Early stage breast cancer patients undergoing mastectomy Patients undergoing pathologic analysis of sentinel lymph nodes (SLNs) during surgery are likely to be overtreated with both axillary lymph node dissection (ALND) and axillary radiation (AxRT), according to a US study. Researchers warn.
The team examined data from more than 40,000 clinically node-negative women who underwent prior mastectomy. Over 8,000 patients were found to have 1–2 of her SLNs, and intraoperative pathology was performed in approximately one-third.
Intraoperative pathology was associated with a >8-fold increase in the likelihood of performing both ALND and AxRT, much higher than any other factor.
These results “provide evidence that a significant proportion of mastectomy patients with disease confined to up to two SLNs may be overtreated…simply put on the operating table. The pathology results are read and acted on while you are in the field,” said senior author Olga Kantor. She is MD, MS, Associate Program Director of the Breast Surgical Oncology Fellowship Program at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston, Massachusetts.
“Notably, post-operative decisions typically involve a multidisciplinary team that includes a radiation oncologist, which is likely to result in a more integrated and holistic treatment plan.
“This study suggests that surgeons should delay ALND decision-making to avoid overtreating patients,” Kantor emphasized.
The study will be presented at the 24th Annual Meeting of the American Society of Breast Surgeons (ASBrS) on April 28, and was highlighted in the pre-conference press conference.
When asked for comment on the new findings, Sarah L. Blair, M.D., Ph.D., professor and associate chair of surgery at the University of California, San Diego Health, said, “There is a wealth of data on deescalation in patient axillary surgery.” increase. I am undergoing radiation breast conservation. “
Blair, who was not involved in the study, said that while some studies in mastectomy patients had similar oncological results, “the topic remains controversial.” It pointed out.
“This study highlights that surgeons are strongly considering gradual reduction of axillary surgery in mastectomy patients to reduce long-term complications,” she said. Medscape medical news.
“When possible, these patients should be discussed in advance in an interdisciplinary manner,” she stressed.
“When surgeons send lymph nodes for frozen sectioning, as this paper shows, they act informed and Axillary dissection for early stage illness. “
Survey details
At a research press conference, Kantor described several clinical trials, including: bitter We have already “established the safety of axillary observation or AxRT as an alternative to ALND” in patients with clinically node-negative breast cancer found to be positive for 1-2 SLNs.
She said, “While mastectomy patients were included in these trials, they constituted a minority of the population ranging from 9% to 18%, leaving controversy over optimal axillary management in this patient population. ” he said.
Intraoperative pathology assessment, checking the SLN at that time, “helps avoid having to return to the operating room for additional axillary surgery,” Kantor said.
However, acting on results during the procedure “does not allow for interdisciplinary debate” and may result in patients undergoing both ALND and postoperative AxRT.
“This dual approach may result in axillary overtreatment in patients who might otherwise be eligible for axillary radiation alone,” she emphasized.
moreover, A recent survey of 680 surgeons According to the ASBrS, 52% perform routine intraoperative pathologic evaluations of SLNs, and 78% of them say they will perform ALND if the results come back positive.
To investigate the impact of intraoperative pathology assessment on axillary management in mastectomy patients eligible for the AMAROS trial, the team examined data from the US National Cancer Database.
They included cT1-2N0 breast cancer patients who underwent upfront mastectomy in 2018-2019 and were found to be positive for 1-2 SLNs.
They defined intraoperative pathology assessment as:
-
“Not done/not done” if ALND was not performed or was performed after pathologic evaluation.
-
“Completed/Accomplished” if both ALND and pathology evaluation were performed on the same day.
In addition, AxRT was defined as post-mastectomy radiation to the chest wall, including radiation to regional lymph nodes.
Researchers identified 40,467 patients, 20.3% of whom had one or two positive SLNs. Of those, axillary management was 33.2% for observation, 26.6% for ALND, 22.2% for AxRT, and 18.0% for ALND and AxRT.
Overall, 37.2% of patients underwent intraoperative pathology, 62.8% did not, of whom 11.8% later returned to the operating room for ALND.
Patients undergoing intraoperative pathology were more likely to have cT2 disease (48.0% vs. 44.1%), lymphovascular invasion (43.4% vs. 37.1%), two positive SLNs (26.5% vs. 19.2%), and no macrometastases. was also likely. (87.6% vs 64.2%, P. < .001 ).
The rate of ALND plus AxRT was significantly higher in patients who had intraoperative pathology/procedures than in those who had no intraoperative pathology/procedures, 41.0% vs. 4.9% (P. < .001).
In an adjusted multivariate analysis, the combination of ALND and AxRT was significantly associated with intraoperative pathology performed/addressed versus not performed/addressed with an odds ratio of 8.99. (P. < .001).
There was also a significant association between both procedure and macrometastases in SLN, with an odds ratio of 3.38 for micrometastases (P. < .001)、および 2 つのノードの場合は 2.14、3 つのノードの場合は 3.92、> Odds ratio of 5.32 vs. number of total positive SLNs at 1 for 3 nodes (P. < .001 ).
The investigators also found that lobular tumors were associated with the combination of ALND and AxRT on histological analysis.P. < .001).
No funding has been declared. Kanter and Blair have not reported any related financial relationships.
24th ASBrS Annual Meeting: Abstract 1388031. To be published on April 28, 2023.
Follow Medscape for more information. Facebook, twitter, Instagram, and Youtube.
