Axillary lymph node failure in patients treated with accelerated partial breast irradiation

BACKGROUND:

Data on the risk of axillary failure (AF) after accelerated partial breast irradiation (APBI) are limited. In this study, the authors determined the rate of AF and regional lymph node failure (RNF) in patients who received various forms of APBI and identified factors that were associated with its occurrence.

METHODS:

In total, 534 patients with early stage breast cancer were treated at William Beaumont Hospital with APBI, including 466 patients (87%) with invasive breast cancer and 68 patients (13%) with ductal carcinoma in situ. Clinical variables (patient age, tumor location), pathologic variables (tumor size, grade, estrogen receptor status, margin status, lymph node status), and treatment‐related variables (receipt of hormone and systemic chemotherapy) were analyzed to determine which factors were associated with AF and RNF. The median length of follow‐up was 63 months (range, 1‐201 months).

RESULTS:

The 5‐year actuarial AF rate was 0.19%. Three patients (0.56%) developed RNF (all patients initially had invasive breast cancer) with a 5‐year actuarial rate of 0.37%. Two of the regional recurrences were in the supraclavicular fossa, and 1 was in the axilla. No variables were associated with AF. However, patient numbers were very small. The median survival after RNF was 0.8 years (range, 0.3‐1.7 years), and 2 of the 3 patients died of disease.

CONCLUSIONS:

The rate of AF and RNF after APBI was low and appeared to be similar to the rate observed with whole‐breast irradiation. No variables were associated with a higher rate of AF after APBI. Cancer 2012;. © 2011 American Cancer Society.     

Axillary lymph node irradiation in breast cancer: state of the art

Place of axillary radiotherapy in the management of patients with breast cancer remains debated. While the prognostic value of axillary lymph node extension has been largely demonstrated, the benefit of axillary treatment is more uncertain. Large clinical trials having demonstrated the benefit of adjuvant radiotherapy in advanced breast cancer comprised large nodal irradiation, including axillary area. Analyzing the true benefit of axillary radiotherapy is rendered difficult by heterogeneity of series, particularly when focusing on the extent of lymph node dissection. Although adjuvant axillary radiotherapy is usually recommended in patients with insufficient lymph node dissection or with bulky axillary involvement, the prognosis in these patients remains poor by metastatic evolution and such strategy exposes to increased toxicity and functional sequels. Further assessments should better define the optimal indications and the true benefit of axillary radiotherapy.     

Axillary lymph node management in breast cancer with positive sentinel lymph node biopsy

The surgical treatment of localized breast cancer has become progressively less aggressive over the years. The management of the axillary lymph nodes has been modified by the introduction of sentinel lymph node biopsy. Axillary dissection can be avoided in patients with sentinel lymph node negative biopsies. Based on randomized trials data, it has been proposed that no lymph node dissection should be carried out even in certain patients with sentinel lymph node positive biopsies. This commentary discusses the basis of such recommendations and cautions against a general omission of lymph node dissection in breast cancer patients with positive sentinel lymph node biopsies. Instead, an individualized approach based on axillary tumor burden and biology of the cancer should be considered.     

Axillary lymph node metastases associated with small invasive breast carcinomas

BACKGROUND: Over the past 20 years the proportion of invasive breast carcinomas measuring < or = 1 cm has increased progressively. Information regarding the effect of clinical and histologic characteristics on the frequency of lymph node metastases associated with small invasive breast carcinomas is limited. METHODS: A review of Surveillance, Epidemiology, and End Results data was performed using cases diagnosed between January 1988 through December 1993. A total of 12,950 patients with invasive breast carcinomas measuring < or = 1 cm undergoing a resection of the primary tumor and an axillary lymph node dissection were included in this study. The effect of clinical and histologic characteristics on the frequency of lymph node metastases was reviewed. RESULTS: The frequency of lymph node metastases associated with T1a tumors was less than that observed from T1b tumors (9.6% vs. 14.3%; P < 0.001). Tumors with favorable histology (mucinous, papillary, and tubular carcinomas) had a lower frequency of lymph node metastases compared with all other histologic types (3.9% vs. 13.9%; P < 0.001). Increasing histologic grade was associated with an increased risk of lymph node metastases ranging from 7.8% in Grade 1 tumors to 21.0% in Grade 4 tumors (P < 0.001). Increasing patient age was associated with a progressively decreasing frequency of associated axillary lymph node metastases ranging from 22.6% in women age < 40 years to 10.2% in women age > or = 70 years (P < 0.001). CONCLUSIONS: Cases in which an axillary lymph node dissection can be avoided are those with an associated frequency of lymph node metastases < or = 5%, including T1a and T1b mucinous and tubular carcinomas, T1a papillary carcinomas, and T1a Grade 1 carcinomas.     

Axillary lymph node metastases in patients with occult noninvasive breast carcinoma

This report describes 8 cases of women who, when first examined, manifested metastatic mammary carcinoma in axillary lymph nodes. At mastectomy, the only demonstrable carcinoma was noninvasive (lobular, 4 patients; duct, 3 patients; duct and lobular, 1 patient) in so far as could be determined by means of light microscopic examination. In 2 cases treated more than five years ago, the patients were free of disease when last seen seven and 11 years postoperatively. It is possible that in these unusual cases, obscure foci of invasion were not found despite exhaustive histologic examination of the entire breast. Alternatively, metastases may have developed in the absence of invasion demonstrable by means of light microscopic examination. Results of electron microscopic studies as reported by others have documented extension of carcinoma cells through the basement membrane when this was not apparent in histologic sections. We have recently studied a series of patients with preinvasive breast carcinoma and observed metastatic breast carcinoma in axillary lymph nodes in 1% of these cases. The finding of carcinoma that appears histologically to be entirely preinvasive, whether duct or lobular in type, in a breast biopsy specimen does not entirely preclude the possibility of metastases in axillary lymph nodes.     

Radiation dose to conceptus resulting from tangential breast irradiation

PURPOSE: To estimate the radiation dose to the conceptus resulting from tangential breast irradiation. METHODS AND MATERIALS: Conceptus radiation doses were measured in anthropomorphic phantoms simulating the geometry of a pregnant woman at the first, second, and third trimesters of gestation. Medial and lateral field irradiations were generated using a 6-MV X-ray beam. Dose measurements were performed with thermoluminescent dosimeters. RESULTS: For a treatment course delivering 50 Gy to the tumor, conceptus dose at the first trimester of gestation was found to be 2.1-7.6 cGy, depending on the field size used and the distance between conceptus and primary irradiation field. The corresponding dose ranges to the conceptus during the second and third trimesters of gestation were 2.2-24.6 cGy and 2.2-58.6 cGy, respectively. Dose data and formulas are presented to estimate conceptus dose for individual patients undergoing breast radiotherapy during the entire pregnancy. CONCLUSIONS: This study may be of value in the management of pregnant women needing tangential breast irradiation, because it provides the required information to estimate conceptus dose.     

Regional lymph node irradiation in breast cancer

A recent meta-analysis, published by the Early Breast Cancer Trialists' Collaborative Group, demonstrated a clear survival advantage of post-operative radiotherapy on the breast, chest wall and regional lymphatics in node-positive disease. The extensive target volume in locoregional irradiation of breast cancer, in close proximity to the heart and lungs, complicates treatment planning. The breast or chest wall fields need to match the supraclavicular/axillary and parasternal fields, at the subclavicular and parasternal matchline, respectively. Dose distribution near the junction area is often inhomogeneous, and under- and over-dosage can occur, which can lead to recurrences and complications. This paper describes briefly the indications, complications and target localization concerning regional lymph node radiotherapy and discusses more extensively the advantages and disadvantages of the most frequently used treatment techniques.     

Axillary lymph node dissection can be avoided in women with breast cancer with intraoperative, false-negative sentinel lymph node biopsies

Background

It is currently unclear which patients with breast cancer with sentinel lymph node (SLN) metastases do not need axillary lymph node dissection (ALND).

Patients and methods

A cohort of 1,132 women who had unilateral invasive breast cancer with clinically negative nodes or nodes suspicious for metastasis, were intraoperatively diagnosed as having negative SLNs, and did not undergo an immediate ALND. Our intraoperative histological investigation uses H&E staining of a frozen section from a maximum cut surface of each SLN. Of these 1,132 women, 132 (11.7%) were postoperatively diagnosed as having positive SLNs, which classifies them as having an intraoperative, false-negative SLN biopsy (SLNB). Patient and tumor characteristics, treatment methods, and the prognoses of these patients were investigated and compared with the remaining 1,000 patients who were negative for SLNB.

Results

Of the 132 patients with intraoperative, false-negative SLNB, none underwent a further ALND. With a median follow-up period of 58.1 months, none of these patients exhibited recurrence in the axillary nodes. Their recurrence-free survival rates were not statistically different from those of patients with negative SLNB.

Conclusions

ALND can be avoided in most patients with breast cancer with intraoperative, false-negative SLNB.     

Axillary lymph node dissection for intraductal breast carcinoma--is it indicated?

One hundred patients with intraductal breast carcinoma (DCIS) were treated with either mastectomy (49 patients) or radiation therapy (51 patients). All patients underwent axillary lymph node dissection (average number of nodes removed, 16) as part of their treatment. No patient had any positive axillary lymph nodes. There has been one recurrence in each treatment group (median follow-up, 27 months) and no deaths. Intraductal breast carcinoma has little potential for metastasis to axillary lymph nodes.     

Axillary disease recurrence after sentinel lymph node dissection for breast carcinoma

BACKGROUND: Surgical recommendation for early-stage breast carcinoma includes removal of the primary breast tumor and evaluation of the axillary lymph nodes on the ipsilateral side. Sentinel lymph node dissection (SLND) is increasingly being used to evaluate axillary lymph nodes in clinically lymph node negative patients as an alternative to axillary lymph node dissection (ALND). Results from SLND are highly predictive of metastatic involvement in the axilla, and are associated with fewer side effects. However, the greatest concern with SLND alone is the potential for a higher rate of axillary lymph node recurrence. The purpose of the current study was to review data collected on 700 consecutive patients with early-stage breast carcinoma who underwent SLND without concomitant ALND. METHODS: A retrospective study was conducted using the oncology registry at Park Nicollet Health Services (Minneapolis, MN). Consecutive breast carcinoma cases with SLND only for axillary surgery, from January 28, 1999 to December 31, 2003, were included in the study. During this period, 700 patients with breast carcinoma were identified who had SLND alone. Fifty-two patients were excluded from the analysis because they had ductal carcinoma in situ. RESULTS: With a median follow-up of 33 months (range, 2-73 mos), axillary lymph node recurrence occurred in 4 of 647 (0.62%) patients overall. In these 4 patients, the axillary lymph node recurrences were isolated to the axillary lymph nodes and amenable to surgery. CONCLUSIONS: Data from the current study showed that axillary lymph node recurrence after SLND occurred very infrequently in early-stage breast carcinoma, and these results were comparable to other studies.     

Axillary lymph node and bone marrow micrometastases of breast cancer]

Micrometastatic disease from breast cancer is a major concern both for clinicians and pathologists. Histologically, they can be defined as potentially invasive microfoci of tumoral cancer cells located in the vicinity of blood vessels and are a distinct entity from residual disease. They are mainly looked for in bone marrow and lymph nodes specimens and their diagnosis is currently easier thanks to immunohistochemistry. Provided a standard definition of micrometastatic disease and standard screening procedures can be met, the presence of micrometastases at the time of diagnosis could represent a major parameter in therapeutic decision-making. Although controversial, the presence of medullary and axillary lymph node micrometastases appears to be a major prognostic factor in terms of survival. Recognition of this entity could help in better defining the high-risk subset of patients who would potentially benefit from adjuvant chemotherapy.     

Axillary lymph node metastases from occult carcinoma of the breast.

From the case records of the Istituto Nazionale Tumori of Milan from 1956 to 1976, 49 cases of metastases in axillary lymph nodes from an occult carcinoma of the breast were selected. Forty-four patients underwent removal of the suspicious breast. In 11 patients no tumor was found at the pathologic examination. The survival of these patients was no different from the survival of those in whom the tumor was found. The 5-year survival of the total series was 87%, confirming that this type of presentation of breast cancer has a prognosis that is better than that generally reported for stage II carcinoma of the breast.     

超声刀联合脂肪溶解液在乳腺癌腋窝淋巴结清除术中应用研究

目的 乳腺癌改良根治术腋窝淋巴结清除术后常有出血,积液及损伤腋窝神经等并发症,精细解剖是较为可靠的方法.本研究应用超声刀联合脂肪溶解液行乳腺癌腋窝淋巴结清除术,探讨其可行性和安全性.方法 回顾性分析青岛市胶州中心医院2013-06-15-2015-04-25乳腺癌改良根治术患者210例临床资料,随机分为超声刀联合脂肪溶解液组(研究组)和高频电刀组(对照组)两组,每组105例.研究组应用Harmonic超声刀配备Focus刀头联合脂肪溶解液行乳腺癌腋窝淋巴结清除术;对照组用高频单极电刀行腋窝淋巴清除术.两组进行对比,观察腋窝清除手术时间、腋窝手术出血量、引流总量及腋窝引流时间等指标并进行统计学分析.结果 研究组腋窝清除术时间为(20.4±9.7) min,短于对照组(31.5±7.8) min,t=2.813,P=0.021;研究组术中出血为(44.3±5.2) mL,少于对照组(75.7±7.9) mL,x2=7.445,P=0.046;研究组淋巴引流总量为(253.6±5.6) mL,较对照组(357.7±8.9) mL少,x2=7.234,P=0.018;研究组超声刀溶脂组术后腋窝引流时间为(6.5±1.5)d,较对照组(12.1±2.6)d明显缩短,x2=6.356,P-0.025.两组清除腋窝淋巴结数目差异无统计学意义,P＞0.05.结论 与高频单极电刀相比,应用超声刀联合脂肪溶解液行乳腺癌腋窝淋巴结清除术,可以缩短手术时间,减少手术出血量和术后腋窝引流时间.两者可以协同发挥作用,安全可靠.     

Axillary lymph node metastasis in lung cancer

Study objectives Axillary lymph node metastasis (ALNM) from lung cancer is rare. Its prognosis and effective treatments remain unknown. To evaluate clinicopatholgical characteristics of such lung cancer patients, we performed a retrospective study of them, who had ALNM at the time of initial presentation or developed ALNM in their clinical courses. Methods We reviewed the medical records and pathological reports of all patients at our division who had a diagnosis of primary lung cancer from January 1985 through August 2007. Results Ten (0.75%) of 1,340 patients had ALNM. In eight of them, ALNM was detected at the time of initial diagnosis, and two patients developed ALNM in their clinical courses. Lymphatic metastasis to mediastinum was evident in all patients. Supraclavicular and cervical lymph nodes were involved in five and three patients, respectively. One patient had direct chest wall invasion from the lung. Three patients had distant metastases other than axillary or cervical lymph nodes. Four patients received systemic chemotherapy, and another four patients received palliative chest irradiation or supportive care because of their poor performance status. Median survival time of 8 patients who were diagnosed as having ALNMs at initial presentation was 7 months. Conclusions The most likely mechanism for axillary node involvement is intercostal lymphatics via spread from mediastinal lymph node metastasis. Routine palpation of the axillae is recommended if chest wall invasion, mediastinal and/or supraclavicular lymph nodes are found either at initial presentation or at follow-up of patients.     

Axillary sentinel lymph node biopsy after neoadjuvant chemotherapy for carcinoma of the breast

BACKGROUND:

The timing and accuracy of axillary sentinel lymph node biopsy (SLNB) in patients who are receiving neoadjuvant chemotherapy (NACT) for breast cancer are controversial. To examine the accuracy of SLNB after NACT, the authors performed SLNB after chemotherapy on all of patients who received NACT at their institution starting in January 1997.

METHODS:

Seventy‐nine women who underwent NACT between 1997 and 2008 comprised this study and were divided as follows: 4 women had stage I disease, 60 women had stage II disease, and 15 women had stage III disease, including 10 women who had multicentric disease. Thirty‐nine women (49.4%) had clinical evidence of axillary metastasis (N1‐N2) at the time of diagnosis. The regimen, the duration of treatment, and the number of cycles of NACT depended on clinical response. The choice of breast conservation therapy or mastectomy was based on the patient's response to treatment and patient preference. All patients underwent SLNB after NACT.

RESULTS:

Seventy‐three patients underwent breast conservation therapy, and 6 patients underwent mastectomy. Sentinel lymph nodes were identified in 98.7% of patients (in 1 patient, SLNB failed to capture 1 proven axillary metastasis), and 29 patients underwent full axillary lymph node dissection. Fourteen patients (17.7%) had no residual carcinoma (invasive or ductal carcinoma in situ) in their breast, 5 patients (6.3%) had residual ductal carcinoma in situ (only), and 60 patients (75.9%) had residual invasive carcinoma. One false‐negative SLNB was reported in the group of 23 patients who underwent full axillary dissection after a negative SLNB. No patient had a subsequent axillary recurrence.

CONCLUSIONS:

SLNB after NACT was feasible in virtually all patients and accurately selected patients who required complete level I and II axillary dissection. NACT frequently downstaged the axilla, converting patients with N1‐N2 lymph node status to N0 status and also avoiding full axillary dissection in these patients. Cancer 2010. © 2010 American Cancer Society.     

Axillary lymphocele after axillary dissection or sampling of sentinel lymph node in breast cancer

The goal of this study was to evaluate the rate of seromas after axillary dissection or sentinel lymph node biopsy. This is a prospective study based upon a series of 229 patients. Among those 229 patients, 179 had an axillary dissection and 50 had a sentinel lymph node biopsy. In the axillary dissection group, 40% of patients developed a seroma. The maximum number of aspirations needed was 8. In the sentinel lymph node group, 18% of patients developed a seroma that never recurred after a single aspiration. Seromas are still a very frequent complication after axillary dissection. The sentinel lymph node biopsy has helped to reduce the rate of axillary seroma, and the number of aspirations needed to evacuate them.     

Axillary recurrence after negative sentinel lymph node biopsy under local anesthesia in breast cancer

The procedure known as sentinel lymph node biopsy (SLNB) under local anesthesia (LA) allows surgical teams to avoid the uncertainties of frozen tissue examination and to perform axillary dissection on patients who have been informed of the risks of lymph node invasion prior to the procedure.