Breast Cancer Surgical Management Of The Axilla: A National Portrait Compared To International Consensus (Part 2)
DOI:
https://doi.org/10.34635/rpc.1036Keywords:
breast cancer units, organization, surgical management of the axillaAbstract
Purpose: The Chapter on Breast Surgery of the Portuguese Society of Surgery aimed to find out from hospitals that treat breast cancer (BC) their contemporary surgical management of the axilla.Methods: Forty-five hospitals were invited to participate in a nationwide survey in March 2023. A qualitative and quantitative description was made. A complementary comparison with national and international BC clinical guidelines was performed.
Results: We received 38 responses (84.4%). To define a negative axilla, 65.8% required physical examination plus axillary ultrasound (US). A positive axilla requires lymph node US-guided biopsy (core biopsy in 76.3% and fine-needle cytology in 52.6%). Most (94.7%) used a combined dual tracer for sentinel node biopsy (SNB). Tc99 plus Patent Blue was the most common (76.3%). Intraoperative pathology was routinely performed in 52.6%. Omission of SNB was consensual in DCIS (86.8%), 68.4% considered it in older patients, but only 2.6% proposed it in low-risk invasive BC. There was a consensus (92.1%) to omit axillary lymph node dissection (ALDN) when one or two positive sentinel nodes were identified intraoperatively in an initially c/uN0 axilla. To perform a targeted axillary dissection (TAD) in a suspicious/positive axilla, 42.1% reported that one or two nodes were biopsied and marked. The most common localization technique was a titanium clip in 84.2% (only 36.8% were US-visible clips). For the cN1 axilla, the majority preferred ALND for upfront surgery (60.5%) or in the absence of a radiological complete response (uCR) after primary systemic therapy (PST)(63.2%). For uCR after PST, 86.8% favoured SNB plus TAD, with a consensus (92.1%) to omit ALND for pathologic complete response in the axilla. Our survey was unable to assess the morbidity of axillary surgery as outcome registries were found in only 42.1% of hospitals.
Conclusion: De-escalation of surgical management of the axilla has been followed in most hospitals in this national portrait. SNB has long been the standard of care for cN0 axilla. A trend toward more conservative multidisciplinary management of positive axilla has also been noted, with the progressive omission of ALND in favour of TAD and axillary RT.
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References
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2. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994 Sep;220(3):391-8; discussion 398-401. doi: 10.1097/00000658-199409000-00015. PMID: 8092905; PMCID: PMC1234400.
3. Veronesi U, Paganelli G, Galimberti V, Viale G, Zurrida S, Bedoni M, Costa A, de Cicco C, Geraghty JG, Luini A, Sacchini V, Veronesi P. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet. 1997 Jun 28;349(9069):1864-7. doi: 10.1016/S0140-6736(97)01004-0. PMID: 9217757.
4. Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR, Ollila DW, Hansen NM, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, Hunt KK, Morrow M. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women with Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017 Sep 12;318(10):918-26. doi: 10.1001/jama.2017.11470. PMID: 28898379; PMCID: PMC5672806.
5. Bartels SAL, Donker M, Poncet C, Sauvé N, Straver ME, van de Velde CJH, Mansel RE, Blanken C, Orzalesi L, Klinkenbijl JHG, van der Mijle HCJ, Nieuwenhuijzen GAP, Veltkamp SC, van Dalen T, Marinelli A, Rijna H, Snoj M, Bundred NJ, Merkus JWS, Belkacemi Y, Petignat P, Schinagl DAX, Coens C, van Tienhoven G, van Duijnhoven F, Rutgers EJT. Radiotherapy or Surgery of the Axilla After a Positive Sentinel Node in Breast Cancer: 10-Year Results of the Randomized Controlled EORTC 10981-22023 AMAROS Trial. J Clin Oncol. 2023 Apr 20;41(12):2159-2165. doi: 10.1200/JCO.22.01565. Epub 2022 Nov 16. PMID: 36383926.
6. de Boniface J, Filtenborg Tvedskov T, Rydén L, Szulkin R, Reimer T, Kühn T, Kontos M, Gentilini OD, Olofsson Bagge R, Sund M, Lundstedt D, Appelgren M, Ahlgren J, Norenstedt S, Celebioglu F, Sackey H, Scheel Andersen I, Hoyer U, Nyman PF, Vikhe Patil E, Wieslander E, Dahl Nissen H, Alkner S, Andersson Y, Offersen BV, Bergkvist L, Frisell J, Christiansen P; SENOMAC Trialists’Group; SENOMAC Trialists’ Group. Omitting Axillary Dissection in Breast Cancer with Sentinel-Node Metastases. N Engl J Med. 2024 Apr 4;390(13):1163-1175. doi: 10.1056/NEJMoa2313487. PMID: 38598571.
7. Gentilini OD, Botteri E, Sangalli C, Galimberti V, Porpiglia M, Agresti R, Luini A, Viale G, Cassano E, Peradze N, Toesca A, Massari G, Sacchini V, Munzone E, Leonardi MC, Cattadori F, Di Micco R, Esposito E, Sgarella A, Cattaneo S, Busani M, Dessena M, Bianchi A, Cretella E, Ripoll Orts F, Mueller M, Tinterri C, Chahuan Manzur BJ, Benedetto C, Veronesi P; SOUND Trial Group. Sentinel Lymph Node Biopsy vs No Axillary Surgery in Patients With Small Breast Cancer and Negative Results on Ultrasonography of Axillary Lymph Nodes: The SOUND Randomized Clinical Trial. JAMA Oncol. 2023 Nov 1;9(11):1557-1564. doi: 10.1001/jamaoncol.2023.3759. PMID: 37733364; PMCID: PMC10514873.
8. Montagna G, Mrdutt MM, Sun SX, Hlavin C, Diego EJ, Wong SM, Barrio AV, van den Bruele AB, Cabioglu N, Sevilimedu V, Rosenberger LH, Hwang ES, Ingham A, Papassotiropoulos B, Nguyen-Sträuli BD, Kurzeder C, Aybar DD, Vorburger D, Matlac DM, Ostapenko E, Riedel F, Fitzal F, Meani F, Fick F, Sagasser J, Heil J, Karanlik H, Dedes KJ, Romics L, Banys-Paluchowski M, Muslumanoglu M, Perez MDRC, Díaz MC, Heidinger M, Fehr MK, Reinisch M, Tukenmez M, Maggi N, Rocco N, Ditsch N, Gentilini OD, Paulinelli RR, Zarhi SS, Kuemmel S, Bruzas S, di Lascio S, Parissenti TK, Hoskin TL, Güth U, Ovalle V, Tausch C, Kuerer HM, Caudle AS, Boileau JF, Boughey JC, Kühn T, Morrow M, Weber WP. Omission of Axillary Dissection Following Nodal Downstaging With Neoadjuvant Chemotherapy. JAMA Oncol. 2024 Apr 25:e240578. doi: 10.1001/jamaoncol.2024.0578. Epub ahead of print. PMID: 38662396; PMCID: PMC11046400.
9. Pfob A, Kokh DB, Surovtsova I, Riedel F, Morakis P, Heil J. Oncologic Outcomes for Different Axillary Staging Techniques in Patients with Nodal-Positive Breast Cancer Undergoing Neoadjuvant Systematic Treatment: A Cancer Registry Study. Ann Surg Oncol. 2024 May 6. doi: 10.1245/s10434-024-15292-y. Epub ahead of print. PMID: 38710911.
10. Bessa JF, Novita GG, Testa L, Freitas-Junior R, Marta GN. Is my patient an appropriate candidate for sentinel node biopsy? Less axillary surgery, for the right patients. Critical review and grades of recommendation. Surg Oncol. 2024 Mar 15;54:102064. doi: 10.1016/j.suronc.2024.102064. Epub ahead of print. PMID: 38518660.
11. Veronesi U, Stafyla V, Luini A, Veronesi P. Breast cancer: from “maximum tolerable” to “minimum effective” treatment. Front Oncol. 2012 Oct 8;2:125. doi: 10.3389/fonc.2012.00125. PMID: 23061042; PMCID: PMC3465814.
12. Banys-Paluchowski M, Rubio IT, Ditsch N, Krug D, Gentilini OD, Kühn T. Real de-escalation or escalation in disguise? Breast. 2023 Jun;69:249-257. doi: 10.1016/j.breast.2023.03.001. Epub 2023 Mar 4. PMID: 36898258; PMCID: PMC10017412.
13. Pinto D, Vargas Moniz J, Azevedo I, Loureiro J, Marques JC, Fougo JL, Ferreira M, Coimbra N, Chinita P. Recomendações de abordagem da axila cN1 após neoadjuvância. In: X Consenso Nacional de Cancro da Mama. Ed. Sociedade Portuguesa de Senologia, 2022.
14. Loibl S, André F, Bachelot T, Barrios CH, Bergh J, Burstein HJ, Cardoso MJ, Carey LA, Dawood S, Del Mastro L, Denkert C, Fallenberg EM, Francis PA, Gamal-Eldin H, Gelmon K, Geyer CE, Gnant M, Guarneri V, Gupta S, Kim SB, Krug D, Martin M, Meattini I, Morrow M, Janni W, Paluch-Shimon S, Partridge A, Poortmans P, Pusztai L, Regan MM, Sparano J, Spanic T, Swain S, Tjulandin S, Toi M, Trapani D, Tutt A, Xu B, Curigliano G, Harbeck N; ESMO Guidelines Committee. Electronic address: clinicalguidelines@esmo.org. Early breast cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2024 Feb;35(2):159-182. doi: 10.1016/j.annonc.2023.11.016. Epub 2023 Dec 13. PMID: 38101773.
15. National comprehensive cancer network. NCCN Breast Cancer Guidelines, Version 2. 2024. https://www.nccn.org/professionals/ physician_gls/pdf/breast.pdf. Accessed Mars 31, 2024.
16. Choosing Wisely. Society of Surgical Oncology. Published July 12, 2016. Updated July 21, 2021. https://www.choosingwisely.org/clinician-lists/sso-sentinel-node-biopsy-in-node-negative-women-70-and-over/. Accessed Mars 31, 2024.
17. Dubsky P, Pinker K, Cardoso F, Montagna G, Ritter M, Denkert C, Rubio IT, de Azambuja E, Curigliano G, Gentilini O, Gnant M, Günthert A, Hauser N, Heil J, Knauer M, Knotek-Roggenbauerc M, Knox S, Kovacs T, Kuerer HM, Loibl S, Mannhart M, Meattini I, Penault-Llorca F, Radosevic-Robin N, Sager P, Španić T, Steyerova P, Tausch C, Peeters MTFDV, Weber WP, Cardoso MJ, Poortmans P. Breast conservation and axillary management after primary systemic therapy in patients with early-stage breast cancer: the Lucerne toolbox. Lancet Oncol. 2021 Jan;22(1):e18-e28. doi: 10.1016/S1470-2045(20)30580-5. PMID: 33387500.
18. Kaidar-Person O, Pfob A, Gentilini OD, Borisch B, Bosch A, Cardoso MJ, Curigliano G, De Boniface J, Denkert C, Hauser N, Heil J, Knauer M, Kühn T, Lee HB, Loibl S, Mannhart M, Meattini I, Montagna G, Pinker K, Poulakaki F, Rubio IT, Sager P, Steyerova P, Tausch C, Tramm T, Vrancken Peeters MJ, Wyld L, Yu JH, Weber WP, Poortmans P, Dubsky P. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus. EClinicalMedicine. 2023 Jul 14;61:102085. doi: 10.1016/j.eclinm.2023.102085. PMID: 37528842; PMCID: PMC10388578.
19. Weber WP, Davide Gentilini O, Morrow M, Montagna G, de Boniface J, Fitzal F, Wyld L, Rubio IT, Matrai Z, King TA, Saccilotto R, Galimberti V, Maggi N, Andreozzi M, Sacchini V, Castrezana López L, Loesch J, Schwab FD, Eller R, Heidinger M, Haug M, Kurzeder C, Di Micco R, Banys-Paluchowski M, Ditsch N, Harder Y, Paulinelli RR, Urban C, Benson J, Bjelic-Radisic V, Potter S, Knauer M, Thill M, Vrancken Peeters MJ, Kuemmel S, Heil J, Gulluoglu BM, Tausch C, Ganz-Blaettler U, Shaw J, Dubsky P, Poortmans P, Kaidar-Person O, Kühn T, Gnant M. Uncertainties and controversies in axillary management of patients with breast cancer. Cancer Treat Rev. 2023 Jun;117:102556. doi: 10.1016/j.ctrv.2023.102556. Epub 2023 Apr 23. PMID: 37126938; PMCID: PMC10752145.
20. Suami H, Chang DW. Overview of surgical treatments for breast cancer-related lymphedema. Plast Reconstr Surg. 2010 Dec;126(6):1853-1863. doi: 10.1097/PRS.0b013e3181f44658. PMID: 21124127.
21. Galimberti V, Cole BF, Viale G, Veronesi P, Vicini E, Intra M, Mazzarol G, Massarut S, Zgajnar J, Taffurelli M, Littlejohn D, Knauer M, Tondini C, Di Leo A, Colleoni M, Regan MM, Coates AS, Gelber RD, Goldhirsch A; International Breast Cancer Study Group Trial 23-01. Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol. 2018 Oct;19(10):1385-1393. doi: 10.1016/S1470-2045(18)30380-2. Epub 2018 Sep 5. PMID: 30196031.
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2024-07-29
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