Targeted Axillary Dissection of Lymph Nodes after Chemotherapy Improves Staging Accuracy of Node-Positive Breast Cancer

“A new procedure developed by surgeons at The University of Texas MD Anderson Cancer Center improves the accuracy of axillary staging and pathologic evaluation in clinically node-positive breast cancer, and reduces the need for a more invasive procedure with debilitating complications.

“The research, published in the Journal of Clinical Oncology, has changed treatment guidelines at the institution for a select group of breast cancer patients with lymph node metastasis, who will now receive Targeted Axillary Dissection (TAD).

“The TAD procedure involves removing sentinel lymph nodes, as well as additional cancerous lymph nodes found during diagnosis. At the time of diagnosis, those select nodes are clipped for identification during later surgery.”

Melanoma Treatment May Not Always Require Extensive Lymph Node Removal

“Not all melanoma patients may need surgery to remove lymph nodes surrounding their tumor, a new clinical trial has found.

“Cancer doctors usually remove all lymph nodes located near a melanoma tumor — the deadliest type of skin cancer — if they find that the cancer has spread to at least one lymph node.

“But such surgery did not improve survival in a group of nearly 500 patients with very small tumors, according to findings scheduled for presentation Saturday at the annual meeting of the American Society of Clinical Oncology (ASCO), in Chicago.

” ‘I think that our study is the beginning of the end of a general recommendation of complete lymph node dissection for patients with positive sentinel nodes,’ senior study author Dr. Claus Garbe, a professor of dermatology at the University of Tubingen in Germany, said in an ASCO news release.”

Unnecessary Lymph Node Dissections Are Frequently Performed for DCIS

“In a study reported in JAMA Oncology, Coromilas et al found that axillary lymph node evaluation is frequently performed in women with ductal carcinoma in situ (DCIS), and a number of hospital or surgeon characteristics are associated with likelihood of evaluation. As noted by the authors, benefit of axillary evaluation in this setting has not been demonstrated.

“The study involved cross-sectional analysis of medical records in the Perspective database for women with DCIS who underwent breast-conserving surgery or mastectomy from January 2006 to December 2012. A total of 35,591 women aged 18 to 90 years were included in the analysis.

“Overall, 9,011 women (25.3%) underwent mastectomy and 26,580 (74.7%) underwent breast-conserving surgery. Axillary evaluation was performed in 63.0% of those undergoing mastectomy and 17.7% of those undergoing breast-conserving surgery…

“The investigators concluded: ‘Despite guidelines recommending against axillary lymph node evaluation in women with DCIS undergoing [breast-conserving surgery] and uncertainty regarding its use with mastectomy, [sentinel lymph node biopsy] or [axillary lymph node dissection] is performed frequently. Given the additional morbidity and cost of these procedures, alternative surgical approaches or prospective evaluation of the clinical benefit of axillary evaluation in women with DCIS is needed.’ “

Axillary Lymph Node Evaluation Performed Frequently in Ductal Carcinoma in Situ

“Axillary lymph node evaluation is performed frequently in women with ductal carcinoma in situ breast cancer, despite recommendations generally against such an assessment procedure in women with localized cancer undergoing breast-conserving surgery, according to a study published online by JAMA Oncology.

“While axillary lymph node evaluation is the standard of care in the surgical management of invasive breast cancer, a benefit has not been demonstrated in ductal carcinoma in situ (DCIS). For women with invasive breast cancer, sentinel lymph node biopsy (SLNB) replaced full axillary lymph node dissection (ALND). The sentinel nodes are the first few lymph nodes into which a tumor drains.

“Guidelines published by the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend against axillary evaluation in women undergoing breast-conserving surgery (BCS). If invasive cancer were to be discovered SLNB could be performed at a later date. But because a total mastectomy precludes future SLNB, the guidelines suggest SLNB may be appropriate for some high-risk patients because axillary evaluation would be indicated if invasive cancer was found, according to background in the study.”

Surgery Improves Survival in Lung Cancer That Has Not Spread to Lymph Nodes

“Resection resulted in greater overall survival and disease-specific survival rates compared with no surgery for patients with lung cancer, according to study results.

“Dan J. Raz, MD, of the City of Hope Medical Center in Duarte, California, and colleagues analyzed data from 4,111 patients to determine differences in survival for patients who had and did not have surgery for biopsy specimen-proven lymph node-negative carcinoid tumors. The data was from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program for the period between 1988 and 2010.

“The overall survival after 5 years was 93% for patients undergoing lobectomy, 92% for patients undergoing sublobar resection and 69% for patients forgoing surgery (P < .0001, for all). Disease-specific survival rates at 5 years were 97%, 98% and 88%, respectively (P < .0001, for all).

“After controlling for age, sex, race and ethnicity, as well as tumor stage, patients who declined surgery had a greater mortality risk than patients who underwent lobectomy (HR = 2.23; 95% CI, 1.67-2.96).”

Many Mastectomy Patients with Locally Advanced Breast Cancer Do Not Get Postop Radiation

“Breast cancer patients who undergo a mastectomy should receive subsequent radiation treatment if their cancer has spread to four or more nearby lymph nodes, however, according to a new study, only 65 percent of these women are getting the recommended postmastectomy radiation therapy (PMRT). The researchers looked at nearly 57,000 cases of breast cancer, and their study has been published as an ‘article in press’ on the Journal of the American College of Surgeons website in advance of print publication this spring.

“Several studies1 have found that PMRT reduces the risk of breast cancer recurrence and improves survival in patients whose cancer is “locally advanced” with a pathologic stage of N2 or N3 using the American Joint Committee on Cancer (AJCC) staging system.2 The AJCC defines N2 cancer primarily as having spread to between four and nine axillary, or underarm, lymph nodes but no other organs, and N3 disease involves 10 or more axillary lymph nodes.2

” ‘My colleagues and I were quite startled by the finding that a third of patients with N2/N3 disease did not receive PMRT, which is the standard of care,’ said lead author Quyen D. Chu, MD, MBA, FACS, professor of surgery at Louisiana State University (LSU) Health Sciences Center, Shreveport.”

Which Breast Cancer Patients Need Lymph Nodes Removed? Ultrasound Narrows It Down

“Which breast cancer patients need to have underarm lymph nodes removed? Mayo Clinic-led research is narrowing it down. A new study finds that not all women with lymph node-positive breast cancer treated with chemotherapy before surgery need to have all of their underarm nodes taken out. Ultrasound is a useful tool for judging before breast cancer surgery whether chemotherapy eliminated cancer from the underarm lymph nodes, the researchers found. The findings are published in the Journal of Clinical Oncology.

“In the past, when breast cancer was discovered to have spread to the lymph nodes under the arm, surgeons routinely removed all of them. Taking out all of those lymph nodes may cause arm swelling called lymphedema and limit the arm’s range of motion.

“Now, many breast cancer patients receive chemotherapy before surgery. Thanks to improvements in chemotherapy drugs and use of targeted therapy, surgeons are seeing more women whose cancer is eradicated from the lymph nodes by the time they reach the operating room, says lead author Judy C. Boughey, M.D. a breast surgeon at Mayo Clinic in Rochester.”

A Minimally Invasive, High-Performance Intervention for Staging Lung Cancer

Editor’s note: Many lung cancer patients undergo surgery to determine the stage of their cancer. However, surgery is a serious procedure, and a less invasive staging method could help patients avoid complications. A new technique called endoscopic biopsy is less invasive and potentially more accurate than surgical staging.

“Endoscopic biopsy of lymph nodes between the two lungs (mediastinum) is a sensitive and accurate technique that can replace mediastinal surgery for staging lung cancer in patients with potentially resectable tumours. Such were the conclusions of a prospective controlled trial conducted under Dr. Moishe Liberman, a researcher at the CHUM Research Centre (CRCHUM) and an Associate Professor at the Université de Montréal. Moreover, the study showed that it is not necessary to perform surgery to confirm negative results obtained through the endoscopic approach during the pre-operative evaluation of patients with this type of cancer. This discovery has many advantages for both the patients and the health-care system.

“Endoscopic biopsy of the is a minimally invasive, non-surgical intervention that has recently begun to be used to stage lung cancer. The study conducted by Dr. Liberman’s team involved 166 with confirmed or suspected non small cell , and was designed to compare the new approach to surgical staging under general anesthesia, as prescribed in current guidelines for this type of cancer. The findings, which were recently published in Chest journal, the official publication of the American College of Chest Physicians, show that the endoscopy approach is not only sensitive and accurate, but also leads to improved staging compared to surgical staging due to its ability to biopsy lymph nodes and metastases not attainable with surgical techniques.”

Response to Neoadjuvant Therapy Could Help Determine Whether Radiation is Needed

The gist: Depending on how well their neoadjuvant therapy works, some breast cancer patients might benefit from extra treatment with radiation after surgery. A large study looked at the records of 11,995 women treated for stage I, II, or III breast cancer. After neoadjuvant therapy, some women had no more signs of an invasive tumor and no cancer in their lymph nodes. Other patients still had residual cancer. The researchers found that patients whose cancer disappeared before surgery had a lower risk of return of their cancer (recurrence). Doctors could use this information by recommending radiation to patients who still have residual cancer after neoadjuvant treatment. 

“An analysis of data from 12 large clinical trials found that the cancer’s pathologic response to neoadjuvant chemotherapy and tumor subtype are strong predictors of locoregional breast cancer recurrence. According to the researchers, the study showed that these two predictors may be more informative than the tumor stage at diagnosis, which is commonly used in current practice, for evaluating locoregional breast cancer recurrence risk. The findings of this study, the largest of its kind to date, were presented yesterday at a presscast in advance of the 2014 Breast Cancer Symposium (Abstract 61).

“Neoadjuvant and adjuvant chemotherapy provide equivalent survival benefits, but more women typically undergo adjuvant therapy. An important advantage of receiving chemotherapy before surgery is that it can shrink and even eradicate the tumor in the breast and axillary lymph nodes, potentially reducing the need for mastectomy, lymph node removal, and radiation therapy after surgery.

“ ‘We’re finding that receiving neoadjuvant chemotherapy is not only a good option for treating breast cancer and preventing future recurrence in other parts of the body, but it also provides important information on the risk for logocregional recurrence,’ said lead study author Eleftherios Mamounas, MD, MPH, FACS, Medical Director of the Comprehensive Breast Program at the UF Health Cancer Center in Orlando, Florida, and Professor of Surgery at the University of Central Florida. ‘This can potentially help to better identify patients at higher risk for recurrence who may benefit from the addition of radiotherapy and those at low risk who may not need it.’ ”