Management of breast cancer: basic principles

Breast cancer is the commonest cancer in the UK. Its incidence is increasing and it accounts for over 10,000 deaths a year. All women referred with breast symptoms should undergo triple assessment with clinical examination, radiological imaging and a biopsy of the abnormality. The treatment of patients with breast cancer should be multidisciplinary and all patients should be discussed and treatment plans formulated at regular multidisciplinary meetings. Patients with breast cancer are usually treated surgically and may have a range of surgical options open to them, although for the majority this will involve mastectomy or breast-conserving surgery. A lymph node staging procedure is also performed to guide the use of adjuvant therapy and achieve loco-regional disease control. Unless there is preoperative evidence of involved axillary lymph nodes this should take the form of a sentinel lymph node biopsy. Throughout the course of treatment, patients should have access to dedicated breast care nurses to help further explain treatment options and help discuss and allay any questions and fears they may have.     

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??Problems and treatment options of sentinel lymph node in breast cancer WU Di, FAN Zhi-min. Department of Breast Surgery??the First Hospital of Jilin University??Changchun 130021??China
Corresponding author: FAN Zhi-min, E-mail:fanzhimn@163.com
Abstract Sentinel lymph node biopsy (SLNB) has been the primary care in clinically node negative breast cancer. Controversy still surrounds the SLNB of the internal mammary nodes. Because different kinds of tracer have respective feature, surgeons should choose the suitable tracer. All blue lymph nodes and any lymph nodes at the end of a blue lymphatic channel should be removed and designated as SLNs.Clinicians should not recommend ALND for women with early-stage breast cancer who have one or two SLN metastases and will receive breast-conserving surgery with conventionally fractionated whole-breast radiotherapy.Clinicians may offer ALND for women with early-stage breast cancer with nodal metastases found on SNB who will receive mastectomy. For patients who recieved neoadjuvant chemotherapy, SLNB after neoadjuvant chemotherapy is optimal.     

乳腺癌前哨淋巴结活检的若干问题和处理方案

前哨淋巴结活检（SLNB）已成为腋窝淋巴结临床阴性早期乳腺癌的首选腋窝手术方式,但其适应证范围已有所扩大。内乳淋巴结是否需要SLNB,尚存争议。不同示踪剂有各自的特点,应用时需要根据各临床中心的实际情况予以选择。寻找前哨淋巴结（SLN）时,原则上要循着色淋巴管解剖至腋窝寻找SLN。对于符合美国外科医师协会肿瘤学组（ACOSOG）Z0011试验入组标准的存在1～2枚SLN转移的病例不需腋窝淋巴结清扫（ALND）。仅行全乳切除的病例,如果SLN阳性,则需要进行腋窝淋巴结清扫。对于接受新辅助治疗病人接受SLNB的时机,目前认为在新辅助治疗后进行为好。     

The value of sentinel lymph node biopsy in elderly breast cancer patients

BACKGROUND: Although sentinel lymph node biopsy has been accepted as a useful procedure for certain breast cancer patients, the value of this procedure in the elderly remains unknown. We undertook this study to evaluate changes in adjuvant treatment attributable to sentinel lymph node biopsy. METHODS: A total of 104 patients > or =65 years underwent sentinel lymph node biopsy plus lumpectomy or mastectomy for the treatment of clinically node-negative invasive breast cancer. Demographic, pathologic, and treatment data were evaluated using an SAS software package (SAS, Cary, North Carolina). RESULTS: Twenty-nine of 104 patients (28%) had metastatic disease in > or =1 sentinel lymph node. Nonsurgical treatment was modified in 38% of patients because of sentinel lymph node biopsy results. Changes included adjuvant chemotherapy and/or hormonal therapy, adjuvant axillary radiotherapy, and decisions against adjuvant therapy. CONCLUSIONS: These data suggest that sentinel lymph node biopsy in elderly breast cancer patients is beneficial.     

Options in Breast Cancer Local Therapy: Who Gets What?

Today, women with primary breast cancer may consider three surgical options: breast-conserving surgery (BCS), mastectomy (MT), and mastectomy with contralateral prophylactic mastectomy (MT?+?CPM). In each case, the ipsilateral axilla is generally managed with a sentinel node biopsy and possibly an axillary lymph node dissection. BCS generally requires breast radiotherapy, except in older women having tumors with a favorable prognosis who will receive endocrine therapy. In contrast, women treated with MT generally do not require radiotherapy, except for those with large tumors or metastases to the axillary nodes. Moreover, MT and MT?+?CPM are usually undertaken with breast reconstruction. Yet, most patients today are suitable candidates for BCS, with a few relative contraindications. Thus, early pregnancy, previous radiotherapy to the breasts, active collagen vascular disease, multicentric breast cancer, large tumors (although neoadjuvant systemic therapy can often reduce tumor size), and the presence of the BRCA mutation are all relative contraindications to BCS. BRCA mutation carriers should consider MT?+?CPM because their risk of contralateral breast cancer is greatly increased. In the U.S., the use of MT for the treatment of primary breast cancer has declined in recent years, while MT?+?CPM rates have increased, and BCS rates have remained relatively stable. The underlying reasons for these trends are not fully understood. Local therapy options should be discussed with each patient in considerable detail, and more studies are needed to better elucidate which factors influence a woman's choice of local therapy following a breast cancer diagnosis.     

Lymphatic mapping and sentinel node biopsy: is the method applicable to patients with colorectal and gastric cancer?

The current status of lymphatic mapping and sentinel node biopsy in the treatment of patients with malignant melanoma and breast cancer is described. The possible use of a similar method in patients with colorectal and gastric cancer is outlined. Peroperative lymphatic mapping and identification of sentinel node(s) in patients with gastrointestinal cancer may lead to modified (tailored) resections and extended lymph node dissections only in those patients in whom the sentinel node(s) contains tumour cells. The method offers the possibility of improving staging by identification of patients with early disseminated disease who should be considered for adjuvant treatment or be included in trials of adjuvant treatment to speed up the breakthrough of more effective adjuvant regimens. Large studies are needed to find out if the sentinel node concept is as valid in gastrointestinal cancer as studies so far have shown that it is for malignant melanoma and breast cancer.     

Prediction of non-SN involvement in patients with SN isolated tumor cells or micrometastases

Sentinel lymph node biopsy has allowed improved staging of the axilla with reduced morbidity in breast cancer patients. However, as with any new technology there are questions as to how to best implement the technique into clinical practice. Changes in the staging system for breast cancer have incorporated sentinel lymph node biopsy findings, resulting in questions as to how to manage the remainder of the axilla when there is low volume disease in the sentinel lymph nodes. The use of the sentinel lymph node to predict additional positive nodes and to direct surgical management of the axilla and adjuvant systemic and radiation therapy is reviewed.     

Lymphatic Mapping and Sentinel Lymph Node Biopsy

The status of the regional nodal basin remains the most important prognostic indicator of survival. The current standard of care for the management of invasive breast cancer is the complete removal of the tumor, with documentation of negative margins by either mastectomy or lumpectomy, followed by complete axillary lymph node dissection. Data suggest that complete lymph node dissection (CLND) provides better local control of the disease and may actually offer a survival advantage. Lymphatic mapping and sentinel lymph node (SLN) biopsy are clearly changing this long-held paradigm and have the potential to change the standard of surgical care of the breast cancer patient. The purpose of this report is to describe the lymphatic mapping experience at the H. Lee Moffitt Cancer Center and Research Institute. From April 1994 to January 1999, 1,147 consecutive breast cancer patients were enrolled in an institutional review board-approved lymphatic mapping protocol. Lymphatic mapping was performed using Tc99m-labeled sulfur colloid and isosulfan blue dye. An SLN was defined as any blue node and/or any hot node with ex vivo radioactivity counts >/=10 times an excised non-SLN or in situ radioactivity counts >/=3 times the background counts. Lymphatic mapping was successful in identifying the SLN in 1,098 of 1,147 (95.7%) cases. In the first 186 patients, all of whom underwent CLND following SLN biopsy, one false-negative biopsy was encountered for a false-negative rate of 0.83%. The method of diagnosis (excisional versus minimally invasive) does not appear to impact on lymphatic mapping. Tumor size, however, is directly related to the probability of axillary lymph node involvement. Advances in technology and the development of minimally invasive surgical techniques have heralded a new era in surgery. Lymphatic mapping and SLN biopsy may actually prove to be a more accurate method of identifying metastases to the axilla by allowing a more focused pathologic examination of the axillary node(s) at highest risk for metastasis. With adequate training, this technique can be readily implemented as a valuable tool in the surgical treatment of breast cancer.     

Sentinel lymph node biopsy examination for breast cancer patients with clinically negative axillary lymph nodes after neoadjuvant chemotherapy

BACKGROUND: The feasibility and accuracy of sentinel lymph node (SLN) biopsy examination for breast cancer patients with clinically node-negative breast cancer after neoadjuvant chemotherapy (NAC) have been investigated under the administration of a radiocolloid imaging agent injected intradermally over a tumor. In addition, conditions that may affect SLN biopsy detection and false-negative rates with respect to clinical tumor response and clinical nodal status before NAC were analyzed. METHODS: Seventy-seven patients with stages II and III breast cancer previously treated with NAC were enrolled in the study. All patients were clinically node negative after NAC. The patients then underwent SLN biopsy examination, which involved a combination of intradermal injection over the tumor of radiocolloid and a subareolar injection of blue dye. This was followed by standard level I/II axillary lymph node dissection. RESULTS: The SLN could be identified in 72 of 77 patients (identification rate, 93.5%). In 69 of 72 patients (95.8%) the SLN accurately predicted the axillary status. Three patients had a false-negative SLN biopsy examination result, resulting in a false-negative rate of 11.1% (3 of 27). The SLN identification rate tended to be higher, although not statistically significantly, among patients who had clinically negative axillary lymph nodes before NAC (97.6%; 41 of 42). This is in comparison with patients who had a positive axillary lymph node before NAC (88.6%; 31 of 35). CONCLUSIONS: The SLN identification rate and false-negative rate were similar to those in nonneoadjuvant studies. The SLN biopsy examination accurately predicted metastatic disease in the axilla of patients with tumor response after NAC and clinical nodal status before NAC. This diagnostic technique, using an intradermal injection of radiocolloid, may provide treatment guidance for patients after NAC.     

Sentinel lymph node biopsy following neoadjuvant chemotherapy: review of the literature and recommendations for use in patient management

Breast cancer is a significant health problem worldwide and is one of the leading causes of cancer-related mortality in women. Preoperative chemotherapy has become the standard of care for patients with locally advanced disease and is being used more frequently in patients with early-stage breast cancer. Sentinel lymph node biopsy has shown great promise in the surgical management of breast cancer patients, but its use following preoperative chemotherapy is yet to be determined. Eleven studies have been published with respect to the accuracy of sentinel lymph node biopsy following neoadjuvant chemotherapy. Ten studies showed favourable results, with the ability to identify a sentinel lymph node in 84% to 98% of cases, and reported false negative rates ranging from 0% to 20%. The accuracy of sentinel lymph node biopsy following preoperative chemotherapy for breast cancer ranges from 88% to 100%, with higher rates when specific techniques and inclusion criteria are applied. The published literature supports the use of sentinel lymph node biopsy for assessment of the axilla in patients with clinically node-negative disease following preoperative chemotherapy.     

Update on Post‐mastectomy Lymphedema Management

Lymphedema is a chronic, progressive condition caused by an imbalance of lymphatic flow. Upper extremity lymphedema has been reported in 16–40% of breast cancer patients following axillary lymph node dissection. Furthermore, lymphedema following sentinel lymph node biopsy alone has been reported in 3.5% of patients. While the disease process is not new, there has been significant progress in the surgical care of lymphedema that can offer alternatives and improvements in management. The purpose of this review is to provide a comprehensive update and overview of the current advances and surgical treatment options for upper extremity lymphedema.     

The role of selective sentinel lymph node dissection in breast cancer

Axillary nodal status continues to be the most statistically significant predictor of survival for patients with breast cancer. Although still providing regional control of axillary disease, axillary dissection is more important as a staging and prognostic tool. Trials are currently underway to investigate the possibility of replacing the current standard treatment of breast cancer, axillary lymph node dissection, with the less invasive lymphatic mapping and sentinel lymph node biopsy. This issue and the technical aspects of sentinel lymph node mapping for breast cancer are discussed in detail in this article.     

Twenty‐five years of change in the management of the axilla in breast cancer

Sentinel lymph node (SLN) biopsy is now used worldwide. It has led to many changes in how we manage the axilla in patients with breast cancer. This review covers four areas of management of the axilla in breast cancer: assessing the clinically node‐negative axilla, managing the clinically negative axilla found to be involved at SLN biopsy, management of the clinically positive axilla in the context of neo‐adjuvant chemotherapy, and treatment of the diseased axilla when radical therapy is required. We suggest that the evidence supports an optimum number of 3 nodes to be removed for accurate SLN biopsy. Breast cancer departments that have not adopted Z0011 patient management cannot continue to avoid change. The evidence is clear: Not all patients with limited axillary nodal disease on sentinel node biopsy need axillary lymph node dissection. For patients who do need axillary treatment, axillary radiotherapy continues to be under‐used. Patients undergoing neo‐adjuvant chemotherapy can be safely assessed by post‐therapy SLN biopsy, with retrieval of any previously biopsied involved nodes by targeted axillary dissection. There is much to support the trend to doing less in the axilla. We are obliged to act based on the available robust clinical trial data in a way that limits morbidity while at the same time does not increase the risk of disease recurrence.     

Sentinel lymph node surgery for staging of breast carcinoma in patients with lymphoproliferative disease

There are few reports confirming the validity of sentinel lymph biopsy in patients with a background of lymphoproliferative disease. We reviewed nine cases of women who underwent sentinel lymph node (SLN) surgery for staging of primary breast cancer with a diagnosis of lymphoproliferative disease. SLN identification rate was 100 per cent with a background of lymphoma in the sentinel node in eight of the nine patients. With a mean follow-up of 37 months, there have been no axillary recurrences in any of these patients. These cases illustrate that SLN staging is feasible and provides axillary staging information in women with breast cancer despite synchronous lymphoproliferative disease.     

Reoperative sentinel lymph node biopsy for ipsilateral breast tumor recurrence after previous axillary lymph node dissection: Report of a case

Sentinel lymph node biopsy has become a standard component of the evaluation of early-stage breast cancer, with a gradually increasing number of indications in this patient population. This report presents the case of a patient who underwent reoperative sentinel lymph node biopsy as part of an evaluation of ipsilateral breast tumor recurrence; she had previously undergone axillary lymph node dissection. Preoperative lymphoscintigraphy showed aberrant lymphatic drainage, and all three sentinel lymph nodes were positive for cancer. Although the optimal management of regional lymph nodes in patients with ipsilateral breast tumor recurrence who have already undergone axillary lymph node dissection has not been established, reoperative sentinel lymph node biopsy in this setting may therefore potentially enable the identification of subclinical, aberrantly located nodal metastasis.     

Non-sentinel lymph node metastases in breast cancer patients with metastatic sentinel nodes

BACKGROUND: Sentinel lymph node biopsy (SLNB) has been shown to be relatively accurate in axillary nodal staging in breast cancer. In more than half of the patients with metastatic sentinel lymph node (SLN), the SLN was the only lymph node involved in the axilla. Methods: A retrospective analysis was performed for those female Chinese breast cancer patients who underwent SLNB. All patients had axillary dissection after SLNB. Those patients with metastatic SLN were selected for analysis. Various tumour factors and SLN factors were analysed to study the association with residual lymph node metastasis. Results: A total of 139 SLNB was performed. The success rate of SLN localization, false negative rate and accuracy were 92%, 9% and 95%, respectively. Fifty-five patients had metastases in the SLN. In 38 patients (69%), SLN was the only lymph node involved in the axilla. Tumours <3 cm, a single metastatic SLN, presence of micro metastases and the absence of extracapsular spread in the SLN were associated with the absence of metastasis in the non-sentinel lymph nodes. Conclusion: Sentinel lymph node biopsy is accurate in the nodal staging of Chinese breast cancer patients. Several factors such as tumour <3 cm, a single metastatic SLN, micro metastases and the absence of extracapsular spread in the sentinel node(s) are useful predictors for the absence of residual disease in the axilla. With further studies and verification, these factors may prove to be important in determining which patients with metastatic SLN will require further axillary treatment. Until such information is available, axillary dissection should be performed when positive sentinel nodes are found.     

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??Standard, controversy and consensus of axillary lymph nodes dissection in breast cancer MA Rong, ZHANG Kai. Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan 250012, China
Corresponding author: MA Rong, E-mail: marongw2000@163.com
Abstract There are many effective methods for breast cancer treatment, surgery is the basis of management of breast cancer. Local control is the symbol of a successful operation. Lymph node status is not only the most important factor in predicting survival in breast cancer, but also the guider of further treatment. Axillary lymph node dissection and pathological examination remains standard management of the axilla and assessment of breast cancer patients. For clinical axillary lymph node metastasis patients, axillary lymph node dissection is critical. Sentinel lymph node biopsy has become standard care for management of the axilla in clinical axillary node-negative early breast cancer patients. It is clear that axillary lymph node dissection should be strongly considered in the management of the sentinel lymph node positive axilla. Omission of axillary lymph node dissection for breast cancer patients with 1-2 positive sentinel lymph nodes is still controversial .     

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??Analysis of related factors of positive results for sentinel lymph node biopsy in patients with early breast cancer LI Yong-tao??NI Duo??YANG Liang??et al. Department of Breast Surgery, Xinjiang Medical University Cancer Institute and Hospital?? Urumqi 830011, China
Corresponding author:ZHU Li-ping, E-mail??doctorzhuliping@yahoo.com.cn
Abstract Objective To explore the factors related to early breast cancer patients underwent sentinel lymph node biopsy. Methods A total of 252 patients with early breast cancer underwent sentinel lymph node biopsy between January 2008 and January 2013 in Xinjiang Medical University Affiliated Tumor Hospital. The clinical pathological characteristics were summarized. The influencing factors of sentinel lymph node biopsy results were analyzed. Results Univariate analysis showed that tumor size??preoperative imaging evaluation, Her-2??Ki-67?? histological grade??molecular typing were correlated with pathologic result of sentinel lymph node biopsy??and the difference was significant statistically. Compared with Lumina type A patients??other early breast cancer molecular subtypes patients underwent sentinel lymph node biopsy were prone to positive results. Multivariate analysis showed that tumor size and Ki-67 expression were correlated with positive results of sentinel lymph node biopsy??and the difference was significant statistically. Conclusion Preoperative pathological data of early breast cancer patients can predict sentinel lymph node biopsy results??which have certain guidance for further treatment of patients.     

Sentinel Lymph Node Biopsy Performed After Neoadjuvant Chemotherapy is Accurate in Patients with Documented Node-Positive Breast Cancer at Presentation

Background The optimal strategy for incorporating lymphatic mapping and sentinel lymph node biopsy into the management of breast cancer patients receiving neoadjuvant chemotherapy remains controversial. Previous studies of sentinel node biopsy performed following neoadjuvant chemotherapy have largely reported on patients whose prechemotherapy, pathologic axillary nodal status was unknown. We report findings using a novel comprehensive approach to axillary management of node-positive-patients receiving neoadjuvant chemotherapy. Methods We evaluated 54 consecutive breast cancer patients with biopsy-proven axillary nodal metastases at the time of diagnosis that underwent lymphatic mapping with nodal biopsy as well as concomitant axillary lymph node dissection after receiving neoadjuvant chemotherapy. All cases were treated at a single comprehensive cancer center between 2001 and 2005. Results The sentinel node identification rate after delivery of neoadjuvant chemotherapy was 98%. Thirty-six patients (66%) had residual axillary metastases (including eight patients that had undergone resection of metastatic sentinel nodes at the time of diagnosis), and in 12 cases (31%) the residual metastatic disease was limited to the sentinel lymph node. The final, post-neoadjuvant chemotherapy sentinel node was falsely negative in three cases (8.6%). The negative final sentinel node accurately identified patients with no residual axillary disease in 17 cases (32%). Conclusions Sentinel lymph node biopsy performed after the delivery of neoadjuvant chemotherapy in patients with documented nodal disease at presentation accurately identified cases that may have been downstaged to node-negative status and can spare this subset of patients (32%) from experiencing the morbidity of an axillary dissection.     

淋巴闪烁显像与乳腺癌前哨淋巴结活检

乳腺癌前哨淋巴结的精确定位是乳腺癌前哨淋巴结活检成功的先决条件之一,明确乳腺淋巴引流途径对乳腺癌前哨淋巴结的准确定位有重要指导意义。术前淋巴闪烁显像可提供个体化的淋巴引流特点,有助于确定前哨淋巴结的位置、数目及是否存在腋窝外前哨淋巴结。现对淋巴闪烁显像在乳腺癌前哨淋巴结活检中的应用现状和存在的问题进行综述。