Total Tumor Load to assist in the decision for additional axillary surgery in the positive sentinel node breast cancer patients

The Total Tumor Load (TTL) concept has been demonstrated to accurately predict the status of the non-sentinel lymph nodes (NSLN) in breast cancer patients. In 2019, our center implemented the TTL cut-off of 30,000 CK19 mRNA copies/μL as sole criterion for deciding on performing ALND. This retrospective, unicentric, study analyzed 87 cT1-3N0 breast cancer patients treated consecutively in a period of two years and aimed to evaluate the performance of this criterion. Secondary objectives included the comparison of the criterion versus our previous Clinical Decision Rule (CDR) versus ACOSOG Z0011 criteria for avoiding an ALND in proportion of patients spared an ALND and in proportion of patients left with a surgically untreated metastasized axilla. An interim analysis revealed new TTL cut-offs for deciding on performing an ALND. The 30,000 CK19 mRNA copies/μL criterion yielded an area under the ROC Curve (AUC) of 0.849, a false positive (FP) rate of 30.1% and a positive predictive value (PPV) of 38.9%. The 30,000 CK19 mRNA copies/μL criterion spared 58.6% of the patients an ALND versus 41.4% with CDR versus 73.6% with Z0011 and left 0.0% patients with a surgically untreated metastasized axilla versus 21.4% with CDR versus 42.9% with Z0011. The new TTL cut-off of 260,000 CK19 mRNA copies/μL for deciding on an ALND yielded an AUC of 0.753, a FP rate of 13.7% and a PPV of 47.4%. This new criterion spared 78.2% of the study sample an ALND and left 35.7% of metastasized axillae surgically untreated. This study emphasizes the need to find a new balance between locoregional control and the morbidity associated with Berg levels I + II axillary lymph node dissection.Corrigendum to “Total Tumor Load to assist in the decision for additional axillary surgery in the positive sentinel node breast cancer patients” [Surg. Oncol. 45 (2022) 101882]: The authors regret . The authors would like to apologise for any inconvenience caused

The impact of the COVID-19 pandemic in the clinical assistance to breast cancer patients

Purpose: We aimed to disclose the impact of the pandemic on breast cancer patients in a specialized breast cancer center (BCC). Methods: A total of 501 breast cancer patients with a first appointment in the BCC from April 1st, 2019 to March 31st, 2021 were divided into four consecutive periods of 6 months. Data from the homologous semesters was compared. Patients with an appointment in the BCC during the study period were eligible for the secondary aim of our study (BCC workload). Results: After the pandemic declaration (period 3), we found a decrease in the referral by screening programs (p = 0.002) and a reduction in the waiting time between the primary care referral and the first BCC appointment (p < 0.001). There were higher rates of palpable axillary nodes (p = 0.001), an increase in N stage 2 and 3 (p = 0.050), and a trend for primary endocrine therapy as the first treatment (p = 0.021) associated with higher rates of complete axillary node dissection (p = 0.030). In period 4, there were more outward diagnoses (p = 0.003) and a higher rate of surgery as the first treatment (p = 0.013). Conclusion: COVID-19 pandemic implied a more advanced nodal stage, which may be related to the delay in breast cancer screening.Open access funding provided by FCT|FCCN (b-on). The authors declare that no funds, grants or other support were received during the preparation of this manuscript

Quality Indicators Compliance and Survival Outcomes in Breast Cancer according to Age in a Certified Center

Simple Summary In this study, we examined how age impacts the outcomes of breast cancer by comparing three age groups: patients 45 years old or younger, patients between 46 and 69 years old, and patients 70 years old or older. Despite similar cancer staging and tumor characteristics among the age groups, the study found that older patients were prone to suboptimal treatment. Older patients also had a lower overall survival rate, but this was not related to cancer itself. Instead, we found that undertreatment was a factor that negatively impacted survival for older women with breast cancer. This study suggests that tumor characteristics and treatment compliance are more important predictors of survival than chronological age. Age as a breast cancer (BC) prognostic factor remains debatable. Several studies have investigated clinicopathological features at different ages, but few make an age group direct comparison. The European Society of Breast Cancer Specialists quality indicators (EUSOMA-QIs) allow a standardized quality assurance of BC diagnosis, treatment, and follow-up. Our objective was to compare clinicopathological features, compliance to EUSOMA-QIs and BC outcomes in three age groups (= 70 years). Data from 1580 patients with staged 0-IV BC from 2015 to 2019 were analyzed. The minimum standard and desirable target on 19 mandatory and 7 recommended QIs were studied. The 5-year relapse rate, overall survival (OS), and BC-specific survival (BCSS) were also evaluated. No meaningful differences in TNM staging and molecular subtyping classification between age groups were found. On the contrary, disparities in QIs compliance were observed: 73.1% in = 70 years women. Despite a unique exception-more invasive G3 tumors in younger patients-no age-specific differences in BC biology impacting outcome were found. Although increased noncompliance in older women, no outcome correlation was observed with QIs noncompliance in any age group. Clinicopathological features and differences in multimodal treatment (not the chronological age) are predictors of lower BCSS.The article publication was supported by National Funds through FCT-Fundacao para a Ciencia e a Tecnologia, I.P., within CINTESIS, R & D Unit (reference UIDB/4255/2020) and within the scope of the project RISE, Associated Laboratory (reference LA/P/0053/2020). ASB, acknowledges FCT-supported funds from UnIC@RISE (UIDB/00051/2020 & UIDP/00051/2020)

Cancro de Mama Masculino: Estudo das Características Clínicas e Biológicas de um Centro de Mama Certificado Português

Introduction: To describe the clinical and biological characteristics of breast carcinoma in men, to compare with the characteristics observed in women and to evaluate the results of the treatment. Methods: A retrospective analysis was conducted involving all male patients with breast carcinoma treated between 2000 and 2022 at the Breast Center of the Unidade Local de Saúde de São João, Porto, Portugal. A 3:1 random selection of women, treated over the same period, was made for comparison. Patients were followed up until 2023 and survival analyses were performed. Results: Thirty-two men and ninety-six women were analyzed. The median age of male patients at diagnosis was 62 years. Compared to women, there was a significantly higher percentage of male patients over the age of 50 years. BRCA2 mutations were identified in a significantly higher percentage of men. We observed larger tumor sizes in male patients (pT2 25.0%), a higher percentage of lymph node metastasis (pN1 40.6%) and a higher percentage of distant metastasis (21.9%) compared with female patients. Significant differences were found in the type of surgery (90.6% of men underwent mastectomy), the use of chemotherapy and axillary lymph node dissection (46.9% and 34.4% of men, respectively). Male patients diagnosed with breast cancer presented a lower cumulative survival than female patients. Age over 50 years and stage IV tumors increased the risk of death. Conclusion: Male patients were diagnosed at an older age with more advanced tumors, which may explain the worse survival rates compared to female patients. Male breast cancer is a significant condition that needs increased awareness, to promote early detection.Introdução: Descrever as características clínicas e biológicas do carcinoma da mama em homens, comparar com as características observadas em mulheres e avaliar os resultados do tratamento. Métodos: Foi realizada uma análise retrospetiva envolvendo todos os doentes do sexo masculino com carcinoma da mama tratados entre 2000 e 2022 no Breast Center da Unidade Local de Saúde de São João, Porto, Portugal. Para comparação, foi feita uma seleção aleatória de mulheres na proporção de 3:1, tratadas no mesmo período. Os doentes foram acompanhados até 2023 e foram realizadas análises de sobrevivência. Resultados: Foram analisados 32 homens e 96 mulheres. A mediana de idade ao diagnóstico nos homens foi de 62 anos. Comparativamente às mulheres, verificou-se uma percentagem significativamente maior de doentes masculinos com mais de 50 anos. As mutações BRCA2 foram identificadas com uma frequência significativamente superior nos homens. Observou-se um maior tamanho tumoral nos doentes masculinos (pT2 25,0%), uma maior percentagem de metástases nos gânglios linfáticos (pN1 40,6%) e uma maior percentagem de metástases à distância (21,9%) em comparação com as doentes femininas. Foram encontradas diferenças significativas no tipo de cirurgia (90,6% dos homens foram submetidos a mastectomia), na utilização de quimioterapia e na dissecção dos gânglios linfáticos axilares (46,9% e 34,4% dos homens, respetivamente). Os doentes masculinos diagnosticados com cancro da mama apresentaram uma menor sobrevivência cumulativa em comparação com as doentes femininas. Idade superior a 50 anos e tumores em estádio IV aumentaram o risco de morte. Conclusão: Os doentes do sexo masculino foram diagnosticados em idades mais avançadas e com tumores mais agressivos, o que pode justificar as taxas de sobrevivência inferiores em comparação com as mulheres. O cancro da mama masculino é uma condição significativa que necessita de maior sensibilização para promover o diagnóstico precoce

Biópsia do Gânglio Linfático Sentinela ou Dissecção Axilar Orientada em Doentes com Cancro da Mama com Gânglios Positivos Submetidas a Terapêutica Neoadjuvante?

Introduction: Targeted axillary dissection (TAD) was designed for nodal staging in cN+ breast cancer (BC) patients submitted to neoadjuvant therapy (NAT). A recent study questioned the need to mark suspicious nodes pre-NAT. Methods: cT1-4 N1-2 BC patients scheduled for NAT were selected for retrospective appraisal. Patients were divided according with SLNB/TAD and ycN0/ycN+ status. Detection rate (DR), concordance rate (CR), predictive factors of successful clipped-node biopsy (CNB), sentinel node (SN) pathological complete response (pCR) and of additional non-sentinel lymph node (NSLN) involvement were assessed. Oncological outcomes were evaluated. Results: The study included 85 consecutive patients. DR was 83.6%, 98.8% and 98.8% for CNB, SLNB and TAD, respectively. CNB did not drive management changes as every CN was sentinel (CR 100.0%). CNB was unsuccessful in 10 patients with 2 (20.0%) re-operated with no additional benefit. Removal of at least 3 SN was associated with successful CNB (p=0.001). Fewer (1 vs 2) suspicious nodes at diagnostic echography and triple-negative or HER2 biological subtype were predictive of SN pCR. Lymph-vascular invasion was predictive of additional NSLN involvement in pSN+ patients (p=0.008). Disease-free survival was worse in ypSN+ (p=0.029) and the only regional recurrence was in an axillary lymph node dissection (ALND) patient. There was no difference in the overall survival between ALND and no-ALND patients (p=0.270). Conclusion: CNB is superfluous if 3 or more SN are retrieved using a dual mapping technique. It is safe to omit ALND if pCR of the SN is achieved. Future studies should assess the need for ALND in ypSN+ patients.Introdução: A disseção axilar orientada (DAO) foi desenvolvida para o estadiamento ganglionar de doentes com cancro de mama com gânglios positivos ao diagnóstico submetidas a terapia neoadjuvante (TNA). Um estudo recente questionou a necessidade de marcar os gânglios suspeitos pré-TNA. Métodos: Doentes com cancro de mama cT1-4 cN1-2 orientadas para TNA foram selecionadas para análise retrospetiva. As doentes foram divididas de acordo com o tipo de cirurgia axilar (biópsia de gânglio sentinela, BGS, vs DAO) e estado pós-TNA (ycN0 versus ycN+). A taxa de deteção (TD), concordância, fatores preditivos de biópsia de gânglio clipado, BGC, com sucesso, fatores preditivos de resposta patológica completa nos gânglios sentinela, GS, e fatores preditivos de metástases adicionais em gânglios não sentinela, GNS, foram pesquisados. Também avaliamos os outcomes oncológicos. Resultados: O estudo incluiu 85 doentes consecutivas. A TD foi de 83,6%, 98,8% e 98,8% para BGC, BGS e DAO, respectivamente. A BGC não motivou alterações no tratamento, uma vez que todos os gânglios clipados eram GS (concordância 100,0%). A BGC não foi bem sucedida em 10 doentes sendo que 2 (20,0%) foram re-operadas sem benefício adicional. A remoção de pelo menos 3 GS foi associada a BGC bem sucedida (p=0,001). Menos (1 vs 2) gânglios suspeitos à ecografia diagnóstica e tipo biológico triplo negativo ou enriquecido em HER2 foram preditivos de resposta patológica completa nos GS. A presença de invasão linfovascular foi preditiva de envolvimento adicional de GNS (p=0,008). A sobrevida livre de doença foi menor em doentes ypGS+ (p=0,029) e a única recorrência regional foi numa doente que realizou esvaziamento ganglionar axilar. Não houve diferença na sobrevida geral entre doentes submetidas versus doentes não submetidas a esvaziamento ganglionar axilar (p=0,270). Conclusão: A BGC é supérflua se pelo menos 3 GS forem obtidos utilizando uma técnica de mapeamento dupla. É seguro omitir o esvaziamento ganglionar axilar se for obtida uma resposta patológica completa nos GS. Estudos futuros devem avaliar a necessidade de esvaziamento ganglionar axilar em doentes ypGS+

Frailty-Independent Undertreatment Negative Impact on Survival in Older Patients With Breast Cancer

Purpose: The management of older adults with breast cancer (BC) remains controversial. The challenging assessment of aging idiosyncrasies and the scarce evidence of therapeutic guidelines can lead to undertreatment. Our goal was to measure undertreatment and assess its impact on survival. Methods: Consecutive patients with BC aged 70 years or older were prospectively enrolled in 2014. Three frailty screening tools (G8, fTRST, and GFI) and two functional status scales (Karnofsky performance score and Eastern Cooperative Oncology Group Performance Status) were applied. Disease characteristics, treatment options, and causes of mortality were recorded during a 5-year follow-up. In addition, we defined undertreatment and correlated its survival impact with frailty. Results: A total of 92 patients were included in the study. The median age was 77 (range 70-94) years. The prevalence of frailty was discordant (G8, 41.9%; fTRST, 74.2%; GFI, 32.3%). Only 47.8% of the patients had a local disease, probably due to a late diagnosis (73.9% based on self-examination). Thirty-three patients (35.6%) died, of which 15 were from BC. We found a considerably high proportion (53.3%) of undertreatment, which had a frailty-independent negative impact on the 5-year survival (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.1-12.5). Additionally, omission of surgery had a frailty-independent negative impact on overall survival (HR, 3.9; 95% CI, 1.9-7.9). Conclusion: BC treatment in older adults should be individualized. More importantly, assessing frailty (not to treat) is essential to be aware of the risk-benefit profile and the patient's well-informed willingness to be treated. Undertreatment in daily practice is frequent and might have a negative impact on survival, as we report.This article publication was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia, I.P., within CINTESIS, R&D Unit (reference UIDB/4255/2020)

Initial experience with targeted axillary dissection after neoadjuvant therapy in breast cancer patients

Background: Targeted axillary dissection (TAD) combines sentinel node biopsy (SNB) with the removal of the previously marked metastatic node. TAD is a promising concept for axillary restaging in node-positive breast cancer patients with pathological complete response (pCR) to neoadjuvant therapy (NAT). We aimed to evaluate TAD feasibility in this context. Methods: A prospective observational study was conducted in biopsy-confirmed cN1 patients. The removal of the clipped node (CN) was guided by intraoperative ultrasound. SNB used indocyanine green and patent blue V dye. If the CN or sentinel lymph nodes (SLN) had any metastatic foci, or the TAD procedure was unsuccessful, the patient underwent axillary lymph node dissection (ALND). Results: Thirty-seven patients were included. TAD and SNB identification rates were 97.3%. Every retrieved CN was also a SLN. At the individual level, SNB identification rate was 89.2% with indocyanine green and 85.5% with patent blue V dye. The CN identification rate was 81.1%, being higher when the CN was localized on the intraoperative ultrasound (84.4% vs 60.0%). Nodal pCR was achieved by 54.1% of our patients and was more frequent in HER2-positive and triple-negative tumors (p = 0.039). Nineteen patients were spared from ALND. Conclusion: TAD with intraoperative ultrasound-guided excision of the CN and SNB with indocyanine green and patent blue V dye is a feasible concept to identify patients without axillary residual disease after NAT, that can be spared from ALND, although the need for marking the biopsied node should be further investigated. © 2022, The Author(s), under exclusive licence to The Japanese Breast Cancer Society

Sentinel Node Total Tumour Load As a Predictive Factor for Non-Sentinel Node Status in Early Breast Cancer Patients – The porttle study

OSNA is a molecular assay for the detection of sentinel node metastasis. TTL emerged as a concept that seems to accurately predict the status of the NSN. Authors tried to confirm this motion. This is a retrospective and multicentric study that analyzed 2164 patients, 579 of whom had positive SN and completion AD. Logistic regression models were performed in order to identify a suitable cutoff to identify patients who benefit from AD. Univariate and multivariate regression analysis showed a relationship between TTL>30000 and the presence of NSN metastasis (OR 2.84, CI 1.99-4.08, p < 0.001). Logistic regression indicated that the cutoff of 30000 copies/μL better discriminates patients with NSN positivity and allows wide use of these criteria. This cutoff value may safely assist clinicians and patients to decide to proceed or not with an AD.info:eu-repo/semantics/publishedVersio

Axillary treatment for operable primary breast cancer

Axillary surgery is an established part of the management of primary breast cancer. It provides staging information to guide adjuvant therapy and potentially local control of axillary disease. Several alternative approaches to axillary surgery are available, most of which aim to spare a proportion of women the morbidity of complete axillary dissection