Role Of Axillary Surgery Research Articles

De-escalating axillary surgery in early-stage breast cancer

The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013–08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.

The Role of Axillary Surgery in Ductal Carcinoma in Situ

The Role of Axillary Surgery in Ductal Carcinoma in Situ

Role of Axillary Surgery After Neoadjuvant Chemotherapy

At the 2019 ASCO Annual Meeting, the optimal approach to axillary surgery for women who received neoadjuvant chemotherapy (NACT) was discussed. If residual axillary disease is detected, patients with triple-negative tumors and human epidermal growth factor receptor 2 (HER2) overexpression can be selected for additional adjuvant treatment with capecitabine or trastuzumab emtansine (T-DM1), respectively.1,2 Failure to identify patients with residual disease can negatively affect their clinical outcome. Techniques proposed to optimize patient selection include placing clips on metastatic lymph nodes before NACT or performing axillary dissection even after a clinical complete response (CR). Does this really make sense? What role does axillary surgery play in patients for whom NACT is indicated?

Is it time to review the role of axillary surgery in the management of DCIS

Is it time to review the role of axillary surgery in the management of DCIS

Predictors of responses and sexual function for women in the St George breast boost randomized trial (StGBBT)

s / The Breast 24 (2015) 302e307 304 Resonance Imaging (CEMRI) is currently the most sensitive imaging technique for breast cancer detection; however, it suffers from many drawbacks including high cost, timely accessibility, patient contraindications and low specificity. Previous studies have shown that contrast enhanced spectral mammography (CESM) may have similar diagnostic capability to CEMRI without these associated costs (2). Methods: The study included patients with biopsy proven breast cancer aged 21 years, fit for surgery, and excluded patients with contra-indications to intravenous contrast or CEMRI, candidates for neo-adjuvant chemotherapy, or who had pure in situ carcinoma. Participants underwent both CESM and CEMRI. Studies were independently double read and results benchmarked against the final surgical histopathology, core biopsy histology or one year follow-up imaging. CESM and CEMRI were compared for 1) detection of additional lesions 2) ability to size the index lesion 3) influence on surgical plan and 4) participant satisfaction. Results: A minimum of 19 participants was analysed for each study objective. For the detection of additional lesions (n1⁄421), the addition of CESM to conventional imaging increased sensitivity from 50% to 67% with specificity unchanged (47%). Addition of CEMRI to standard imaging increased sensitivity from 50% to 100% but with considerable reduction in specificity (47% to 7%). The geometric mean of index lesion size at pathology was similar for CESM and CEMRI (n1⁄424). For 19 patients, CESM and CEMRI had identical influence on the surgery plan. Participants preferred CESM to CEMRI (n1⁄434, p1⁄40.0005). Conclusions: Results so far suggest CESM has similar diagnostic capacity to CEMRI and is preferred by patients.

Axillary Surgery: Clinical Judgment Required

The Halsted radical mastectomy included an en bloc resection of axillary contents. Now, more than a century later, there is little controversy about the use of breast-conserving surgical treatments in place of mastectomy, while the routine use of axillary dissection, or at least axillary sampling, has persisted despite the fact that it is the greatest source of morbidity from breast surgery. Is it time to abandon this procedure all together, at least in some patients? Halsted and his successors removed and/or irradiated lymph nodes because they thought that breast cancer always spreads regionally before metastasizing distantly, and that all regional disease had to be removed to improve survival. The National Surgical Adjuvant Breast and Bowel Project (NSABP) demonstrated in trial B04 that this is not the case. 1 One thousand seventy-nine patients without clinical evidence of axillary adenopathy were randomly assigned to simple mastectomy, a radical mastectomy with lymph node dissection, or simple mastectomy with radiation therapy to the chest wall and axilla. Sixty-eight (19%) of the patients randomly assigned to receive no surgery or radiotherapy to the axilla eventually developed positive axillary nodes. This was about half of the rate expected from the incidence of positive nodes in the radical mastectomy arm of the study, and proved that disease left behind can be kept in check or eradicated by the body’s own defense mechanisms. It was possible to remove the axillary recurrence in all but one of the 68 patients, thus removing the argument that axillary recurrences cannot be managed surgically. Most importantly, with 25 years of follow-up, no significant survival differences have emerged. There have been no randomized trials of similar or larger size addressing the role of axillary surgery without axillary radiotherapy subsequent to NSABP B04. In this issue of the Journal of Clinical Oncology, the International Breast Cancer Study Group (IBCSG) 2 reports the result of a trial in which older patients (defined as those 60 years of age) who were to be treated with tamoxifen regardless of nodal status were randomly assigned to receive clearance of the axillary lymph nodes or no surgical intervention in the axilla after either mastectomy or lumpectomy. Among those randomly assigned to axillary clearance, 28% were node-positive. Radiotherapy was not recommended for patients treated with mastectomy; 60% of those treated with breast-conserving therapy (33% of all patients in the study) had radiotherapy. There was significantly more restriction in arm movement and arm pain during the first few months after treatment among those randomly assigned to axillary clearance, but these differences were small and not significant after longer followup, and there were no differences in overall quality of life parameters. There were no differences in disease-free or overall survival, but there were only 473 patients in the study and the median follow-up was just 6.6 years. This study was originally designed to be much larger, but because of poor accrual the study goals were amended to focus on quality-of-life issues. It seems plausible that the poor accrual reflects a lack of uncertainty by the patients and physicians involved in this trial about the value of axillary node dissection in this patient population. Because of the small size of this study, champions of axillary

Which patients with early breast cancer need axillary clearance?

The role of axillary surgery in the management of early breast cancer is currently the topic of intense debate in the literature. There are strong indications that women are presenting with earlier tumours and hence the majority have negative axillary nodes making axillary dissection less beneficial both in terms of disease control and less likely to result in an alteration of management. Alternative less morbid axillary staging and non-axillary staging methods are being investigated, but sentinel node biopsy shows the most promise for reliable assessment of the axilla. This review aims to assess the current literature regarding the role of axillary surgery in breast cancer management. The reasoning why axillary dissection is still the gold standard in breast cancer management is explained and related to the other methods of axillary assessment and therapy. Suggested guidelines for current optimal management are made.