Management of the axilla in breast cancer: outcome analysis in a series of ductal versus lobular invasive cancers

Abstract

Introduction Axillary lymph node dissection (ALND) has been considered essential for the staging of breast cancer (BC). As the impact of tumor biology on clinical outcomes is recognized, a surgical de-escalation approach is being implemented. We performed a retrospective study focused on surgical management of the axilla in invasive lobular carcinoma (ILC) versus invasive ductal carcinoma (IDC). Materials and methods 1151 newly diagnosed BCs, IDCs (79.6%) or ILCs (20.4%), were selected among patients treated at our Breast Cancer Unit from 2012 to 2018. Tumor characteristics and clinical information were collected and predictors of further metastasis after positive sentinel lymph node biopsy (SLNB) analyzed in relation to disease-free survival (DFS) and overall survival (OS). Results 27.5% of patients with ILC had ≥ 3 metastatic lymph nodes at ALND after positive SLNB versus 11.48% of IDCs (p = 0.04). Risk predictors of further metastasis at ALND were the presence of > 2 positive lymph nodes at SLNB (OR = 4.72, 95% CI 1.15-19.5 p = 0.03), T3-T4 tumors (OR = 4.93, 95% CI 1.10-22.2, p = 0.03) and Non-Luminal BC (OR = 2.74, 95% CI 1.16-6.50, p = 0.02). The lobular histotype was not associated with the risk of further metastasis at ALND (OR = 1.62, 95% CI 0.77-3.41, p = 0.20). Conclusions ILC histology is not associated with higher risk of further metastasis at ALND in our analysis. However, surgical management decisions should be taken considering tumor histotype, biology and expected sensitivity to adjuvant therapies.

Current and future diagnostic and treatment strategies for patients with invasive lobular breast cancer

“…110 Several studies report a higher nodal stage at diagnosis and a higher number of positive lymph nodes at the time of surgery in ILC compared to NST, resulting in a higher rate of axillary lymph node dissection. 9,10,111 This might be attributable to the larger tumour sizes and other confounding factors, as this was no longer seen in multivariate analysis. 112 Following sentinel lymph node biopsy, there is a 38% rate of nodal positivity in clinically node-negative patients, highlighting the challenges of clinical nodal assessment in ILC.…”

“…In general, at diagnosis, women with ILC are slightly older than women with NST (mean age 63.4 versus 59.5 years, respectively). 8,9 ILC is more difficult to detect through standard screening programs and presents more often as a larger tumour 9 and with nodal involvement, 10 as compared to NST. Additionally, ILC is more often multifocal.…”

“…Prevalence of some genomic altera s might differ 31,42 Poten role of lipid metabolism in estrogen-independent growth of ILC 182 Long-term outcomes of prognos and pr ve v gene prognos tests Clinic ¹⁵⁶ Choice of surgery (mastectomy versus BCS; SLNB versus ALND) dependent on tumour and pa nt characteris 108,109 Mastectomy more o en carried out for ILC due t focality and tumour size 32,108,109 ALND more o en carried out due to higher nodal involvement 9,10,111,113 Emerging de-escala techniques…”

Axillary lymph node status and invasive lobular breast cancer

“…The axillary lymph node (ALN) involvement represents one of the most important prognostic factors in early BC [19][20][21][22][23][24][25]; however, previous studies have shown controversial results regarding the ALN status between ILC and IDC. There are many studies demonstrating that the ALN involvement does not differ between both groups [10,26,27]; however, some studies showed an association between ILC and a higher incidence of positive ALN involvement [8,28,29]. In contrast, there are studies reporting less frequent ALN positivity in ILC [30,31].…”

Analysis of sentinel lymph node biopsy and non-sentinel lymph node metastasis in invasive ductal and invasive lobular breast cancer: a nationwide cross-sectional study (CSBrS-001)

“…Information regarding the implementation of SLNB in patients with invasive lobular carcinoma (ILC) is sparse. Whether ILC patients with 1-2 positive SLNs can be exempted from ALND remains controversial (11)(12)(13).…”