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Sökning: id:"swepub:oai:DiVA.org:oru-85079" > Axillary Staging in...

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FältnamnIndikatorerMetadata
00009273naa a2200673 4500
001oai:DiVA.org:oru-85079
003SwePub
008200826s2020 | |||||||||||000 ||eng|
0247 a https://urn.kb.se/resolve?urn=urn:nbn:se:oru:diva-850792 URI
0247 a https://doi.org/10.1245/s10434-020-08630-32 DOI
040 a (SwePub)oru
041 a engb eng
042 9 SwePub
072 7a vet2 swepub-contenttype
072 7a art2 swepub-publicationtype
1001 a Karakatsanis, Andreasu Department for Surgical Sciences, Faculty of Medicine, Uppsala University and Section for Breast Surgery, Uppsala University Hospital, Uppsala, Sweden4 aut
2451 0a Axillary Staging in the Setting of a Preoperative Diagnosis of Ductal Cancer In Situ (DCIS) :b Results of an International Expert Panel and a Critical Guideline Performance Using Frequentist and Bayesian Analysis
264 c 2020-05-30
264 1b Springer,c 2020
338 a print2 rdacarrier
520 a Background/Objective: Sentinel lymph node biopsy (SLNB) is not routine in DCIS. Guidelines suggest SLNB when there is high risk for underlying invasion (large size, high grade, symptomatic lesion) or for detection failure (e.g., after mastectomy). However, guidelines and current practice patterns are inconsistent. Moreover, whilst SLNB is thought to be feasible and accurate after wide local excision (WLE), there is less consensus to support its use after oncoplastic breast-conserving surgery (OPBCS), which can reduce the need for mastectomy (Mx) and is gradually adopted as standard of care. The study aim was to assess if guidelines or individualized assessment result in optimal selection of patients for upfront SLNB.Methods: A panel of 28 international experts (20 surgeons, 8 oncologists, Europe 20, USA 5, Asia/Australia 3) was formed, all blind to the identity of the others. They reviewed anonymized patient cases from the SentiNot study (n=184, m. age 60 years, DCIS m. size 4 cm, Grade 2/3= 36%/64%, mass lesions 13,4%, underlying invasion 24.5%) and answer if they would consider upfront SLNB and why. Consensus and majority were set to >75 and >50%. At the same time, 6 independent raters (4 surgeons, 2 oncologists) reviewed guidelines and assessed the same patient cases per each guideline. Accuracy in relation to underlying invasion was assessed by Receiver Operating Characteristic (ROC) curves and Area Under the Curve (AUC) was reported. Agreement was investigated by kappa statistics and decision-making patterns by logistic multivariate regression and cluster analysis. To allow for flexibility and adaptation to current knowledge, both a frequentist and a Bayesian approach were undertaken. Priors were adjusted after a literature review regarding the factors that are commonly thought to be associated with higher risk for underlying invasion.Results: A total of 44,896 decisions were retrieved and analysed. The panel reached consensus/majority for upfront SLNB in 41.3/61.4%, whereas individual rates ranged from 11 to 100%. Agreement among panelists was low (kappa=0.37). In multivariate regression analysis for the entire panel, type of surgery was the most common determinant, (simple WLE=less, OPBCS=more and Mx=constant for SLNB), followed by symptomatic diagnosis and DCIS size. Most (26) members had a clear decision-making pattern regarding SLND, based mainly on DCIS size and type of surgery. Individual decision-making performed modestly in identifying patients with underlying invasion (AUC range 0,47-0,59), resulting mainly in overtreatment in 44-77% of patients. The panel performed similarly by majority (AUC 0,5) and by consensus (AUC 0,55) but “undertreated” 60-75% of patients with invasion, failing to identify them as "high-risk." After the recognition of different decision-making patterns, panelists were divided in subgroups with similar decision-making pattern. Analysis identified subgroups with difference in SLNB rate but not with better AUC. The disagreement among panelists in the same subgroups was significant, not only regarding which patients should undergo SLNB, but also on what factors that recommendation was based on. Eight guidelines with relevant recommendations were identified [USA (ASCO/NCCN), Europe (ESMO), Sweden, Denmark, UK, Netherlands and Italy, retrieval date May 2019]. Agreement among raters for each guideline separately varied (kappa: 0.23-0.9). Interpretation as to whether SLNB should be performed ranged widely (40-90%) and with varying concordance (32-88%). No guideline demonstrated accuracy (AUC range 0.45-0.55). Overtreatment risk was high (50-90%), whereas 10-50% of patients with invasion were not identified as “high- risk.” Agreement across guidelines was low (kappa=0.24), meaning that different patients had similar risk to be treated inaccurately, regardless of which guideline was examined.Conclusions: Individualized decision-making and guideline interpretation may be highly subjective and with low accuracy in terms of prediction of invasive disease, resulting in almost random risk for over- or undertreatment of the axilla in patients with DCIS. This suggests that current views and guidelines should be challenged. More accurate preoperative workup and novel techniques to allow for delayed SLNB may be of value in this setting.
650 7a MEDICIN OCH HÄLSOVETENSKAPx Klinisk medicinx Cancer och onkologi0 (SwePub)302032 hsv//swe
650 7a MEDICAL AND HEALTH SCIENCESx Clinical Medicinex Cancer and Oncology0 (SwePub)302032 hsv//eng
7001 a Foukakis, Theodorosu Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden4 aut
7001 a Karlsson, Peru Sahlgrenska Academy / Sahlgrenska University Hospital, Gothenburg, Sweden4 aut
7001 a Mamounas, Eleftheriosu Orlando Health UF Health Cancer Center, Orlando FL, USA4 aut
7001 a Chagpar, Aneesu Yale University School of Medicine, New Haven CT, USA4 aut
7001 a Boyages, Johnu Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia4 aut
7001 a Rubio, Isabelu Navarra University Clinic, Madrid, Spain4 aut
7001 a Naume, Bjørnu Oslo University Hospital, Oslo, Norway4 aut
7001 a Mauri, Davideu Faculty of Medicine, University of Ioannina, Ioannina, Greece4 aut
7001 a van der Wall, Elskenu University Medical Center Utrecht, Utrecht, Netherlands4 aut
7001 a Shah, Chiragu Taussig Cancer Institute, Cleveland Clinic, Cleveland OH, USA4 aut
7001 a Kwong, Avau The University of Hong Kong, Queen Mary and Tung Wah Hospital and The University of Hong Kong-ShenZhen Hospital, Hong Kong4 aut
7001 a McAuliffe, Priscillau Women's Cancer Research Center, Magee-Womens Research Institute, University of Pittsburgh, UPMC Hillman Cancer Center, Division of Surgical Oncology, Department of Surgery, Pittsburgh PA, USA4 aut
7001 a Gentilini, Oresteu IRCCS San Raffaele, Milan, Italy4 aut
7001 a Ignatiadis, Michailu Institut Jules Bordet and Université Libre de Bruxelles (ULB), Brussels, Belgium4 aut
7001 a Schlichting, Ellenu Oslo University Hospital, Oslo, Norway4 aut
7001 a Zgajnar, Janezu Institute of Oncology Ljubljana, Ljubljana, Slovenia4 aut
7001 a Meani, Francescou Lugano Hospital, Lugano, Switzerland4 aut
7001 a Tasoulis, Marios Konstantinosu Royal Marsden Hospital, London, United Kingdom4 aut
7001 a Whitworth, Patu Nashville Breast Center, Nashville TN, USA4 aut
7001 a Weber, Walteru Basel University Hospital, Basel, Switzerland4 aut
7001 a Charalampoudis, Petrosu University College London Hospitals, London, United Kingdom4 aut
7001 a Gulluoglu, Bahadiru Marmara University Hospital, Istanbul, Turkey4 aut
7001 a Pistioli, Lidau Institute of Clinical Sciences- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden4 aut
7001 a Tvedskov, Tove Filtenborgu Rigshospitalet, Copenhagen, Denmark4 aut
7001 a Leidenius, Marjutu Helsinki University Central Hospital, Helsinki, Finland4 aut
7001 a Mann, Bruceu The University of Melbourne, Melbourne, Australia4 aut
7001 a Witkamp, Arjenu University Medical Center Utrecht, Utrecht, Netherlands4 aut
7001 a Wyld, Lyndau University of Sheffield, Sheffield, United Kingdom4 aut
7001 a di Micco, Rosau IRCCS San Raffaele, Milan, Italy4 aut
7001 a Markopoulos, Christosu National and Kapodistrian University, Athens, Greece4 aut
7001 a Valachis, Antonis,d 1984-u Örebro universitet,Institutionen för medicinska vetenskaper,Region Örebro län4 aut0 (Swepub:oru)asvs
7001 a Wärnberg, Fredriku Uppsala University, Uppsala, Sweden4 aut
7102 a Department for Surgical Sciences, Faculty of Medicine, Uppsala University and Section for Breast Surgery, Uppsala University Hospital, Uppsala, Swedenb Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden4 org
7730 t Annals of Surgical Oncologyd : Springerg 27:Suppl. 2, s. S337-S338q 27:Suppl. 2<S337-S338x 1068-9265x 1534-4681
8564 8u https://urn.kb.se/resolve?urn=urn:nbn:se:oru:diva-85079
8564 8u https://doi.org/10.1245/s10434-020-08630-3

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