Changes in Surgical Management of the Axilla Over 11 Years – Report on More Than 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial

Boughey, Judy C.; Yu, Hongmei; Piltin, Mara A.; Postlewait, Lauren M.; Son, Jennifer D.; Edmiston, Kirsten K.; Godellas, Constantine V.; Lee, Marie Catherine; Carr, Michael J.; Tonneson, Jennifer E.; Crown, Angelena; Lancaster, Rachel B.; Woriax, Hannah E.; Ewing, Cheryl A.; Chau, Harrison; Patterson, Anne; Wong, Jasmine; Alvarado, Michael; Yang, Rachel; Chan, Theresa W.; Sheade, Jori; Ahrendt, Gretchen; Larson, Kelsey E.; Switalla, Kayla; Tuttle, Todd M.; Tchou, Julia; Rao, Roshni; Tamirisa, Nina; Singh, Puneet; Gould, Rebekah E.; Terando, Alicia M.; Sauder, Candice A M; Hewitt, Kelly; Chiba, Akiko; Esserman, Laura J.; Mukhtar, Rita A.

doi:10.1245/s10434-023-13759-y

Cited by 22 publications

(5 citation statements)

References 29 publications

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“…Existing literature reports a wide range of SLNB proportions in cN1+ breast cancer patients effectively treated with NAT, varying from 14.6% to 56.5%. Simultaneously, the rate of ALND decreased from 100% to 29.4% ( 11 , 13 , 17 ). Various factors have been associated with the reduction in ALND rates after NAT, including breast cancer molecular subtype ( 11 , 13 ), higher histological grade ( 11 ), residual breast lesions, and vascular infiltration ( 11 , 19 ).…”

Section: Discussionmentioning

confidence: 97%

“…Simultaneously, the rate of ALND decreased from 100% to 29.4% ( 11 , 13 , 17 ). Various factors have been associated with the reduction in ALND rates after NAT, including breast cancer molecular subtype ( 11 , 13 ), higher histological grade ( 11 ), residual breast lesions, and vascular infiltration ( 11 , 19 ). However, Weber et al.…”

Section: Discussionmentioning

confidence: 97%

“…SLN staging after NAT has demonstrated greater accuracy in reflecting prognosis compared to the initial axillary status. Most studies support the implementation of SLNB after NAT ( 1 , 13 , 15 , 19 , 21 ). It is recommended to utilize the dual tracer method or positioning clip for marking positive lymph nodes, with SLN detection rates ranging from 80.1% to 96%, and false negative rates from 6.8% to 17% ( 1 , 12 , 16 , 19 – 24 ).…”

Section: Discussionmentioning

confidence: 99%

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Prognostic analysis of cT1-3N1M0 breast cancer patients who have responded to neoadjuvant therapy undergoing various axillary surgery and breast surgery based on propensity score matching and competitive risk model

Zhang,

Sun,

et al. 2024

Front. Oncol.

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BackgroundSentinel lymph node biopsy (SLNB) in breast cancer patients with positive clinical axillary lymph nodes (cN1+) remains a topic of controversy. The aim of this study is to assess the influence of various axillary and breast surgery approaches on the survival of cN1+ breast cancer patients who have responded positively to neoadjuvant therapy (NAT).MethodsPatients diagnosed with pathologically confirmed invasive ductal carcinoma of breast between 2010 and 2020 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. To mitigate confounding bias, propensity score matching (PSM) analysis was employed. Prognostic factors for both overall survival (OS) and breast cancer-specific survival (BCSS) were evaluated through COX regression risk analysis. Survival curves were generated using the Kaplan-Meier method. Furthermore, cumulative incidence and independent prognostic factors were assessed using a competing risk model.ResultsThe PSM analysis matched 4,890 patients. Overall survival (OS) and BCSS were slightly worse in the axillary lymph node dissection (ALND) group (HR = 1.10, 95% CI 0.91-1.31, p = 0.322 vs. HR = 1.06, 95% CI 0.87-1.29, p = 0.545). The mastectomy (MAST) group exhibited significantly worse OS and BCSS outcomes (HR = 1.25, 95% CI 1.04-1.50, p = 0.018 vs. HR = 1.37, 95% CI 1.12-1.68, p = 0.002). The combination of different axillary and breast surgery did not significantly affect OS (p = 0.083) but did have a significant impact on BCSS (p = 0.019). Competing risk model analysis revealed no significant difference in the cumulative incidence of breast cancer-specific death (BCSD) in the axillary surgery group (Grey’s test, p = 0.232), but it showed a higher cumulative incidence of BCSD in the MAST group (Grey’s test, p = 0.001). Multivariate analysis demonstrated that age ≥ 70 years, black race, T3 stage, ER-negative expression, HER2-negative expression, and MAST were independent prognostic risk factors for both OS and BCSS (all p < 0.05).ConclusionFor cN1+ breast cancer patients who respond positive to NAT, the optimal surgical approach is combining breast-conserving surgery (BCS) with SLNB. This procedure improves quality of life and long-term survival outcomes.

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

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Prognostic analysis of cT1-3N1M0 breast cancer patients who have responded to neoadjuvant therapy undergoing various axillary surgery and breast surgery based on propensity score matching and competitive risk model

Zhang,

Sun,

et al. 2024

Front. Oncol.

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“…The recommended surgical procedure for patients with residual nodal disease after NACT remains ALND [32,55,56]. However, the omission of ALND is becoming more frequent and increasingly accepted amongst clinicians despite limited evidence on oncologic outcomes [32,131]. The probability of additional positive nodes seems to be related to the type of residual nodal disease, which may enable a more differentiated approach.…”

Section: Patients With Clinically Node-positive Breast Cancer and Res...mentioning

confidence: 99%

Axillary Surgery for Breast Cancer in 2024

Heidinger,

Weber

2024

Cancers

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Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous ‘one size fits all’ radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.

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“…The response to NAT also holds prognostic significance, being closely linked to long-term oncological outcomes [ 4 , 6 , 7 , 8 , 9 ]. Furthermore, successful tumor reduction through NAT can minimize the extent of surgery required, eliminating the need for unnecessary axillary lymph node dissection (ALND) [ 10 , 11 ] and making breast-conserving surgery (BCS) possible for patients initially considered for mastectomy [ 12 , 13 , 14 , 15 ]. In the upfront surgical setting, BCS has been proven to be a safe alternative to mastectomy in terms of overall survival (OS) [ 16 , 17 ], with recent studies even suggesting superior survival rates associated with BCS [ 18 , 19 ].…”

Section: Introductionmentioning

confidence: 99%

De-Escalation Surgery in cT3-4 Breast Cancer Patients after Neoadjuvant Therapy: Predictors of Breast Conservation and Comparison of Long-Term Oncological Outcomes with Mastectomy

Tinterri,

Barbieri,

Sagona

et al. 2024

Cancers

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Background: Neoadjuvant therapy (NAT) has become increasingly employed for the treatment of cT3-4 breast cancer (BC), enabling breast-conserving surgery (BCS) in cases traditionally considered for mastectomy. This study aims to identify predictors for breast conservation post-NAT and to evaluate whether BCS influences long-term oncological outcomes. Methods: We retrospectively analyzed data from patients with cT3-4 BC who received NAT at the Breast Unit of IRCCS Humanitas Research Hospital, Milan, Italy, from October 2009 to April 2020. Surgical outcomes and long-term oncological results, such as disease-free survival (DFS), distant DFS (DDFS), overall survival (OS), and BC-specific survival (BCSS), were compared between the BCS and mastectomy groups. Results: Among 114 patients analyzed, 37 (32.5%) underwent BCS, and 77 (67.5%) had a mastectomy. The key predictors for opting for BCS included absence of vascular invasion, reduced tumor size post-NAT, and achieving ypT0 status. No significant differences in DFS, DDFS, OS, and BCSS were observed between the two surgical groups (log-ranks, p = 0.520, p = 0.789, p = 0.216, p = 0.559, respectively). Conclusions: BCS after NAT is a feasible and safe option for patients with cT3-4 BC, without adversely affecting long-term oncological outcomes. Identifying predictors of breast conservation can guide surgical decision-making, ensuring that patients receive optimal treatment.

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Changes in Surgical Management of the Axilla Over 11 Years – Report on More Than 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial

Cited by 22 publications

References 29 publications

Prognostic analysis of cT1-3N1M0 breast cancer patients who have responded to neoadjuvant therapy undergoing various axillary surgery and breast surgery based on propensity score matching and competitive risk model

Prognostic analysis of cT1-3N1M0 breast cancer patients who have responded to neoadjuvant therapy undergoing various axillary surgery and breast surgery based on propensity score matching and competitive risk model

Axillary Surgery for Breast Cancer in 2024

De-Escalation Surgery in cT3-4 Breast Cancer Patients after Neoadjuvant Therapy: Predictors of Breast Conservation and Comparison of Long-Term Oncological Outcomes with Mastectomy

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