Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 13/2022

11-08-2022 | Mastectomy | Breast Oncology

Omission of Intraoperative Frozen Section May Reduce Axillary Overtreatment Among Clinically Node-Negative Patients Having Upfront Mastectomy

Authors: Austin D. Williams, MD, MSEd, Atif J. Khan, MD, MS, Varadan Sevilimedu, MBBS, DrPH, Andrea V. Barrio, MD, Monica Morrow, MD, Anita Mamtani, MD

Published in: Annals of Surgical Oncology | Issue 13/2022

Login to get access

Abstract

Background

The growing use of postmastectomy radiation/regional nodal irradiation (PMRT) has resulted in many women receiving both axillary dissection (ALND) and PMRT, increasing lymphedema rates. After developing standardized PMRT criteria, we adopted a policy of ALND omission among cN0 patients with 1–2 positive sentinel nodes (+SLNs) requiring PMRT. We evaluated how often overtreatment with ALND+PMRT was avoided with this approach.

Methods

A retrospective review of a prospectively maintained database was performed beginning 1 year before policy adoption. Intraoperative SLN evaluation was routine pre- and post-policy. ALND was performed for SLN macrometastasis pre-policy, and selectively performed post-policy for 1–2 +SLNs based on PMRT criteria. ALND+PMRT was required for ≥ 3 +SLNs.

Results

From March 1, 2018 to November 30, 2020, a total of 2207 cT1-3N0 patients had mastectomy and 231 had +SLNs; 109 (47%) were treated pre-policy and 122 (53%) post-policy. Most (81%) had 1–2 +SLNs. There was no change in rates of ALND+PMRT (64% pre-policy vs. 58% post-policy, p = 0.09), including in patients with 1–2 +SLNs (61% vs. 51%, p = 0.20). Post-policy, ALND was omitted in 9 (7%) patients recognized intraoperatively as PMRT candidates; avoidable ALND was performed in 40 (33%) patients not identified as PMRT candidates until receipt of final pathology. Overall, had intraoperative SLN evaluation been deferred, only 5.7% of patients would have required completion ALND: 2.2% (n = 49/2207) for ≥ 3 +SLNs and 3.5% (n = 77/2207) for 1–2 +SLNs without PMRT indication.

Conclusions

Most patients could have avoided ALND+PMRT if decision making was deferred until final pathology was available. Selective intraoperative SLN evaluation in cN0 patients having upfront mastectomy may reduce avoidable overtreatment.
Literature
1.
Donker M, van Tienhoven G, Straver ME, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981–22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014;15(12):1303–10.CrossRefPubMedPubMedCentral
2.
Sávolt Á, Péley G, Polgár C, et al. Eight-year follow up result of the OTOASOR trial: the optimal treatment of the axilla—surgery or radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: a randomized, single centre, phase III, non-inferiority trial. Eur J Surg Oncol. 2017;43(4):672–9.CrossRefPubMed
3.
Huo D, Hou N, Jaskowiak N, Winchester DJ, Winchester DP, Yao K. Use of postmastectomy radiotherapy and survival rates for breast cancer patients with T1–T2 and one to three positive lymph nodes. Ann Surg Oncol. 2015;22(13):4295–304.CrossRefPubMed
4.
McGale P, Taylor C, Correa C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383(9935):2127–35.CrossRefPubMed
5.
Ohri N, Sittig MP, Tsai CJ, et al. Trends and variations in postmastectomy radiation therapy for breast cancer in patients with 1 to 3 positive lymph nodes: a National Cancer Data Base analysis. Cancer. 2018;124(3):482–90.CrossRefPubMed
6.
Moossdorff M, Nakhlis F, Hu J, et al. The potential impact of AMAROS on the management of the axilla in patients with clinical T1–2N0 breast cancer undergoing primary total mastectomy. Ann Surg Oncol. 2018;25(9):2612–9.CrossRefPubMed
7.
Weiss A, Lin H, Babiera GV, et al. Evolution in practice patterns of axillary management following mastectomy in patients with 1–2 positive sentinel nodes. Breast Cancer Res Treat. 2019;176(2):435–44.CrossRefPubMed
8.
Gregorowitsch ML, Verkooijen HM, Houweling A, et al. Impact of modern-day axillary treatment on patient reported arm morbidity and physical functioning in breast cancer patients. Radiother Oncol. 2019;131:221–8.CrossRefPubMed
9.
Kantor O, Means J, Grossmith S, et al. Optimizing axillary management in clinical T1–2N0 mastectomy patients with positive sentinel lymph nodes. Ann Surg Oncol. 2022;29(2):972–80.CrossRefPubMed
10.
Tadros AB, Moo TA, Stempel M, Zabor EC, Khan AJ, Morrow M. Axillary management for young women with breast cancer varies between patients electing breast-conservation therapy or mastectomy. Breast Cancer Res Treat. 2020;180(1):197–205.CrossRefPubMedPubMedCentral
11.
Sávolt A, Polgár C, Musonda P, et al. Does the result of completion axillary lymph node dissection influence the recommendation for adjuvant treatment in sentinel lymph node-positive patients? Clin Breast Cancer. 2013;13(5):364–70.CrossRefPubMed
12.
Recht A, Comen EA, Fine RE, et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update. J Clin Oncol. 2016;34(36):4431–42.CrossRefPubMed
13.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology Version 2.2022: Breast Cancer. Available at: www.​nccn.​com. Accessed 1 April 2022.
14.
Jagsi R, Momoh AO, Qi J, et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. J Natl Cancer Inst. 2018;110(2):157–65.CrossRef
15.
Shah C, Kundu N, Arthur D, Vicini F. Radiation therapy following postmastectomy reconstruction: a systematic review. Ann Surg Oncol. 2013;20(4):1313–22.CrossRefPubMed
16.
de Boniface J, Frisell J, Andersson Y, et al. Survival and axillary recurrence following sentinel node-positive breast cancer without completion axillary lymph node dissection: the randomized controlled SENOMAC trial. BMC Cancer. 2017;17(1):379.CrossRefPubMedPubMedCentral
17.
Goyal A, Mann B, Thompson AM. POSNOC: positive sentinel node—adjuvant therapy alone versus adjuvant therapy plus clearance or axillary radiotherapy. Meeting Abstract No. TPS600, 2018 American Society of Clinical Oncology Annual Meeting. J Clin Oncol. 2018;36(15):TPS600.
Metadata
Title
Omission of Intraoperative Frozen Section May Reduce Axillary Overtreatment Among Clinically Node-Negative Patients Having Upfront Mastectomy
Authors
Austin D. Williams, MD, MSEd
Atif J. Khan, MD, MS
Varadan Sevilimedu, MBBS, DrPH
Andrea V. Barrio, MD
Monica Morrow, MD
Anita Mamtani, MD
Publication date
11-08-2022
Publisher
Springer International Publishing
Keyword
Mastectomy
Published in
Annals of Surgical Oncology / Issue 13/2022
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-022-12238-0

Other articles of this Issue 13/2022

Annals of Surgical Oncology 13/2022 Go to the issue

ASO Visual Abstract

ASO Visual Abstract: Surveillance Patterns for Hepatocellular Carcinoma Among Screening-Eligible Patients in the Medicare Population

ASO Visual Abstract

ASO Visual Abstract: Contemporary Trends in Breast Reconstruction Use and Impact on Survival Amongst Women with Inflammatory Breast Cancer

Peritoneal Surface Malignancy

Natural History and Management of Small-Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy

ASO Visual Abstract

ASO Visual Abstract: Very Early Recurrence After Curative-Intent Surgery for Gastric Adenocarcinoma

Gastrointestinal Oncology

Letter to the Editor: Comment on “Prediction of Survival Outcomes Based on Preoperative Clinical Parameters in Gastric Cancer”

ASO Author Reflections

ASO Author Reflections: The Robotic Versus Laparoscopic Approach to Left and Extended Left Hepatectomy