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Background and purpose: The incidence of deep venous thrombosis (DVT) for patients with breast cancer after surgery is 2.00%-6.40%. The purpose of this study was to evaluate the correlation between postoperative DVT complications and surgical timing in breast cancer patients with coronavirus disease 2019 (COVID-19) infection, in order to guide clinical decision-making. Methods: From December 20, 2022 to March 20, 2023, 317 patients with breast cancer diagnosed with COVID-19 and with signs and symptoms of infection turning negative in Shandong Institute of Cancer Prevention and Treatment (Shandong Cancer Hospital), Shandong First Medical University (Shandong Academy of Medical Sciences) were enrolled. The control group included 329 patients with breast cancer who underwent surgery between May 1, 2019 and September 30, 2019 in the same hospital. Patients were grouped according to the interval between the date of COVID-19 infection and the date of surgery, and the interval time and postoperative DVT occurrence were analyzed. Results: Among 317 patients with breast cancer who underwent surgery after COVID-19 infection, 17 (5.36%), 29 (9.15%), 31 (9.78%), 50 (15.78%) and 190 (59.90%) underwent surgery after 0-2, 3-4, 5-6, 7-8 and 8 weeks, respectively. The incidence of postoperative DVT was 11.76%, 3.45%, 3.23%, 6.00% and 1.58%, respectively. The incidence of postoperative DVT in 329 patients without COVID-19 infection was 1.21%, and the incidence of postoperative DVT in patients receiving operation within 2 weeks of COVID-19 infection was significantly higher (OR=10.556; 95% CI: 1.095-303.313, P=0.03), the incidence of postoperative DVT in patients undergoing operation 3-8 weeks following COVID-19 infection was 4.55%. Multivariate analysis showed that COVID-19 infection interval was an independent predictor of DVT (OR=2.795; 95% CI: 0.692-11.278, P=0.024). All 10 patients with DVT after breast cancer surgery were recovered without serious complications such as pulmonary embolism, and the follow-up adjuvant anti-tumor therapy was not affected after symptomatic treatment. Conclusion: The incidence of DVT after breast cancer surgery within 8 weeks of COVID-19 infection is significantly higher than that of uninfected patients, especially the incidence of DVT in patients undergoing surgery within 2 weeks of COVID-19 infection is as high as 11.76%. Elective surgery for breast cancer within 2 weeks of COVID-19 infection should be avoided. Although the incidence of DVT in patients undergoing surgery 3 weeks after COVID-19 infection is still slightly high, surgical treatment can be recommended considering the urgency of breast cancer treatment, the good prognosis of DVT and the lack of influence on subsequent adjuvant therapy. However, detailed records of COVID-19 infection history of patients, early prevention and close monitoring should be made, and postoperative DVT should be treated.

Background and purpose: With the increasing sensitivity of axillary imaging and ultrasound guided biopsy, some clinically axillary negative patients were upstaged to axillary positive (cN1) and received axillary lymph node dissection (ALND). This study aimed to assess the feasibility of sentinel lymph node (SLN) biopsy (SLNB) in patients with axilla negative evaluation by physical examination but suspicious lymph nodes finding on preoperative imaging and metastasis confirmed with a fine-needle aspiration cytology/core-needle biopsy pathology (FNAC/CNBP). Methods: This retrospective cohort study included patients with early breast cancer who had axilla negative evaluation by physical examination but suspicious lymph nodes finding on preoperative imaging and metastasis confirmed with a FNAC/CNBP from October 2015 to December 2022 in the Breast Cancer Centre of Shandong Cancer Hospital and Institute. All patients received ALND. The data were analyzed by using SPSS version 27.0 statistical software, and P

Background and purpose: Multiple guidelines and consensus have confirmed the feasibility of sentinel lymph node biopsy (SLNB) after neoadjuvant therapy (NAT) in clinical nodal positive (cN+) patients converting to negative after NAT. There are few studies on the metastasis of axillary lymph node (ALN) at each anatomic level after NAT. This study aimed to explore the metastasis of ALN in each anatomic level, in order to provide more basis for the axillary de-escalation management after NAT. Methods: From April 2018 to 2020, 499 patients in Shandong Cancer Hospital were enrolled in this study. Patients (n=157) with initial cN+ and ycN0 disease after NAT underwent SLNB plus axillary lymph node dissection (ALND). Patients (n=342) with initial cN+ and ycN+ disease after NAT had undergone ALND directly. At the same time, from May 2020 to December 2020, 46 patients with initial cN1 and ycN0 disease after NAT underwent targeted axillary dissection (TAD). These patients underwent clip insertion into the most suspicious ALN. Axillary surgery was performed with SLNB plus ALND. The ALN status at each anatomic level was analyzed. Results: Among the 499 patients, the incidence of ALN “skip metastasis” was 0.8% (4/499), similar to those patients without NAT, and it was 0.5% and 1.0% in SLNB group and directly ALND, respectively. Out of the sentinel lymph node (SLN)-positive patients after NAT, 41.4% of them had positive non-SLN (NSLN). Out of the SLN-negative patients after NAT, 10.1% of them had positive NSLNs, and the rates of positive NSLNs were 8.1% (5/62), 8.7% (2/23) and 21.3% (3/11) in cN1, cN2, and cN3 subgroups, respectively. In the cN1 subgroup, the NSLNs metastasis rate were 11.8% (4/34), 4.6% (1/22), and 0.0% (0/6) when patients had 1, 2, and 3 negative SLN, respectively. Among the 46 patients receiving TAD, if clips were inserted into the most suspicious ALNs and removed during surgery, the incidence of positive NSLN was 4.3% (2/46). The rates of positive NSLN were 5% (1/20), 5% (1/20), and 0% (0/6) when 1, 2, and 3 negative SLNs were detected, respectively, and it was not related to the number of detected negative SLN. Conclusion: ALND is still the standard axillary treatment in SLN-positive patients after NAT. For patient with initial cN1 and ycN0 disease after NAT, if clips were used to identify biopsied lymph nodes at diagnosis, the number of negative SLN might be no longer the requirement for SLNB to omit ALND after NAT.

Background and purpose: Internal mammary lymph node irradiation (IMNI) improves survival in patients with internal mammary lymph node (IMLN) high-risk metastatic breast cancer. The purpose of this study was to study the advantages of internal mammary sentinel lymph node (IMLN) biopsy (IM-SLNB) for assessing prognosis and directing individualized IMNI. Methods: This study evaluated patients recruited in three prospective clinical trials (NCT01642511, NCT03541278, and NCT03024463) from November 2011 to December 2021, assessed for prognostic risk variables based on IMSLN metastatic status and prognosis between subgroups. In patients who received regional lymph node irradiation, the implementation status, survival benefit, and influence of IMNI on radiation-induced lung injury (RILI) were studied. The primary endpoint was disease-free survival (DFS), with overall survival (OS) and RILI as secondary endpoints. Results: The study enrolled 537 patients and had a 60-month median follow-up. Patients with IMSLN metastasis had a significantly worse 5-year DFS and OS (DFS: 95.1% vs 71.4%, OS: 99.1% vs 90.1%, both P

Background and purpose: The modified injection technique developed in Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences has significantly improved the visualization rate of internal mammary sentinel lymph nodes (IMSLN), however there is still a gap between the visualization rate of IMSLN obtained by this technique and that of axillary sentinel lymph nodes (ASLN). The study aimed to further improve the IMSLN visualization rate and promote the widespread use of internal mammary sentinel lymph node biopsy (IM-SLNB) by optimizing the modified injection technique. Methods: A total of 159 patients with primary breast cancer were enrolled in a prospective group and divided into the optimized radiotracer technique group (group A, n=81) and the modified injection technique group (group B, n=78). In group A, 99mTc-sulfur colloid was injected averagely into parenchyma in the gland's three most abundant regions under ultrasound guidance (total radioactive intensity 1.0-1.3 mCi; 0.8-1.0 mL/point). In group B, 99mTc-sulfur colloid was injected averagely into the parenchyma of the breast at 6 and 12 points under ultrasound guidance (total radioactive intensity 1.0-1.3 mCi; 0.8-1.0 mL/point). Single photon emission computed tomography (SPECT)/computed tomography (CT) lymphoscintigraphy was performed preoperatively, and the sentinel lymph nodes were detected intraoperatively by γ probe. In this study, we evaluated the differences in IMSLN and ASLN visualization rates between the groups, and also analyzed the factors that may affect the IMSLN visualization rate. Results: There was no statistically significant difference in visualization rate of IM-SLN measured by preoperative SPECT/CT between the two groups (P=0.806). The intraoperative visualization rate of IM-SLN was significantly higher in group A than in group B (87.65% vs 70.51%, P=0.008). Analysis of subgroups showed that the intraoperative visualization rate of IMSLN was 92.31% and 83.33% (P=0.315) in group A patients aged ≤50 years and >50 years, respectively, and the intraoperative visualization rate of IMSLN was significantly higher in group B patients aged ≤50 years than in patients aged >50 years (81.58% vs 60.00%, P=0.037). The median in vitro radioactivity count of IMSLN was significantly higher in group A than in group B (160.50 vs 59.00, P=0.005). Conclusion: The optimized radiotracer technique can effectively increase the lymphatic drainage and uptake in the internal mammary region of the radiotracer, which can significantly improve the visualization rate of IM-SLN without affecting the visualization rate of ASLN, and is conducive to the promotion and application of IM-SLNB.

Regional lymph node status is one of the important prognostic indicators of breast cancer, which can guide the staging and adjuvant treatment strategy. Sentinel lymph node biopsy (SLNB) for breast cancer has developed rapidly over the past three decades, evidence-based medicine class Ⅰ evidence supports that SLNB is a safe and effective axillary staging technique for patients with clinically negative axillary lymph node in early breast cancer. The risk of axillary recurrence and complications in breast cancer patients with negative/few-positive sentinel lymph node omitting axillary lymph node dissection is very low. Locoregional management of breast cancer should consider the metastatic risk of the primary tumor, the efficacy and side effects of systemic therapy, and the efficacy and side effects of locoregional therapy (surgery/radiotherapy). This view has promoted the continuous expansion of the SLNB population. SLNB with neoadjuvant therapy and internal mammary SLNB will further promote the de-escalation therapy, and the ongoing studies of omission of axillary surgery should be anticipated. The era of precision medicine for regional lymph node management of breast cancer has gradually arrived with the development of SLNB. This article evaluated the latest progress of precise regional processing of breast cancer in the sentinel lymph node era, in order to provide reference for clinical doctors.