Search Results (140)

Background: Breast cancer-related lymphedema (BCRL) is one of the most debilitating long-term morbidities after axillary lymph node dissection (ALND), severely impairing quality of life through reduced mobility, independence, and chronic burden, especially in older women. Axillary reverse mapping (ARM) aims to preserve upper extremity lymphatics while maintaining oncologic safety. Evidence in older adult populations with long-term follow-up remains limited. Methods: This retrospective cohort study included 138 female patients (median age 72.5 years) undergoing ALND for invasive breast cancer between January 2018 and January 2024. Patients were divided into ARM (n = 72) and non-ARM (n = 66) groups. BCRL was graded 0–3 according to adapted International Society of Lymphology (ISL) criteria (2013 consensus document). Assessments were performed preoperatively and at 3, 6, 12, 24, 36, 48, and 60 months using blinded circumference measurements and bioimpedance spectroscopy. Results: Baseline characteristics were comparable. Mean follow-up was 46.5 ± 8.8 months. Clinically relevant BCRL (Grades 2–3) was dramatically lower in the ARM group (18.1% vs. 60.6%, p < 0.0001), while subclinical changes (Grade 1) were similar (31.9% vs. 27.3%, p = 0.55). Kaplan–Meier analysis showed significantly better clinically relevant lymphedema-free survival with ARM (log-rank p = 0.00019), with curve separation after 30–40 months—indicating a sustained long-term benefit for quality of life in this frail population. Recurrence rates were comparable (8.3% vs. 10.6%, p = 0.776). Multivariable Cox regression confirmed ARM as an independent protective factor (adjusted HR 0.22, 95% CI 0.11–0.44, p < 0.0001). Conclusions: In older women with breast cancer, ARM significantly reduces clinically relevant lymphedema—a major determinant of long-term quality of life—without compromising oncologic safety. These findings support the routine consideration of ARM during ALND to preserve upper-extremity function, mobility, and independence in this vulnerable population, thereby balancing aggressive oncologic treatment with enhanced long-term quality of life and reduced treatment-related morbidity. Full article

Background: Accurate axillary staging is vital in breast cancer. While dual tracers (Tc-99m + methylene blue dye) are standard for sentinel lymph node biopsy (SLNB), indocyanine green (ICG) offers a cost-effective, safe alternative, especially where nuclear medicine access is limited. Despite growing global use, data from low- and middle-income countries (LMICs) remain scarce. This study presents India’s largest cohort using ICG in SLNB. Methods: We analyzed data from 678 breast cancer patients (2013–2023), of whom 609 underwent SLNB. For analysis, patients were grouped into: isotope + blue dye (control), ICG + blue dye (study group), and ICG alone. False-negative rate (FNR) was evaluated in cases where SLNB was followed by axillary lymph node dissection (ALND). All other outcomes were assessed across the SLNB cohort. Results: In upfront surgery, the study group had an identification rate (IR) of 95.6%, an FNR of 5%, and a median node yield of four, compared to the control group (IR 94.1%, FNR 0%, median of three). Post-neoadjuvant systemic therapy (NAST), the study group outperformed the control (IR 92% vs. 88.2%; both FNR 10%), with higher node yield (three vs. two). From 2021, ICG alone showed 100% IR, 0% FNR (upfront), and 95.6% IR (post-NACT), with high median node retrieval. Overall recurrence was 7.8%; loco-regional recurrence was 3.09%. Conclusions: ICG offers high efficacy, safety, and feasibility as a sole tracer, especially in LMICs. Its integration into SLNB and oncoplastic workflows supports its broader adoption as a practical alternative to radioisotopes in breast cancer surgery. Full article

Background: Axillary lymph node dissection (ALND) remains necessary for selected patients with breast cancer but is associated with lymphatic morbidity, including seroma formation and breast cancer-related lymphedema (BCRL). The Total Sealing Technique (TST) is a technique-centered operative concept that emphasizes systematic sealing of lymphatic and vascular structures during ALND. Methods: This review integrates mechanistic rationale and clinical evidence derived from comparative cohort studies evaluating TST (using advanced bipolar vessel-sealing systems) versus conventional electrocautery (CONV). Key perioperative and long-term outcomes are summarized quantitatively. Results: In a comparative cohort of total mastectomy with ALND, TST significantly reduced total drainage volume (360.5 ± 187.9 vs. 820.6 ± 661.6 mL; p < 0.001) and shortened time to drain removal (4.8 ± 1.3 vs. 6.8 ± 2.1 days; p < 0.001). Postoperative hospital stay was reduced by 3.7 days on average (5.9 ± 1.3 vs. 9.6 ± 3.4 days; p < 0.001). The incidence of seroma decreased from 65.9% to 28.6% (p = 0.001), with fewer aspiration procedures (1.8 vs. 4.6 per patient; p = 0.022). Importantly, long-term follow-up demonstrated a statistically significant reduction in BCRL incidence (2.9% vs. 22.2%; p = 0.028). Operative time and blood loss were not increased. Conclusions: Current single-center data indicate that TST is associated with substantial reductions in postoperative lymphatic morbidity and a statistically significant decrease in BCRL incidence. While independent multicenter validation is warranted, TST represents a reproducible technique-centered approach with meaningful clinical impact in ALND. Full article

Background: Breast cancer is the most common malignancy in women, and sentinel lymph node (SLN) biopsy is essential for accurate nodal staging while avoiding unnecessary axillary dissection. Aim: This study aimed to compare SLN detection rates between two dual-tracer techniques: indocyanine green plus patent blue (ICG + PB) and technetium-99m plus patent blue (99mTc + PB), and to identify factors associated with detection failure for each tracer. Methods: All clinically node-negative breast cancer patients undergoing SLN biopsy between January 2014 and December 2024 were retrospectively evaluated. SLN detection was considered successful when at least one node was identified intraoperatively and confirmed histologically. Multivariate analysis assessed clinical and tumor-related predictors of failure. Results: A total of 269 procedures (258 patients) were analyzed, including 152 ICG + PB and 117 99mTc + PB procedures. Detection rates were comparable between groups (95.4% vs. 94.9%, p = 0.96), with no significant differences in the number of SLNs retrieved or nodal positivity. Multivariate analysis identified increasing patient age as the only independent predictor of PB failure, while no variables were associated with ICG failure. Tumor location in the upper-inner quadrant was the sole predictor of 99mTc failure. Conclusions: ICG + PB and 99mTc + PB provide equivalent and high SLN detection rates. ICG appears to be a robust, radiation-free alternative with no identifiable predictors of failure, supporting its role as an effective mapping strategy, particularly in centers aiming to optimize workflow and patient safety, despite the limited available data on its efficacy. Full article

Background: Tailored axillary surgery (TAS) and axillary reverse mapping (ARM)-guided axillary lymph node dissection (ALND) have been developed to avoid arm lymphedema without increasing a risk of axillary recurrence. However, the oncological feasibility of TAS and ARM-guided ALND remains a crucial consideration. Methods: This article reviewed the oncological feasibility of TAS and ARM-guided ALND based on the current literature. Results: For ALND performed after TAS, additional involved nodes were found in 70% of upfront surgery patients and 60% of neoadjuvant chemotherapy (NAC) patients. ARM nodes were also involved in up to 64.7% of patients after ALND. However, it is not necessary to preserve all ARM nodes and lymphatics because multiple ARM lymphatic pathways exist. Selective preservation of ARM nodes closest to the axillary vein significantly reduced the incidence of involved ARM nodes (from 64.7% to 15.7%). Conclusions: TAS and ARM-guided ALND remain much less radical than ALND. However, residual nodal disease after TAS or ARM-guided ALND does not always develop axillary recurrence. Postoperative irradiation is effective in achieving local control in patients with low-volume (microscopic) residual nodal disease after TAS or ARM-guided ALND. We await the long-term results of prospective randomized clinical trials comparing TAS and ARM-guided ALND with conventional ALND. Full article

Hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR+/HER2−) early breast cancer (EBC) is the most common breast cancer subtype and encompasses a biologically heterogeneous group of tumours. Endocrine therapy (ET) remains the cornerstone of treatment, but decisions regarding chemotherapy, cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, and bone-modifying agents must be tailored to tumour biology, clinical stage, and menopausal status. REAL Canadian Breast Cancer Alliance (REAL Alliance), a pan-Canadian group of breast cancer specialists, convened to develop national clinical consensus recommendations for the systemic management of HR+/HER2− EBC. Using a structured consensus process, 28 recommendations were endorsed, spanning neoadjuvant and adjuvant systemic therapy, surgical considerations, and use of bisphosphonates. Key recommendations include the selective use of neoadjuvant chemotherapy for high-risk or locally advanced disease; genomic testing to guide chemotherapy decisions, particularly in postmenopausal patients; ET as the foundation of adjuvant therapy with intensification using CDK4/6 inhibitors in higher-risk patients; and adjuvant bisphosphonates in postmenopausal women to reduce recurrence and improve survival. These consensus recommendations provide practical, evidence-based guidance to support individualized, patient-centred management of HR+/HER2− EBC in the Canadian context. Full article

Breast cancer-related lymphedema (BCRL) is a chronic and debilitating complication of breast cancer treatment, commonly associated with mastectomy, axillary lymph node dissection, and adjuvant radiation therapy. Though demographic and treatment-related risk factors for BCRL are well documented, emerging evidence suggests that certain genetic polymorphisms may predispose some patients to developing the condition. This review aims to summarize the current research regarding the genetic variants implicated in the development and severity of BCRL. Several candidate genes related to lymphangiogenesis, inflammation, immune cell activation, and lymphatic contractility have been identified. Unfortunately, the existing literature remains limited by the small number of manuscripts, modest sample sizes, and heterogeneous methodologies of available studies. However, further research may shed light on screening options and lead to more personalized treatment strategies to mitigate the incidence and severity of secondary lymphedema. Full article

Background and Objectives: Axillary lymph node (ALN) status is one of the most important prognostic factors in breast cancer. Numerous studies have evaluated less invasive methods for accurate staging. To investigate the diagnostic performance of ultrasound (US), mammography, and ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in predicting axillary lymph node metastasis in breast cancer patients. Materials and Methods: Axillary involvement detected by US, mammography, and ¹⁸F-FDG PET/CT was analyzed in patients who underwent axillary dissection. Preoperatively, 365, 318, and 85 of 557 patients were evaluated with US, mammography, and PET/CT, respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of each imaging modality were calculated. Results: The sensitivity, specificity, PPV, NPV, and accuracy of US were 33.3%, 97.5%, 94.4%, 51.0%, and 57.8%, respectively. False-negative US findings were more frequent in T1 (84.6%) and N1 (76.3%) tumors (p < 0.001 for both). For mammography, these values were 12.9%, 97.74%, 88.89%, 44.67%, and 52.9%, while for ¹⁸F-FDG PET/CT they were 72.5%, 100%, 100%, 67.65%, and 82.5%, respectively. Conclusions: Ultrasound remains useful for evaluating axillary lymph node involvement in advanced breast cancer but is insufficient for early-stage disease. Full article

Background and Objectives: Chest wall recurrence can occur infrequently after mastectomy in breast cancer patients. While wide excision of chest wall recurrence is indicated in operable patients without metastasis elsewhere, management of the axilla remains controversial. We reviewed the literature to determine the role of axillary staging in patients with a preoperative diagnosis of isolated chest wall recurrence. Materials and Methods: A PubMed search was performed for relevant articles dated between 1 January 2000 and 31 December 2024. Only English articles comprising female patients with invasive chest wall recurrence after mastectomy were included. Patients with concomitant metastasis elsewhere, no operation for recurrence and no oncological outcomes were excluded. The outcomes were compared between patients with or without axillary staging during recurrence. Results: A total of 15 studies with 485 eligible patients were analyzed. Of these patients, 242 (49.9%), 182 (37.5%), 53 (10.9%), and 8 (1.6%) patients had sentinel lymph node biopsy (SLNB), no axillary surgery, failed SLNB, and upfront axillary lymph node dissection (ALND), respectively, for restaging. Among operated patients with reported axillary status, 33/231 (14.3%) had metastatic nodes on axillary staging. On follow-up of 38.2 months (range: 10–61.2), 101/485 (20.8%) patients developed a second recurrence, of which 16/447 (3.6%) developed ipsilateral axillary recurrence. Ipsilateral axillary recurrence among patients with and without axillary surgery was 12/182 (6.6%) and 4/265 (1.5%), respectively. Conclusions: Ipsilateral axillary recurrence was low in patients with or without axillary restaging on medium-term follow-up. Due to the heterogeneity of the studies, larger studies with longer follow-up periods are needed to determine the best management for the axilla. Full article

Background/Objectives: Over the last decade, the role and timing of lymph node dissection (LND) in stage III melanoma has shifted from completion LND after a positive sentinel node to a mainly therapeutic procedure for clinically evident nodal disease, driven by randomized evidence showing no survival benefit for routine completion dissection. In this evolving landscape, real-world data on postoperative morbidity—by nodal basin—and on whether complications may influence melanoma-specific survival (MSS) and disease-free survival (DFS) remain limited. We evaluated 90-day postoperative complications after cervical, axillary, and inguino–iliac–obturator LND and explored their association with survival outcomes and treatment era. Methods: We retrospectively analyzed 185 consecutive stage III melanoma patients undergoing LND at a single tertiary center (January 2004–August 2025). Postoperative morbidity was recorded up to 90 days and graded by Clavien–Dindo; given the very low rate of grade > II events, the primary endpoint was a composite of loco-regional surgical field–related complications (persistent seroma, wound dehiscence, surgical-site infection, limb lymphedema). Risk factors were assessed using logistic regression; Firth’s penalized models were applied when appropriate. MSS and DFS were estimated by Kaplan–Meier and explored with Cox models. Results: Median follow-up was 105 months. Surgical field–related complications occurred in 16.8% (31/185), and postoperative mortality was 1.0% (2/185). In multivariable analyses, inguino–iliac–obturator LND was associated with higher odds of overall complications (OR 4.03) and specifically wound dehiscence (OR 4.79) and infection (OR 7.18) versus axillary LND. MSS (n = 179) was 82% at 1 year, 55% at 5 years, and 49% at 10 years; DFS (n = 171) was 63%, 42%, and 41%, respectively. In era-based comparisons, nodal yield decreased in the post–MSLT-II period without clear separation of MSS/DFS curves; exploratory models did not show a consistent independent signal linking postoperative complications to MSS/DFS. Conclusions: In stage III melanoma, LND was associated with low major morbidity, but clinically meaningful locoregional complications persisted—most notably after inguino–iliac–obturator dissection. These data support careful patient selection and basin-tailored strategies to reduce groin morbidity within modern multidisciplinary management. Full article

Background/Objectives: Male breast cancer (MBC) is rare, accounting for less than 1% of all breast cancers. Given its low incidence, male breast cancer (MBC) remains understudied; this 33-year Serbian cohort was assessed for clinicopathological features, therapeutic approaches, genetic alterations, and survival. Methods: We retrospectively analyzed MBC patients diagnosed between 1991 and 2024 at the Institute for Oncology and Radiology of Serbia. Data included demographics, tumor characteristics, and stage, treatment, hormone receptor and HER2 status, Ki-67 index, genetic testing, and survival. Results: A total of 191 patients were identified (median age 66). Family history was negative in 91% and positive in 5.8%. T2 tumors were most frequent (36%), and 96% presented without metastasis. Mastectomy with axillary or sentinel lymph node dissection was performed in 78.5%. Neoadjuvant chemotherapy and radiotherapy were administered in 5.8% and 8.4%. Estrogen receptor positivity was 72%, progesterone receptor 88%, HER2 overexpression 11.0%, and triple-negative tumors 2.6% (40% with axillary involvement). High Ki-67 (≥15%) was recorded in 28.8%. Adjuvant chemotherapy, radiotherapy, and hormone therapy were given in 36%, 58%, and 68%. Among 37 genetically tested patients, seven had pathogenic variants (BRCA1, BRCA2, CHEK2, PALB2). Disease recurrence occurred in 30%. Median follow-up was 53 months. Median disease-free survival (DFS) was 82 months (1-, 2-, 5-, 10-year DFS: 87%, 73%, 57%, 39%). Median overall survival (OS) 131 months (1-, 2-, 5-, 10-year OS: 95%, 93%, 73%, 53%). Conclusions: This long-term cohort highlights the predominance of hormone-receptor positivity, the infrequency of germline mutations, and moderate survival rates, informing patient management and guiding future studies. Full article

Background and Objectives: Sentinel lymph node (LN) biopsy (SLNB) remains to be the standard approach for surgical axillary staging of breast cancer (BC) patients. The aim of this study was to investigate the factors that affect axillary LN involvement in early BC patients. Materials and Methods: Clinically node negative early stage (cT1-2N0) BC patients having undergone breast conserving surgery (BCS) between February 2021 and January 2024 were included. During axillary exploration of all cases, sentinel LNs were excised and reserved for permanent section pathological examination (PS) only. Historical records of patients including clinicopathological features, surgical outcomes as well as pathological results were recorded and analyzed retrospectively. p < 0.05 indicated statistically significant results. Results: The study group consisted of 150 women with cT1-2N0 BC having undergone BCS with a median age of 59 (range: 25–81) years. According to the PS results of the sentinel LNs, the need for reoperation to complete axillary lymph node dissection was present in three (2%) patients. Tumors of the Luminal B subtype were significantly associated with increased sentinel LN positivity (p = 0.014). The risk of sentinel LN metastasis was found to be 5.2 times greater in patients with a Ki-67 ≥ %14 [OR: 5.224 (%95 CI:1.73–15.82, p = 0.003)] and the Ki-67 proliferation index was determined as an independent risk factor. Conclusions: In early-stage BC patients, PS of the excised sentinel LN offers sufficient axillary LN staging. On the other hand, a more careful clinical assessment is necessary for early BC patients harboring tumors with an elevated Ki-67 index and/or tumors of the Luminal B subtype. Full article

Axillary management in early-stage, HER2-negative, hormone receptor-positive breast cancer has undergone major changes in recent years. While axillary lymph node dissection (ALND) was once considered essential for staging and regional control, increasing evidence supports the safety of surgical de-escalation in selected patients. At the same time, systemic therapies such as CDK4/6 and PARP inhibitors rely on nodal burden to define eligibility, raising new challenges in balancing oncologic benefit with treatment-related morbidity. This narrative review summarizes current strategies in axillary management for patients undergoing upfront surgery for HR-positive, HER2-negative early breast cancer. It explores the role of sentinel lymph node biopsy (SLNB), the indications for ALND, the integration of adjuvant systemic therapy, and the emerging role of radiotherapy and predictive tools in guiding individualized treatment decisions. Key randomized trials including Z0011, AMAROS, SENOMAC, SOUND, and INSEMA have demonstrated that omission of ALND is safe in patients with limited nodal involvement, especially when combined with whole-breast or regional nodal radiotherapy. However, trials such as MonarchE and OlympiA have introduced systemic therapies whose indications are closely tied to nodal status, prompting reconsideration of the extent of axillary staging. Advances in imaging and risk stratification tools offer new avenues for safely limiting surgical intervention while preserving access to systemic options. In conclusion, modern axillary management in HR-positive, HER2-negative breast cancer involves navigating the intersection between de-escalated surgery and risk-adapted systemic therapy. Future strategies should prioritize individualized care, incorporating tumor biology, imaging findings, and patient preferences, with multidisciplinary collaboration playing a central role in optimizing outcomes. Full article

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