Purpose
1. To systematically analyse studies comparing survival outcomes between axillary lymph-node dissection (ALND) and axilla observation (Obs), in women with low-risk, clinically node-negative breast cancer. 2. To consider results in the context of current axillary surgery de-escalation trials and studies.
Methods
9 eligible studies were identified, 6 RCTs and 3 non-randomized studies (4236 women in total). Outcomes assessed: overall survival (OS) and disease-free survival (DFS). The logged (ln) hazard ratio (HR) was calculated and used as the statistic of interest. Data was grouped by follow-up.
Results
Meta-analyses found no significant difference in OS at 5, 10 and 25-years follow-up (5-year ln HR = 0.08, 95% CI − 0.09, 0.25, 10-year ln HR = 0.33, 95% CI − 0.07, 0.72, 25-year ln HR = 0.00, 95% CI − 0.18, 0.19). ALND caused improvement in DFS at 5-years follow-up (ln HR = 0.16, 95% CI 0.03, 0.29), this was not demonstrated at 10 and 25-years follow-up (10-year ln HR = 0.07, 95% CI − 0.09, 0.23, 25-year ln HR = − 0.03, 95% CI − 0.21, 0.16). Studies supporting ALND for DFS at 5-years follow-up had greater relative chemotherapy use in the ALND cohort.
Conclusion
ALND does not cause a significant improvement in OS in women with clinically node-negative breast cancer. ALND may improve DFS in the short term by tailoring a proportion of patients towards chemotherapy. Our evidence suggests that when the administration of systemic therapy is balanced between the two arms, axillary de-escalation studies will likely find no difference in OS or DFS.
Orange palpebral spots are described as bilateral, ovoid, poorly defined orange-yellow macules on the superior eyelid and are predominantly reported in Caucasian populations. Previous reports have found correlations with melatonin incontinence secondary to trauma, lipofuscin accumulation in patients with superficial fatty tissue and palpebral thinness, and vitamin E, carotenoid and beta-cryptoxanthin levels. We present, to our knowledge, the first case of orange palpebral spots reported in the United Kingdom, in a patient with a background of atopy, significant sun exposure, bilateral cataracts and retinal detachment. The 59-year-old male initially presented with a dorsal nasal lesion with the differential: basal cell/trichoblastic carcinoma. During his excisional Mohs surgery, bilateral orange-yellow discolourations of the superior palpebrae were noted. The history was not significant for consumption of dietary sources of pigmentation, such as carotenoids, xanthophylls and vitamin E – found in green leafy vegetables and nut oils, respectively. The age of onset was unknown. A diagnostic skin punch biopsy was suggestive of orange palpebral spots and showed thinning of the epidermis, high-situated superficial and mature fat cells, with minimal pigment incontinence and perivascular lymphocytic infiltration. In addition, solar elastoses were identified on histology. After review in our local clinic-pathological meeting and of the published literature, a diagnosis of orange palpebral spots was given. The pathogenesis of orange palpebral spots remains to be elucidated. The role of sun exposure as a contributing factor to the generation of orange palpebral spots is therefore discussed.
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