ASO Author Reflections: Future View: A Recent Scientific Contribution Towards a Staging Revision of Contralateral Axilla
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Future View: A Recent Scientific Contribution Towards a Staging Revision of Contralateral Axillary Lymph Node Metastases from Breast Cancer Francesca Magnoni, MD, PhD1
, and Mattia Intra, MD2
Division of Breast Cancer Surgery, European Institute of Oncology, IRCCS, Milan, Italy; 2Department of Surgery, European Institute of Oncology, IRCCS, Milan, Italy 1
PAST Contralateral axillary lymph node metastasis (CAM) is a rare clinical entity with a reported incidence of between 1.9 and 6%.1 Its origin may be related to the source of metastatic disease; as contralateral dissemination from primary breast cancer diagnosed during follow-up, for many years CAM has represented a debatable issue in breast cancer management, with unsure prognostic impact. It occurs after local treatment for breast cancer, in particular surgery and radiotherapy (RT), with metachronous or synchronous clinical detection.1 Traditionally, contralateral lymph nodes were considered a distant site and CAM was consequently classified as advanced breast cancer;2 therefore, CAM tended to be preferentially liable to palliative treatment. Likewise, in this context, prior to the 6th edition of the American Joint Commission on Cancer (AJCC) staging manual, ipsilateral supraclavicular lymph node metastasis in breast cancer patients without distant metastases was defined as M1 disease (stage IV).2 PRESENT Thanks to the results of the study by Brito et al.3, breast cancer metastases to an ipsilateral supraclavicular lymph node are now assigned an N3 status in the TNM system and have thus been reclassified as locoregional disease, i.e. stage III disease in the AJCC staging manual.4 On the
contrary, for CAM, the past still influences the present; CAM without distant metastases is currently assigned M1 status (stage IV) instead of N3 status (stage III)4 due to the paucity of retrospective studies on this topic. However, in the majority of published studies in the literature, CAM, particularly if metachronous, has been managed with curative intent rather than palliative intent, and is associated with a not so severe prognosis.5 Furthermore, a recent retrospective study evaluating outcome in locally advanced breast cancers with internal mammary chain or supraclavicular lymph node involvement demonstrated an improvement in outcome compared with that reported by previous analogous studies,6 likely due to the current multimodal systemic approach, underlining the importance of multidisciplinary treatment with curative intent of these N3 diseases. Aberrant lymphatic drainage after previous breast surgery or RT is, moreover, frequent, and, although observed in the literature in a small population, CAM survival is not comparable with distant disease.4 The literature reports that most patients received locoregional and systemic treatment, suggesting that CAM could be a regional event to be treated with curative purpose.5 At present, it remains controversial as to whether CAM, as first event of recurrence after the treatment
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