Adjuvant extension of chemotherapy after neoadjuvant therapy may not improve outcome in early-stage breast cancer.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) is equivalent to adjuvant therapy (AdC) in terms of survival and disease-free interval. Many institutions add AdC after NAC and surgery. However, such extended chemotherapy (ExC) is not evidence based. Study aim was to investigate if ExC improved disease-free (DFS) and overall survival (OS). PATIENTS AND METHODS: From 1998 to 2006 356 consecutive patients received NAC (45 pts), AdC (221 pts) or ExC (90 pts). We analysed these 3 groups to determine effects of ExC and to identify patients who might benefit. NAC consisted in 93% of 3-6 cycles of epirubicin+docetaxel, AdC comprised EC+/-taxanes in 72%. Median age in the NAC, AdC, and ExC-groups was 54, 56 and 52 years with follow-up of 30, 57, and 55 months. RESULTS: After NAC, 35% achieved downstaging and 10% pathologic complete remission. Surprisingly ExC seemed to result in reduction of 5-year DFS: compared to 85% and 82% after NAC and AdC, DFS was 61% after ExC (p=0.001). OS was not significantly affected (79, 91, and 78% after NAC, AdC and ExC, p=0.13). In multivariate analysis after correction for age, menopausal status, stage, grading, hormone receptors, her2-status, radiotherapy and surgery, ExC seemed to adversely affect DFS (HR 2.15, p=0.008), loco-regional and distant recurrence-rates (HR 3.0, p=0.03 and HR 2.0, p=0.02). DISCUSSION: In this single-center analysis ExC could not show advantages in terms of DFS and OS. Because multivariate analyses of retrospective data cannot account for all potential biases, these data require confirmation in randomized clinical trials. Until then, extended chemotherapy should be considered carefully. As in previous studies, no differences were found between NAC and AdC groups.

Medium-term follow-up data after sentinel node biopsy alone for breast cancer.

AIMS: In patients with early breast cancer sentinel node biopsy (SNB) proved to be an accurate procedure for axillary staging with significantly reduced morbidity. Medium- and long-term observational studies are needed to establish, whether SNB alone is able to prevent locoregional recurrence without impairing long-term survival. METHODS: 298 patients with invasive breast cancer were subjected to SNB in a prospective audit. Lymphatic mapping was performed with blue dye and radiocolloids. 180 patients had SNB alone (group 1), while 118 subsequently underwent axillary dissection (AD; group 2). In ten patients AD was omitted despite the tumor burden in the SN. Clinical follow-up studies were performed at regular intervals. The mean follow-up time was 47months in group 1 (range 7-90) and 46months in group two (range 1-87months). RESULTS: Sentinel nodes were identified in 286 out of 298 patients (96%). One patient in group 1 developed axillary and simultaneous supraclavicular lymph node recurrence. After AD regional relapses have so far not been observed. One ipsilateral local recurrence was detected in each group. Five patients in group 1 and 15 patients in group 2 developed distant metastases. Three out of six and eight out of nine patients, respectively, died of their advanced disease. All patients with SN tumor infiltration not subjected to AD are alive and well. CONCLUSIONS: Axillary recurrence is rare after sentinel node biopsy alone. Its rate is comparable to that after AD, even in patients with SN micrometastases. These conclusions are confirmed by reports in the literature.

Shoulder-arm morbidity following axillary dissection and sentinel node only biopsy for breast cancer.

AIMS: The purpose of this study was to examine the outcome of shoulder-arm morbidity in patients with breast cancer after various axillary staging procedures. We used a new specific summation score to compare conventional axillary node dissection (AD) and sentinel node only biopsy for postoperative shoulder-arm morbidity. METHODS: Eighty-five patients undergoing conventional AD and 66 patients undergoing sentinel node biopsy were evaluated both subjectively (questionnaire) and objectively (clinical examination) for reduced muscle strength, limited range of motion, lymphedema and pain, dysesthesias and loss of sensitivity. The symptoms elicited were rated by their severity with a single summation score describing all symptoms reported. RESULTS: Subjective evaluation of patients undergoing breast conserving surgery showed a highly significant difference in favor of SNB only (P< or =0.002). On clinical examination the outcome of patients with SNB only was also significantly or highly significantly better (difference in arm volume:P =0.007; difference in arm muscle strength: P=0.016; loss of sensitivity: P<0.001). Of a total score of 100 (=no symptoms), the mean for AD patients was 80.2 vs 92.8 for SNB patients (P=0.001). In patients undergoing total mastectomy the difference was only significant for pain sensations and total scores. CONCLUSIONS: SNB appears to reduce morbidity. Summation scores are a suitable and practicable tool for describing the symptoms associated with axillary surgery.

[Sentinel node biopsy in breast cancer--a minimally invasive procedure for staging of the axilla]. / Die Sentinel Node Biopsy beim Mammakarzinom--ein minimal invasives Verfahren zum exakten Staging der Axilla.

Clinical examinations and imaging methods are not sufficiently reliable for an exact staging of axillary nodes in breast cancer. The sentinel node biopsy concept is a minimally invasive procedure to locate and remove the first and important nodes responsible for draining a tumor. Histologic examinations using immunohistochemical methods permit more accurate staging than hematoxylin and eosin staining alone. Between 4/1997 and 9/1998 a total of 62 patients with 65 breast cancers underwent surgery. The sentinel node procedure with radio tracers and/or blue dye was performed in patients with clinically negative or unclear positive findings in the axilla, with a primary tumor size less than 5 cm; 11 patients had received preoperative chemotherapy. The sentinel node biopsy was followed by axillary dissection in 44 cases. In 58 (89%) cases we found one or more (on an average 1.4) sentinel nodes with radio tracers (in 73%) and/or the blue dye method (in 85%). Axillary nodal status was correctly predicted in 43 of 44 (97.7%) cases; only in one patient was the sentinel node false negative. After preoperative chemotherapy sentinel nodes were found in 9 cases; all of these were predictive. Micrometastases were found in two patients only after cytokeratine staining. Our results concur with the experience of other study groups in regard of sentinel node biopsy. The sentinel node concept is a fascinating method; its importance in breast cancer treatment appears to be comparable with introduction of breast saving surgery in the 1980's.