NSQIP Analysis of Axillary Lymph Node Dissection Rates for Breast Cancer: Implications for Resident and Fellow Participation

Nocera, Nadia F.; Pyfer, Bryan J.; Cruz, Lucy M. De La; Chatterjee, Abhishek; Thiruchelvam, Paul; Fisher, Carla S.

doi:10.1016/j.jsurg.2018.02.020

Cited by 15 publications

(13 citation statements)

References 27 publications

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“…One advantage of neoadjuvant therapy in the treatment of breast cancer is the potential to downstage the axilla and reduce the extent of morbid axillary surgery [1][2][3][4][5][6] . The nodal response to neoadjuvant therapy can impact both surgical planning and the appropriate duration and type of neoadjuvant therapy.…”

Section: Introductionmentioning

confidence: 99%

Accuracy of breast MRI in evaluating nodal status after neoadjuvant therapy in invasive lobular carcinoma

et al. 2021

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Neoadjuvant therapy in breast cancer can downstage axillary lymph nodes and reduce extent of axillary surgery. As such, accurate determination of nodal status after neoadjuvant therapy and before surgery impacts surgical management. There are scarce data on the diagnostic accuracy of breast magnetic resonance imaging (MRI) for nodal evaluation after neoadjuvant therapy in patients with invasive lobular carcinoma (ILC), a diffusely growing tumor type. We retrospectively analyzed patients with stage 1–3 ILC who underwent pre-operative breast MRI after either neoadjuvant chemotherapy or endocrine therapy at our institution between 2006 and 2019. Two breast radiologists reviewed MRIs and evaluated axillary nodes for suspicious features. All patients underwent either sentinel node biopsy or axillary dissection. We evaluated sensitivity, specificity, negative and positive predictive values, and overall accuracy of the post-treatment breast MRI in predicting pathologic nodal status. Of 79 patients, 58.2% received neoadjuvant chemotherapy and 41.8% neoadjuvant endocrine therapy. The sensitivity and negative predictive value of MRI were significantly higher in the neoadjuvant endocrine therapy cohort than in the neoadjuvant chemotherapy cohort (66.7 vs. 37.9%, p = 0.012 and 70.6 vs. 40%, p = 0.007, respectively), while overall accuracy was similar. Upstaging from clinically node negative to pathologically node positive occurred in 28.0 and 41.7%, respectively. In clinically node positive patients, those with an abnormal post-treatment MRI had a significantly higher proportion of patients with ≥4 positive nodes on pathology compared to those with a normal MRI (61.1 versus 16.7%, p = 0.034). Overall, accuracy of breast MRI for predicting nodal status after neoadjuvant therapy in ILC was low in both chemotherapy and endocrine therapy cohorts. However, post-treatment breast MRI may help identify patients with a high burden of nodal disease (≥4 positive nodes), which could impact pre-operative systemic therapy decisions. Further studies are needed to assess other imaging modalities to evaluate for nodal disease following neoadjuvant therapy and to improve clinical staging in patients with ILC.

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Section: Introductionmentioning

confidence: 99%

Accuracy of breast MRI in evaluating nodal status after neoadjuvant therapy in invasive lobular carcinoma

et al. 2021

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“…The results of DeCOG-SLT and MSLT-II will no doubt lead to a decline in the number of lymphadenectomies performed by surgeons. The treatment of invasive breast cancer witnessed a similar downward trend in axillary lymph node dissections in favor of SLNB, with rates having decreased 2.43% per year, each year from 2007 to 2014 [45•]. In melanoma, as with invasive breast cancer, the decrease in rates of CLND will likely witness a concomitant increase in the complexity of nodal dissection.…”

Section: Completion Lymph Node Dissectionmentioning

confidence: 99%

Sentinel Lymph Node Biopsy and Completion Lymph Node Dissection for Melanoma

Masoud

Perone

Farrow

et al. 2018

Curr. Treat. Options in Oncol.

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This review critically evaluates recent trials which have challenged the practice of completion lymph node dissection (CLND) for melanoma patients diagnosed with regional metastasis by positive sentinel lymph node biopsy (SLNB). Two trials in the last 2 years, DeCOG-SLT and MSLT-II, found no significant differences in melanoma-specific survival between patients, whether they received immediate CLND or observation after positive SLNB, despite decreases in nodal recurrence achieved by dissection. These trials together disfavor routine CLND in most patients after positive SLNB. However, their conclusions are limited by study populations which overall harbored a lower burden of SLN disease. Special attention needs to be given to patients who do have higher risk disease, with SLN tumor burdens exceeding 1 mm in diameter, for whom CLND may remain both prognostic and therapeutic. Current guidelines thus recommend either CLND or careful observation after positive SLNB after appropriate risk stratification of patients. While a decline in CLND is inevitable, treatment of stage III melanoma is witnessing the concurrent rise of effective adjuvant therapies. PD-1 inhibitors such as nivolumab, or combination BRAF/MEK inhibitors for V600E or K mutant melanoma, which were previously available to only trial patients with completely resected stage III disease, are now approved for use in patients with positive SLNB alone. Providers are better equipped than ever to treat clinically occult, regional metastatic disease with SLNB followed by adjuvant therapy for most patients, but should take steps to avoid undertreatment of high-risk patients who may proceed to disease relapse or progression.

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“…However, this may be more difficult in the future as new trainees have less experience with ALND. 23,24 The negative resection margin was consistently associated with improved OS in all three cohorts. While the rate of negative Patients who met the standards were significantly younger and were more likely to be treated at an academic center.…”

Section: Discussionmentioning

confidence: 83%

“…In all cohorts, the examined LN standard had the lowest rates of adherence, suggesting that this may be a potential target to improve patient outcomes. However, this may be more difficult in the future as new trainees have less experience with ALND …”

Section: Discussionmentioning

confidence: 99%

Adherence to surgical and oncologic standards improves survival in breast cancer patients

Zhao

Tsai

Hunt

et al. 2019

Journal of Surgical Oncology

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Background Adherence to evidence‐based standards can lead to improved outcomes for patients with breast cancer. However, adherence rates to standards and their effects on patient outcomes are unknown. Objectives To examine adherence rates to standards compiled by the American College of Surgeons Clinical Research Program and its effects on patient outcomes. Methods Using the National Cancer Database (2004‐2015), we identified cohorts of breast cancer patients: clinical T1N0M0 under age of 70 (cT1), clinical T2N0M0 or T3N0M0 (cT2/3), and clinical M0 and pathologic N2 or N3 (pN2/3). Standards included negative margins, any adjuvant therapy, and two or more lymph nodes (LNs) examined (for cT1 or cT2/3 patients) or more than 10 LNs examined (for pN2/3 patients). We performed Kaplan‐Meier and Cox proportional hazards analysis. Results We identified 318 853 (65.0%) cT1, 164 593 (67.3%) cT2/3, and 77 626 (67.7%) pN2/3 patients who met the standards. More than 90% of patients had negative margins and adjuvant therapy, but less than 80% met LN standards. The median overall survival (OS) was significantly longer for patients who met the standards. Individual components of the standards were predictors of improved OS. Conclusions One‐third of patients did not meet the evidence‐based standards in their treatment for breast cancer. Efforts to improve the knowledge of and adherence to these standards should be emphasized.

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NSQIP Analysis of Axillary Lymph Node Dissection Rates for Breast Cancer: Implications for Resident and Fellow Participation

Cited by 15 publications

References 27 publications

Accuracy of breast MRI in evaluating nodal status after neoadjuvant therapy in invasive lobular carcinoma

Accuracy of breast MRI in evaluating nodal status after neoadjuvant therapy in invasive lobular carcinoma

Sentinel Lymph Node Biopsy and Completion Lymph Node Dissection for Melanoma

Adherence to surgical and oncologic standards improves survival in breast cancer patients

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