Axillary de-escalation after neoadjuvant chemotherapy for advanced lymph node involvement in breast cancer.

INTRODUCTION: Sentinel lymph node biopsy reduces morbidity in patients with clinically node-positive breast cancer who achieve axillary pathologic complete response following neoadjuvant therapy (NACT). De-escalation trials primarily addressed cN1 disease, with underrepresentation of cN2 disease. This study evaluates the role of de-escalation in patients with cN2 breast cancer. METHODS: A retrospective analysis of the National Cancer Database (2013-2020) included women over 18 with T1-2 invasive breast cancer and clinical N2 disease who received NACT followed by ALND or SLNB then ALND. The primary outcome was pathologic nodal status post-NACT. RESULTS: Of 5852 cN2 patients treated, 18.15 â€‹% achieved ypN0, 0.97 â€‹% had isolated tumor cells, 19.14 â€‹% were ypN1, 49.64 â€‹% were ypN2, and 12.20 â€‹% were ypN3 following NACT. Achieving ypN0 was associated with pCR in the breast, HER2-positive and triple-negative receptor status, cT2 tumors, and younger age. CONCLUSION: Despite some patients with cN2 disease achieving ypN0, most exhibited residual axillary disease post-NACT. These findings indicate that axillary de-escalation may not be feasible for most patients with cN2 disease, underscoring the importance of meticulous patient selection and assessment.

Nodal Response and Survival After Neoadjuvant Endocrine Therapy in Hormone Receptor-Positive Breast Cancer: 20-Year Experience from a Single Institution.

INTRODUCTION: Axillary response to neoadjuvant endocrine therapy (NET) for the treatment of hormone receptor-positive breast cancer (HR+ BC) is not well-described. This study was designed to characterize nodal response after NET. METHODS: Patients receiving NET followed by curative intent surgery at a comprehensive cancer center from 1998 to 2022 in a prospectively collected registry were included. Patients with distant metastasis were excluded. Primary outcome was nodal pathologic complete response (pCR). Downstaging was defined as post-NET decrease in category. RESULTS: We included 123 patients; the majority were cT2 (n = 59) or cT3 (n = 35), and cN0 (n = 81). Median age was 70.0 years (interquartile range 62.1-76.0). Forty-two patients (34.1%) were clinically node-positive. After NET, 73 (59.8%) underwent breast-conserving surgery. All patients underwent sentinel lymph node biopsy, and 12 (9.8%) underwent completion axillary lymph node dissection. In-breast downstaging was achieved in 51 (41.5%) patients, 1 (0.8%) had breast pCR, and 14 (11.4%) had breast upstaging. Axillary downstaging was achieved in 10 (23.8%), 6 patients (14.3%) had nodal pCR, and 14 (33.3%) had axillary upstaging. At 10-year follow-up, local recurrence was 1% and distant recurrence was 14%, while disease-free survival was 82%. After adjusting for demographic and clinical factors, age was the only characteristic associated with mortality (hazard ratio 1.07, 95% confidence interval 1.01-1.13). CONCLUSIONS: In HR+ BC treated with NET, long-term disease-free survival is good, although nodal pCR is uncommon for cN+ patients. Future studies are needed to elucidate optimal neoadjuvant systemic therapy and to delineate oncologically safe strategies to deescalate axillary management for residual microscopic disease.

The Banaras Convention: A Safe and Reliable Technique for Axillary Dissection by Lateral exposure of Latissimus Dorsi Pedicle.

Breast cancer is rising among women in India. Most of the cases are presented at the locally advanced stage where axillary dissection is needed. In this article, we have described our approach of axillary dissection in the technically challenging high nodal burden axillas.

Preoperative MRI Features Associated With Axillary Nodal Burden and Disease-Free Survival in Patients With Early-Stage Breast Cancer.

OBJECTIVE: To investigate the potential association among preoperative breast MRI features, axillary nodal burden (ANB), and disease-free survival (DFS) in patients with early-stage breast cancer. MATERIALS AND METHODS: We retrospectively reviewed 297 patients with early-stage breast cancer (cT1-2N0M0) who underwent preoperative MRI between December 2016 and December 2018. Based on the number of positive axillary lymph nodes (LNs) determined by postoperative pathology, the patients were divided into high nodal burden (HNB; ≥3 positive LNs) and non-HNB (<3 positive LNs) groups. Univariable and multivariable logistic regression analyses were performed to identify independent risk factors associated with ANB. Predictive efficacy was evaluated using the receiver operating characteristic (ROC) curve and area under the curve (AUC). Univariable and multivariable Cox proportional hazards regression analyses were performed to determine preoperative features associated with DFS. RESULTS: We included 47 and 250 patients in the HNB and non-HNB groups, respectively. Multivariable logistic regression analysis revealed that multifocality/multicentricity (adjusted odds ratio [OR] = 3.905, 95% confidence interval [CI]: 1.685-9.051, P = 0.001) and peritumoral edema (adjusted OR = 3.734, 95% CI: 1.644-8.479, P = 0.002) were independent risk factors for HNB. Combined peritumoral edema and multifocality/multicentricity achieved an AUC of 0.760 (95% CI: 0.707-0.807) for predicting HNB, with a sensitivity and specificity of 83.0% and 63.2%, respectively. During the median follow-up period of 45 months (range, 5-61 months), 26 cases (8.75%) of breast cancer recurrence were observed. Multivariable Cox proportional hazards regression analysis indicated that younger age (adjusted hazard ratio [HR] = 3.166, 95% CI: 1.200-8.352, P = 0.021), larger tumor size (adjusted HR = 4.370, 95% CI: 1.671-11.428, P = 0.002), and multifocality/multicentricity (adjusted HR = 5.059, 95% CI: 2.166-11.818, P < 0.001) were independently associated with DFS. CONCLUSION: Preoperative breast MRI features may be associated with ANB and DFS in patients with early-stage breast cancer.

Who still needs surgical staging of the axilla for invasive breast cancer?

Sentinel lymphadenectomy may be safely omitted for postmenopausal patients with low-risk estrogen-receptor-positive cancers who have a negative pretreatment axillary ultrasound. Surgical staging should still be done for patients who are premenopausal or postmenopausal with high-risk estrogen receptor-positive cancers, for those having neoadjuvant chemotherapy, or those with estrogen-receptor-negative or human epidermal growth factor receptor-positive cancers.

Cords of the Brachial Plexus and Their Branches Positioned Laterally to the Axillary Artery.

The brachial plexus, which supplies the upper limb, extends from the interscalene triangle in the root of the neck to the axilla and is closely related to the subclavian and axillary arteries. Variations in the formation, branching pattern, and relations are profound, and it is generally stated that variant anatomy of the plexus appears to be a rule rather than an exception. In previous studies, it was hypothesized that the anomalous development of the subclavian-axillary stem and the persistence of intersegmental arteries could induce variations in the plexus. In this study, all three cords of the brachial plexus (lateral, medial, and posterior) and their terminal branches are consistently found lateral to the third part of the axillary artery. Most of the studies reported variation in one or the other cord or its branches, but very few studies have reported about all cords lateral to the brachial plexus. The brachial plexus variations are usually also associated with the variations in the branches of the axillary artery, but in this study, no such variation is noted in the branches of the axillary artery. These differences impact the methods of surgery and the application of regional anesthesia. For successful outcomes, it is important to know how neurovascular relationships work, such as where the cords are in relation to the axillary artery. We report an interesting case of all cords and their branches positioned lateral to the axillary artery in the axilla in an adult male cadaver.

Axillary Management Following Neoadjuvant Chemotherapy in Clinically Node-Positive Breast Cancer.

INTRODUCTION: Clinical trial data indicate that omitting axillary lymph node dissection (ALND) is feasible and may reduce morbidity for carefully selected patients with clinically node-positive breast cancer who achieve a pathological complete response (pCR) after neoadjuvant chemotherapy (NCT). However, there remains a need to understand how these findings translate to broader clinical practice and to identify which patients benefit most. This study utilizes a national dataset to assess outcomes in axillary management, aiming to inform best practice in axillary de-escalation. METHODS: The National Cancer Data Base was used to identify women diagnosed with clinically node-positive invasive breast cancer between 2012 to 2020 who received NCT and subsequent ALND. Associations between clinicopathologic factors and axillary pCR were analyzed statistically. RESULTS: Of the 59,791 patients included, 8,827 (14.76%) achieved nodal pCR. Patients with HR-negative and HER2-positive receptor status more frequently underwent ALND instead of sentinel lymph node biopsy. Conversely, patients over the age of 70, those with private or public insurance, and cases classified as ypT1 or ypT2 were less likely to undergo ALND. CONCLUSION: A subset of patients with clinically node-positive breast cancer received ALND despite achieving axillary pCR following NCT. This highlights an opportunity to enhance precision in identifying candidates for axillary de-escalation, potentially reducing morbidity and tailoring treatment more closely to individual patient needs.

An unusual relationship between the axillary artery and brachial plexus in a cross-breed dog cadaver: a proposal for revising the terminology for nerve loops.

In the left axilla of a formalin-embalmed adult female cross-breed dog, an unusual course of the axillary artery in relation to the brachial plexus was noted. A part of the axillary artery after the origin of the subscapular artery coursed through the loop formed by the contributions of the caudal pectoral and lateral thoracic nerves and then between the median and ulnar nerves. Thus, the common trunk for the latter two nerves was missing. Instead, in the proximal brachium, they communicated with each other in both directions. A communicating branch between the cranial and caudal pectoral nerves forming a nerve loop, ansa pectoralis lacked the axillary artery and was instead traversed by the subscapular artery. This is a variation in the relationship between the axillary artery and brachial plexus in the domestic dog and has not been reported in the literature yet. The axillary artery entrapped by the contributions of the caudal and lateral thoracic nerves may be considered as a risk factor for the neuroarterial compressions with non-specific signs and should be taken into account both in surgery and imaging.

Axillary Management: How Much Is Too Much?

PURPOSE OF REVIEW: To review the current management of the axilla in breast cancer. RECENT FINDINGS: Axillary dissection is no longer indicated in patients with clinically node-negative axilla with 1-2 positive sentinel lymph nodes following upfront surgery or in patients with clinically node-negative axilla following neoadjuvant chemotherapy. Breast cancer has evolved away from routine axillary clearance to the less invasive sentinel lymph node biopsy to now complete omission of axillary sampling in select patients. We will review the most salient evidence that has shaped these practice changes over the last three decades. Current practice controversies are especially relevant for elderly populations and those receiving neoadjuvant therapy. Ongoing clinical trials will provide data to further guide breast cancer surgical management.

Lichen Planus Pigmentosus Inversus: A Case Report of a Man Presenting With a Pigmented Lichenoid Axillary Inverse Dermatosis (PLAID).

Lichen planus pigmentosus is an uncommon subtype of lichen planus and lichen planus pigmentosus inversus is a rare variant of lichen planus pigmentosus. Lichen planus pigmentosus inversus typically presents as hyperpigmented patches or plaques, particularly in the intertriginous areas such as the axillae, the groin and inguinal folds, and in the submammary region. In some patients with lichen planus pigmentosus inversus, the condition can present as a pigmented lichenoid axillary inverse dermatosis (PLAID) when the lesions are in the axillae. A 49-year-old Hispanic man who had hyperlipidemia and diabetes mellitus developed lichen planus pigmentosus inversus and presented with a PLAID. Skin biopsies established the diagnosis of lichen planus pigmentosus inversus. The clinical differential diagnosis of lichen planus pigmentosus inversus includes inherited disorders, primary cutaneous dermatoses, acquired dyschromias, and reactions to topical or systemic medications. Friction in intertriginous areas has been related to the development of lichen planus pigmentosus inversus. Factors that can precipitate lichen planus pigmentosus inversus include not only topical exposure to almond oil, amala oil, cold and cosmetic creams, henna, and paraphenyldiamine but also either topical contact or consumption of mustard oil and nickel. Lichen planus pigmentosus inversus can be associated with autoimmune conditions (hypothyroidism), endocrinopathies (diabetes mellitus), and hyperlipidemia. The dyschromia found in patients with lichen planus pigmentosus inversus is frequently refractory to treatment. Initial management includes removal of potential disease triggers such as eliminating tight clothing to stop friction with the adjacent skin. Topical corticosteroids do not result in improvement; however, topical calcineurin inhibitors such as tacrolimus have been reported to be efficacious. In conclusion, inverse lichen planus and lichen planus pigmentosus inversus can present with a PLAID; whereas topical corticosteroids may be helpful to resolve inverse lichen planus lesions, topical tacrolimus may be useful to improve the dyschromia in lichen planus pigmentosus inversus.

Benign Phyllodes Tumor of Axillary Tail USG and Elastography Evaluation with Histopathological Correlation.

The axillary tail, also known as spencer's tail or axillary process, is a continuation of tissue from the upper lateral quadrant of the breast that travels into the axilla through a foramen of Langer in the deep fascia. Axillary inflammation or lump is a typical clinical symptom that necessitates imaging evaluation. Since the axilla consists of lymph nodes as well as nonlymphatic tissue such as accessory breast tissue, skin, fat, muscles, nerves, and blood vessels, it has a wide variety of differential diagnoses. The radiologists should be well acquainted with axillary anatomy and imaging aspects of various axillary lesions. Here, we present a 35-year-old female with a right axillary lump which was suggestive of benign tumor on ultrasonography and was proven to be benign phyllodes tumor on histopathology.

Sentinel node in breast cancer as an indicator of quality in medical care: Evaluation of statistics in Colombia.

BACKGROUND: Sentinel lymph node biopsy in breast cancer is considered the standard of staging in cases of clinically negative lymph nodes. Its omission in favor of axillary dissection generates significant morbidity. OBJECTIVE: To determine the total number of sentinel node biopsy procedures in breast cancer in Colombia from 2017 through 2020, model and analyze them as if they were performed only in stage I breast cancer patients, and integrate their results into the concepts of quality of medical care. METHODS: Search in a database of the Ministry of Health and Social Protection of Colombia with sentinel lymph node biopsy codes, and filters of breast cancer and year. Their results are contrasted with the number of cases in stage I of breast cancer. RESULTS: Breast cancer TNM staging was reported in 22154 cases, 3648 stage I. In the same time frame, the number of sentinel lymph node biopsies for breast cancer in Colombia was 1045, 28.64% of the total cases reported in stage I. CONCLUSIONS: Colombia is far from complying with the standard indicator of sentinel lymph node biopsy. It is recommended to concentrate breast cancer cases in hospitals that provide the conditions for its performance.

Modern management of the axilla.

Surgical management of the axilla has evolved considerably in recent years, with a strong focus on de-escalation to minimise morbidity whilst maintaining oncological outcomes. Current trials will focus on the omission of Sentinel node biopsy in select groups of patients, while axillary lymph node dissection will be reserved for those with more aggressive disease.

Primary Invasive Ductal Carcinoma Arising in Axillary Accessory Breast: A Case Report.

Ectopic breast tissue can develop along the mammary ridge from the axilla to the groin, and the most common site is the axillae. Primary carcinoma of ectopic breast tissue is extremely rare. We report a rare case of a 61-year-old woman with a palpable mass in her left axilla who had a history of surgical excision of accessory breast tissue in the same area. Mammography (MMG), including axillary tail view, ultrasound (US), and breast MRI were performed. We evaluated the extent and characteristics of the microcalcifications in the axillary tail view. A US-guided biopsy was done, and histopathology revealed an invasive ductal carcinoma. Enhanced abdominal CT revealed multiple hepatic masses consistent with metastases, and the patient received palliative chemotherapy. Herein, we present a rare case of breast cancer arising from accessory breast tissue in the axilla, best appreciated on the axillary tail view of the patient's MMG.

Improving resource utilization: Axillary lymph node core biopsy triaging for lymphoma.

OBJECTIVES: To evaluate the utilization of hematopathology resources within our enterprise on axillary lymph node core biopsy (AxLNCB) specimens, particularly those obtained in the context of breast cancer screening. METHODS: The utilization of hematopathology resources was determined for all AxLNCB specimens over a 30-month period from across our enterprise, and chart review was performed for select patient demographics and radiographic features. The AxLNCB cases with benign histology were reviewed for subtyping of histologic patterns. RESULTS: Of the total 594 AxLNCB specimens, 61.6% were benign and 38.6% malignant. Of malignant cases, only 9.3% contained any hematologic malignancy, yet 94% of all cases received tissue triage for lymphoma, and 81% were reviewed at least in part by a hematopathologist. Six clinical parameters were found to independently predict risk of hematologic malignancy: male sex (P = .041), bilateral lymphadenopathy (P = .004), diffuse cortical thickening (P = .005), lack of breast cancer (P = .001), older age (P < .001), and history of hematologic malignancy (P < .001). CONCLUSIONS: Our enterprise overused hematopathology resources in the evaluation of AxLNCB performed in the study period. Our process could improve from the application of a simple tool generated from this cohort to predict percent risk of the specimen containing hematologic malignancy using patient characteristics easily found via routine chart review.

Outcomes of sentinel node biopsy according to MRI response in an association with the subtypes in cN1-3 breast cancer after neoadjuvant systemic therapy, multicenter cohort study.

BACKGROUND: This study investigated the feasibility of sentinel lymph node biopsy (SLNB) after neoadjuvant systemic therapy (NAST) in patients with initially high nodal burden. METHODS: In the multicenter retrospective cohort, 388 individuals with cN1-3 breast cancer who underwent NAST and had SLNB followed by completion axillary lymph node dissection were included. In an external validation cohort, 267 patients with HER2+ or triple-negative breast cancer (TNBC) meeting similar inclusion criteria were included. Primary outcome was the false-negative rates (FNRs) of SLNB according to the MRI response and subtypes. We defined complete MRI responders as patients who experienced disappearance of suspicious features in the breast and axilla after NAST. RESULTS: In the multicenter retrospective cohort, 130 (33.5%) of 388 patients were of cN2-3, and 55 (14.2%) of 388 patients showed complete MRI responses. In hormone receptor-positive HER2- (n = 207), complete and non-complete responders had a high FNRs (31.3% [95% CI 8.6-54.0] and 20.9% [95% CI 14.1-27.6], respectively). However, in HER2+ or TNBC (n = 181), the FNR of complete MRI responders was 0% (95% CI 0-0), whereas that of non-complete responders was 33.3% (95% CI 20.8-45.9). When we validated our findings in the external cohort with HER2+ or TNBC (n = 267), of which 34.2% were cN2-3, the FNRs of complete were 7.1% (95% CI 0-16.7). CONCLUSIONS: Our findings suggest that SLNB can be a reliable option for nodal status evaluation in selected patients who have responded well to NAST, especially in HER2+ and TNBC patients who show a complete MRI response.

Investigating the role of tumour-to-skin proximity in predicting nodal metastasis in breast cancer.

BACKGROUND: Understanding the factors influencing nodal status in breast cancer is vital for axillary staging, therapy, and patient survival. The nodal stage remains a crucial factor in prognostication indices. This study investigates the relationship between tumour-to-skin distance (in T1-T3 tumours where the skin is not clinically involved) and the risk of nodal metastasis. METHODS: We retrospectively reviewed data from 100 patients who underwent neoadjuvant chemotherapy (NACT). Besides patient demographics and tumour variables, a radiologist retrospectively reviewed pre-operative MRI to measure tumour-to-skin distance. R core packages were used for univariate (χ2 and T-Wilcoxon tests) and bivariate logistic regression statistical analysis. RESULTS: Of 95 analysable datasets, patients' median age was 51 years (IQR: 42-61), 97% were symptomatic (rest screen detected), and the median tumour size was 43 mm (IQR, 26-52). On multivariate analysis, increasing invasive tumour size (p = 0.02), ER positivity (p = 0.007) and shorter tumour-to-skin distance (p = 0.05) correlated with nodal metastasis.  HER2 was not included in multivariate analysis as there was no association with nodal status on univariate analysis. In node-positive tumours, as tumour size increased, the tumour-to-skin distance decreased (r = - 0.34, p = 0.026). In node-negative tumours, there was no correlation (r = + 0.18, p = 0.23). CONCLUSION: This study shows that non-locally advanced cancers closer to the skin (and consequent proximity to subdermal lymphatics) are associated with a greater risk of nodal metastasis. Pre-operative identification of those more likely to be node positive may suggest the need for a second-look USS since a higher nodal stage may lead to a change in therapeutic strategies, such as upfront systemic therapy, node marking, and axillary clearance without the need to return to theatre following sentinel node biopsy.

Cat Scratch Disease of the Breast/Axilla: Recognition of a Rare Disease and Approaches for Differential Diagnosis.

Cat scratch disease rarely presents as a breast or axillary mass mimicking carcinoma both clinically and radiologically. Diagnosing breast/axillary cat scratch disease is challenging due to its rarity and nonspecific findings. Here, we reported 2 patients with breast cat scratch disease and reviewed 14 patients with cat scratch disease involving breast/axilla from the past 30 years. It mainly affects women (median age: 48), consistently presenting as axillary lymphadenopathy, and demonstrates ipsilateral breast mass in half of patients (50%, 8/16). The breast mass was most commonly located in the upper outer quadrant (88%, 7/8), indicating the possibility of disease extension from axillary adenopathy. Around half of patients (56%, 9/16) reported cat exposure. Histologically, most patients (93%, 14/15) presented as necrotizing granulomas, with characteristic stellate-shaped necrosis in 5 patients. Although pathologic differential diagnoses between cat scratch disease and cancer are straightforward, distinguishing cat scratch disease from other granulomatous mastitis poses diagnostic challenges. Silver stains should be included in the diagnostic workup panel when highly suspecting cat scratch disease clinically. However, they were only able to highlight the causative microorganism in 54% (7/18) patients, and the gram stain was negative in all 12 tested patients. In contrast, polymerase chain reaction (PCR) for the causative microorganism was consistently positive in all 3 tested patients, while serologic test confirmed diagnosis in 85% (11/13) patients; 1 patient with negative serology showed a positive PCR result. Therefore, upfront PCR tests with or without serologic study should be considered to confirm the diagnosis of cat scratch disease in a timely manner.

The anatomical variations of median nerve in Shiraz, Iran.

The origin and distribution of median nerve varies among the different individuals. The median nerve variations in axillary region were reported by many authors previously. Understanding of these variations is especially necessary for clinicians to prevent iatrogenic nerve damage. The current work aimed to evaluate the possible anatomical variations of median nerve in the axillary region in a sample of the Iranian cadavers (Shiraz, Fars). We dissected 26 upper limbs from 13 male cadavers to investigate the different variations of median and musculocutaneous nerves according to Venieratos and Anagnostopoulou classification. In 23.07% of specimens (n=6), the medial root united with 2 lateral roots and formed the median nerve proximal to the coracobrachialis muscle. In one case, a communicating branch separated from the musculocutaneous nerve distal to the coracobrachialis and connected to the median nerve in upper arm. Our results suggest that there are anatomical variations of the median nerve in terms of its origin and its communication with the musculocutaneous nerve in the population of southern Iran. The anatomical knowledge of the median nerve variations is important for clinicians to improve patient health outcome. Theses variations of the median nerve should be considered during surgical procedures of the axillary region and nerve block of the infra clavicular part of the brachial plexus.