BACKGROUND: In the current era of targeted axillary dissection (TAD), there are still cases where axillary lymph node dissection (ALND) is indicated, but histopathological examination confirms the regression of nodal metastases (ypN0). In this situation, ALND may represent undesirable overtreatment. METHODS: A retrospective study at the Comprehensive Cancer Centre was conducted based on a prospectively maintained database. Patients who underwent surgery after neoadjuvant chemotherapy (NAC) between 2020 and 2023 were selected, specifically those for whom ALND was directly indicated after NAC. Subsequently, clinical-pathological characteristics were compared between cases with ypN0 and those with persistent metastases (ypN+). The reasons for indicating ALND in ypN0 cases were extracted from the medical records. RESULTS: ALND was indicated in 118 cases across 117 patients, of which ypN0 was observed in 44 cases (37%). There were significantly more ypN0 cases for inflammatory carcinomas (68%), the non-luminal HER2-positive phenotype (76%), and carcinomas with histopathological regression of the primary tumor (76%) or the persistence of only the non-invasive component of ypTis (67%). Typical reasons for ALND in ypN0 cases included inflammatory carcinoma (n = 13, 29.5%), locally advanced carcinoma (n = 5, 11.4%), occult carcinoma (n = 2, 4.5%), or persistent lymphadenopathy on ultrasound examination after NAC, especially in the tumor phenotypes HER2-positive and triple-negative breast cancer (TNBC) (n = 8, 18.2%). CONCLUSIONS: Through real-world evidence data analysis, subgroups of breast cancer patients treated with NAC were identified who may experience surgical overtreatment in the axilla. These include patients with inflammatory carcinoma, locally advanced carcinoma, occult carcinoma, or patients with persistent lymphadenopathy on US examination after NAC, particularly in the tumor phenotypes HER2-positive and TNBC.

• Klíčová slova
• axillary dissection, breast cancer, neoadjuvant chemotherapy, targeted axillary dissection,
• Publikační typ
• časopisecké články MeSH

Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy ( ± targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.

• Klíčová slova
• Axillary management, Breast cancer, Consensus, Patient journey,
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

OBJECTIVES: The purpose of the study was to investigate the oncological sufficiency of level I axillary dissection for adequate histological nodal staging (ypN) in patients with breast cancer and tumor-involved sentinel lymph node (SLN) after neoadjuvant chemotherapy (NAC). MATERIAL AND METHODS: A prospective multicentre pilot study took place from 01.01.2018 to 30.11.2020 in three mammary centres in the Czech Republic in patients with breast cancer after NAC (NCT03556397). Patients in the cohort with positive histological frozen section of SLN were indicated to separate axillary dissection of levels I and II. RESULTS: Sixty-one patients with breast cancer after NAC were included in the study according to inclusion and exclusion criteria. Twelve patients with breast cancer and tumour involved SLN after NAC were further included in the analysis. Two (16.7%) patients had positive non-sentinel lymph nodes in level I only, one (8.3%) patient had positive lymph nodes in level II only, and seven (58.3%) patients had positive lymph nodes in both levels. Level I axillary dissection in a patient with tumour involved SLN after NAC would have resulted in understaging in five (41.7%) patients, mostly ypN1 instead of ypN2. CONCLUSION: According to our pilot result, level I axillary dissection is not sufficient in terms of adequate histological nodal staging in breast cancer patients after NAC, and level II axillary dissection should not be omitted.

• Klíčová slova
• Breast cancer, axillary dissection, level I axillary dissection, neoadjuvant chemotherapy, sentinel lymph node biopsy,
• Publikační typ
• časopisecké články MeSH

Sentinel lymph node biopsy (SLNB) has become the preferred method of surgical pathological nodal staging of early breast cancer by the end of the nineties. As the most likely sites of metastasis, the SLNs allow a more precise staging, and indeed gross sectioning, step sectioning, immunohistochemistry, and molecular staging methods have been used to disclose metastatic involvement of these lymph nodes. This review summarizes the backgrounds of SLNB, trends in related surgery and pathology. It also gives an insight into European National recommendations related to SLN and divergent daily practices in European pathology departments, on the basis of replies to questionnaires from 84 pathologists from 38 European countries. The questionnaires revealed the post-neoadjuvant setting as an area where a significant minority of pathologists report less confidence in classifying residual nodal involvement into TNM categories. The review also summarizes the neoadjuvant therapy-related aspects of SLNB.

• Klíčová slova
• Breast cancer, Lymph nodes, Neoadjuvant treatment, Questionnaire, Sentinel lymph nodes,
• MeSH
• axila patologie   MeSH
• biopsie sentinelové lymfatické uzliny MeSH
• lidé MeSH
• lymfadenektomie MeSH
• lymfatické metastázy diagnóza   patologie   MeSH
• lymfatické uzliny patologie   MeSH
• nádory prsu * patologie   MeSH
• neoadjuvantní terapie MeSH
• sentinelová uzlina * patologie   MeSH
• staging nádorů MeSH
• Check Tag
• lidé MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

INTRODUCTION: Axillary dissection has little diagnostic and therapeutic benefit in node-positive breast cancer patients in whom axillary disease has been completely eradicated after neoadjuvant chemotherapy (ypN0). We sought to assess the efficacy of an algorithm used for the identification of the ypN0 patient consisting of intraoperative evaluation of sentinel and tattooed (initially positive) lymph nodes. METHODS: Included were T1 and T2 breast cancer patients with 1-3 positive axillary lymph nodes marked with carbon who were referred for neoadjuvant chemotherapy followed by a surgery. Axillary dissection was performed only in the patients with residual axillary disease after neoadjuvant chemotherapy on ultrasound or with metastases described in the sentinel or tattooed lymph nodes either intraoperatively or in the final histology. RESULTS: Out of 62 initially included node-positive patients, 15 (24%) were spared axillary dissection. The detection rate of tattooed lymph nodes after neoadjuvant chemotherapy was 81%. The ypN0 patients were identified with 91% sensitivity and 38% specificity using ultrasound and intraoperative assessment of both sentinel and tattooed lymph node according to the final histology. DISCUSSION/CONCLUSION: Lymph node marking with carbon dye is a useful and cost-effective method, which can be successfully implemented in order to reduce the number of patients undergoing axillary dissection. Low specificity of the presented algorithm was caused mostly by the overestimation of residual axillary disease on ultrasound.

• Klíčová slova
• Axilla, Breast cancer, Carbon, Neoadjuvant chemotherapy, Sentinel lymph node,
• Publikační typ
• časopisecké články MeSH

In the last two decades, surgical methods for axillary staging in breast cancer patients have become less extensive, and full axillary lymph node dissection (ALND) is confined to selected patients. In initially node-positive patients undergoing neoadjuvant chemotherapy, however, the optimal management remains unclear. Current guidelines vary widely, endorsing different strategies. We performed a literature review on axillary staging strategies and their place in international recommendations. This overview defines knowledge gaps associated with specific procedures, summarizes currently ongoing clinical trials that address these unsolved issues, and provides the rationale for further research. While some guidelines have already implemented surgical de-escalation, replacing ALND with, e.g., sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) in cN+ patients converting to clinical node negativity, others recommend ALND. Numerous techniques are in use for tagging lymph node metastasis, but many questions regarding the marking technique, i.e., the optimal time for marker placement and the number of marked nodes, remain unanswered. The optimal number of SLNs to be excised also remains a matter of debate. Data on oncological safety and quality of life following different staging procedures are lacking. These results provide the rationale for the multinational prospective cohort study AXSANA initiated by EUBREAST, which started enrollment in June 2020 and aims at recruiting 3000 patients in 20 countries (NCT04373655; Funded by AGO-B, Claudia von Schilling Foundation for Breast Cancer Research, AWOgyn, EndoMag, Mammotome, and MeritMedical).

• Klíčová slova
• breast cancer, marked lymph node, neoadjuvant therapy, targeted axillary dissection, therapy response,
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH