4-year median follow-up, 3 deaths, 5 locoregional recurrences, and 14 distant metastases occurred. Immediate pre-pectoral BR is safe and effective, with low rates of acute and early-late complications. BMI and previous breast surgery were related to higher complications but not failure; smoking and preoperative chemotherapy were related to TE/I explant. Previous RT and PMRT were related neither to early-late toxicity nor failure.

Evaluation of the combined role of axillary ultrasound with fine-needle aspiration cytology and sentinel lymph node biopsy in detecting axillary metastasis in clinically N0 axilla at tertiary care center Kerala

Background: Sentinel lymph node biopsy (SLNB) is the gold standard for histopathological staging of early breast cancer. Combination of axillary ultrasound with fine-needle aspiration cytology (Ax US with FNAC) of suspicious lymph nodes, specificity for diagnosis of metastatic lymph nodes can be increased.Methods: This prospective study was done among 205 cases with clinically N0 axilla visited at surgical oncology department at Amrita institute of medical sciences from January 2014 to February 2017. Exclusion criteria was patients with locally advanced breast cancer, previous axillary surgery, prior breast irradiation, proven distant metastasis, inflammatory breast cancer and neo-adjuvant chemotherapy. All patients were subjected to ultrasound of breast and axilla during preoperative evaluation. Suspicious looking nodes were subjected to image guided FNAC. Benign appearing nodes or a negative FNAC, a SLNB procedure with intra-operative frozen section sentinel node (FS SN) was performed at the time of surgery.Results: Present study found sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of Ax US was 62.9%, 84.4%, 67.7%, 81.4% and 77.1% respectively. Sensitivity, specificity, PPV, NPV and accuracy of Ax US with FNAC was 90.0%, 100.0%, 100.0%, 83.3% and 93.3% respectively. Sensitivity, specificity, PPV, NPV and accuracy of SLNB with FS SN was 64.5%, 97.5%, 87.0%, 91.5% and 90.8% respectively.Conclusions: US guided fine-needle aspiration biopsy (FNAB) has highest specificity and sensitivity. Combining Ax US±FNAC and intra-operative FS SN in the detecting axillary metastasis very much decrease the chance of false results. The results of sonography would allow patients with sonographically positive axillae to be directed to axillary lymph node dissection (ALND). The remaining patients would be candidates for SN biopsy.

Axillary management in T1-3N1M0 breast cancer patients with needle biopsy proven nodal metastases at presentation after neoadjuvant chemotherapy (ATNEC).

TPS600 Background: Neoadjuvant chemotherapy (NACT) results in eradication of cancer in the axillary nodes in 40% to 70% of patients. This raises questions about the benefit of further axillary treatment in those patients with no evidence of residual nodal disease (ypN0) after NACT. Methods: Design: ATNEC is a phase 3, randomised (1:1), multi-centre trial, with embedded economic evaluation, comparing standard axillary treatment (axillary lymph node dissection [ALND] or axillary radiotherapy [ART]) with no further axillary treatment in T1-3N1M0 breast cancer patients with needle biopsy proven axillary nodal metastases, who after NACT have no residual nodal disease (ypN0) on dual tracer sentinel node biopsy (SNB) and removal of at least 3 nodes (sentinel nodes and marked involved node). Stratification: Institution, type of surgery (breast conserving surgery vs mastectomy), receptor status (triple negative vs HER2 positive vs ER positive and/or PR positive and HER2 negative). Inclusion criteria are: Age ≥ 18, Male or female, T1-3N1M0 breast cancer at diagnosis (pre-NACT), FNA or core biopsy confirmed axillary nodal metastases at presentation, ER and HER2 status evaluated on primary tumour, received standard NACT as per local guidelines, ultrasound of the axilla at completion of NACT, dual tracer SNB after NACT and at least 3 nodes removed (sentinel nodes and marked node), no evidence of nodal metastases post NACT (ypN0). Exclusion criteria are: bilateral invasive breast cancer, SNB prior to NACT, marked node not removed except where at least one node removed shows evidence of down-staging with complete pathological response e.g. fibrosis/scarring and at least 3 nodes removed, previous ipsilateral axillary surgery, previous cancer within last 5 years or concomitant malignancy except basal or squamous cell carcinoma of the skin, in situ carcinoma of the cervix, in situ or stage 1 melanoma, contra- or ipsilateral in situ breast cancer. Aims: To assess whether, omitting further axillary treatment (ALND and ART) for patients with early stage breast cancer and axillary nodal metastases on needle biopsy - who after NACT have no residual nodal disease on SNB (ypN0) - is non-inferior to axillary treatment in terms of disease free survival, and reduces the risk of lymphoedema at 5 years. Statistical methods: All analyses will be carried out on an intention-to-treat basis to preserve randomisation, avoid bias from exclusions and preserve statistical power. Radiotherapy quality assurance: Study has in-built radiotherapy QA programme that will be co-ordinated by National Radiotherapy Trials QA (RTTQA) group. Target accrual: 1900. Trial status: Recruiting. Number of sites: 100. Clinical trial information: NCT04109079.

Sentinel Lymph Node Biopsy Following Previous Axillary Surgery in Recurrent Breast Cancer

Background: Ipsilateral 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.

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.

Sentinel lymph node biopsy in patients with recurrent breast cancer and previous axillary surgery: A review

Sentinel lymph node biopsy in patients with recurrent breast cancer and previous axillary surgery: A review

Cephalic vein transposition in autologous breast reconstruction salvage: a review of outcomes and implications for patient care

Success in microsurgical autologous breast reconstruction is reliant on establishing an effective circulation. Cephalic vein transposition (CVT) is a technique for augmentation, supercharging or replacement of problematic venous anastomoses for free flap salvage. Little is known about the consequences of using this valuable surgical lifeboat for patients. We investigated our experience of CVTs, focusing on the development of lymphedema in the cephalic vein donor limb. A retrospective review was undertaken of consecutive patients undergoing autologous microsurgical breast reconstruction between 2009 and 2015. Patients requiring CVTs were identified and notes reviewed. Outcome measures included further surgery, flap survival, and complications. Between 2009 and 2015, 1208 autologous free tissue transfers for breast reconstruction were performed at our institution. Twelve patients required CVTs for flap salvage. Eleven notes were available for review. Mean age at reconstruction was 51 (43–74). All patients had previous axillary surgery, with post-mastectomy lymphedema noted in four patients. Reconstructions were seven MS-TRAM and four DIEP flaps. Indications for CVT were venous insufficiency in all but one patient, who had scarred internal mammary vessels. No anastomoses required revision and all flaps survived. No wound healing or scar problems were encountered. Lymphedema worsened in two patients and arose de novo in another two patients. The cephalic vein is an excellent local option for free flap salvage in breast reconstruction. Lymphedema, however, developed or worsened in one third of our patients. All patients undergoing microsurgical breast reconstruction are now counseled about the potential need for CVT and the risk of lymphedema. Level of Evidence: Level IV, therapeutic study.

Repeat Sentinel Lymph Node Biopsy for Ipsilateral Breast Tumor Recurrence: A Systematic Review of the Results and Impact on Prognosis.

During recent years, an increasing number of patients with ipsilateral breast tumor recurrence (IBTR) and previous axillary surgery have undergone repeat sentinel lymph node biopsy (rSLNB). The influence of axillary nodal status on prognosis for IBTR patients remains unclear. This study aimed to evaluate the technical success rate, follow-up assessment, and prognostic value of rSLNB for patients with IBTR. A systematic search conducted in MEDLINE, Embase, and the Cochrane Library up to July 2017 included all studies on rSLNB in IBTR. A total of 34 articles describing 1761 patients were identified. A repeat sentinel lymph node (rSLN) was successfully harvested from 64.3% of the patients with IBTR, and the rate was significantly higher for the patients who had a previous SLNB than for those who had a previous axillary lymph node dissection (ALND) (75.7% vs. 46.1%; P<0.0001). The rSLN was tumor-positive for 18.2% of the rSLNs, 40% of which were harvested in basins other than the ipsilateral axilla. The negative predictive value of the rSLNB was 96.5%. Overall survival, reported for 21.5% of the patients, was 95.2% after a mean follow-up period of 29.6months. The prognostic impact of rSLN-positive versus rSLN-negative IBTR remains unclear. Further studies are needed to fill in the gap in the management of lymph nodes for patients with IBTR. However, based on the current evidence, rSLNB is feasible for 64% of patients, especially after previous SLNB. With a negative predictive value of 96.5%, rSLNB appears to be highly specific, with substantial advantages over ipsilateral ALND in IBTR.

Abstract P2-01-37: Technical feasibility and validity of sentinel lymph node biopsy in patients with ipsilateral breast tumor recurrence

Abstract Background: The incidence of ipsilateral breast tumor recurrence (IBTR) was reported to be approximately 5-10% of breast cancer patients who had breast-conserving surgery. However, the role of sentinel lymph node biopsy (SLNB) in patients with IBTR still remains to be elucidated. The aim of this study wasto evaluate feasibility and validity of sentinel lymph node biopsy for ipsilateral breast tumor recurrence (second SLNB). Patients and methods: A prospective database of 1607 patients with clinically node-negative breast cancer who underwent SLNB from January 2005 to May 2015 was analyzed and 46 patients with IBTR underwent SLNB. Lymphatic mapping was performed using a combined method of blue dye and radioisotope. ICG fluorescence imaging was performed in cases with failure of identification by blue dye and radioisotope. Results: The median age was 52 (range: 36-82) years at the time of second SLNB and the mean size of recurrent tumor was 1.39 ± 0.63 cm. Thirty-one (67.4%) and 10 (21.7%) patients had a history of previous SLNB and axillary lymph node dissection (ALND), respectively. Another five (10.9%) patients had no previous axillary surgery for primary tumors. Preoperative lymphatic mapping by lymphoscintigraphy was successfully performed in 24 of 36 patients (66.7%). The identification rate by lymphoscintigraphy among patients with previous SLNB, ALND, and no axillary surgery was 64.0% (16/25), 66.6% (6/9) and 100% (2/2), respectively (P= 0.583). Overall, sentinel lymph nodes (SLNs) were successfully identified in 37 (80.4%) of 46 patients during surgery. The identification rate in patients with previous SLNB, ALND and no axillary surgery was 80.6% (25/31), 80.0% (8/10) and 80.0% (4/5), respectively (P=0.990). The aberrant lymphatic drainage to extra-ipsilateral axilla was found more frequently in patients with previous ALND compared with previous SLNB and no axillary surgery (40.0% vs. 6.5% vs. 0%, P=0.015).Among three (6.5%) patients with SLN metastases, one patient with previous SLNB had macrometastasis at the ipsilateral axilla and ALND found a positive non-SLN (1/21). The remaining two patients with previous SLNB and ALND had micrometastases at ipsilateral and contralateral axilla, respectively and both patients underwent no further axillary treatment. After second SLNB, systemic treatment including chemotherapy, endocrine therapy and trastuzumab was performed in 17 (37.0%), 36 (78.3%) and seven (15.2%) patients, respectively. No axillary recurrence was observed after a median follow-up time of 37.2 months from surgery for IBTR. Conclusions: Second SLNB is technically feasible regardless of types of previous axillary surgery and may avoid complications from unnecessary ALND for IBTR. Furthermore, it could improve risk prediction for IBTR and provide valid information for deciding adjuvant therapy. Citation Format: Matsumoto A, Jinno H, Yanagisawa T, Yoshikawa M, Takahashi Y, Seki T, Takahashi M, Hayashida T, Ikeda T, Kitagawa Y. Technical feasibility and validity of sentinel lymph node biopsy in patients with ipsilateral breast tumor recurrence [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 P2-01-37.

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.

Feasibility of Axillary Reverse Mapping and Clinicopathological Features Predicting ARM Node Metastasis in Breast Cancer-a Pilot Study.

The axillary reverse mapping (ARM) technique has been described as an attempt to map and preserve the upper extremity lymphatic drainage during axillary lymph node dissection (ALND) and/or SLNB. This technique is based on the hypothesis that the lymphatic pathway from the upper extremity is not involved by metastasis from primary breast cancer. The ARM node/s however, has been found, in various studies, to be involved with metastatic foci in patients with extensive axillary lymph node metastases. Therefore, the oncological safety of this procedure has not yet been determined. In this pilot study, we assessed the ARM node intraoperatively for various parameters and compared it to final HPR, to try and determine the oncologic safety of preserving the ARM node. Seventy-two breast cancer patients were screened for this prospective pilot study which was planned to recruit 20 patients. The study was initiated on May 2014, 20 patients were recruited till July 2015. Eligibility criterion was as follows: patients requiring primary axillary lymph node dissection based on a clinically positive axilla. Forty-five patients were ineligible because they had either received neoadjuvant chemotherapy or underwent previous axillary surgery or axillary radiation (exclusion criteria). Seven patients refused to give consent. ARM node identification rate was 75%. The most common location of the ARM node was lateral to the latissimus dorsi pedicle (42.10%), none of them being malignant. None of the oval or firm nodes were malignant. Tumor deposits were identified in 13%. Fine-needle aspiration cytology (FNAC) had 100% specificity, 94.4% negative predictive value, 100% positive predictive value, and 50% sensitivity. ARM is feasible using blue dye alone, with an acceptable identification rate. Location, consistency, and intraoperative FNAC of the ARM node, put together, may be reliable parameters to predict involvement of the ARM node with metastasis.

Technical feasibility of sentinel lymph node biopsy in patients with ipsilateral breast tumor recurrence and previous axillary surgery

IntroductionThe role of sentinel lymph node biopsy (SLNB) in patients with ipsilateral breast tumor recurrence (IBTR) remains to be elucidated. The aim of this study was to evaluate feasibility and validity of SLNB in patients with IBTR. MethodsA prospective database of 1172 patients with clinically node-negative breast cancer who underwent SLNB from January 2005 to December 2013 at Keio University Hospital was analyzed and 35 patients with IBTR underwent SLNB. Sentinel lymph nodes (SLNs) were detected using a combined method of blue dye and radioisotope or indocyanine green fluorescence in cases with failure of identification by blue dye and radioisotope. ResultsTwenty-two patients had previous SLNB, eight had previous axillary lymph node dissection (ALND), and five had no previous axillary surgery. Overall, SLNs were successfully identified in 28 (80.0%) of 35 patients. The identification rate in patients with previous SLNB, ALND and no axillary surgery was 81.8% (18/22), 75% (6/8) and 80% (4/5), respectively (P = 0.52). Aberrant drainage outside the ipsilateral axilla was found more frequently in patients with previous ALND compared with SLNB and no axillary treatment (37.5% vs. 4.5% vs. 0%, P = 0.048). No axillary recurrence was observed after median follow-up of 40.3 months from the second surgery for IBTR. ConclusionsSLNB is a technically feasible and valid procedure for staging and treatment of regional lymph nodes in patients with IBTR.

Abstract P2-01-07: Reoperative sentinel lymph node biopsy for ipsilateral breast tumor recurrence: Impact of axillary surgery and radiation therapy on lymphatic drainage patterns

Abstract Background: While sentinel lymph node biopsy (SLNB) is a well-established method for patients with clinically node-negative primary breast cancer, reoperative sentinel lymph node biopsy (re-SLNB) for ipsilateral breast tumor recurrence (IBTR) still remains controversial. The aim of this study was to evaluate the location of reoperative sentinel lymph nodes (re-SLNs) and the factors related to aberrant drainage patterns after breast conserving surgery (BCS). Methods: Between April 2005 and August 2013, we performed re-SLNB on 132 patients who developed IBTR with no metastatic lymph nodes in preoperative examination. Both injection of radioisotope (Tc-99m phytate) and preoperative lymphoscintigraphy were performed on 97 patients of them, who were eligible for this retrospective study. We divided these patients into two groups according to their previous axillary surgery: 55 patients with just SLNB or no axillary surgery to the group S, and 42 patients with previous axillary lymph node dissection (ALND) to the group D. The patients in the group S were divided into two subgroups: 19 with adjuvant radiation therapy (RT) and 36 without RT. We compared visualization rates of lymph drainage patterns in these groups statistically by using Chi-square test. We evaluated the relationship between previous local treatments and lymphatic drainage patterns. Results: Number of cases in which lymphatic drainage was visualized were 52 (94.5%) in the group S and 33 (78.6%) in the group D (P &amp;lt; 0.001). Re-SLNs were observed at ipsilateral axilla in 47 patients (90%) in the group S and 19 patients (58%) in the group D (P &amp;lt; 0.001), at internal mammary (IM) in 9 (17%) and 16(49%) (P &amp;lt; 0.01), and at contralateral axilla in 8 (15%) and 5(15%), respectively. Within the group S, lymphatic drainage was visualized in 34 (94.4%) of 36 patients without RT and 18 (94.7%) of 19 patients who had received RT after BCS. Re-SLNs were visualized at ipsilateral axilla in 34 (100%) and 13 (72%) (P &amp;lt; 0.01), at IM in 5 (15%) and 4 (22%), and at contralateral axilla in 1 (3%) and 7 (39%) (P &amp;lt; 0.001). Re-SLNB was successfully performed in 62 (94%) of 66 patients whose lymphatic drainage was observed at ipsilateral axilla. Metastases for carcinoma in re-SLNs were found in 8 (13%) of them. At IM, re-SLNB was successful in 15 (60%) of 25, and 2 (13%) of them were positive for cancer. At contralateral axilla, re-SLNB was successful in 8 (62%) of 13 while no metastases were found among them. Conclusion: Previous ALND affected the visualization rates of re-SLNs. In patients after previous ALND, SLN was more likely to be in IM. Adjuvant RT effected a change in lymphatic drainage patterns, but did not affect the visualization rate of re-SLN. At ipsilateral axilla, the rates of successful re-SLNB and metastases at re-SLNs were similar to SLNB for primary breast cancer. Metastasis to SLN of recurrent cancer is one of the most important information for management of IBTR. However, it was very difficult to predict localization of re-SLN because lymphatic drainage patterns could have been affected by previous treatments. Therefore, we recommend re-SLNB using radioisotope with lymphoscintigraphy in surgery for IBTR. Citation Format: Ayaka Sato, Takehiko Sakai, Fumiko Moroo, Kiyomi Kimura, Masahiko Tanabe, Rie Horii, Futoshi Akiyama, Takuji Iwase. Reoperative sentinel lymph node biopsy for ipsilateral breast tumor recurrence: Impact of axillary surgery and radiation therapy on lymphatic drainage patterns [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-07.

Sentinel Lymph Node Dissection in Locally Recurrent Breast Cancer

The aim of this study was to investigate the use of sentinel lymph node dissection (SLND) in the treatment of patients with locally recurrent breast cancer. A total of 147 patients with locally recurrent breast cancer were included from five different breast surgery departments in Denmark. Data on previous breast and axillary surgery, adjuvant treatment, second operation in the breast and axilla, and lymphoscintigraphy were collected retrospectively from the original patient files. SLND after recurrence (SLNDAR) was successful in 72 of 144 patients (50%). The detection rate was significantly higher after previous SLND (66%) compared with previous ALND (34%) [p=0.0001]. Thirty-seven patients (51%) who had previous SLND had a negative sentinel node. These patients could be spared an ALND. Six patients (8%) who had a previous ALND had a metastatic sentinel node at recurrence; 17% of patients had a sentinel node located outside the ipsilateral axilla; and eight patients with negative sentinel node at SLNDAR underwent completion ALND. None of these patients had metastases at completion ALND, corresponding to a false negative rate of 0%. SLNDAR seems to be a feasible procedure in locally recurrent breast cancer and can spare a clinically significant number of patients an unnecessary ALND and the following risk of sequelae. In patients who had previous ALND, SLNDAR identified metastases that would have been overlooked following the current guidelines. A large proportion of patients had aberrant drainage, suggesting a need for lymphoscintigraphy.