Axillary lymph node dissection is not obligatory in breast cancer patients with biopsy-proven axillary lymph node metastasis

Yoo, Tae-Kyung; Kang, Bong Joo; Kim, Sung Hun; Song, Byung Joo; Ahn, Juneyoung; Park, Woo-Chan; Chae, Byung Joo

doi:10.1007/s10549-020-05636-z

Cited by 13 publications

(5 citation statements)

References 25 publications

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“…Yoo et al showed that nearly half of patients with a preoperative biopsy-proven ALN metastasis had only 1–2 positive LNs on ALND. They concluded that patients with few abnormal ALNs on only one imaging modality, meeting ACOSOG Z0011 criteria, are appropriate for SLNB and omission of ALND can be considered [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

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Does ultrasound evaluation of the axilla increase the rate of axillary lymph node dissection in early stage clinically node negative breast cancer patients?

et al. 2022

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Background Management and axillary staging of breast cancer has become less invasive and more conservative, over the decades. Considering Z011, axillary lymph node dissection (ALND) can be avoided in T1-2 N0-1 breast cancers with one or two positive sentinel lymph nodes (SLNs), if they are candidates for breast conserving surgery and radiotherapy. The aim of this study was to recognize if pre-operative axillary US evaluation in early-stage breast cancer could lead to more ALND in post Z011 era. Method 463 breast cancer patients were evaluated. 368 early-stage breast cancer patients (T1-2 N0) were included. We did not perform axillary US in early stage clinically node negative patients; however, 97 patients had axillary US prior to our visit. If axillary US could detect more than two suspicious LNs, US guided biopsy was performed. The remaining clinically node negative patients underwent upfront SLNB. ALND was performed if more than two SLNs were metastatic, or US-guided ALN biopsy proved metastatic involvement. Results 97 patients had axillary US evaluation before the surgery. 67 patients (69.2%) did not have any suspicious US detected axillary LNs, 17 patients (17.5%) had one, 7 patients (7.2%) had two, and 6 patients (6.2%) had more than two suspicious LNs according to their axillary US evaluation. Those with more than two suspicious LNs underwent ALN US-guided biopsy. Metastatic involvement of the LNs was proved in all of them and they underwent upfront ALND. ALND revealed more than 2 metastatic LNs in 2/6 patients (33.3%). 91 patients who were evaluated by axillary US, had less than two US detected suspicious LNs and underwent SLNB. Amongst 24 patients with one or two US detected suspicious LNs, 1/24 patient had more than two positive SLNs and underwent ALND. In this group 15.6% underwent ALND and 5.2% of them were unnecessary according to the recent guidelines. Axillary US had a false positive rate of 36.6%. The sensitivity of axillary US in distinguishing patients with more than two suspicious LNs in clinically node negative patients was 25%. In the second group (without pre-operative axillary US evaluation), SLNB was performed. 204/272 patients (75%) did not have LN metastasis. 54/272 patients (19.9%) had one or two metastatic SLNs and according to Z011, ALND was omitted. 5.1% had more than two metastatic SLNs and underwent ALND. Conclusion US evaluation of the axilla in early stage, clinically node negative breast cancer patients, is not sensitive enough to recognize more than two metastatic ALNs. It leads to more unnecessary ALND. Despite the small number of patients in this study, these results question the rationale of axillary US guided biopsy in low burden (less than two) suspicious LNs. looking for an imaging modality with a higher sensitivity in detecting the Burdon of axillary metastatic involvement is mandatory.

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Section: Discussionmentioning

confidence: 99%

“…In the post Z011 era, a positive axillary node needle biopsy does not indicate an upfront ALND in all patients [ 7 ]. Today, it is recommended in some studies that US-guided biopsy is beneficial to patients with multiple suspicious nodes on US [ 8 , 9 ].…”

Section: Introductionmentioning

confidence: 99%

Does ultrasound evaluation of the axilla increase the rate of axillary lymph node dissection in early stage clinically node negative breast cancer patients?

et al. 2022

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“…Panelists and affiliates disagreed regarding axillary ultrasonography at the time of diagnosis. Although helpful in defining the need for adjuvant radiotherapy, this may have increased axillary lymph node dissection (ALND) rather than SLNB [ 23 ]. The panelists suggested individualizing axillary ultrasonography according to the potential for a change in treatment.…”

Section: Discussion and Consensusmentioning

confidence: 99%

“…22 Department of Pathology, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil. 23 Hospital de Base, Federal District, Brasília, DF, Brazil. 24 Barão de Lucena Hospital, Federal University of Pernambuco, Recife, PE, Brazil.…”

Section: Acknowledgementsmentioning

confidence: 99%

Management of early-stage triple-negative breast cancer: recommendations of a panel of experts from the Brazilian Society of Mastology

et al. 2022

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Background Triple-negative breast cancer (TNBC) is a heterogenous subtype involving different patterns of behavior and clinical course, demanding a complex, individualized sequence of treatment. The knowledge and attitudes of the affiliated members of the Brazilian Society of Mastology regarding TNBC were evaluated and a consensus regarding management and treatment was reached. Methods Affiliates completed a survey involving 44 objective questions. In addition, a specialist meeting was held with 27 experts and 3 ad hoc consultants. The panelists completed the survey before and after brainstorming. Answers achieving 70% of agreement were considered consensual. The chi-square test was used to compare answers between panelists and affiliates and the Kappa coefficient to calculate agreement. Results Consensus among the panelists increased from 26 (59.1%) to 32 questions (72.7%) following brainstorming (p = 0.17), including 7/10 questions on systemic treatment. Among the affiliates, consensus was achieved for 24 questions (54.5%), resulting in moderate agreement (κ = 0.445). Neoadjuvant chemotherapy should be indicated for almost all cases (except cT1a-b N0) and should include platinum agents. When indicated, immunotherapy is part of the standard of care. The panel reaffirmed the concept of no ink on tumor as indicative of adequate margins and the possibility of sentinel lymph node biopsy for cN1 patients who become cN0 following neoadjuvant therapy. Controversies remain on combining immunotherapy with capecitabine/olaparib in pertinent cases. Conclusion Expert consensus was achieved for > 70% of the questions, with moderate agreement between panelists and affiliates. Educational interventions on systemic breast cancer treatment affected decision-making in 60% of the questions.

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“…This has been proposed as a technique to identify LN metastases while reducing operative complications associated with aggressive LND [4]. According to the recent reports, intraoperative pathological examination of the SLN has been performed some malignancies [5][6][7][8]. In fact, SLN biopsy is clinically used to determine the extent of LND in breast cancer and malignant melanoma, however, there are no reports regarding GBC.…”

Section: Introductionmentioning

confidence: 99%

Applicability of sentinel lymph node oriented treatment strategy for gallbladder cancer

et al. 2021

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Background Utility of the sentinel lymph node (SLN) biopsy in some malignancies has been reported, however, research on that of gallbladder cancer (GBC) is rare. The aim of this study is to investigate whether the concept of SLN is applicable to T2/3 GBC. Methods A total of 80 patients who underwent resection for gallbladder cancer were enrolled in this study. Patients with GBC were stratified into two groups based on the location of tumor, peritoneal-side (T2p or 3p) and hepatic-side (T2h or 3h) groups. We evaluated the relationship between cystic duct node (CDN) and downstream lymph node (LN) status. CDN was defined as a SLN in this study. Results Thirty-eight patients were classified into T2, including T2p (n = 18) and T2h (n = 20), and 42 patients into T3, including T3p (n = 22) andT3h (n = 20). The incidence of LN metastasis was significantly higher in hepatic-side than peritoneal-side in both T2 and T3 (P = 0.036 and 0.009, respectively). In T2, 14 T2p had negative CDN and downstream LN, however, three T2h had negative CDN and positive downstream LNs (defined as a skipped LN metastasis) (P = 0.043). In T3, patients with skipped LN metastasis were significantly higher in T3h (n = 11) than those in T3p (n = 2) (P<0.001). There was no recurrence of the local lymph node. Disease-free survival in the T2p and T3p were significantly better than those in the T2h and T3h (P = 0.005 and 0.025, respectively). Conclusion The concept of SLN can be applicable to T2p GBC, where the downstream LNs dissection can be omitted.

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Axillary lymph node dissection is not obligatory in breast cancer patients with biopsy-proven axillary lymph node metastasis

Cited by 13 publications

References 25 publications

Does ultrasound evaluation of the axilla increase the rate of axillary lymph node dissection in early stage clinically node negative breast cancer patients?

Does ultrasound evaluation of the axilla increase the rate of axillary lymph node dissection in early stage clinically node negative breast cancer patients?

Management of early-stage triple-negative breast cancer: recommendations of a panel of experts from the Brazilian Society of Mastology

Applicability of sentinel lymph node oriented treatment strategy for gallbladder cancer

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