Yukako Ohno

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.

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.

Oncoplastic breast conserving surgery: Volume replacement vs. volume displacement

Oncoplastic breast conserving surgery (BCS) has emerged as a third option between conventional BCS and mastectomy. Oncoplastic BCS includes two fundamentally different approaches: volume replacement and volume displacement. The former involves partial mastectomy and immediate reconstruction of the breast with the transposition of autologous tissue from elsewhere, while the latter involves partial mastectomy and using the remaining breast tissue to fill the defect resulting from extirpation of the tumor. There are several benefits associated with oncoplastic BCS. First, it allows partial mastectomy without cosmetic penalties, and can achieve better cosmetic outcomes than total mastectomy with immediate breast reconstruction. Second, it avoids the need for total mastectomy in an increasing number of patients without compromising local control. Third, partial breast reconstruction is less extensive and has fewer complications than conventional procedures. Partial mastectomy and partial breast reconstruction can be carried out either simultaneously as a one-stage procedure, or using a two-stage approach. Although patients prefer a one-stage procedure, it requires intraoperative confirmation of complete tumor excision using frozen-section analysis. Moreover, oncoplastic BCS requires combined skills, knowledge, and understanding of both oncological and plastic surgeries, which may be optimally achieved by an oncoplastic surgeon.

Is axillary reverse mapping feasible in breast cancer patients

In the surgical treatment of breast cancer, axillary lymph node dissection (ALND) can be avoided not only in sentinel lymph node (SLN)-negative patients but also in SLN-positive patients who undergo breast-conserving surgery with whole-breast irradiation and systemic therapy. However, it should be performed not only in clinically node-positive patients but also in other SLN-positive patients who do not meet the Z-0011 criteria. The axillary reverse mapping (ARM) technique has been developing for identifying and preserving lymphatic drainage from the arm during ALND, thereby expected to minimize arm lymphedema. Nevertheless, ARM nodes could be involved not only in clinically node-positive patients but also in clinically node-negative patients. Previously, it was considered that preservation of the ARM lymphatics or lymph nodes is not oncologically safe in patients with axillary lymph node metastases. However, recent studies have demonstrated that the ARM procedure is oncologically feasible in clinically node-negative, SLN-positive patients when ARM nodes do not coincide with SLNs. When ARM nodes do not coincide with SLNs, they are not involved even in SLN-positive patients. On the other hand, ARM lymphatics/nodes within the boundaries of a standard ALND should be resected in SLN-positive patients, when ARM nodes are SLN-ARM nodes. Therefore, surgical treatment of the axilla can be individualized on the basis of the axillary nodal status.

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.

Feasibility study of axillary reverse mapping for patients with clinically node-negative breast cancer

BACKGROUND The axillary reverse mapping (ARM) procedure was developed to identify and preserve arm lymphatic drainage during axillary lymph node dissection (ALND), thereby theoretically reducing the incidence of arm lymphedema. However, the oncological safety of this procedure has not yet been determined. METHODS Two hundred ninety-two patients with clinically negative nodes (cN0) underwent both sentinel lymph node (SLN) biopsy and ARM. SLN was identified by dye and gamma probe methods, and ARM nodes were identified using a fluorescence imaging system. If SLN was histologically positive, ALND was performed with removal of ARM nodes. Otherwise, identified ARM nodes were preserved unless they coincided with SLN. Postoperatively, SLN as well as ARM nodes were histologically examined with H&E staining. RESULTS SLN was identified in 286 of 292 patients, and ARM nodes were identified in 90 patients. In 54 patients with positive SLN, SLN was the same as the ARM node in 19 patients (the concordance type), whereas it was not an ARM node in the remaining 35 patients (the separate type). Non-SLN and ARM node was not involved in 51 of 54 patients with positive SLN, while it was involved in 3 patients of the concordance type. CONCLUSIONS When ARM nodes were involved in patients with cN0, these were most often the SLN-ARM nodes. Therefore, it may be concluded that ARM nodes that do not coincide with SLNs might be preserved during ALND in SLN-positive patients.

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.

A novel oncoplastic technique for breast cancer localized in the lower pole of the breast

1 Breast Center, Kanazawa Medical University Hospital, Uchinada-Daigaku, Ishikawa, Japan 2Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Uchinada-Daigaku, Ishikawa, Japan 3Department of Surgical Oncology, Kanazawa Medical University Hospital, UchinadaDaigaku, Ishikawa, Japan 4Department of Plastic Surgery, Kanazawa Medical University Hospital, UchinadaDaigaku, Ishikawa, Japan

P3-07-44: Feasibility of Axillary Reverse Mapping during Sentinel Lymph Node Biopsy in Breast Cancer.

Background: 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. Methods: The ARM nodes were identified using a fluorescence imaging system. Sentinel lymph node (SLN) biopsy was performed in patients with clinically uninvolved nodes. If the SLN was positive, ALND was performed with removal of ARM nodes. Otherwise, the identified ARM nodes were preserved unless they were the same as the SLN. Results: The ARM node was identified in 30 of 91 patients who underwent SLN biopsy, and it was the same as the SLN in 23 patients. However, in 13 patients with a positive SLN who subsequently underwent ALND, ARM nodes were tumor-free when they were not the same as the positive SLN. Conclusions: There are limits to the principle of non-overlap between breast and arm nodes. However, it may be feasible to spare ARM nodes during ALND in patients with clinically negative nodes. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-44.

P2-15-13: Oncologic and Cosmetic Outcome in Breast Cancer Patients Who Underwent “Moving Window” Operation.

Background: An inappropriate skin incision on the breast reduces the cosmetic benefit of breast-conserving surgery (BCS). Methods: To improve the cosmetic outcome, we have performed “Moving window” operation in which BCS can be performed via a periareolar incision (periareolar approach) and/or axillary incision (axillary approach) under direct visualization. Axillary lymph node dissection is also performed via an axillary incision. Results: Periareolar approach was performed in 65 patients and axillary approach in 43 patients. Average operation time was 130 minutes in periareolar approach and 131 minutes in axillary approach. Average blood loss was 37 mL and 50 mL, respectively. Postoperatively, the surgical margin of breast tissue was histologically confirmed to be negative in 107 (99%) of 108 patients, while two patients underwent reoperation because of positive surgical margin. Fifty-two patients (85%) in periareolar approach and 37 patients (86%) in axillary approach had excellent or good cosmetic results. With a mean follow-up of 36 months, one patient with DCIS developed in-breast recurrence, while 3 patients who had neoadjuvant chemotherapy developed in-breast recurrence. Conclusion: The moving window operation can improve a cosmetic outcome of the conserved breast without compromising the oncological safety. Moreover, it can reduce operating time and blood loss when compared with the endoscope-assisted BCS. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-15-13.