Identifying Residual Nodal Disease in Sentinel Lymph Node Surgery After Neoadjuvant Chemotherapy for Breast Cancer

Annals of Surgical Oncology -     

Assessment of the performance of the Stanford Online Calculator for the prediction of nonsentinel lymph node metastasis in sentinel lymph node‐positive breast cancer patients

BACKGROUND:

Several models for the prediction of nonsentinel lymph node (NSLN) metastasis in sentinel lymph node (SLN)‐positive breast cancer patients have been proposed. In this study, the authors evaluate the Stanford Online Calculator (SOC), which was designed to predict the likelihood of NSLN metastasis using only 3 variables: primary tumor size, SLN metastasis size, and angiolymphatic invasion status. They compared it with the Mayo and Memorial Sloan‐Kettering Cancer Center (MSKCC) nomograms.

METHODS:

The SOC was used to calculate the probability of NSLN metastasis in 464 breast cancer patients with SLN metastasis who underwent completion axillary lymph node dissection at the Mayo Clinic. The area under the receiver operating characteristic curve (AUC) was calculated for each model. Mean probabilities of patients with and without NSLN metastasis were compared. Patients with ≤5%, ≤10%, and 100% NSLN metastasis probabilities were examined.

RESULTS:

The AUCs of the Stanford, MSKCC, and Mayo models were 0.72, 0.74, and 0.77, respectively (P = .13). The mean Stanford probabilities for patients with and without NSLN metastasis were 0.75 (range, 0.06‐1.0) and 0.50 (range, 0.05‐1.0), respectively (P < .0001). The false‐negative rates for patients with a Stanford probability of ≤5% and ≤10% were 0% and 13%, respectively. Of the patients with a Stanford probability of 100%, 26% did not have NSLN metastasis.

CONCLUSIONS:

Despite using only 3 variables, the Stanford nomogram appears to perform on a par with, but not better than, the MSKCC and Mayo nomograms. Further validation in other patient populations is needed. Cancer 2009. © 2009 American Cancer Society.     

Quality of life after breast cancer surgery: What have we learned and where should we go next?

Treatment options for women with newly diagnosed breast cancer include breast conservation therapy and mastectomy with or without reconstruction, which provide equivalent cancer outcomes in properly selected patients. Although multiple studies have evaluated breast surgery quality‐of‐life outcomes, the data are inconsistent. This factor is important to consider when counseling patients and defining surgical quality measures. J. Surg. Oncol. 2009;99:447–455. © 2009 Wiley‐Liss, Inc.     

The Feasibility of Breast-Conserving Surgery for Multiple Ipsilateral Breast Cancer: An Initial Report from ACOSOG Z11102 (Alliance) Trial

Background

Historically, multiple ipsilateral breast cancer (MIBC) has been a contraindication to breast-conserving therapy (BCT). We report the feasibility of BCT in MIBC from the ACOSOG Z11102 trial [Alliance], a single arm noninferiority trial of BCT for women with two or three sites of malignancy in the ipsilateral breast.

Methods

Women who enrolled preoperatively in ACOSOG Z11102 were evaluated for conversion to mastectomy and need for reoperation to obtain negative margins. Characteristics of women who successfully underwent BCT and those who converted to mastectomy were compared. Factors were examined for association with the need for margin reexcision.

Results

Of 198 patients enrolled preoperatively, 190 (96%) had 2 foci of disease. Median size of the largest tumor focus was 1.5 (range 0.1–7.0) cm; 49 patients (24.8%) had positive nodes. There were 14 women who underwent mastectomy due to positive margins, resulting in a conversion to mastectomy rate of 7.1% (95% confidence interval [CI] 3.9–10.6%). Of 184 patients who successfully completed BCT, 134 completed this in a single operation. Multivariable logistic regression analysis did not identify any factors significantly associated with conversion to mastectomy or need for margin reexcision.

Conclusions

Breast conservation is feasible in MIBC with 67.6% of patients achieving a margin-negative excision in a single operation and 7.1% of patients requiring conversion to mastectomy due to positive margins. No characteristic was identified that significantly altered the risk of conversion to mastectomy or need for reexcision.

ClinicalTrials.gov Identifier

NCT01556243.

     

Impact of Neoadjuvant Chemotherapy on Nodal Disease and Nodal Surgery by Tumor Subtype

Background

Neoadjuvant chemotherapy (NAC) is known to downstage disease in the breast and increase breast conservation. It can also decrease nodal disease extent. We evaluated the impact of NAC on nodal positivity, nodal burden, and nodal surgery by tumor subtype.

Methods

All cT1–4c breast cancers from 2010 to 2014 in the National Cancer Database were evaluated, comparing patients receiving NAC with those undergoing primary surgery (PS). Rates of pathologic node-negative status (pN0) and sentinel lymph node (SLN) surgery (1–5 nodes) were compared using chi-square tests, and adjusted odds ratios (OR) were estimated.

Results

Of 461,549 patients, 36,715 (8.0%) received NAC and 424,834 (92.0%) had PS. In cN0 patients, pN0 rates were higher in NAC compared with PS patients in ER?/HER2+ [93.2 vs. 79.0%, odds ratio (OR) 3.64, p < 0.001], ER?/HER2? (89.9 vs. 85.2%, OR 1.55, p < 0.001), and ER+/HER2+ (84.7 vs. 78.3%, OR 1.54, p < 0.001). Patients with cT2–3, N0 tumors had significantly higher rate of SLN surgery for NAC versus PS for each biologic subtype except for ER+/HER2? tumors, amongst which this was true only for T3 tumors. In cN1–3 patients, pN0 rates after NAC were 61.3% in ER?/HER2+, 47.7% in ER+/HER2+, 47.3% in ER?/HER2?, and 20.2% in ER+/HER2? and SLN surgery was highest in ER?/HER2+ (28.9%, p < 0.05 versus other subtypes).

Conclusion

NAC increases rates of pN0 among cN0 patients compared with PS. Among cN+ patients, 20–61% undergoing NAC convert to pN0 depending on tumor type, with lowest nodal response in ER+/HER2? disease. Use of NAC results in less extensive axillary surgery than in patients treated with PS in both cN0 and cN+ disease.

     

Margin assessment after neoadjuvant chemotherapy in invasive lobular cancer

Background

Optimal surgical management of patients with invasive lobular carcinoma (ILC) who undergo neoadjuvant chemotherapy (NAC) is unknown. We evaluated optimal margin distance and local recurrence (LR) rates for these patients.

Methods

Ninety-three (30%) of 311 patients with ILC received NAC. We examined margin status, residual disease after re-excision, and clinical outcomes.

Results

Margin positivity rates after the final operative procedure were similar between the NAC and surgery-first group (P > .05). The proportion of patients, stratified by margin status, who were taken back for re-excision was not different between the 2 groups, and, similarly, there were no differences in frequency of residual disease (all P > .05). At a median follow-up of 3.1 years, 1 patient in the NAC group and 2 in the surgery-first group developed LR (P = 1.0).

Conclusions

Patients with ILC who have undergone NAC and have margins >1 mm have a low probability of residual disease and LR.     

Simple Prediction Models for Breast Cancer Patients with Solitary Positive Sentinel Nodes––are they Valid?

Abstract:  Identification and prediction of breast cancer patients with metastases isolated to the sentinel lymph node(s) would potentially allow avoidance of axillary dissection and its complications. In this study, we evaluate the performance of two recently published models (Alkhatib et al. and Chagpar et al.) that attempt to predict patients who have isolated sentinel lymph node metastases. Both of these models reported a 5% rate of positive nonsentinel nodes in their respective lowest risk category. From 1997 to 2004, 465 breast cancer patients had a positive sentinel node and underwent axillary lymph node dissection at Mayo Clinic. To evaluate the Alkhatib model, patients were assigned to the following groups: group 1: 1 positive sentinel node and ≥1 negative sentinel node(s); group 2: >1 positive sentinel node and ≥1 negative sentinel node(s); group 3: 1 positive sentinel node and no negative sentinel node(s); group 4: >1 positive sentinel node and no negative sentinel node(s). To evaluate the Chagpar model, patients were assigned a score based on the sum of three factors: tumor size (T1a = 1, T1b or T1c = 2, T2 = 3, and T3 = 4 points), number of positive sentinel nodes (>1 positive sentinel node = 1 point), and ratio of positive/total sentinel nodes (>50% positive = 1 point). The chi-square test was used to compare our results to those of the original studies. For the Alkhatib model, we found that 30% (p < 0.0001) of Group 1 patients had nonsentinel node metastases. Using the Chagpar model, the percentage of patients with a cumulative score of 1 with a nonsentinel node metastasis was 17% (p = 0.19). In our cohort, neither model accurately predicted which patients have a ≤ 5% chance of having nonsentinel metastases. These models are not adequate to identify patients in whom axillary dissection can be omitted.