Sentinel Node-positive Breast Cancer Patients Research Articles

ASO Visual Abstract: Trends of Axillary Treatment in SentinelNode-Positive Breast Cancer Patients Undergoing Mastectomy.

ASO Visual Abstract: Trends of Axillary Treatment in SentinelNode-Positive Breast Cancer Patients Undergoing Mastectomy.

Trends of Axillary Treatment in Sentinel Node-Positive Breast Cancer Patients Undergoing Mastectomy

BackgroundThe ACOSOG-Z0011- and the AMAROS-trial obviated the need for axillary surgery in most sentinel node-positive (SLN+) breast cancer patients undergoing breast-conserving surgery (BCS). Data for patients who undergo mastectomy is scarce. The purpose of this study was to investigate patterns of axillary treatment in SLN+ patients treated by mastectomy in the years after the publication of landmark studies regarding axillary treatment in SLN+ breast cancer patients undergoing BCS.MethodsThis was a population-based study in cT1-3N0M0 breast cancer patients treated by mastectomy and staged as SLN+ between 2009 and 2018. The performance of an axillary lymph node dissection (ALND) and/or administration of postmastectomy radiotherapy (PMRT) were primary outcomes and were studied over time.ResultsThe study included 10,633 patients. The frequency of ALND performance decreased from 78% in 2009 to 10% in 2018, whereas PMRT increased from 4 to 49% (P < 0.001). In ≥N1a patients, ALND performance decreased from 93 to 20%, whereas PMRT increased to 70% (P < 0.001). In N1mi and N0itc patients, ALND was abandoned during the study period, whereas PMRT increased to 38% and 13% respectively (P < 0.001), respectively. Age, tumor subtype, N-stage, and hospital type affected the likelihood that patients underwent ALND.ConclusionsIn this study in SLN+ breast cancer patients undergoing mastectomy, use of ALND decreased drastically over time. By the end of 2018 most ≥N1a patients received PMRT as the only adjuvant axillary treatment, whereas the majority of N1mi and N0itc patients received no additional treatment.

Abstract P3-20-05: Trends of axillary treatment in sentinel node-positive breast cancer patients undergoing amputation

Abstract Objectives: To evaluate patterns of care in axillary treatment of Dutch patients - who were diagnosed with stage I-IV primary invasive breast cancer, underwent amputation and were found positive by sentinel lymph node biopsy (SLNB) - in the years following the publication of the American College for Surgeons Oncology Group (ACOSOG)-Z0011 and After Mapping of the Axilla: Radiotherapy Or Surgery (AMAROS) trials. Methods: Data from females diagnosed between January 1st 2009 and December 31st 2018 were obtained from the Netherlands Cancer Registry (NKR). Trends in completion axillary lymph node dissection (cALND), administration of adjunctive radiotherapy and, inversely, of omission of any kind of axillary treatment, were revealed by descriptive analyses on SNL positive patients. Results: Of 28,070 cT1-4 breast cancer patients undergoing amputation with SLNB from 2009 up until 2018, 10,706 were diagnosed as SLN positive. In the latter, the frequency of subsequent cALND went down significantly from 78% in 2009 to 10% in 2018 (P &amp;lt; 0.001), while adjunctive radiotherapy increased from 4% to 49% (P &amp;lt; 0.001). Omission of any additional local treatment increased from 18% to 41% (P &amp;lt; 0.001). In N1 patients cALND decreased from 57% to 13% (P &amp;lt; 0.001) and was mostly replaced by radiotherapy, increasing from 2% to 70% (P &amp;lt; 0.001). In N1mi and N0i+ patients, cALND decreased to less than 1% of cases in 2018, while radiotherapy increased from 4% to 40% and 8% to 13% (P &amp;lt; 0.001), respectively. Conclusion: In SLN positive breast cancer patients undergoing breast amputation, cALND had become rare 10 years following the AMAROS and Z0011 trial results. While radiotherapy mostly replaced cALND in the vast majority of N1 patients, less than half of N1mi and only a tenth of N0i+ patients received radiotherapy as the only adjunctive axillary treatment by the end of 2018. Citation Format: Eline EF Verreck, Julia van Steenhoven, Anne Kuijer, Marissa van Maaren, Sabine Siesling, Thijs van Dalen. Trends of axillary treatment in sentinel node-positive breast cancer patients undergoing amputation [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-20-05.

Prediction score model for non-sentinel and four or more nodal metastases using a combined method of one-step nucleic acid amplification and histology in sentinel node-positive breast cancer patients

BackgroundALN dissection (ALND) is the only way to obtain information on ALN metastasis status accurately when sentinel lymph node (SLN) metastasis is present. In this study, we established a model for intraoperatively predicting non-SLN metastasis and the presence of four or more ALNs (pN2), based on the combined use of one-step nucleic acid amplification (OSNA) and histological examination following SLN biopsy. Materials and methodsSubjects comprised 318 consecutive breast cancer patients (cTis-3, N0) who underwent SLN biopsy with a combination of OSNA and histological examination, and who were found to have SLN metastasis and were treated by ALND. We allotted points to each patient according to their SLN metastasis status as defined by both OSNA and histology, then defined the “National Cancer Center sentinel lymph node metastatic score” (NCS score) based on the total points. Correlations between the NCS score and both non-SLN metastasis and pN2 status were analyzed by logistic regression analysis. The accuracy of this score was evaluated using receiver operating characteristic (ROC) analysis. ResultsThe NCS score was significantly correlated with both non-SLN metastasis and pN2 status (adjusted odds ratio: 1.26 for non-SLN metastasis, 1.56 for pN2 status). The area under the ROC curve (AUC) of the NCS score demonstrated 0.74 for non-SLN metastasis, 0.91 for pN2 status. ConclusionsThe NCS score was a strong independent predictor of non-SLN metastasis and pN2 status. Use of this score will facilitate the selection of optimal adjuvant therapies without requiring unnecessary ALND.

The clinical outcomes of sentinel node-positive breast cancer patients treated without axillary lymph node dissection

The clinical outcomes of sentinel node-positive breast cancer patients treated without axillary lymph node dissection

The administration of adjuvant chemo(-immuno) therapy in the post ACOSOG-Z0011 era; a population based study

PurposeThe ACOSOG-Z0011-study has resulted in a trend to a more conservative treatment of the axilla for selected sentinel-node-positive patients. However, axillary nodal involvement has always been an important factor for tumor staging and tailoring adjuvant chemotherapy plans. This study evaluates the impact of omitting completion axillary lymph node dissection (cALND) on the administration of adjuvant chemo (-immuno)therapy in Dutch clinical T1-2N0M0 (cT1-2N0M0) sentinel-node-positive breast cancer patients. MethodsData were obtained from the nationwide NABON breast cancer audit. Descriptive analyses were used to demonstrate trends in axillary surgery and adjuvant chemo (-immuno)therapy. Multivariable logistic regression analyses were used to identify factors associated with the prescription of chemo (-immuno)therapy. ResultsIn this cohort of 4331 patients, the omission of a cALND increased from 34% to 92%, and the administration of chemo (-immuno)therapy decreased from 68% to 55%, between 2011 and 2015 (P < 0.001). Patients treated with cALND had an OR of 2.2 for receiving adjuvant chemo (-immuno)therapy compared with SLNB only patients. Lower age, a hormone receptor (HR) status other than HR-positive, HER2-negative, increasing tumor grade and stage, and a lymph node status ≥ pN2 were independently associated with a higher probability of chemo (-immuno)therapy (P < 0.05). ConclusionsThis study showed that Dutch cT1-2N0M0 sentinel node-positive breast cancer patients treated with cALND had a higher independent probability for receiving adjuvant chemo (-immuno)therapy compared with SLNB only patients, even when corrected for lymph node status and HR-status. Probably, the decisions to administer adjuvant chemo (-immuno)therapy were not only based on guidelines and tumor characteristics, but also on the preferences from physicians and patients.

Abstract OT2-01-01: Observational study of axilla treatment for breast cancer patients with 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes

Abstract [Background] Axilla surgery in node-positive breast cancer is dramatically changing from axillary lymph node dissection (ALND) to sentinel node biopsy (SNB). From the results of ACOSOG Z0011, IBCSG23-01 and AMAROS trials, adjuvant therapy and regional node irradiation could reduce regional lymph node recurrence for sentinel node-positive breast cancer patients. However, optimal indication of SNB alone remains uncertain. Trial design: To evaluate the outcome of sentinel node-positive breast cancer patients, the Japanese Society for Sentinel Node Navigation Surgery (SNNS) conducted a prospective cohort study in 2013 (UMIN000011782, Jpn J Clin Oncol, p.876-9, 2014). [Eligibility criteria] For eligible patients, SNB was performed or scheduled after 1 January 2012. Then 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes are confirmed by histological or molecular diagnosis. Primary chemotherapy before or after SNB is also acceptable for registration. [Specific aims] The primary endpoint is the 5-year recurrence rate of regional lymph node in patients treated with SNB alone. The secondary endpoint is the 5-year overall survival rate of this cohort. Patients treated with SNB followed by ALND are also registered simultaneously to compare the prognosis. The propensity score matching (PSM) is used to make the distributions of baseline risk factors comparable. [Statistical method] Based on an estimated recurrence rate of 5% at 5 years among patients treated with SNB alone, 240 patients are needed to give a 80% power to reject the null hypothesis that the recurrence rate is 10% with a one-sided type I error rate of 2.5%. If we consider that some patients will be lost to follow-up or become ineligible, a total of 250 patients will be needed to comprise the sample. [Present accrual] Eight hundred and eighty patients who underwent SNB alone or SNB followed by ALND were registered from 27 participating institutes between 2013 and 2016. Data cleaning is being performed. Patient's background and PSM will be reported. Citation Format: Imoto S, Saito Oba M, Masuda N, Nagashima T, Wada N, Takashima T, Kitada M, Kawada M, Hayashida T, Taguchi T, Aihara T, Miura D, Toh U, Yoshida M, Sugae S, Yoneyama K, Matsumoto H, Jinno H, Sakamoto J. Observational study of axilla treatment for breast cancer patients with 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-01-01.

The Omission of Axillary Lymph Node Dissection in Sentinel Node-Positive Breast Cancer Patients Requires Careful Consideration

The Omission of Axillary Lymph Node Dissection in Sentinel Node-Positive Breast Cancer Patients Requires Careful Consideration

Survival and axillary recurrence following sentinel node-positive breast cancer without completion axillary lymph node dissection: the randomized controlled SENOMAC trial

BackgroundThe role of axillary lymph node dissection (ALND) has increasingly been called into question among patients with positive sentinel lymph nodes. Two recent trials have failed to show a survival difference in sentinel node-positive breast cancer patients who were randomized either to undergo completion ALND or not. Neither of the trials, however, included breast cancer patients undergoing mastectomy or those with tumors larger than 5 cm, and power was debatable to show a small survival difference.MethodsThe prospective randomized SENOMAC trial includes clinically node-negative breast cancer patients with up to two macrometastases in their sentinel lymph node biopsy. Patients with T1-T3 tumors are eligible as well as patients prior to systemic neoadjuvant therapy. Both breast-conserving surgery and mastectomy, with or without breast reconstruction, are eligible interventions. Patients are randomized 1:1 to either undergo completion ALND or not by a web-based randomization tool. This trial is designed as a non-inferiority study with breast cancer-specific survival at 5 years as the primary endpoint. Target accrual is 3500 patients to achieve 80% power in being able to detect a potential 2.5% deterioration of the breast cancer-specific 5-year survival rate. Follow-up is by annual clinical examination and mammography during 5 years, and additional controls after 10 and 15 years. Secondary endpoints such as arm morbidity and health-related quality of life are measured by questionnaires at 1, 3 and 5 years.DiscussionSeveral large subgroups of breast cancer patients, such as patients undergoing mastectomy or those with larger tumors, have not been included in key trials; however, the use of ALND is being questioned even in these groups without the support of high-quality evidence. Therefore, the SENOMAC Trial will investigate the need of completion ALND in case of limited spread to the sentinel lymph nodes not only in patients undergoing any breast surgery, but also in neoadjuvantly treated patients and patients with larger tumors.Trial registrationNCT 02240472, retrospective registration date September 14, 2015 after trial initiation on January 31, 2015.

Usefulness of Breast MRI for Safe Omission of Axillary Lymph Nodes Dissection in Sentinel Node-Positive Breast Cancer Patients

Background: Preoperative identification of patients with extensive lymph node metastasis (LNM) is important for safe omission of axillary lymph node dissection (ALND) in sentinel node (SN)-positive (SN+) breast cancer patients. Methods: We evaluated retrospectively the collected data of 758 breast cancer patients who underwent axillary surgery between 2008 and 2017, excluding those who received neoadjuvant chemotherapy. Results: Of the 758 patients, 607 were not suspicious to have LNM by axillary ultrasound (AUS-), but 38 suspicious cases were found by breast magnetic resonance imaging (MRI). Of 15 patients undergoing axillary fine needle biopsy (AFNA) due to second-look axillary ultrasound (AUS), 9 underwent ALND because of a positive AFNA (AFNA+). Among 81 (10.9%) patients undergoing ALND due to SN+ findings, 6 (7.4%) had extensive LNM (LNM ≥ 4). If MRI was not performed, among the 90 of 673 patients undergoing ALND who had SN+ findings, 12 (13.3%) had LNM ≥ 4. Conclusions: The proportion of cases with LNM ≥ 4 was reduced from 13.3% to 7.4% among patients undergoing SN biopsies combined with breast MRI. ALND might be omitted safely in SN+ cases according to detailed preoperative evaluations using additional breast MRI to ultrasound.

A Dutch Prediction Tool to Assess the Risk of Additional Axillary Non–Sentinel Lymph Node Involvement in Sentinel Node-Positive Breast Cancer Patients

BackgroundMultiple predictive systems have previously been developed to identify the sentinel lymph node (SLN)-positive patients at low risk of additional axillary non-SLN involvement and for whom completion axillary lymph node dissection (ALND) could be avoided. However, previous studies showed that these tools had poor performance in Dutch patients with breast cancer, probably owing to variations in pathology settings and differences in population characteristics. The aim of the present study was to develop a predictive tool for the risk of non-SLN involvement in a Dutch population with SLN-positive breast cancer. Materials and MethodsThe data from 513 patients with SLN-positive breast cancer at 10 participating hospitals, who had undergone ALND from January 2007 to December 2008 were studied. The uni- and multivariable associations of predictors for non-SLN metastases were analyzed, and a predictive model was developed. The discriminatory ability of the model was measured by the area under the receiver operating characteristic curve (AUC) and the agreement between predicted probabilities and observed frequencies was visualized by a calibration plot. ResultsA predictive model was developed that included the 2 strongest predictors: the size of the SLN metastases in millimeters and the presence of a negative sentinel lymph node. The model showed good discriminative ability (AUC, 0.75) and good calibration over the complete range of predicted probabilities. ConclusionWe have developed a tool to predict additional non-SLN metastases in Dutch patients with SLN-positive breast cancer that is easy to use in daily clinical breast cancer practice.

Characteristics and Outcomes of Sentinel Node–Positive Breast Cancer Patients after Total Mastectomy without Axillary-Specific Treatment

Regional failure rates are low in patients with a positive sentinel lymph node biopsy (SLNB) who undergo breast-conserving therapy without axillary lymph node dissection (ALND). The applicability of these findings to total mastectomy (TM) patients is not established. Our aims were to evaluate the characteristics and outcomes of SLNB-positive TM patients who did not receive axillary-specific treatment and to compare them to similar patients who underwent breast-conserving surgery (BCS). A total of 535 patients with early-stage breast cancer who underwent definitive breast surgery (210 TM, 325 BCS), had a positive SLNB and did not receive ALND between 1997 and 2009 were identified from an institutional database. Characteristics and outcomes were compared between the TM and BCS groups. Most patients had stage I to IIA, estrogen receptor-positive, progesterone receptor-positive, Her2-negative invasive ductal carcinoma, with minimal nodal disease. Compared to the BCS group, TM patients were younger, had larger tumors, had higher nomogram scores predicting additional axillary disease and were more likely to receive chemotherapy. Ninety-four percent of the BCS cohort and 5% of the TM cohort received adjuvant radiotherapy. At a median follow-up of 57.8months, the 4-year local, regional and distant failure rates were 1.7, 1.2 and 0.7% in the TM group and 1.4, 1.0 and 3.7% in the BCS group. The 4-year disease-free and overall survival rates were 94.8 and 97.8% in the TM group and 90.1 and 92.6% in the BCS group. Early-stage breast cancer patients with minimal sentinel node disease experience excellent outcomes without ALND, whether they undergo BCS or TM.

Predicting possibility of positive non-sentinel nodes in sentinel node–positive breast cancer patients: A Singapore series.

51 Background: Sentinel lymph node (SLN) biopsy is an accepted method for determining the axillary status in early breast cancer patients. If positive, a standard axillary clearance is performed. However, recent studies have shown that many of these patients may not have additional positive non sentinel nodes, and the removal of these additional nodes may not be necessary or confer any benefit. We set out to identify factors that determine non sentinel node positivity and whether this could be predicted from our series of early breast cancer patients. Methods: We retrospectively reviewed 337 of our early breast cancer patients from 2005 to 2008 who had atleast one positive sentinel node and had undergone a full axillary clearance. Tumour factors and sentinel node variables were collected and compared between those patients with additional positive non sentinel nodes and those with no positive nodes in the axillary clearance. Results: Five factors were found on univariate analysis to be associated with non sentinel node positivity. They are ratio of positive SLN to total number of SLN, number of positive SLNs, size of metastasis in the SLN, tumour size and lymphovascular invasion. The first 3 factors were used to model a logistic-regression model which has good prediction ability to predict positivity of non SLNs (value under ROC curve 0.726 [95% CI 0.666-0.786]). Conclusions: Tumor factors and SLN variables are able to help us predict the possibilty of additional positive non SLN once at least a SLN is positive. This can help the surgeon and patient in the decision making process on the need for a full axillary clearance.

Treatment of sentinel node-positive breast cancer

Sentinel node biopsy has become well accepted as a minimally invasive means of accurately staging the axilla in breast cancer patients. Patients with metastases in the sentinel node(s) have traditionally proceeded to completion of axillary node dissection, whereas patients who are node negative can be spared the morbidity of this procedure. Recently, there has been some debate as to what constitutes node-positive disease and whether patients with metastasis in the sentinel node(s) require completion axillary dissection. This review addresses the controversies regarding the management of sentinel node-positive breast cancer patients.