Real de-escalation or escalation in disguise?

Banys‐Paluchowski, Maggie; Rubio, Isabel T.; Ditsch, Nina; Krug, David; Gentilini, Oreste Davide; Kühn, Thorsten

doi:10.1016/j.breast.2023.03.001

Cited by 8 publications

(5 citation statements)

References 78 publications

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“…In terms of surgery, there is data relating safety in breast conservation amongst patients who have achieved good or complete tumor response in the breast [ 35 ]. In comparison, the concept of avoiding ALND after NACT has somewhat slower adoption rates amongst surgeons, despite data from several trials have now indicated surgical de-escalation in the axilla is not related to worse survival outcome [ 36 ]. Therefore, the potential use of TILs in predicting axillary response and patient selection could further add to the accuracy of selective de-escalation in axillary surgery.…”

Section: Discussionmentioning

confidence: 99%

Tumor-infiltrating lymphocytes as a predictor of axillary and primary tumor pathological response after neoadjuvant chemotherapy in patients with breast cancer: a retrospective cohort study

Chin,

Landén,

Kovács

et al. 2024

Breast Cancer Res Treat

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Purpose Tumor-infiltrating lymphocytes (TILs) can predict complete pathological response (pCR) of tumor in the breast but not so well-defined in the axilla after neoadjuvant chemotherapy. Since axillary surgery is being increasingly de-escalated after NACT, we aimed to investigate the relationship between TILs and pCR in the axilla and breast, as well as survival amongst NACT patients. Methods Clinicopathological data on patients who underwent NACT between 2013 and 2020 were retrospectively examined. Specifically, pre-TILs (before NACT), post-TILs (after NACT) and ΔTIL (changes in TILs) were assessed. Primary endpoint was pCR and secondary endpoints were breast cancer-free interval (BCFI) and overall survival (OS). Results Two hundred and twenty patients with nodal metastases were included. Overall axillary and breast pCR rates were 42.7% (94/220) and 39.1% (86/220), respectively, whereas the combined pCR rate was 32.7% (72/220). High pre-TILs (OR 2.03, 95% CI 1.02–4.05; p = 0.04) predicted axillary pCR whereas, high post-TILs (OR 0.33, 95% CI 0.14–0.76; p = 0.009) and increased ΔTILs (OR 0.25, 95% CI 0.08–0.79; p = 0.02) predicted non-axillary pCR. TILs were not a significant predictor for BCFI and OS. Conclusions This study supports the potential use of pre-TILs to select initially node-positive patients for axillary surgical de-escalation after NACT.

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Section: Discussionmentioning

confidence: 99%

Tumor-infiltrating lymphocytes as a predictor of axillary and primary tumor pathological response after neoadjuvant chemotherapy in patients with breast cancer: a retrospective cohort study

Chin,

Landén,

Kovács

et al. 2024

Breast Cancer Res Treat

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“…It is worth noting that for cN0 patients with 3–5 metastatic nodes, the proportion of omitted ALND quadrupled after 2009 up to 21% as well, although the above mentioned studies did not explore this clinical setting, and a recent analysis suggested impaired long-term survival without ALND in this patient group [17 ▪ ]. Recently, concern has been raised that a surgical de-escalation in cases with positive SN and initially cN0 may lead to a radiation therapy escalation in these patients [18 ▪ ]. While often seen as an example of therapy de-escalation, axillary management in cN0/pN1 patients may in fact represent a de-escalation of one treatment modality (surgery), and at the same time an escalation of another one (radiation therapy).…”

Section: Controversies In the Cn0 Settingmentioning

confidence: 99%

Controversies in axillary management of patients with breast cancer – updates for 2024

Tauber,

Bjelic-Radisic,

Thill

et al. 2023

Current Opinion in Obstetrics &Amp; Gynecology

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Purpose of review For some time now, the question of de-escalation in axillary staging in breast cancer patients has been raised. The aim is to improve the patients’ quality of life and reduce morbidity by optimizing surgical strategies with a high level of oncological safety. This review offers a current overview of published evidence and clinical practice, aiming to guide the surgical community as they reassess and reshape their practices. Recent findings Years after introducing sentinel lymph node biopsy (SLNB) in clinically node negative breast cancer patients several guidelines suggest completely omitting SLNB in older patients with low-risk tumors. It is worth noting that for patients with a metastatic sentinel lymph node in the upfront surgery setting, a de-escalation of axillary surgery may in fact lead to an escalation of radiation therapy. Currently, there is limited evidence on the axillary surgical approach for patients with initially positive node status achieving complete axillary response (ycN0), resulting in heterogenous guideline recommendations. Summary Innovative trials are contributing to a growing evidence on de-escalation of axillary surgery with the aim of reducing arm morbidity and improving long-term health-related quality of life.

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“…It should be noted, however, that in contrast to patients undergoing primary surgery, cALND is recommended even in cases of low tumor burden in the axillary SLN after NACT [54, 55]. The rationale for this recommendation is that not only in the case of macro- but also in the case of micrometastases in the SLN after NACT, further axillary lymph node metastases are detectable in more than 60% of cases [55, 56].…”

Section: Introductionmentioning

confidence: 99%

Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy

Banys-Paluchowski,

Hartmann,

Ditsch

et al. 2023

Breast Care

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Background: The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer. Summary: Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5–6 weeks to 1–3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement. Key Messages: Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.

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Real de-escalation or escalation in disguise?

Cited by 8 publications

References 78 publications

Tumor-infiltrating lymphocytes as a predictor of axillary and primary tumor pathological response after neoadjuvant chemotherapy in patients with breast cancer: a retrospective cohort study

Tumor-infiltrating lymphocytes as a predictor of axillary and primary tumor pathological response after neoadjuvant chemotherapy in patients with breast cancer: a retrospective cohort study

Controversies in axillary management of patients with breast cancer – updates for 2024

Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy

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