Florian Ebner1, Achim Wöckel2, Wolfgang Janni3, Rolf Kreienberg3, Lukas Schwentner3, Manfred Wischnewsky4. 1. Department of Gynaecology and Obstetrics, University of Ulm, Prittwitzstraße 43, 89075, Ulm, Germany. florian.ebner@uniklinik-ulm.de. 2. Department of Gynaecology and Obstetrics, University of Würzburg, Josef-Schneider-Str. 4, Haus C15, 97080, Würzburg, Germany. 3. Department of Gynaecology and Obstetrics, University of Ulm, Prittwitzstraße 43, 89075, Ulm, Germany. 4. Department of Mathematics and Computer Science, University of Bremen, Universitätsallee, 28359, Bremen, Germany.
Abstract
PURPOSE: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) for the staging of clinically node-negative breast cancer patients (BCP), demonstrating equivalent survival to ALND while resulting in reduced morbidity. ALND has remained the standard of care for the majority of BCP with clinical axillary metastases or metastases found on SLN biopsy. More recently, it is debated whether ALND could be avoided not only in SLN-negative BCP but also in selected SLN-positive disease or even in all patients. This analysis of pN+ BCP shows the impact of the number of excised lymph nodes on RFS and OAS adjusted by age, tumor size, intrinsic subtypes and adjuvant systemic therapy. METHODS: In this retrospective, multicenter cohort study, we investigated data from 2992 pN+ primary BCP recruited from 17 participating certified breast cancer centers in Germany between 2001 and 2008 within the BRENDA study group. RESULTS: The median number of excised lymph nodes was 17. The number of excised lymph nodes was neither significant for RFS (p = 0.085) nor for OAS (p = 0.285). Adjustments were made for age, tumor size and intrinsic subtypes. The most important significant parameters for RFS were intrinsic subtypes (p < 0.001) and tumor size (p < 0.001) and for OAS age (p < 0.001) and intrinsic subtypes (p < 0.001). There were no significant differences in RFS and OAS in any subgroup stratified by the number of excised lymph nodes. Only for T3/T4 tumors, there is a very small significant advantage of ALND for RFS but not for OAS. After adjusting in addition by guideline adherence of adjuvant systemic therapy (AST), intrinsic subtypes and guideline-adherent AST are the most important significant (p < 0.001) parameters for RFS and OAS. CONCLUSIONS: The number of excised lymph nodes of pN+ BCP neither correlates with RFS nor with OAS. Survival of pN+ BCP is primarily determined by the biology and the guideline-adherent AST based on the corresponding intrinsic subtypes. These results support the omission of a radical ALND at least for pN+ patients scheduled for breast-conserving surgery (not mastectomy), provided they receive whole breast irradiation and guideline-adherent AST.
PURPOSE: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) for the staging of clinically node-negative breast cancerpatients (BCP), demonstrating equivalent survival to ALND while resulting in reduced morbidity. ALND has remained the standard of care for the majority of BCP with clinical axillary metastases or metastases found on SLN biopsy. More recently, it is debated whether ALND could be avoided not only in SLN-negative BCP but also in selected SLN-positive disease or even in all patients. This analysis of pN+ BCP shows the impact of the number of excised lymph nodes on RFS and OAS adjusted by age, tumor size, intrinsic subtypes and adjuvant systemic therapy. METHODS: In this retrospective, multicenter cohort study, we investigated data from 2992 pN+ primary BCP recruited from 17 participating certified breast cancer centers in Germany between 2001 and 2008 within the BRENDA study group. RESULTS: The median number of excised lymph nodes was 17. The number of excised lymph nodes was neither significant for RFS (p = 0.085) nor for OAS (p = 0.285). Adjustments were made for age, tumor size and intrinsic subtypes. The most important significant parameters for RFS were intrinsic subtypes (p < 0.001) and tumor size (p < 0.001) and for OAS age (p < 0.001) and intrinsic subtypes (p < 0.001). There were no significant differences in RFS and OAS in any subgroup stratified by the number of excised lymph nodes. Only for T3/T4 tumors, there is a very small significant advantage of ALND for RFS but not for OAS. After adjusting in addition by guideline adherence of adjuvant systemic therapy (AST), intrinsic subtypes and guideline-adherent AST are the most important significant (p < 0.001) parameters for RFS and OAS. CONCLUSIONS: The number of excised lymph nodes of pN+ BCP neither correlates with RFS nor with OAS. Survival of pN+ BCP is primarily determined by the biology and the guideline-adherent AST based on the corresponding intrinsic subtypes. These results support the omission of a radical ALND at least for pN+ patients scheduled for breast-conserving surgery (not mastectomy), provided they receive whole breast irradiation and guideline-adherent AST.
Authors: Viviana Galimberti; Bernard F Cole; Stefano Zurrida; Giuseppe Viale; Alberto Luini; Paolo Veronesi; Paola Baratella; Camelia Chifu; Manuela Sargenti; Mattia Intra; Oreste Gentilini; Mauro G Mastropasqua; Giovanni Mazzarol; Samuele Massarut; Jean-Rémi Garbay; Janez Zgajnar; Hanne Galatius; Angelo Recalcati; David Littlejohn; Monika Bamert; Marco Colleoni; Karen N Price; Meredith M Regan; Aron Goldhirsch; Alan S Coates; Richard D Gelber; Umberto Veronesi Journal: Lancet Oncol Date: 2013-03-11 Impact factor: 41.316
Authors: John A Olson; Linda M McCall; Peter Beitsch; Pat W Whitworth; Douglas S Reintgen; Peter W Blumencranz; A Marilyn Leitch; Sukamal Saha; Kelly K Hunt; Armando E Giuliano Journal: J Clin Oncol Date: 2008-07-20 Impact factor: 44.544
Authors: Harri Sihto; Johan Lundin; Mikael Lundin; Tiina Lehtimäki; Ari Ristimäki; Kaija Holli; Liisa Sailas; Vesa Kataja; Taina Turpeenniemi-Hujanen; Jorma Isola; Päivi Heikkilä; Heikki Joensuu Journal: Breast Cancer Res Date: 2011-09-13 Impact factor: 6.466
Authors: E H Lips; L Mulder; J J de Ronde; I A M Mandjes; B B Koolen; L F A Wessels; S Rodenhuis; J Wesseling Journal: Breast Cancer Res Treat Date: 2013-07-05 Impact factor: 4.872
Authors: Amelie de Gregorio; Peter Widschwendter; Susanne Albrecht; Nikolaus de Gregorio; Thomas W P Friedl; Jens Huober; Wolfgang Janni; Florian K Ebner Journal: Geburtshilfe Frauenheilkd Date: 2018-11-26 Impact factor: 2.915