“This house believes that: Sentinel node biopsy alone is better than TAD after NACT for cN+ patients”

Galimberti, Viviana; Fontana, Sabrina Kahler Ribeiro; Vicini, Elisa; Morigi, Consuelo; Sargenti, Manuela; Corso, Giovanni; Magnoni, Francesca; Intra, Mattia; Veronesi, Paolo

doi:10.1016/j.breast.2022.12.010

Cited by 19 publications

(19 citation statements)

References 43 publications

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“…Clipping of the biopsy-proven positive node and subsequent retrieval has been shown to decrease the false negative rate of SLNB in node-positive patients following neoadjuvant chemotherapy [ 24 , 25 ]. However, the added benefit of clipping the node over standard SLNB on the long-term oncologic outcomes has been questioned [ 3 ]. Logically, this technique can be extrapolated to the use of SLNB in the upfront surgery setting to ensure retrieval of the known positive node.…”

Section: Discussionmentioning

confidence: 99%

“…However, it should be noted, that potentially more patients may have two surgeries with this approach (SLNB followed by ALND, compared to ALND alone). Additionally, depending on the method of localization used for targeted axillary surgeries, the costs of this procedure tend to exceed that of SLNB alone [ 3 ]. As healthcare systems around the world work to increase capacity to address backlogs in breast cancer screening and treatment, resources focused on the cost-effective yet safe assessment of symptomatic women should be paramount to reduce resultant morbidity and mortality [ 28 ].…”

Section: Discussionmentioning

confidence: 99%

“…The last half-century has seen a fundamental evolution in the surgical management of invasive breast cancer to reduce the morbidity of treatment. Much research has focused on the de-escalation of axillary surgery as axillary lymph node dissection (ALND) is associated with an estimated 25% risk of lymphedema, which can reduce the quality of life in affected patients [ 1 , 2 , 3 ]. The safety of sentinel lymph node biopsy(SLNB) in node-negative patients was established by the NSABP B-32 trial, which showed no difference in overall survival between patients undergoing ALND and SLNB [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

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Safety and Accuracy of Sentinel Lymph Node Biopsy Alone in Clinically Node-Positive Patients Undergoing Upfront Surgery for Invasive Breast Cancer: A Systematic Review

2023

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Landmark trials (Z0011 and AMAROS) have demonstrated that axillary lymph node dissection (ALND) can be safely omitted in patients with breast cancer and 1–2 positive sentinel nodes. Extrapolating from these and other cardinal studies such as NSABP B-04, guidelines state that patients with 1–2 needle biopsy-proven positive lymph nodes undergoing upfront surgery can have sentinel lymph node biopsy (SLNB) alone. The purpose of this study is to systematically review the literature to identify studies examining the direct application of SLNB in such patients. EMBASE and Ovid MEDLINE were searched from inception to 3 May 2022. Studies including patients with nodal involvement confirmed on pre-operative biopsy and undergoing SLNB were identified. Studies with neoadjuvant chemotherapy were excluded. Search resulted in 2518 records, of which 68 full-text studies were reviewed, ultimately yielding only 2 studies meeting inclusion criteria. Both studies used targeted axillary surgery (TAS) with pre-operative localization of the biopsy-proven positive node in addition to standard SLNB techniques. In a non-randomized single-center prospective study, Lee et al. report no regional recurrences in patients undergoing TAS or ALND, and no difference in distant recurrence or mortality at 5 years. In the prospective multicenter TAXIS trial by Webber et al., the median number of positive nodes retrieved with TAS in patients undergoing upfront surgery was 2 (1, 4 IQR). Within the subset of patients who underwent subsequent ALND, 61 (70.9%) had additional positive nodes, with 26 (30.2%) patients having ≥4 additional positive nodes. Our review demonstrates that there is limited direct evidence for SLNB alone in clinically node-positive patients undergoing upfront surgery. Available data suggest a high proportion of patients with residual disease in this setting. While the totality of the data, mostly indirect evidence, suggests SLNB alone may be safe, we call on clinicians and researchers to prospectively collect data on this patient population to better inform decision-making.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Safety and Accuracy of Sentinel Lymph Node Biopsy Alone in Clinically Node-Positive Patients Undergoing Upfront Surgery for Invasive Breast Cancer: A Systematic Review

2023

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“…Our results are in line with the previously cited work (FNRs of SLNB in patients with normal vs. suspicious LN status upon post-chemotherapy US of 30.0% and 14.29%, respectively) and, in addition, we found that the CLN procedure is effective also in the first category (normal LN status upon post-chemotherapy US), improving the diagnostic performance of nodal staging (FNR = 9.09%) and helping practitioners to choose patients for whom ALND can be safely omitted. However, it must be highlight that the impact of the FNR of SLNB on oncologic outcomes is still unclear and does not seem to correspond to an increase in axillary recurrences or worsening of disease-free survival or overall survival [ 36 ]. Ongoing studies, such as AXANA (a large, prospective, non-interventional cohort study), aim to demonstrate which is the best method of axillary surgery after NACT in cases starting with a positive axilla, with the primary endpoints being invasive-disease-free survival, the axillary recurrence rate, quality of life, and arm morbidity [ 37 ].…”

Section: Discussionmentioning

confidence: 99%

Selective Axillary Dissection after Neoadjuvant Chemotherapy in Patients with Lymph-Node-Positive Breast Cancer (CLYP Study): The Radio-Guided Occult Lesion Localization Technique for Biopsy-Proven Metastatic Lymph Nodes

Rella

Conti

Bufi

et al. 2023

Cancers

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(1) Background: To help to refine the accuracy of sentinel lymph node biopsy (SLNB) in breast cancer (BC) patients with biopsy-proven nodal disease prior to neoadjuvant chemotherapy (NACT), a method of marking the biopsy-proven positive LN at diagnosis to enable its removal during surgery was proposed. The aim of this study was to evaluate the accuracy of the Radio-Guided Occult Lesion Localization (ROLL) technique of biopsy-proven metastatic LN in nodal staging after NACT among node-positive BC patients. (2) Methods: Patients with invasive BC and biopsy-proven axillary metastases receiving NACT were enrolled. A clip marker was placed on the sampled LN (clipped lymph node, CLN) before NACT. Before surgery, the ROLL procedure (radioactive tracer injection into CLN under ultrasound guidance) was performed, and the CLN was surgically resected. The correspondence between the CLNs and SLNs was evaluated. The pathologic findings of the CLNs and SLN(s) were compared with remaining axillary nodes at ALND to determine false negative rates (FNRs). (3) Results: Seventy-two patients were analyzed. Surgery successfully identified the CLN in 70/72 procedures (97.2%). For 60/72 patients who underwent ALND, the FNRs dropped from 19.35% for SLNB to 3.13% for CLN biopsy. (4) Conclusions: The ROLL procedure got CLNs is accurate in axillary nodal staging after NACT in node-positive BC patients at diagnosis.

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“…Despite growing evidence on new surgical techniques in cN + patients after NACT, the impact of surgical de-escalation on oncological outcomes and health-related quality of life is still unclear [62, 77]. In this context it is worth noting that several recently published retrospective trials reported low (0–1.6%) axillary recurrence rates after SLNB alone in cN+ → ycN0 patients, suggesting that high FNRs of SLNB do not necessarily translate into worse clinical outcome [78]. Axillary staging techniques in cN + patients after NACT and their impact on oncological outcome and arm morbidity are being currently evaluated in the prospective multicentre AXSANA study with an estimated enrollment of 4,500 patients (NCT04373655) [77].…”

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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“This house believes that: Sentinel node biopsy alone is better than TAD after NACT for cN+ patients”

Cited by 19 publications

References 43 publications

Safety and Accuracy of Sentinel Lymph Node Biopsy Alone in Clinically Node-Positive Patients Undergoing Upfront Surgery for Invasive Breast Cancer: A Systematic Review

Safety and Accuracy of Sentinel Lymph Node Biopsy Alone in Clinically Node-Positive Patients Undergoing Upfront Surgery for Invasive Breast Cancer: A Systematic Review

Selective Axillary Dissection after Neoadjuvant Chemotherapy in Patients with Lymph-Node-Positive Breast Cancer (CLYP Study): The Radio-Guided Occult Lesion Localization Technique for Biopsy-Proven Metastatic Lymph Nodes

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

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