Search Results (127)

Background and Objectives: The axillary lateral vessel thoracic junction (ALTJ) is a key lymphatic drainage pathway for the arm and a potential structure to spare during regional nodal irradiation (RNI) to reduce lymphedema risk in breast cancer patients. This study aims to demonstrate the feasibility of ALTJ-sparing radiation therapy (RT) planning using Tomotherapy. Materials and Methods: Ten breast cancer patients who had undergone axillary lymph node dissection and whose dissected axillary levels were excluded from the RNI target volume were included. A TomoDirect intensity-modulated RT plan was generated at a dose of 50 Gy in 25 fractions. The dissected axilla was not designated as an organ at risk (OAR) in the original treatment plan. For this study, the axillary lymph node level I (AXL1) and the ALTJ were delineated retrospectively, with the ALTJ considered an OAR in the newly generated study plan. A total of 20 RT plans (10 per group) were statistically compared using various dose-volume parameters. Results: Compared to the original plans, the study plans with ALTJ as an OAR significantly reduced the incidental dose to both the ALTJ (mean: 41.7 ± 3.4 Gy vs. 27.2 ± 1.3 Gy; p = 0.005) and the AXL1 (mean: 43.9 ± 2.0 Gy vs. 37.7 ± 1.9 Gy; p = 0.005). All other dosimetric parameters (V25Gy, V35Gy, V40Gy, Dmin, Dmax) for the ALTJ were also significantly lower in the study plans. This ALTJ sparing was achieved while maintaining all required dose-volume constraints for target volumes and standard OARs such as the lung and heart. Conclusions: This study demonstrates that simply excluding the dissected axilla from the target volume without designating it as an OAR still results in a substantial incidental dose to this region. Our findings also show the feasibility of using Tomotherapy to selectively spare the axilla, particularly the ALTJ subregion of AXL1, which is critical for lymphedema risk in breast cancer patients. Full article

We aimed to develop and internally validate a nomogram to estimate axillary pathological complete response (pCR, ypN0) after neoadjuvant systemic therapy (NAST) in clinically node-positive (cN1–2) breast cancer. In a single-center retrospective cohort of 144 consecutive patients treated with NAST (anti-HER2 as indicated), all underwent standardized pre- and post-NAST 18F-FDG PET/CT and axillary staging (sentinel lymph node biopsy [SLNB], targeted axillary dissection [TAD], or axillary lymph node dissection [ALND]). Axillary pCR occurred in 51.4% (74/144). In a multivariable analysis, independent positive determinants of ypN0 included the triple-negative subtype, Modified PERCIST (SUVmax-based) reduction ≥ 80.70%, pre-NAST tumor-to-axilla SUVmax ratio ≥ 1.21, and residual breast tumor size < 0.5 mm; conversely, conglomerate/matted nodal morphology at diagnosis was inversely associated. The model showed good internal discrimination (AUC 0.857, 95% CI 0.797–0.917) and acceptable calibration (Hosmer–Lemeshow p = 0.425). Exploratory, subtype-restricted signals were observed for inflammatory indices within Luminal B (HER2+) but were not retained in the final model. The resulting nomogram—combining tumor biology, PET/CT response, and pre-NAST nodal features—may support risk stratification for axillary de-escalation after NAST; however, prospective external validation—ideally embedded in ongoing de-escalation frameworks—remains essential before clinical implementation, and the tool should currently be regarded as hypothesis-generating rather than a stand-alone decision aid for routine practice. Full article

Background: Breast cancer-related lymphedema (BCRL) remains a challenging complication for breast cancer survivors. Currently, there are no effective pharmacological options available to address this condition. Emerging research highlights the critical role of inflammation, lymphatic dysfunction, and T-cell activity in the development of BCRL. Tacrolimus, a calcineurin inhibitor, has demonstrated promising results in preclinical studies for reducing inflammation, enhancing lymphatic function, and modulating T-cell activity—key mechanisms implicated in BCRL pathogenesis. This study investigates whether topical tacrolimus ointment can reduce the incidence and severity of BCRL, providing a novel approach to mitigate this debilitating condition. Methods: A parallel, open-label non-randomized controlled multicenter clinical pilot trial was conducted from February 2020 to June 2022. Female participants undergoing axillary lymph node dissection (ALND) were recruited and divided into an intervention group (n = 22) receiving topical tacrolimus 0.1% ointment daily for 12 months and a control group (n = 39). Outcomes included lymphedema diagnosis (primary), arm volume, bioimpedance spectroscopy, quality of life (QOL) scores, and adverse events. Assessments were performed at baseline and at 3, 6, 9, and 12 months. Results: At 12 months, lymphedema was diagnosed in 3 of 18 patients (16.7%) in the intervention group and 4 of 37 patients (10.8%) in the control group (p > 0.05). Mean increase in at-risk arm volume was 80.7 mL in the intervention group versus 116.1 mL in the control group (p > 0.05). Disease-specific quality of life scores worsened in both groups, but scores returned to baseline at 12 months in the intervention group only. Adverse events were mild and manageable, with no serious events reported. Conclusions: While topical tacrolimus did not significantly reduce the incidence of lymphedema, exploratory patterns in symptom onset and quality-of-life measures indicate that further investigation in larger randomized trials may be warranted. Full article

Background: Breast cancer is the most prevalent malignancy among women and the leading cause of cancer-related mortality. Sentinel lymph node biopsy (SLNB) has emerged as an alternative to axillary lymph node dissection (ALND), with the ACOSOG Z0011 trial demonstrating that SLNB alone yields equivalent oncologic outcomes to ALND for patients with 1–2 positive sentinel lymph nodes (SLNs). Objective: This study evaluates the adoption of Z0011 recommendations at the American University of Beirut Medical Center (AUBMC) and their impact on oncologic outcomes. Methods: This retrospective cohort study includes female patients with early-stage breast cancer (T1–T2, N0, M0) who underwent breast-conserving surgery with SLNB at AUBMC, between January 2011 and December 2016. Data were extracted from the institutional breast cancer database, including demographics, tumor characteristics, surgical management, and follow-up outcomes. Results: SLNB alone was adopted, following publication of the Z0011 trial, in 93.4% of patients, with 6.6% undergoing ALND. Among patients with 1–2 positive SLNs, 27.1% underwent completion ALND. The median number of lymph nodes retrieved increased from two to four over the study period. The most common molecular subtypes observed were luminal A (54.1%), characterized by a predominant stage T1 presentation and small tumor sizes (median tumor size, 1.4 cm). Among patients with 1–2 positive SLNs who underwent ALND, no recurrences or metastatic events were reported. The 5-year overall survival (OS) and disease-free survival (DFS) rates were 95.9% and 93.4%, respectively. No notable differences in OS and DFS were observed between the SLNB alone and ALND groups. Conclusions: Our study demonstrates that SLNB alone provides comparable oncologic outcomes to ALND, supporting its safety and effectiveness as an alternative for early-stage breast cancer patients with 1–2 positive SLNs. These findings extend the Z0011 trial’s applicability to diverse populations, reinforcing SLNB as a less invasive, safe alternative to ALND. Full article

Background: Personalized medicine in breast cancer surgery aims to tailor therapeutic strategies not only to tumor biology but also to patient-specific risk factors and surgical outcomes. The Alexis^® retractor, originally designed for abdominal and pelvic surgery, may represent an innovative tool to optimize axillary surgical procedures in selected patients. Its atraumatic design and protective sheath provide enhanced visibility, minimized tissue trauma, and a potentially lower risk of postoperative complications, thus contributing to individualized surgical care. Methods: We conducted a retrospective, single-center study at Fondazione Policlinico Universitario Agostino Gemelli IRCCS between January 2024 and April 2025. Patients undergoing breast-conserving surgery or mastectomy with axillary access were included. The Alexis^® retractor was used for axillary tissue retraction in procedures such as sentinel lymph node biopsy and axillary dissection. Outcomes were assessed at 7, 14, and 30 days postoperatively, with particular focus on complication rates and surgical efficiency. Results: Thirty-seven patients (38 procedures) were analyzed. Seromas occurred in four patients (10.8%) and were managed with ultrasound-guided aspiration. Wound dehiscence occurred in two patients (5.4%) and was treated with advanced dressings. No infections, hemorrhages, or flap necrosis were observed. No systemic complications occurred. Conclusions: The preliminary results suggest that the Alexis^® retractor may support a more personalized approach to axillary surgery in breast cancer, by reducing early postoperative complications and improving surgical ergonomics. Its atraumatic design and protective sheath may help tailor surgical management to individual patient risk profiles, minimizing tissue damage and infection risk while enhancing intraoperative visibility and efficiency. Further prospective, controlled studies with larger cohorts are needed to confirm its role in precision breast surgery and to define which patient subgroups may benefit the most. Full article

Background/Objectives: De-escalation of axillary surgery with sentinel lymph node biopsy (SLNB) has been shown to decrease morbidity in breast cancer patients without affecting oncological outcomes. However, there are very few reports on its applicability in real-world clinical practice, especially in middle-income countries. Methods: A retrospective historical cohort study was conducted, including 787 patients with clinical stage I–IIIA breast cancer treated from 2013 to 2023 at the INC in Colombia. Two groups were analyzed based on the timing of the axillary procedure: patients undergoing SLNB as initial surgery (Upfront SLNB) and those receiving neoadjuvant chemotherapy (Post-NACT SLNB). Results: The overall sentinel lymph node (SLN) identification rate was 99.3%. SLN positivity was 32% in Upfront SLNB and 13.1% in Post-NACT SLNB. Axillary lymph node dissection (ALND) was omitted in 56% of patients with node-positive Upfront SLNB; it was avoided in 86.8% of the Post-NACT group with complete axillary response (ypN0). Regional recurrence rates were 2.33%. In multivariate analysis, the main factors linked to recurrence and mortality were triple-negative and luminal B HER2-negative biological subtypes, histological grade 2, and tumor size ≥ 2 cm. At 60 months of follow-up, 91.4% (95% CI: 88.9–93.9) of patients remained recurrence-free (time-recurrence (TR)), and overall survival (OS) was 96.1% (95% CI: 94.5–97.7), with no differences observed based on the axillary surgical strategy. Conclusions: Sentinel lymph node biopsy (SLNB) is an oncologically safe procedure for patients with early-stage and locally advanced breast cancer with an adequate response to neoadjuvant systemic treatment. Full article

Background and Objectives: Breast cancer-related lymphedema (BCRL) is a complication of axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) may help to decrease lymphedema after ALND by creating lymphatic bypasses. This retrospective single-institution study aimed to compare lymphedema in patients undergoing ALND with and without ILR. Materials and Methods: Bioimpedance and limb measurements determined the presence of BCRL. The categorical data that were collected and analyzed included BMI, comorbidities, BCRL onset, and number of lymphatic bypasses. Pearson’s chi-square test and multivariable logistic regression were performed to identify factors associated with the onset of lymphedema. An odds ratio compared the incidence of BCRL with and without ILR. Results: In total, 186 patients underwent ALND, 44 (24%) with ILR and 142 (76%) without. The mean number of bypasses during ILRs created was 3.54. The odds of developing lymphedema with ILR were 64% lower than for ALND alone. ILR patients who developed BCRL had a mean onset of 543 days post-operatively versus 389 days in the control group. Age, ethnicity, BMI, and bypass amount had no significant influence on lymphedema development. Conclusions: ILR was associated with lower rates of BCRL after ALND. Patients who developed lymphedema despite undergoing ILR did so 8 months later than the controls. Full article

Yin Yang 1 (YY1) is a multifunctional transcription factor implicated in gene regulation, cell proliferation, and survival. While its role in breast cancer (BC) has been explored, its prognostic significance remains controversial. In this study, we evaluated nuclear YY1 expression in 276 BC tissue samples using immunohistochemistry (IHC), tissue microarrays (TMAs), and digital pathology (DP). Nuclear staining was quantified using Aperio ImageScope software, focusing on tumor regions to avoid confounding from stromal or non-tumor tissues. This selective and standardized approach enabled precise quantification of YY1 expression. Our results show elevated median YY1 expression in tumor vs. normal matched tissues (p < 0.001). The optimal cutoff for medium-intensity nuclear YY1 expression in tumor areas for overall survival (OS) was established by a receiver operating characteristic (ROC) curve (AUC = 0.718, 95% CI: 0.587–0.849, p = 0.008). In contrast, ROC curves showed no prognostic impact (AUC and p-value) for YY1 quantification in whole spots (tumor + normal). As a categorical variable, high YY1 expression was correlated with more aggressive BC features, including tumor size > 3 cm (57.7% vs. 44.2% p = 0.037), the triple-negative breast cancer (TNBC) molecular subtype (27.3% vs. 13.9% p = 0.026), and advanced prognostic stage (III) (31.8% vs. 16.7% p = 0.003), while as a continuous variable, YY1 was associated with higher histological (p = 0.003) and nuclear grades (p = 0.022). High YY1 expression was significantly associated with a reduced OS of BC patients, as shown by Kaplan–Meier curves (HR = 2.227, p = 0.002). Since YY1 was significantly enriched in TNBC, we evaluated its prognostic resolution in this subgroup. But, probably due to the small number of patients within this subset, our results were not statistically significant (HR = 1.317, 95% CI: 0.510–3.405, p = 0.566). Next, we performed multivariate Cox regression, confirming YY1 as an independent prognostic factor for overall survival (HR = 1.927, 95% CI: 1.144–3.247, p = 0.014). In order to improve prognostic value, we constructed a mathematical model derived from the multivariate Cox regression results, including YYI, AJCC prognostic stage (STA), and axillary lymph node dissection (ALN), with the following equation: h(t) = h₀(t) × exp (0.695 × YY1 + 1.103 × STA − 0.503 × ALN). ROC analysis of this model showed a better AUC of 0.915, similar sensitivity (83.3%), and much higher specificity (92%). Bioinformatic analysis of public datasets supported these findings in BC, showing YY1 overexpression in multiple cancer types and its association with poor outcomes in BC. These results suggest that YY1 may play a role in tumor progression and serve as a valuable prognostic biomarker in BC. DP combined with molecular data enhanced biomarker accuracy, supporting clinical applications of YY1 in routine diagnostics and personalized therapy. Additionally, developing a combined score based on the modeling of multiple prognostic factors significantly enhanced survival predictions, representing a practical tool for risk stratification and the guidance of therapeutic decisions. Full article

Background. Axillary lymph node biopsy (ALND) has traditionally been considered the gold standard for axillary staging and treatment in clinically node-positive breast cancer patients. However, in patients with nodal disease, the therapeutic benefit of ALND is uncertain. This study, based on a large cohort, aims to evaluate breast cancer-specific survival depending on the extent of axillary surgery in non-metastatic breast cancer using real-world data from the Surveillance, Epidemiology, and End Results (SEER) database. Methods. This retrospective cohort study comprised 825,240 patients diagnosed with breast cancer between 2000 and 2020. Results. ALND was associated with a worse survival outcome in pN0 and pN1 populations (respectively, hazard ratio [HR] 1.16; 95% confidence interval [CI] 1.12–1.2; p < 0.001 and HR 1.38; 95%CI 1.3–1.46; p < 0.001). In pN2 and pN3 populations, there was ~4.3% relative reduction in the hazard of breast cancer-related death for each additional node removed; and higher positive-to-removed lymph node ratio was associated with worse prognosis (HR 3.450; 95%CI 2.99–3.98; p < 0.001). Conclusions. SLNB is associated with significantly better specific survival compared to ALND in negative/low axillary involvement, in higher axillary involvement categories extensive axillary surgery was associated with better prognosis. Full article

Background: Sentinel lymph node biopsy (SLNB) has traditionally been used to stage the axilla in early-stage breast cancer. However, its utility in women over 70 with hormone receptor-positive tumors and negative axillary imaging is increasingly questioned due to limited therapeutic benefit and potential complications. Objectives. To assess the feasibility of omitting SLNB in women aged 70 and older with clinically node-negative, luminal-type breast cancer. Methods: A retrospective analysis was conducted on women aged 70 and above with histologically confirmed invasive breast cancer, negative axillary imaging, and surgery between January 2021 and December 2024. Eligible patients were selected based on normal axillary ultrasound findings. All underwent SLNB. We examined demographics, clinical characteristics, surgical outcomes, and oncological variables such as recurrence and mortality. Results: A total of 149 women underwent surgery, with a mean age of 77.2 (5.24) years. SLNB was positive in 23.5% of cases, but only 6.7% required axillary dissection. Sensitivity and specificity of SLNB declined notably after age 76. No axillary or breast recurrences were reported. Most patients (89.9%) received hormonal therapy, while 11.4% had chemotherapy and 17.5% axillary radiotherapy. Outpatient management was feasible in 87.9% of cases, and no clinically significant lymphedema was observed. Conclusions: Omitting SLNB in women ≥70 years with luminal breast cancer and negative axillary imaging appears safe and does not compromise oncological outcomes. This strategy minimizes surgical risks and enhances quality of life, supporting a more tailored and less invasive approach to axillary management in older patients. Full article

A 51-year-old female presented to the emergency department with vertigo, visual disturbances, involuntary rapid repetitive eye movements, incoordination, and imbalance. Physical examination revealed opsoclonus, myoclonus, and bilateral limb and gait ataxia. Initial workup was negative for intracranial abnormalities, and no abnormalities were noted on blood work or cerebrospinal fluid analysis. Tumor markers were within normal limits. As part of her diagnostic workup, a positron emission tomography (PET) scan was performed, which showed a highly FDG-avid solitary 7 mm left axillary lymph node. Ultrasound-guided percutaneous biopsy revealed metastatic poorly differentiated carcinoma. Histopathological examination could not conclusively distinguish between adenocarcinoma and squamous cell carcinoma. She was diagnosed with seronegative opsoclonus-myoclonus ataxia syndrome of paraneoplastic origin from an occult primary malignancy and started on pulsatile corticosteroids and intravenous immunoglobulin (IVIG), with only moderate symptomatic improvement. Given the anatomic location and immunohistochemical staining pattern of the lymph node, the malignancy was considered as being of primary breast origin. A left axillary lymph node dissection was performed, with 1/12 nodes testing positive for poorly differentiated carcinoma. The patient experienced significant improvement in her neurological symptoms 2–3 days following resection of the solitary malignant lymph node, largely regaining her functional independence. She went on to receive adjuvant radiotherapy to the breast and axilla, as well as adjuvant hormonal therapy. Full article

Breast cancer-related lymphedema (BCRL) is a debilitating complication in breast cancer survivors, with axillary lymph node dissection (ALND) as the greatest independent risk factor. Beyond non-surgical therapies such as complete decongestive and compression therapy, there has been increased interest in immediate microsurgical reconstruction via immediate lymphatic reconstruction (ILR) anastomosing transected lymphatic vessels to a local venous recipient at the time of ALND to mitigate the risks of BCRL. This work provides a scoping review of the landscape surrounding ILR, spanning the updated literature investigating patient outcomes, current accepted best practices, and critical components of surgical techniques for a successful multidisciplinary approach. While limited by heterogeneity in the methods of lymphedema detection, a growing body of work demonstrates the protective effects of ILR. From the pioneering work by Boccardo et al. in 2009 and his introduction of Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) using an intussusception-type end-to-end microanastmosis, to the first randomized control trial by Coriddi in 2023, which importantly employed relative upper extremity volume change as an outcome measure to circumvent the confounding effects of body size and BMI, the current literature supports ILR following ALND in the prevention of BCRL. Collaboration between the oncologic breast surgeon and reconstructive microsurgeon are central to the success of ILR. Critical components for operative success include preoperative and intraoperative lymphatic mapping, preservation of suitable venous targets, availability of supermicrosurgical instruments and sutures, as well as aptitude with a variety of microsurgical anastomotic techniques. Full article

Background and Objectives: Lymphedema is one of the most important morbid complications of modified radical mastectomy (MRM) surgery. It can cause limb movement restriction and psychosocial deformities in some patients. This study aimed to determine and compare the physiological and pathological changes that develop in the axillary venous structures in patients who underwent axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB). Materials and Methods: Patients diagnosed with breast cancer who underwent MRM and breast-conserving surgery (BCS) plus SLNB between 2017 and 2022 were retrospectively examined. The patients’ operation side and contralateral axillary vein diameter and the difference between them, axillary vein flow rate and the difference between them, axillary vein wall thickness and the difference between them, severity of lymphedema, extremity joint restriction examination, and the Nottingham Health Profile (NHP) data were recorded. The relationship of these parameters with the lymph node dissection width and radiotherapy was analyzed. Results: Fifty-eight patients in total were included in the study. In the distribution of lymphedema and lymphedema severity according to ALND groups, there is a statistically significant difference (p < 0.001). A statistically significant difference was determined in the distribution of the difference in the axillary vein blood flow rate and axillary vein diameter difference between the two arms according to the lymph node dissection groups. In the distribution of physical therapy and rehabilitation scales according to the lymph node dissection groups, a significant difference was found in the disabilities of the arm, shoulder, and hand (DASH), shoulder flexion restriction variables, and NHP sleep variables (all p < 0.001). Conclusions: This study demonstrated that ALND leads to more pronounced physiological and pathological changes in axillary venous structures—including increased vein wall thickness, altered flow rates, and diameter differences—compared to SLNB combined with breast-conserving surgery. These changes may be attributed to lymphovenous disruption and postoperative edema. Furthermore, radiotherapy appears to contribute to these changes, though to a lesser extent than ALND. Therefore, SLNB followed by radiotherapy may be preferable in eligible patients to reduce postoperative complications such as lymphedema, joint restriction, and sleep disturbances. Full article

Axillary lymph node dissection (ALND), although increasingly less necessary, is still required in specific breast cancer surgery scenarios, such as cases with a high axillary tumor burden. However, traditional practices are being reassessed due to the associated morbidity and impacts on recovery. This review explores five critical and controversial innovations in ALND: (1) same-day discharge, (2) omission of surgical drains, (3) application of fibrin sealants, (4) minimally invasive techniques, and (5) their collective influence on quality of life (QoL). Same-day discharge has proven to be safe and cost-effective, increasing patient satisfaction without raising complication rates. The omission of drains, while slightly increasing seroma volumes, is linked to shorter hospital stays and fewer complications. The use of fibrin sealants shows promising results in reducing the seroma volume and duration, expediting recovery, although their routine use remains under debate. Minimally invasive and endoscopic techniques reduce morbidity and improve cosmetic outcomes while maintaining oncological safety. Quality of life (QoL) is essential in the evaluation of breast cancer treatment and is evaluated using tools such as EORTC QLQ-C30, QLQ-BR23, and FACT-B, SF-36, which assess physical, emotional, and psychosocial recovery. Innovations in ALND seem to improve QoL by minimizing pain, increasing arm function, and reducing psychological stress, underscoring the importance of patient-centered strategies. Although axillary lymphadenectomy increases arm morbidity compared to sentinel node biopsy, its overall impact on quality of life appears limited, likely due to the overlapping effects of systemic therapies and breast surgery. Full article

Accurate lymph node staging is crucial for both prognosis (in the event of early-stage disease) and treatment (for local control of disease) in patients with breast cancer. Sentinel lymph node biopsy (SLNB) has been studied in numerous international trials, showing that it allows about 70% of axillary lymph node dissection (ALND) to be avoided and thus significantly reduces the morbidity associated with ALND. SLNB represents a necessary step in the diagnostic algorithm for breast neoplasms because the surgical treatment for breast cancer has become progressively less invasive. We present a case of a 70-year-old woman with multicentric breast cancer (MBC) treated by surgery at “Cuza Vodă” Women’s University Hospital, Iassy, Romania. In this case, only the ultrasonography established the diagnosis of left MBC with certainty. Conclusion: The detection of sentinel lymph nodes (SLNs) for MBC must be indicated. In this type of cancer, SLNB is accurate and practical, with sufficient quality control and interdisciplinary collaboration between surgical, nuclear medicine, and pathology units. Lymphoscintigraphy allows the patient to avoid axillary clearance surgery if the sentinel node is negative for metastatic disease. The variability of Ki67, PR, HER2, and ER status supports the idea that all individual foci should be tested in MBC cases to provide the best management and prognosis. Full article