Effectiveness of ultrasound in the detection of axillary metastasis in patients with breast cancer without clinical evidence of axillary disease: Clinical impact / Efectividad de la ecografía en la detección de metástasis axilares en pacientes con cáncer de mama sin evidencia clínica de enfermedad axilar: impacto clínico

Introduction Preoperative ultrasound in patients with breast cancer without evidence of clinical axillary disease represents an attempt to reliably identify axillary lymph node metastasis. However, the usefulness of ultrasound for the detection of axillary disease should be evaluated. Materials and methods The study included a retrospective cohort of 826 patients with diagnosed invasive breast cancer, treated at the National Cancer Institute of Mexico, from 2014 to 2018. All patients underwent ipsilateral axillary ultrasound for staging purposes. Besides the descriptive analysis of the preoperative ultrasound, findings of the cohort were compared with their corresponding cytology and histopathology reports. Results Diagnostic index for axillary ultrasound was calculated as follows: 32.8% sensitivity, 82.5% specificity, 37.1% positive predictive value (PPV), 79.6% negative predictive value (NPV), 70.6% diagnostic accuracy, 1.86 positive likelihood ratio (LR+), and 0.81 negative likelihood ratio (LR−). Loss of fatty hilum was associated with a higher risk of axillary metastasis on the multivariate analysis (OR 3.645; 95% CI, 1.664–7.985, p<0.001). Conclusions The utility of axillary ultrasound as a method of determining the nodal status prior to surgery in patients with breast cancer without clinical evidence of axillary disease was not demonstrated in this study. (AU)

Introducción La ecografía preoperatoria en pacientes con cáncer de mama sin evidencia de enfermedad clínica axilar representa un intento de identificar de manera confiable metástasis a ganglios linfáticos axilares. Sin embargo, se debe evaluar la utilidad de la ecografía para la detección de la enfermedad axilar. Material y métodos El estudio incluyó una cohorte retrospectiva de 826 pacientes con cáncer de mama invasivo diagnosticado en el Instituto Nacional de Cancerología de México, de 2014 a 2018. Todos los pacientes se sometieron a una ecografía axilar ipsilateral con fines de estadificación. Además del análisis descriptivo de la ecografía preoperatoria, los resultados de la cohorte se compararon con sus correspondientes informes de citología e histopatología. Resultados Los índices diagnósticos para la ecografía axilar fueron: 32,8% de sensibilidad, 82,5% de especificidad, 37,1% de valor predictivo positivo (VPP), 79,6% de valor predictivo negativo (VPN), 70,6% de precisión diagnóstica, 1,86 de razón de verosimilitud positiva (LR+) y 0,81 de razón de verosimilitud negativa (LR−). La pérdida de hilio graso se asoció con un mayor riesgo de metástasis axilares en el análisis multivariado (RM: 3.645; IC al 95%: 1.664-7.985; p<0,001). Conclusiones La utilidad de la ecografía axilar como método para determinar el estado ganglionar antes de la cirugía en pacientes con cáncer de mama sin evidencia clínica de enfermedad axilar no se demostró en este estudio. (AU)

The Role of Postmastectomy Radiotherapy in Locally Advanced Breast Cancer After Pathological Complete Response to Neoadjuvant Chemotherapy.

The Case A previously healthy woman, aged 32 years, presented to the oncology clinic with a 6-month history of left-breast tumor, mastalgia, and swollen axillary nodes. Physical examination was relevant for a 6-cm palpable mass in the upper outer quadrant of the left breast and an ipsilateral 2-cm, nonfixed axillary lymph node. Mammography showed a 1-cm mass in the upper outer quadrant, a 5.2-cm mass in the lower outer quadrant, and enlarged pathologic lymph nodes (BI-RADS category 5 disease). Breast ultrasound revealed 3 axillary lymph nodes with cortical thickening and loss of normal morphology (the largest with a 2.6-cm length in the long axis) (Figure 1A-B). The breast´s core biopsy revealed a grade 3 apocrine invasive carcinoma with lymphovascular invasion; immunohistochemistry testing showed HER2-negative, hormone receptor-negative disease (estrogen receptor, 0%; progesterone receptor, 0%; HER2-negative, Ki67, 50%) (Figure 2A-B). A fine-needle aspiration biopsy of the axillary lymph nodes showed invasive breast carcinoma as well. Bone scintigraphy and a chest/abdomen CT scan ruled out metastatic disease. Upon initial diagnosis, clinical stage was deemed as cT3N1M0 (American Joint Committee on Cancer 8th edition: anatomic stage IIIA, clinical prognostic stage IIIC). After a multidisciplinary tumor board discussion, the patient underwent neoadjuvant chemotherapy with weekly paclitaxel, followed by 4 cycles of dose-dense doxorubicin plus cyclophosphamide. After completing neoadjuvant treatment, clinical examination was relevant for a residual 1-cm palpable left breast mass and no palpable axillary nodes. Mammography and breast ultrasound showed a 77% partial response in the primary tumors, and axillary nodes with normal morphology and size (Figure 1C-D). Due to multicentric tumor disease, breast-conserving surgery would not confer satisfactory cosmetic results on her, and a modified radical mastectomy with intraoperative sentinel lymph node biopsy (and second-stage breast reconstruction) was planned. However, during surgery, the surgeons failed to identify the mapped lymph node, and level I-III axillary lymph node dissection was performed. The pathology report described complete pathological response: Miller and Payne criteria grade 5 response with the absence of malignant cells within the mastectomy specimen and in 24 lymph nodes (Figure 2C-E). Pathological staging after neoadjuvant treatment concluded ypT0N0M0 disease. Subsequent treatment for this patient was discussed in another tumor board.

IMMUNOTHERAPY TREATMENT AGAINST CERVICAL CANCER.

Cervical cancer (CC) is one of the most common gynecological tumors and an important health problem, especially in developing countries. The vast majority of patients in early stages are cured of the disease with surgical treatment and with concomitant chemoradiotherapy in locally advanced stages. However, in patients with recurrent, persistent, or metastatic cervical CC, the effectiveness of treatment is limited, except for the combination of chemotherapy based on platinum doublets plus bevacizumab, the treatment that has achieved the best results to date. Programmed cell death-1/PD ligand-1 (PD-1/PD-L1) inhibitors could be a novel and cutting-edge therapeutic option to improve clinical outcomes in this group of patients. Thus far, there are a few Phase I/II clinical trials that have assessed the usefulness of pembrolizumab and nivolumab in this group of patients; these include the KEYNOTE 028, KEYNOTE 158, and CHECKMATE 358 trials, in which clinical benefit has been proven with PD-1/PD-L1 inhibitors in recurrent, persistent, or metastatic CC, as second-line treatment. There are also some ongoing trials that could provide further evidence on the PD-1/PD-L1 pathway as a therapeutic target in CC. In this review, we will focus on the usefulness of these PD-1/PDL1 inhibitors in CC, as well as on trials that are still in the recruitment phase, to confirm their effectiveness in this clinical setting.

Immunotherapy treatment against cervical cancer

ABSTRACT Cervical cancer (CC) is one of the most common gynecological tumors and an important health problem, especially in developing countries. The vast majority of patients in early stages are cured of the disease with surgical treatment and with concomitant chemoradiotherapy in locally advanced stages. However, in patients with recurrent, persistent, or metastatic cervical CC, the effectiveness of treatment is limited, except for the combination of chemotherapy based on platinum doublets plus bevacizumab, the treatment that has achieved the best results to date. Programmed cell death-1/PD ligand-1 (PD-1/PD-L1) inhibitors could be a novel and cutting-edge therapeutic option to improve clinical outcomes in this group of patients. Thus far, there are a few Phase I/II clinical trials that have assessed the usefulness of pembrolizumab and nivolumab in this group of patients; these include the KEYNOTE 028, KEYNOTE 158, and CHECKMATE 358 trials, in which clinical benefit has been proven with PD-1/PD-L1 inhibitors in recurrent, persistent, or metastatic CC, as second-line treatment. There are also some ongoing trials that could provide further evidence on the PD-1/PD-L1 pathway as a therapeutic target in CC. In this review, we will focus on the usefulness of these PD-1/PDL1 inhibitors in CC, as well as on trials that are still in the recruitment phase, to confirm their effectiveness in this clinical setting.

Nutrient Recommendations for Cancer Patients Treated with Pelvic Radiotherapy, with or without Comorbidities.

Radiotherapy is one of the main treatment options used in pelvic cancers. Ionizing radiation induces damage to surrounding tissues, resulting in disruption of normal physiological functions and symptoms such as diarrhea, tenesmus, incontinence, and rectal bleeding, which can all significantly alter the patient's quality of life. These patients are at increased risk of developing protein-calorie malnutrition and micronutrient deficiencies. Therefore, designing a proper nutritional intervention plan, with an optimal proportion of protein, fat, and carbohydrates, is required to reduce or even reverse the patients' poor nutritional status, increase their tolerance and response to oncology treatment, decrease the rate of complications and improve their quality of life. The aim of this review was to establish a nutritional plan that includes recommendations on macronutrient proportions and micronutrient intake in patients receiving pelvic radiotherapy. The following nutritional plan has been recommended in the literature: Energy: 28-31 kcal/kg/day, using the Harris-Benedict formula adjusted for body weight in obese patients; protein: 20-30%; fat: 30-40%; and carbohydrates: 40-50%. The maintenance of adequate levels of Vitamin D, Vitamin E, Vitamin A, calcium, magnesium, thiamin, riboflavin, and niacin must be emphasized. Physical activity must also be increased to maintain muscle mass. Nutrient requirements must be established in an integral manner, considering the patient's age, nutritional status, and the presence of comorbidities. Unnecessary dietary restrictions should be avoided to ensure an adequate nutritional status.