Skip to main content

Advertisement

SpringerLink
Log in

Omission of Surgical Axillary Lymph Node Staging in Patients with Tubular Breast Cancer

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

With more effective screening and treatment strategies, there is debate over whether surgical axillary staging should be deescalated for patients with small favorable breast cancers, such as tubular carcinoma (TC).

Patients and Methods

We identified patients with TC [defined as > 90% tubular tubules (angulated, not multilayered)] and known surgical axillary staging from our institutional database (2000–2018). Using the National Cancer Database (NCDB) (2004–2015), we identified patients with TC, ductal carcinoma in situ (DCIS), and pT1 estrogen receptor (ER)-positive invasive ductal carcinoma (IDC). We determined the rates of lymph node (LN) metastases, and the 5- and 10-year overall survival (OS) for patients with LN-negative versus LN-positive disease using the Kaplan–Meier method and propensity match analysis.

Results

In our institutional cohort, we identified 112 patients with T1 TC; only one (0.9%) patient had nodal involvement. In the NCDB cohort, we identified 6938 patients with T1 TC; 323 (4.7%) patients had axillary LN disease. The rate of axillary LN involvement for TC was comparable to that identified for patients with DCIS (4.2%), and much lower than that found for patients with grade I–III, T1, ER-positive IDC (20.5%), and patients with grade I, T1, ER-positive IDC (14.4%). There was no difference in 5-year (94.6% versus 95.4%, p = 0.67) and 10-year (83.9% versus 85.2%, p = 0.98) OS between TC patients with or without LN involvement. Kaplan–Meier survival curves even after propensity score matching suggest that tubular histology is independently associated with improved survival.

Conclusions

T1 TC is an excellent starting point for deescalation of surgical axillary staging.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Sentinel Node Vs Observation After Axillary Ultra-souND (SOUND). ClinicalTrials.gov Identifier: NCT 02167490.

  2. Comparison of Axillary Sentinel Lymph Node Biopsy versus No Axillary Surgery (INSEMA). ClinicalTrials.gov Identifier NCT 02466737.

  3. Land SR, Kopec JA, Julian TB, et al. Patient-reported outcomes in sentinel node-negative adjuvant breast cancer patients receiving sentinel-node biopsy or axillary dissection: National Surgical Adjuvant Breast and Bowel Project phase III protocol B-32. J Clin Oncol. 2010;28(25):3929–36.

    Article  Google Scholar 

  4. DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013;14(6):500–15.

    Article  Google Scholar 

  5. Gartner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009;302(18):1985–92.

    Article  Google Scholar 

  6. Krag DN, Anderson SJ, Julian TB, et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 2007;8(10):881–88.

    Article  CAS  Google Scholar 

  7. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569–75.

    Article  CAS  Google Scholar 

  8. Rao R, Euhus D, Mayo HG, Balch C. Axillary node interventions in breast cancer: a systematic review. JAMA. 2013;310(13):1385–94.

    Article  CAS  Google Scholar 

  9. Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC trial. J Natl Cancer Inst. 2006;98(9):599–609.

    Article  Google Scholar 

  10. Intra M, Rotmensz N, Veronesi P, et al. Sentinel node biopsy is not a standard procedure in ductal carcinoma in situ of the breast: the experience of the European Institute of Oncology on 854 patients in 10 years. Ann Surg. 2008;247(2):315–9.

    Article  Google Scholar 

  11. Francis AM, Haugen CE, Grimes LM, et al. Is sentinel lymph node dissection warranted for patients with a diagnosis of ductal carcinoma in situ? Ann Surg Oncol. 2015;22(13):4270–9.

    Article  Google Scholar 

  12. Cooper HS, Patchefsky AS, Krall RA. Tubular carcinoma of the breast. Cancer. 1978;42(5):2334–42.

    Article  CAS  Google Scholar 

  13. Diab SG, Clark GM, Osborne CK, Libby A, Allred DC, Elledge RM. Tumor characteristics and clinical outcome of tubular and mucinous breast carcinomas. J Clin Oncol. 1999;17(5):1442–8.

    Article  CAS  Google Scholar 

  14. Weiss MC, Fowble BL, Solin LJ, Yeh IT, Schultz DJ. Outcome of conservative therapy for invasive breast cancer by histologic subtype. Int J Radiat Oncol Biol Phys. 1992;23(5):941–7.

    Article  CAS  Google Scholar 

  15. Kader HA, Jackson J, Mates D, Andersen S, Hayes M, Olivotto IA. Tubular carcinoma of the breast: a population-based study of nodal metastases at presentation and of patterns of relapse. Breast J. 2001;7(1):8–13.

    Article  CAS  Google Scholar 

  16. Thurman SA, Schnitt SJ, Connolly JL, et al. Outcome after breast-conserving therapy for patients with stage I or II mucinous, medullary, or tubular breast carcinoma. Int J Radiat Oncol Biol Phys. 2004;59(1):152–9.

    Article  Google Scholar 

  17. Leonard CE, Philpott P, Shapiro H, et al. Clinical observations of axillary involvement for tubular, lobular, and ductal carcinomas of the breast. J Surg Oncol. 1999;70(1):13–20.

    Article  CAS  Google Scholar 

  18. Sullivan T, Raad RA, Goldberg S, et al. Tubular carcinoma of the breast: a retrospective analysis and review of the literature. Breast Cancer Res Treat. 2005;93(3):199–205.

    Article  Google Scholar 

  19. Fernandez-Aguilar S, Simon P, Buxant F, Fayt I, Noel JC. Is complete axillary lymph node dissection necessary in T1 stage invasive pure tubular carcinomas of the breast? Breast. 2005;14(4):325–8.

    Article  Google Scholar 

  20. Leikola J, Heikkila P, von Smitten K, Leidenius M. The prevalence of axillary lymph-node metastases in patients with pure tubular carcinoma of the breast and sentinel node biopsy. Eur J Surg Oncol. 2006;32(5):488–91.

    Article  CAS  Google Scholar 

  21. Cserni G, Bianchi S, Vezzosi V, et al. Sentinel lymph node biopsy and non-sentinel node involvement in special type breast carcinomas with a good prognosis. Eur J Cancer. 2007;43(9):1407–14.

    Article  Google Scholar 

  22. Javid SH, Smith BL, Mayer E, et al. Tubular carcinoma of the breast: results of a large contemporary series. Am J Surg. 2009;197(5):674–7.

    Article  Google Scholar 

  23. Dejode M, Sagan C, Campion L, et al. Pure tubular carcinoma of the breast and sentinel lymph node biopsy: a retrospective multi-institutional study of 234 cases. Eur J Surg Oncol. 2013;39(3):248–54.

    Article  CAS  Google Scholar 

  24. Lea V, Gluch L, Kennedy CW, Carmalt H, Gillett D. Tubular carcinoma of the breast: axillary involvement and prognostic factors. ANZ J Surg. 2015;85(6):448–51.

    Article  Google Scholar 

  25. Ramzi S, Hyett EL, Wheal AS, Cant PJ. The case for the omission of axillary staging in invasive breast carcinoma that exhibits a predominant tubular growth pattern on preoperative biopsy. Breast J. 2018;24(4):493–500.

    Article  Google Scholar 

  26. Kitchen PR, Smith TH, Henderson MA, et al. Tubular carcinoma of the breast: prognosis and response to adjuvant systemic therapy. ANZ J Surg. 2001;71(1):27–31.

    Article  CAS  Google Scholar 

  27. Winchester DJ, Sahin AA, Tucker SL, Singletary SE. Tubular carcinoma of the breast. Predicting axillary nodal metastases and recurrence. Ann Surg. 1996;223(3):342–347.

  28. Downs-Canner SM, Gaber CE, Louie RJ, et al. Nodal positivity decreases with age in women with early-stage, hormone receptor-positive breast cancer. Cancer. 2020;126(6):1193–201.

    Article  CAS  Google Scholar 

  29. Chagpar AB, McMasters KM, Edwards MJ, North American Fareston Tamoxifen Adjuvant T. Can sentinel node biopsy be avoided in some elderly breast cancer patients? Ann Surg. 2009;249(3):455–60.

  30. Boughey JC, Haffty BG, Habermann EB, Hoskin TL, Goetz MP. Has the time come to stop surgical staging of the axilla for all women age 70 years or older with hormone receptor-positive breast cancer? Ann Surg Oncol. 2017;24(3):614–7.

    Article  Google Scholar 

Download references

Acknowledgements

We acknowledge and thank all the patients who participated in making this research possible.

Funding

None.

Author information

Author notes

  1. Mehra Golshan MD, MBA

    Present address: Department of Surgery, Yale University School of Medicine, New Haven, CT, USA

Authors and Affiliations

  1. Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, USA

    Enver Özkurt MD, Stephanie Wong MD, Esther Rhei MD, Mehra Golshan MD, MBA & Thanh U. Barbie MD

  2. Breast Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Topkapi, Istanbul, Turkey

    Enver Özkurt MD

  3. Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA

    Stephanie Wong MD, Esther Rhei MD, Mehra Golshan MD, MBA & Thanh U. Barbie MD

  4. Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA

    Jane Brock MD, PhD

Authors
  1. Enver Özkurt MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stephanie Wong MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Esther Rhei MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mehra Golshan MD, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jane Brock MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Thanh U. Barbie MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

TUB conceived, developed, and supervised the findings of this work. JB performed the pathology review. JB, TUB, and EO analyzed the institutional and NCDB data. Statistical analysis was performed by EO and SW. ER, SW, and MG provided critical feedback and helped shape the research, analysis, and manuscript. All authors discussed the results and contributed to the final manuscript.

Corresponding author

Correspondence to Thanh U. Barbie MD.

Ethics declarations

Disclosure

None pertinent to this work. Outside of submitted work: T.U.B. is a consultant for N-of-One/Qiagen. Spouse is consultant for N-of-One/Qiagen, Tango Therapeutics, and MADALON consulting. Spouse is cofounder of Xsphera Biosciences. Spouse has received research funding from Novartis and Bristol Myers Squibb.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Co-senior authors: Jane Brock and Thanh U. Barbie.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Özkurt, E., Wong, S., Rhei, E. et al. Omission of Surgical Axillary Lymph Node Staging in Patients with Tubular Breast Cancer. Ann Surg Oncol 28, 2589–2598 (2021). https://doi.org/10.1245/s10434-020-09223-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-020-09223-w

Search

Navigation