Masakuni Noguchi

Axillary reverse mapping with indocyanine fluorescence imaging in patients with breast cancer

The ARM technique was proposed to prevent arm lymphedema after ALND and/or SLN biopsy. However, several problems remain to be resolved in the practical application of this technique.

Axillary reverse mapping using a fluorescence imaging system in breast cancer

The axillary reverse mapping (ARM) procedure is based on the hypothesis that the lymphatic drainage from the upper arm is different from that of the breast. However, the oncologic safety of the procedure has not yet been determined.

Axillary reverse mapping for breast cancer

The axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during axillary lymph node dissection (ALND) and/or sentinel lymph node (SLN) biopsy, thereby minimizing arm lymphedema. However, several problems remain to be resolved in the practical application of this technique. This article presents a review of current knowledge regarding ARM and discusses the practical applicability and relevance of this technique. Identification rates of ARM nodes were insufficient using blue dye. Although this was improved using radioisotopes, radioisotopes alone do not permit visual mapping of ARM lymphatics. Fluorescence imaging may be useful to improve the identification rate of ARM nodes and lymphatics. On the other hand, the ARM nodes may be involved with metastatic foci in patients with extensive axillary lymph node metastases. Moreover, the SLN draining the breast may be the same as the ARM node draining the upper extremity in a minority of patients. These issues represent important drawbacks of the ARM procedure. The success of ARM in reducing lymphedema has not yet been determined. Further studies are needed before this can be accepted as a standard procedure in surgical management of breast cancer.

Long-term outcome of breast cancer patients treated with radiofrequency ablation.

BACKGROUND Radiofrequency ablation (RFA) is considered to be the most promising non-surgical ablation technique for the treatment of small breast cancer. However, few data are available regarding long-term follow-up of patients treated with this modality. METHODS Since 2005, we have performed RFA and sentinel lymph node (SLN) biopsy in 19 cases. Axillary lymph node dissection (ALND) was performed in patients with positive SLNs. From 24 to 202 days after RFA, the ablated tumour tissue was excised by mammotome biopsy and examined histologically or immunohistochemically with H&E staining, nicotinamide adenine dinucleotide (NADH)-diaphorase staining, and single-stranded (ss) DNA staining. All cases were followed-up after breast radiation and systemic therapies. RESULTS Although complete response was histologically confirmed in only 8 cases, NADH-diaphorase and ssDNA staining did not demonstrate any viable tumour cells in the ablated lesions. At a mean follow-up of 60 months (follow-up range, 37-82 months), there were no cases of in-breast recurrence, although one patient died due to hepatic metastases. Cosmesis of the conserved breast was excellent or good in all of the cases, but a hard lump was persistent after RFA in half of the cases. CONCLUSIONS The long-term outcome of patients treated with RFA is encouraging with regard to cosmesis and local control. Because a persisted lump may cause patient discomfort, anxiety and fear, however, further studies are needed to establish the optimal technique. Moreover, a prospective study will be required to determine the equivalency in local recurrence rates between the RFA therapy and conventional breast-conserving treatment.

Histopathological and immunohistochemical evaluations of breast cancer treated with radiofrequency ablation

Although RF ablation is a promising non‐surgical ablation technique for the treatment of breast cancer, assessment of the efficacy requires not only imaging of tumor necrosis but also histological confirmation.

The changing role of axillary lymph node dissection for breast cancer

Currently, it is standard practice that patients with negative sentinel lymph nodes (SLNs) do not undergo axillary lymph node dissection (ALND), whereas ALND is mandated in those with positive SLNs. However, the Z0011 trial showed that ALND could be safely omitted in selected patients with positive SLNs. This article presents a review and discussion of the current role and practice of ALND in the surgical management of breast cancer. A review of the English-language medical literature was performed using the MEDLINE database and cross-referencing major articles on the subject. It may be concluded that ALND can be avoided not only in patients with negative SLNs but also in those with positive SLNs who undergo breast-conserving therapy with whole-breast irradiation and appropriate systemic therapy. However, the omission of ALND would be indicated only in patients with a low axillary tumor burden. On the other hand, ALND remains a standard method of treating regional disease not only in patients with clinically positive nodes but also in other SLN-positive patients who do not meet the above criteria. Although the role of ALND has been limited to the prevention of axillary recurrence, SLN biopsy with whole-breast irradiation and systemic therapy can replace ALND in patients with a low axillary tumor burden.

Axillary reverse mapping for preventing lymphedema in axillary lymph node dissection and/or sentinel lymph node biopsy

The Japanese Breast Cancer Society 2009 Axillary lymph node dissection (ALND) is a standard surgical treatment in patients with involved axillary lymph nodes. Unfortunately, arm lymphedema develops in 2.7– 5.0% of patients treated by partial ALND (level I and II), in 3.1–9.6% of those undergoing total ALND, and in 26– 38% of patients treated with ALND and radiotherapy [1]. The risk of lymphedema is often used as an argument against ALND. Currently, sentinel lymph node (SLN) biopsy has become a highly utilized and widely accepted method for surgical staging of axillary lymph nodes in breast cancer. It can avoid an unnecessary ALND in patients with node-negative breast cancer, thereby pre

Local therapy and survival in breast cancer with distant metastases.

This review article presents an evaluation of the effects of local therapy on survival of breast cancer patients with distant metastases along with a discussion of their relevance. Primary and recurrent breast cancers with distant metastases are systemic diseases with poor prognosis. However, several retrospective studies have demonstrated that surgical removal of the primary breast tumor has a favorable impact on the prognosis of stage IV breast cancer patients. Similarly, it has been reported that surgical resection of metastatic lesions in the lung as well as the liver yields unexpectedly promising results. The interaction of local treatment and systemic therapy may be important, because surgery and radiotherapy are only local treatments. However, it remains uncertain whether these encouraging findings are due to the surgical procedure itself or preoperative patient selection. Only a randomized prospective study can definitively show whether local treatment can prevent death from stage IV disease or recurrent breast cancer with distant metastases. Until data from prospective studies are available, clinicians must weigh retrospective experiences and clinical judgment in deciding whether to offer surgery or radiotherapy to these patients. J. Surg. Oncol. 2012; 105:104–110.

Nipple- or Skin-Sparing Mastectomy by the “Moving Window” Operation and Immediate Breast Reconstruction

Skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) by the “Moving Window” operation and immediate breast reconstruction (IBR) with tissue expander have been developed to minimize the skin incision and improve the cosmetic outcome of the reconstructed breast for patients with breast cancer. The authors describe SSM or NSM via a small periareolar incision with axillary incision using wound retractors without disposable endoscopic instruments. After the entire breast tissue was removed, immediate breast reconstruction (IBR) using a tissue expander was performed through the axillary incision. Although the follow-up period in this study was short, the moving window operation appears to be useful to minimize skin incision, reduce blood loss, and improve cosmetic outcome of SSM or NSM with IBR without compromising local control.

Z-11 trial and rethinking axillary reverse mapping

Axillary lymph node dissection (ALND) was an integral part of the surgical procedure of breast cancer in the era of radical mastectomy. However, a randomized clinical trial has demonstrated that it does not reduce systemic recurrence or improve survival. Therefore, ALND was regarded as a surgical procedure for assessing nodal status and preventing axillary recurrence. Recently, sentinel lymph node (SLN) biopsy has become a standard method for assessing nodal status in breast cancer. Several randomized studies confirmed that SLN biopsy achieves the same survival and regional control as ALND in SLN-negative patients with invasive breast cancer. This procedure can avoid unnecessary ALND in SLN-negative patients, thereby minimizing arm lymphedema. However, SLNpositive patients who undergo ALND do not benefit from SLN biopsy. In 2011, the American College of Surgeons Oncology Group (ACOSOG) reported the results of the Z-11 trial. This trial was designed to address whether ALND is necessary in SLN-positive patients who underwent breastconserving surgery (BCS) with whole-breast irradiation and systemic therapy [1]. The results indicated a remarkably low rate of axillary recurrence in SLN-positive patients who did not undergo ALND. At a median followup of 6.3 years, axillary recurrence rates were similar between each arm with 4 (0.9 %) patients in the SLN biopsy group compared with 2 (0.5 %) in the ALND group, and there was no trend towards improvement of diseasefree or overall survival with ALND. Morrow et al. [2] stated that ALND could be safely omitted in selected women with T1-2, clinically node-negative (cN0) breast cancer who undergo SLN biopsy and BCS with wholebreast irradiation and appropriate systemic therapy. The Z-11 trial is a landmark study. Even in patients with positive SLNs, ALND is not a critical component of surgical therapy. In ACOSOG Z-11, regional recurrence after SLNB alone was \0.1 %, despite the fact that 27 % of patients randomized to the ALND arm of the study had additional metastases identified [1]. However, this trial did not lead to the abandonment of SLN biopsy itself in cN0 patients, even if ALND can be avoided irrespective of the SLN status. It demonstrated that SLN biopsy with wholebreast irradiation and systemic therapy can replace ALND in preventing axillary recurrence in patients with macrometastatic SLNs. Thus, a combination therapy of surgical resection and irradiation is effective not only for the primary breast cancer but also for the axillary metastases. Obviously, ALND should not be omitted in patients who underwent total mastectomy, patients who received neoadjuvant therapy, and patients who underwent BCS without breast radiotherapy. Currently, nippleor skin-sparing mastectomy with immediate breast reconstruction using breast implant has become increasingly popular for patients with multicentric and multifocal tumors. However, either breast or axillary irradiation would not be preferable for these patients because of the increasing rate of capsular contracture. Therefore, ALND remains the standard procedure of treating regional disease in these patients. Nevertheless, conventional ALND is frequently associated with morbidities, including arm lymphedema, seroma, disturbance of shoulder movement and sensory loss. Arm This study was presented at the Breast Service Conference in the Memorial Sloan-Kettering Cancer Center, October 14th, 2014, New York, NY, USA.