Clinical practice guidelines for sentinel lymph node biopsy in patients with early-stage breast cancer: Chinese Society of Breast Surgery (CSBrS) practice guidelines 2021

Axillary lymph node assessment is one of the important indicators in the clinical pathological staging of breast cancer.Studies have shown that sentinel lymph node biopsy(SLNB)has the advantages of fewer complications and less trauma than conventional axillary lymph node dissection(ALND)/[1] Common mapping methods for SLNB include blue dye,radioisotopes,a combination of blue dye and radioisotopes,and fluorescence imaging.

Prognostic value of tumor-infiltrating lymphocyte subtypes in residual tumors of patients with triple-negative breast cancer after neoadjuvant chemotherapy

Background:After neoadjuvant chemotherapy(NAC),non-pathological complete response of breast cancer patients can benefit from tailored adjuvant chemotherapy.However,it is difficult to select patients with poorer prognosis for additional adjuvant chemotherapy to maximize the benefits.Our study aimed to explore whether the subtypes of tumor-infiltrating lymphocytes(TILs)in residual tumors(RT)is related to the prognosis of triple-negative breast cancer(TNBC)after NAC.Methods:Data from patients with primary TNBC consecutively diagnosed at the Breast Disease Center of Peking University First Hospital from 2008 to 2014 were retrieved,and the cases with RT in the breast after NAC were enrolled.TILs subtypes in RT were observed by double-staining immunohistochemistry,and counted with the median TILs value per square millimeter as the cut-off to define high versus low TILs density in each subtype.The relationships between the TIL density of each subgroup and the clinicopathological characteristics of the RT after NAC patients were analyzed by Fisher exact test.Disease-free survival(DFS)and overall survival(OS)were analyzed by the Kaplan-Meier method and log-rank statistics.Results:A total of 37 eligible patients were included in this study,and the median follow-up period was 50 months(range 17–106 months).There was no significant correlation between the infiltrate density of CD4^+,CD8^+,CD20^+,and CD68^+lymphocytes and clinic-pathological characteristics.Significantly better prognosis was observed in patients with high CD4^+-TILs(DFS:P=0.005,OS:P=0.021)and high CD8^+-TILs(DFS:P=0.018)and low CD20^+-TILs(OS:P=0.042).Further analysis showed that patients with CD4^+/CD20^+ratio greater than 1(DFS:P=0.001,OS:P=0.002)or CD8^+/CD20^+ratio greater than 1(DFS:P=0.009,OS:P=0.022)had a better prognosis.Conclusions:Subtypes of TILs in RT is a potential predictive biomarker of survival in TNBC patients after NAC.

A Retrospective Survival Analysis of Anatomic and Prognostic Stage Group Based on the American Joint Committee on Cancer 8th Edition Cancer Staging Manual in Luminal B Human Epidermal Growth Factor Receptor 2-negative Breast Cancer

Background： Current understanding of tumor biology suggests that breast cancer is a group of diseases with different intrinsic molecular subtypes. Anatomic staging system alone is insufficient to provide future outcome information. The American Joint Committee on Cancer （AJCC） expert panel updated the 8th edition of the staging manual with prognostic stage groups by incorporating biomarkers into the anatomic stage groups. In this study, we retrospectively analyzed the data from our center in China using the anatomic and prognostic staging system based on the AJCC 8th edition staging manual. Methods： We reviewed the data from January 2008 to December 2014 for cases with Luminal B Human Epidermal Growth Factor Receptor 2 （HER2）-negative breast cancer in our center. All cases were restaged using the AJCC 8th edition anatomic and prognostic staging system. The Kaplan-Meier method and log-rank test were used to compare the survival differences between different subgroups. SPSS software version 19.0 （IBM Corp., Armonk, NY, USA） was used for the statistical analyses. Results： This study consisted of 796 patients with Luminal B HER-negative breast cancer. The 5-year disease-free survival （DFS） of 769 Stage I-III patients was 89.7%, and the 5-year overall survival （OS） of all 796 patients was 91.7%. Both 5-year DFS and 5-year OS were significantly different in the different anatomic and prognostic stage groups, There were 372 cases （46.7%） assigned to a different group. The prognostic Stage II and III patients restaged from anatomic Stage III had significant differences in 5-year DFS （v2 = 11.319; P = 0.001） and 5-year OS （χ2 = 5.225, P = 0.022）. In addition, cases restaged as prognostic Stage I, II, or III from the anatomic Stage II group had statistically significant differences in 5-year DFS （χ2 = 6.510, P = 0.039） but no significant differences in 5-year OS （χ2 = 5.087, P = 0.079）. However, the restaged prognostic Stage I and II cases from anatomic Stage I had no statistically significant differences in either 5-year DFS （χ2 = 0.440, P = 0.507） or 5-year OS （χ2= 1.530, P = 0.216）. Conclusions： The prognostic staging system proposed in the AJCC 8th edition refines the anatomic stage group in Luminal B HER2-negative breast cancer and will lead to a more personalized approach to breast cancer treatment.

Retrospective analysis of sentinel lymph node biopsy using methylene blue dye for early breast cancer

Background:Methylene blue is the most commonly used tracer for sentinel lymph node(SLN)biopsy(SLNB)in China.This study aimed to investigate the feasibility of clinical application of SLNB using methylene blue dye(MBD)for early breast cancer and the prognosis of patients with different SLN and non-SLN statuses.Methods:We retrospectively analyzed the clinicopathological data of patients with early breast cancer treated at the Peking University First Hospital between 2013 and 2018.We calculated the SLN identification rate(IR)in SLNB with MBD and the false-negative rate(FNR),and analyzed the prognosis of patients with different SLN and non-SLN statuses using Kaplan-Meier curves.Results:Between January 2013 and December 2018,1603 patients with early breast cancer underwent SLNB with MBD.The SLN IR was 95.8%(1536/1603).Two SLNs(median)were detected per patient.There were significant differences in FNR between patients with SLN micrometastasis and macrometastasis(19.0%vs.4.5%,χ^(2)=12.771,P<0.001).Chi-square test showed that there were significant differences in SLN successful detection rates among patients with different vascular tumor embolism status(96.3%vs.90.8%,χ^(2)=9.013,P=0.003)and tumor(T)stages(96.6%vs.94.1%,χ^(2)=5.189,P=0.023).Multivariate analysis showed that vascular tumor embolism was the only independent factor for SLN successful detection(odds ratio:0.440,95%confidence interval:0.224-0.862,P=0.017).Survival analysis showed a significant difference in disease-free survival(DFS)between patients with non-SLN metastasis and patients without non-SLN metastasis(P=0.006).Conclusion:Our single-center data show that,as a commonly used tracer in SLNB in China,MBD has an acceptable SLN IR and a low FNR in frozen sections.This finding is consistent with reports of dual tracer-guided SLNB.Positive SLNs with non-SLN metastasis are associated with DFS.

Chinese breast cancer surgery:clinical practice and research

According to GLOBOCAN 2018,the global cancer statistic database by the International Agency for Research on Cancer,breast cancer is the most commonly diagnosed cancer in women.[1]In 2018,more than 2 million new breast cancer cases were reported,with an age standardized rate(ASR)of 46.3 per 100,000,and over 600,000 deaths from breast cancer were estimated,with an ASR of 13.0 per 100,000,worldwide.The number of breast cancer cases continues to increase.In China,more than 270,000 new cases were diagnosed in 2015,with 70,000 reported deaths.[2]In 2018,the number of new cases in the country increased to 367,900.[1]Thus,we urgently need more clinical researches and expert consensus on optimal therapies for breast cancer.

Clinicopathologic analysis of 722 breast cancer patients who met the inclusion criteria of the TAILORx trial

Background:The results of the Trial Assigning IndividuaLized Options for Treatment(TAILORx)suggested that approximately 70%of T1-2N0M0,hormone receptor-positive,human epidermal growth factor receptor 2(HER2)-negative breast cancer patients can avoid chemotherapy and receive only adjuvant endocrine therapy.We conducted a retrospective analysis of the clinicopathologic features and prognostic factors of patients with breast cancer who met the inclusion criteria of the TAILORx trial.Methods:According to the enrollment criteria of the TAILORx trial,a retrospective analysis was performed on patients with breast cancer who were treated from January 2008 to December 2015 at Peking University First Hospital.The clinicopathologic characteristics of all patients were analyzed,and prognoses were calculated using the Kaplan-Meier method and a Cox proportionate hazards model.Results:A total of 2430 patients with early stage breast cancer who were admitted at our hospital had complete clinicopathologic data and follow-up information.Of these patients,722 met the inclusion criteria and were enrolled in the present study,accounting for 29.7%of all patients.Among them,417(57.8%)patients received only adjuvant endocrine therapy(the non-chemo group),and 305(42.2%)patients received adjuvant chemotherapy followed by adjuvant endocrine therapy(the chemo group).No statistically significant difference was observed in overall survival(OS)between the two groups(non-chemo vs.chemo:5-year OS:97.9%vs.97.9%,χ^2=1.00,P=0.995;hazard ratio[HR]=1.00,95%confidence interval[CI]:0.46–2.21).A significant difference was observed in disease-free survival(DFS)between the two groups(non-chemo vs.chemo:5-year DFS:97.9%vs.94.7%,χ^2=8.65,P=0.003;HR=3.05,95%CI:1.40–6.67).The choice of adjuvant therapy was associated with clinicopathologic factors,such as the age at diagnosis,T stage,histologic grade,the Ki67 index,the presence of intravascular tumor thrombus(P<0.001),pathologic type,and menstrual status(P=0.014).Conclusions:In the absence of internationally recognized multigene testing methods,for patients with early hormone receptorpositive,HER2-negative breast cancer,clinicians can develop a treatment plan based on clinicopathologic features only,which can effectively screen some patients who do not need adjuvant chemotherapy.However,nearly half of patients still receive adjuvant chemotherapy,and whether these patients can be exempted from chemotherapy warrants further exploration.

Re-examination of the standardization of colon cancer surgery

The standardization of colon cancer surgery has been an area of intense interest.The recent establishment of the complete mesocolic excision(CME)technique has defined the operative approach for colon cancer surgeries and enabled the collection of high-quality oncological specimens for histopathological evaluation.Standard for the Diagnosis and Treatment of Colorectal Cancer(2010),issued by the Ministry of Health of China,has provided legal bases for the treatment of colorectal cancers.However,certain confusions remain due to lack of detailed guidelines for operations.This raised the key question:‘‘What is the standardized colon cancer surgery?’’The present study re-examined the core ideas of General Rules for Clinical and Pathological Studies on Cancer of the Colon,Rectum and Anus(seventh edition)published by the Japanese Society for Cancer of the Colon and Rectum.CME-related studies published in English academic journals between April 2009 and July 2012 were surveyed and analysed.Several technical issues related to the requirement of R0 resection were analysed,including the theoretical basis for the safety range of bowel resection and the rational determination of the range of regional lymph node dissection.