Breast cancer is one of the most common malignant tumors among women. Typically, the operation of breast cancer should include breast surgery and axillary lymph node surgery since breast cancer first metastasizes to regional axillary lymph nodes. However, postoperative breast cancer-related lymphedema (BCRL) in upper limb is the most common long-term complication. The injury to upper limb lymphatic system contributes to causing the postoperative BCRL. Therefore, precision medicine in the extent of axillary lymph node surgery plays an important role in preventing BCRL which can improve the quality of life in breast cancer patients.
ObjectiveTo explore the factors associated with non-sentinel lymph node (NSLN) metastasis in early breast cancer patients with 1-2 positive sentinel lymph nodes (SLN), seeking the basis for exempting some SLN-positive patients from axillary lymph node dissection. MethodsA total of 299 early breast cancer patients who were diagnosed with positive sentinel lymph node (SLN) biopsy and underwent axillary lymph node dissection at the Affiliated Hospital of Southwest Medical University from January 2019 to April 2023 were selected. Univariate analysis was performed on the clinical and pathological data of patients, and multivariate logistic regression analysis was conducted to identify factors related to axillary non-sentinel lymph node (NSLN) metastasis of patients with SLN positive in early breast cancer. GraphPad Prim 9.0 was used to draw receiver operating characteristic (ROC) curve, and the area under curve (AUC) of ROC was calculated to quantify the predictive value of risk factors. ResultsAmong the 299 breast cancer patients with 1-2 SLN positive, 101 cases (33.78%) were NSLN positive and 198 cases (66.22%) were NSLN negative. Univariate analysis showed that the number of positive SLN, clinical T staging and lymphovascular invasion were related to the metastasis of NSLN (P<0.001). Multivariate logistic regression analysis indicated that having 2 positive SLN [OR=3.601, 95%CI (2.005, 6.470), P<0.001], clinical T2 staging [OR=4.681, 95%CI (2.633, 8.323), P<0.001], and presence lymphovascular invasion [OR=3.781, 95%CI (2.124, 6.730), P<0.001] were risk factors affecting axillary NSLN metastasis. The AUCs of the three risk factors were 0.623 3, 0.702 7 and 0.682 5, respectively, and the AUCs all were greater than 0.6, suggesting that the three risk factors had good predictive ability for NSLN metastasis. ConclusionThe number of positive SLN, clinical T staging, and lymphovascular invasion are related factors affecting NSLN metastasis in early breast cancer patients with positive SLN, and these factors have guiding significance for whether to exempt axillary lymph node dissection.
ObjectiveTo investigate the risk factors of internal mammary lymph node (IMLN) metastasis in breast cancer patients, and to provide evidence for clarifying the TNM stage of tumors and formulating precise treatment plans. Methods The female patients who were admitted to the First Affiliated Hospital of Chongqing Medical University from February 2019 to January 2020 and diagnosed with breast cancer by tissue biopsy pathology based on the new tracer technology were retrospectively collected. All IMLNs were dissected. The associations of IMLN metastasis with patients’ age, tumor size (long diameter), tumor location, tumor grade, estrogen and progesterone receptor statuses, human epidermal growth factor receptor-2 (HER2) status, number of axillary lymph node (ALN) metastasis, and pathological molecular typing were analyzed. ResultsA total of 28 patients were included in this study. The visualization rates in the ALN and IMLN by the new tracer technique were 96.4% (27/28) and 35.7% (10/28), respectively. The pathological results of IMLN biopsy confirmed that 6 patients (The 6 cases were all displaying) had IMLN metastases, with an IMLN metastasis rate of 21.4%. The IMLN metastasis was related to the tumor location and ALN metastasis number of patients with breast cancer (P<0.05). That is to say, when the tumor located in the medial quadrant and the number of ALN metastasis was 4 or more, the IMLN metastasis rates were higher than those in the lateral quadrant (57.1% vs. 10.0%, P=0.028) and in the patients with ALN metastasis number <4 (50.0% vs. 11.1%, P=0.038). It was not found that IMLN metastasis was related to age, tumor size, tumor grade, estrogen and progesterone receptor statuses, HER2 status, and pathological molecular typing of patients with breast cancer (P>0.05). And the area of the receiver operating characteristic curve of the number of ALN metastasis for assessing IMLN metastasis was 0.697. ConclusionFrom the summarized results of cases in this study, the visualization rate of IMLN is higher based on the new tracer technology. When breast cancer locates in the medial quadrant and the number of ALN metastasis is 4 or more, it is recommended to actively carry out IMLN biopsy to clarify the results of pathological diagnosis, so as to accurately assess the tumor stage and formulate appropriate individualized treatment plan.
ObjectiveTo understand the progress of postmastectomy radiotherapy (PMRT) in patients with T1–2N1M0 breast cancer. MethodThe studies and the treatment guidelines relevant to PMRT in the patients with T1–2N1M0 breast cancer in recent years were analyzed and summarized. ResultsThe ability of PMRT to improve the prognosis of patients with T1–2N1M0 breast cancer remained controversial. Owing to the patients with T1–2N1M0 breast cancer were heterogeneous, and the indications for PMRT had not been standardized. With the increasing use of neoadjuvant chemotherapy for early-stage breast cancer, some studies had attempted to formulate decisions about PMRT based on changes in tumor characteristics before and after neoadjuvant chemotherapy, but the findings were currently controversial. ConclusionsWhether PMRT can improve prognosis and decision-making for patients with T1–2N1M0 breast cancer is still controversial. Some ongoing clinical trials may provide some references for the optimal decision-making of PMRT for patients with T1–2N1M0 breast cancer.
Objective To investigate the effect of radiotherapy after neoadjuvant chemotherapy and modified radical surgery on breast cancer specific survival (BCSS) of patients with stage cT1–2N1M0 breast cancer. Methods A total of 917 cT1–2N1M0 stage breast cancer patients treated with neoadjuvant chemotherapy and modified radical surgery from 2010 to 2017 were extracted from the The Surveillance, Epidemiology, and End Results (SEER) database. Of them 720 matched patients were divided into radiotherapy group (n=360) and non-radiotherapy group (n=360) by using propensity score matching (PSM). Cox proportional hazard regression model was used to explore the factors affecting BCSS. Results Patients were all interviewed for a median follow-up of 65 months, and the 5-year BCSS was 91.9% in the radiotherapy group and 93.2% in the non-radiotherapy group, there was no significant difference between the 2 groups (χ2=0.292, P=0.589). The results were the same in patients with no axillary lymph node metastasis, one axillary lymphnode metastasis, two axillary lymph node metastasis and 3 axillary lymph node metastasis group (χ2=0.139, P=0.709; χ2=0.578, P=0.447; χ2=2.617, P=0.106; χ2=0.062, P=0.803). The result of Cox proportional hazard regression analysis showed that, after controlling for Grade grade, time from diagnosis to treatment, efficacy of neoadjuvant chemotherapy, number of positive axillary lymph nodes, molecular typing, and tumor diameter at first diagnosis, radiotherapy had no statistically significant effect on BCSS [HR=1.048, 95%CI (0.704, 1.561), P=0.817]. Conclusions The effect of radiotherapy on the BCSS of patients with stage cT1–2N1M0 breast cancer who have received neoadjuvant chemotherapy and modified radical surgery with 0 to 3 axillary lymph nodes metastases is limited, but whether to undergo radiotherapy should still be determined according to the comprehensive risk of individual tumor patients.
ObjectiveThe study was aimed to further explore risk factors of axillary lymph node metastasis in Luminal A breast cancer and revealed high-risk clinicopathological features.MethodsFrom January 2017 to December 2019, the clinical and pathological data of 237 Luminal A breast cancer patients diagnosed in our hospital were retrospectively analyzed. For the identification of related risk factors of axillary lymph node metastasis in Luminal A breast cancer, χ2 test for univariate analysis and logistic regression model for multivariate analysis were conducted.ResultsAmong the 237 patients with Luminal A breast cancer, 115 patients were associated with lymph node metastasis (48.5%). The univariate analysis indicated that multifocal tumor (P=0.001), p53 mutation (P=0.012), and lymphovascular invasion (P=0.022) were correlated with axillary lymph node metastasis in the Luminal A breast cancer. The multivariate analysis identically showed that multifocal tumor (P=0.009), p53 mutation (P=0.019), and lymphovascular invasion (P=0.021) were independent risk factors of axillary lymph node metastasis.ConclusionMultifocal breast cancer, p53 mutation, and lymphovascular invasion are risk factors of axillary lymph node metastasis in Luminal A breast cancer.
Objective To explore the diagnostic value of contrast-enhanced ultrasonography (CEUS) in axillary and internal mammary lymph node metastasis of invasive breast cancer. Methods A total of 100 patients with invasive breast cancer treated from September 2020 to September 2022 were selected. Preoperative CEUS examination was completed, and the perfusion sequence, enhancement mode and enhancement sequence of lymph nodes were dynamically observed. The CEUS characteristics of metastatic and benign lymph nodes were compared. Using postoperative pathological results as the gold standard, the diagnostic efficacy of CEUS in evaluating lymph node status was analyzed. Results Among the 100 patients, 28 patients were diagnosed with metastatic axillary lymph nodes (ALN) by pathological biopsy. The sensitivity, specificity, accuracy, positive prediction rate and negative prediction rate of CEUS in evaluating ALN status were 71.4%, 87.5%, 83.0%, 69.0% and 88.7%, respectively. In 9 patients, CEUS showed internal mammary lymph node metastasis, and postoperative pathological examination confirmed that 5 patients had internal mammary lymph node metastasis, so the positive predictive rate of CEUS was 55.6%. Conclusion CEUS can evaluate the metastatic status of axillary and internal mammary lymph nodes.
Objective To explore the axillary lymph node dissection (ALND) could be safely exempted in younger breast cancer patients (≤40 years of age) who receiving breast-conserving surgery combined with radiotherapy in metastasis of 1–2 sentinel lymph node (SLN) and T1–T2 stage. Methods The data of pathological diagnosis of invasive breast cancer from 2004 to 2015 in SEER database were extracted. Patients were divided into SLN biopsy group (SLNB group) and ALND group according to axillary treatment. Propensity matching score (PSM) method was used to match and equalize the clinicopathological features between two groups at 1∶1. Multivariate Cox proportional risk model was used to analyze the relationship between axillary management and breast cancer specific survival (BCSS), and stratified analysis was performed according to clinicopathological features. Results A total of 1 236 patients with a median age of 37 years (quartile: 34, 39 years) were included in the analysis, including 418 patients (33.8%) in the SLNB group and 818 patients (66.2%) in the ALND group. The median follow-up period was 82 months (quartile: 44, 121 months), and 111 cases (9.0%) died of breast cancer, including 33 cases (7.9%) in the SLNB group and 78 cases (9.5%) in the ALND group. The cumulative 5-year BCSS of the SLNB group and the ALND group were 90.8% and 93.4%, respectively, and the log-rank test showed no significant difference (χ2=0.70, P=0.401). After PSM, there were 406 cases in both the SLNB group and the ALND group. The cumulative 5-year BCSS rate in the ALND group was 4.1% higher than that in the SLNB group (94.8% vs. 90.7%). Multivariate Cox proportional hazard analysis showed that ALND could further improve BCSS rate in younger breast cancer patients [HR=0.578, 95%CI (0.335, 0.998), P=0.049]. Stratified analyses showed that ALND improved BCSS in patients diagnosed before 2012 or with a character of lymph node macrometastases, histological grade G3/4, ER negative or PR negative. Conclusions It should be cautious to consider the elimination of ALND in the stage T1–T2 younger patients receiving breast-conserving surgery combined with radiotherapy when 1–2 SLNs positive, especially in patients with high degree of malignant tumor biological behavior or high lymph node tumor burden. Further prospective trials are needed to verify the question.
The treatment of breast cancer has fully entered the era of precision therapy. Sentinel lymph node biopsy (SLNB) first replaced axillary lymph node dissection (ALND) in breast cancer patients with negative clinical lymph nodes. Subsequent clinical studies have confirmed the feasibility of using SLNB alone in selected patients with limited lymph node metastasis, which has changed clinical practice. For even lower-risk patients, there is growing evidence supporting the complete omission of axillary surgery. Furthermore, with the emerging evidence from studies on axillary preservation after neoadjuvant therapy in patients from cN+ to cN0 status, it has become possible for these patients to avoid ALND. Even for those with persistent node-positive disease after neoadjuvant therapy, the possibility of avoiding ALND is under clinical investigation. However, it is important to acknowledge the remaining uncertainties in clinical practice. These include the challenges to the conventional concept of radical resection, the balance between axillary surgery and radiotherapy, the implications of de-escalated axillary staging on systemic therapy decisions. Careful evaluation and a balanced integration of surgery, radiotherapy, and systemic therapy are crucial to achieving truly precise de-escalation in axillary management.
ObjectiveTo summarize recent research on the surgical treatment of breast cancer after neoadjuvant chemotherapy (NAC) and to review the impact of NAC on the surgical treatment of breast cancer. MethodRelevant studies on NAC and surgical treatment of breast cancer from both domestic and international sources were reviewed. The literatures were analyzed, summarized, and discussed. ResultsFollowing NAC, the survival outcomes and risk of local recurrence in patients undergoing breast-conserving surgery were similar to those undergoing mastectomy. The using of image-guided minimally invasive biopsy accurately predicted pathological complete remission (pCR) of breast lesions after NAC, potentially allowed some breast cancer patients to undergo only radiation therapy after NAC, thus avoiding breast surgery. For patients with positive axillary lymph nodes, techniques such as dual-tracer, triple-tracer, and targeted axillary lymph node dissection had achieved clinical requirements in terms of detection rate and false-negative rate of sentinel lymph node biopsy, provided a safe alternative to axillary lymph node dissection. ConclusionsNAC is an important component of comprehensive breast cancer treatment. However, there is still controversy regarding the local treatment of the primary breast lesion and axillary lymph nodes after NAC. Currently, individualized treatment based on the specific circumstances of the patient remains the approach in clinical practice, aiming to achieve the optimal control of local recurrence and survival benefits for patients.