Background
Completion axillary node dissection (CLND) is routinely omitted in cT1-2 N0 breast cancer treated with upfront, breast-conserving therapy and sentinel node biopsy (SLNB) showing one to two ...positive sentinel nodes (SLNs). The purpose of this study was to determine the incidence and impact of axillary treatment among patients treated with mastectomy in a contemporary cohort.
Methods
A prospective, institutional database was reviewed from 2006 to 2015 to identify patients with T1-2 breast cancer treated with upfront mastectomy and SLNB found to have one to two positive SLNs. Patients were stratified by axillary therapy including CLND and/or post-mastectomy radiation therapy (PMRT), and clinicopathologic factors and incidence rates of local-regional and distant recurrence were analyzed.
Results
A total of 548 patients were identified, including 126 (23%) without CLND. Rates of PMRT were similar between those with and without CLND (35.3% vs. 28.6%,
p
= 0.16). On multivariate analysis, two rather than one positive SLN, larger SLN metastasis size, frozen-section analysis of the SLNB, and adjuvant chemotherapy were significantly associated with receipt of CLND. At a median follow-up of 7 years, there were only two local-regional recurrences in the no-CLND group, of which only one was an axillary recurrence. The 5-years incidence rate of LRR was not significantly different for those with and without CLND (1.3% vs. 1.8%,
p
= 0.93).
Conclusions
We found extremely low rates of local-regional recurrence among those with T1-2 breast cancer undergoing upfront mastectomy with 1–2 positive SLNs. Further axillary surgery may not be indicated in selected patients treated with a multidisciplinary approach, including adjuvant therapies.
This review provides historical and current data to support the role of imaging-based axillary lymph node staging and sentinel lymph node biopsy as the standard of care for axillary management in ...women with a diagnosis of breast cancer, before and after neoadjuvant systemic therapy.
The implications of surgical trials (American College of Surgeons Oncology Group ACOSOG Z011 and ACOSOG Z1071) on imaging protocols for the axilla are reviewed, in conjunction with the American Joint Committee on Cancer nodal staging guidelines.
Background
Inflammatory breast cancer (IBC) represents a rare (2–3 %) but aggressive subset of breast cancer with a historically reported 5-year overall survival rate of 50 % and a 3-year ...local-regional recurrence (LRR) rate of 20 %. This study aimed to evaluate long-term LRR in a contemporary cohort of non-metastatic IBC patients undergoing trimodal therapy at a single institution and identify factors associated with local and distant failure.
Methods
The study identified 262 patients with non-metastatic IBC who received trimodal therapy (neoadjuvant chemotherapy, modified radical mastectomy, adjuvant radiation) from an institutional prospective database (2007–2019). Long-term outcomes of local-regional and distant metastasis were reported. Survival outcomes were analyzed using the Cox proportional hazards regression model.
Results
The median age at diagnosis was 52 years, and the median follow-up period was 5.1 years. In this cohort, 82 (31.3 %) patients achieved a pathologic complete response (pCR) in the breast and axilla. Local-regional recurrence was observed in 18 (6.9 %) patients (11 isolated to the chest wall, 4 isolated to regional nodes, and 3 involving chest wall and ipsilateral axillary nodes). Distant metastasis was observed in 92 (35.1 %) patients. During the follow-up period, 90 deaths occurred. In the multivariate analysis, pCR was associated with improved disease-free survival (hazard ratio HR, 0.26; 95 % confidence interval CI, 0.13–0.51;
p
= 0.001) and overall survival (HR, 0.31; 95 % CI, 0.15–0.65;
p
= 002).
Conclusions
During a median follow-up period longer than 5 years, the local-regional relapse rate for the IBC patients treated with contemporary trimodal therapy was 6.9%, similar to that for the non-IBC patients. After chemotherapy, surgical resection with modified radical mastectomy to negative margins and postmastectomy radiation therapy resulted in excellent long-term local-regional control.
Background
Minimally invasive surgical techniques are increasingly being implemented in oncologic care. This study assesses the impact of minimally invasive surgery on oncologic and perioperative ...outcomes in the management of gastric cancer in the USA.
Methods
From the American College of Surgeons and American Cancer Society National Cancer Data Base, we identified 6427 patients who underwent gastrectomy for cancer from 2010 to 2012. Treatment groups were categorized with an intention-to-treat paradigm as robotic, laparoscopic, and open surgery. Univariate and multivariate analyses were performed to estimate the impact of the surgical approach on oncologic and perioperative outcomes.
Results
Of patients undergoing definitive surgical intervention, 3.5 % (
n
= 223) underwent robotic gastrectomy, 23.1 % (
n
= 1487) underwent laparoscopic gastrectomy, and 73.4 % (
n
= 4717) underwent open surgery. Minimally invasive gastrectomy was more frequently performed on white (
P
= 0.018), privately insured patients (
P
= 0.049) treated at academic centers (
P
< 0.0001) in the eastern USA (
P
< 0.0001). After demographics, comorbidities, and tumor-related factors had been controlled for, patients who underwent laparoscopic gastrectomy had the postoperative length of stay decreased by 1.08 days (
P
< 0.0001) and greater odds of having at least 15 lymph nodes resected (odds ratio 1.16,
P
= 0.023). Use of robotic surgery did not have a statistically significant effect on the postoperative length of stay relative to open surgery (
P
= 0.222) but the patients so treated had greater odds of having at least 15 lymph nodes resected (odds ratio 1.51,
P
= 0.005). There were no differences in R0 resection rates or perioperative mortality on the basis of the surgical approach alone.
Conclusions
These findings suggest that use of minimally invasive surgery for gastric cancer in the USA is impacting the adequacy of oncologic resection but is not yet having a clinically significant impact on perioperative outcomes relative to a conventional open approach.
Neoadjuvant systemic therapy (NST) for triple-negative breast cancer and HER2-positive breast cancer yields a pathological complete response in approximately 60% of patients. A pathological complete ...response to NST predicts an excellent prognosis and can be accurately determined by percutaneous image-guided vacuum-assisted core biopsy (VACB). We evaluated radiotherapy alone, without breast surgery, in patients with early-stage triple-negative breast cancer or HER2-positive breast cancer treated with NST who had an image-guided VACB-determined pathological complete response.
This multicentre, single-arm, phase 2 trial was done in seven centres in the USA. Women aged 40 years or older who were not pregnant with unicentric cT1–2N0–1M0 triple-negative breast cancer or HER2-positive breast cancer and a residual breast lesion less than 2 cm on imaging after clinically standard NST were eligible for inclusion. Patients had one biopsy (minimum of 12 cores) obtained by 9G image-guided VACB of the tumour bed. If no invasive or in-situ disease was identified, breast surgery was omitted, and patients underwent standard whole-breast radiotherapy (40 Gy in 15 fractions or 50 Gy in 25 fractions) plus a boost (14 Gy in seven fractions). The primary outcome was the biopsy-confirmed ipsilateral breast tumour recurrence rate determined using the Kaplan-Meier method assessed in the per-protocol population. Safety was assessed in all patients who received VACB. This study has completed accrual and is registered with ClinicalTrials.gov, NCT02945579.
Between March 6, 2017, and Nov 9, 2021, 58 patients consented to participate; however, four (7%) did not meet final inclusion criteria and four (7%) withdrew consent. 50 patients were enrolled and underwent VACB following NST. The median age of the enrolled patients was 62 years (IQR 55–77); 21 (42%) patients had triple-negative breast cancer and 29 (58%) had HER2-positive breast cancer. VACB identified a pathological complete response in 31 patients (62% 95% CI 47·2–75·4). At a median follow-up of 26·4 months (IQR 15·2–39·6), no ipsilateral breast tumour recurrences occurred in these 31 patients. No serious biopsy-related adverse events or treatment-related deaths occurred.
Eliminating breast surgery in highly selected patients with an image-guided VACB-determined pathological complete response following NST is feasible with promising early results; however, additional prospective clinical trials evaluating this approach are needed.
US National Cancer Institute (National Institutes of Health).
Background
Triple-negative breast cancer (TNBC) is known to portend a worse prognosis compared with same-stage, hormone receptor-positive disease. However, with the recent change in practice to ...include pembrolizumab in neoadjuvant chemotherapy (NAC) for TNBC, an increase in pathologic complete responses (pCRs) has been reported. The perioperative repercussions of adding pembrolizumab to standard NAC regimens for TNBC are currently unknown. We aimed to explore the perioperative implications of adding pembrolizumab to standard NAC regimens for non-metastatic TNBC.
Methods
This was a retrospective review of the perioperative outcomes in patients with non-metastatic TNBC treated with pembrolizumab-NAC from January 2018 to October 2022 conducted at a high-volume cancer center. Patient demographics, comorbidities, clinical and pathological staging, NAC treatment regimen, initiation, and completion, as well as date of surgery and postoperative complications were analyzed.
Results
Of 87 patients, 67.8% had an overall pCR and 86% had an axillary pCR; 37.2% of cN+ patients were spared from axillary lymph node dissection. However, 24.1% of patients experienced surgical complications, 9% of patients were receiving steroids at the time of breast surgery secondary to adverse effects of pembrolizumab-NAC, and 7% underwent a change in the initial surgical plan such as omission of reconstruction.
Conclusion
Pembrolizumab-NAC has not only significant oncologic benefit but also noteworthy perioperative implications in the surgical management of TNBC.
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