Axillary Nodal Management Following Neoadjuvant Chemotherapy

Pilewskie, Melissa; Morrow, Monica

doi:10.1001/jamaoncol.2016.4163

Cited by 210 publications

(150 citation statements)

References 53 publications

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“…Amongst surgeons who have incorporated SLND into their practice, there is significant variation in techniques employed to minimize the FNR. 18–21 The goal of this study was to determine surgeon familiarity with the trials and to determine if and how they have incorporated the results into their practice. We also sought to identify barriers and issues that have contributed to lack of acceptance of the trial results, which might elucidate opportunities for future studies.…”

mentioning

confidence: 99%

Use of Sentinel Lymph Node Dissection After Neoadjuvant Chemotherapy in Patients with Node-Positive Breast Cancer at Diagnosis: Practice Patterns of American Society of Breast Surgeons Members

et al. 2017

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Background The accuracy of sentinel lymph node dissection (SLND) in clinically node-positive patients who receive neoadjuvant chemotherapy has been investigated in clinical trials. This survey was designed to assess familiarity and impact of these trial findings into practice. Methods American Society of Breast Surgeons members were invited by e-mail to complete an anonymous online survey. 642 members responded (21% of 3090 eligible members). Results were summarized as proportions based on the number of responses to each question. Results Respondents indicated knowledge of the Z1071 (86%), SENTINA (57%), and SN-FNAC (39%) trials. The published false negative rates (FNR) of the trials were correctly reported by 53% (336/638) of respondents. Before the trials, 45% (285/636) offered SLND compared to 85% (543/638) after the trials. In the 556 respondents who reported knowledge of at least one trial, 310 (56%) currently offer SLND to >50% of patients, 175 (31%) offer to <50%, and 70 (13%) routinely perform axillary lymph node dissection. Respondents who reported knowledge of the trials but did not change their practice to incorporate SLND (n=67) cited concerns over lack of outcome data (64%), worries about FNR (42%), lack of resources (34%), or objections from radiation oncologists (25%), medical oncologists (18%), or other surgeons (8%). Conclusions The publication of trials evaluating SLND in clinically node positive patients has resulted in changes in practice. Concerns over the FNR and lack of outcome data limit incorporation of SLND into practice by some surgeons.

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confidence: 99%

Use of Sentinel Lymph Node Dissection After Neoadjuvant Chemotherapy in Patients with Node-Positive Breast Cancer at Diagnosis: Practice Patterns of American Society of Breast Surgeons Members

et al. 2017

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“…Studies report good rates of nodal pathologic complete response (pCR). The rate of pCR depends on tumor subtype, ranging from 40% to 60% overall, and approaching 70%‐80% among patients with triple‐negative and HER2‐amplified tumors . Current NCCN guidelines endorse the use of post‐NACT SLNB for axillary staging in patients with cN + disease who convert to clinically node‐negative following systemic therapy.…”

Section: Discussionmentioning

confidence: 99%

Axillary dissection in patients with preoperative positive nodal cytology: Genuine need or overtreatment?

et al. 2019

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Recent studies demonstrated the possibility to avoid axillary dissection (ALND) in selected patients with one or two metastatic nodes. Otherwise, patients with positive nodal ultrasound‐guided fine‐needle aspiration cytology (US‐FNAC) currently undergo ALDN. The aim of this study is to quantify the nodal burden in patients with positive US‐FNAC treated with ALND and to evaluate if clinical or pathological characteristics associated with low nodal involvement can be identified. This is a multicentric retrospective study involving 297 patients who underwent ALND because of a positive preoperative US‐FNAC. A total of 157 patients showed bulky axillary lymph nodes at diagnosis, and 70% of them had three or more metastatic nodes. One hundred and forty patients had a clinically negative axilla and in 50% of them, 4 or more metastatic nodes were found with axillary dissection. Overall, the median number of metastatic nodes was 5. Favorable pathological characteristics of tumors were found in patients with only one or two metastatic nodes: smaller primary tumor, a lower proportion of grade 3, invasive lobular carcinomas and a higher proportion of low‐Ki67 tumors. In the group of patients with clinically negative axilla and potentially meeting ACOSOG Z0011 criteria, 22 (31%) showed less than three metastatic axillary nodes. A preoperative positive axillary FNAC is associated with a metastatic nodal burden significantly higher than in patients with positive sentinel lymph node biopsy (SLNB). Nevertheless, about 30% of patients with cN0 axilla, positive axillary FNAC performed because of suspicious nodes on imaging, T1‐2 primary tumor and breast‐conserving surgery showed less than three metastatic axillary nodes, thus meeting ACOSOG Z0011 trial's criteria and therefore would be eligible for skipping ALND according to current guidelines.

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“…It is recommended for patients with inflammatory carcinoma and for those with large lesions, allowing for downstaging and breast conservation instead of mastectomy when appropriate. It can also decrease nodal burden, allowing for sentinel lymph node biopsy to be performed rather than axillary lymph node dissection and, importantly, provide information about the efficacy of tumor response to the chemotherapy regimen . It is now also common practice to prescribe neo‐adjuvant chemotherapy and targeted therapies for patients with triple‐negative disease, HER2+ lesions, high proliferative rate, or poorly differentiated cancers due to well‐described high rates of pathologic complete response of 30%‐40% …”

Section: Recent Advancesmentioning

confidence: 99%

The ongoing evaluation and evolution of breast cancer surgical care

Ferstenberg

Julian

2020

Breast J

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Surgery has always been the backbone of breast cancer management. Throughout the past century, there have been great advances in chemotherapy regimens, especially in the neo‐adjuvant setting. As a result of this progress, a patient's disease can be potentially down‐staged and thus surgical intervention can therefore be de‐escalated for the breast as well as the axilla. Current clinical trials are evaluating the role of imaging and core needle biopsy as predictive tools for the efficacy of neo‐adjuvant chemotherapy. Results from these trials may help to clarify how the intricate relationship among imaging, pathology, radiotherapy, and surgery will affect the future management of patients undergoing neo‐adjuvant chemotherapy for invasive breast cancer.

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Axillary Nodal Management Following Neoadjuvant Chemotherapy

Cited by 210 publications

References 53 publications

Use of Sentinel Lymph Node Dissection After Neoadjuvant Chemotherapy in Patients with Node-Positive Breast Cancer at Diagnosis: Practice Patterns of American Society of Breast Surgeons Members

Use of Sentinel Lymph Node Dissection After Neoadjuvant Chemotherapy in Patients with Node-Positive Breast Cancer at Diagnosis: Practice Patterns of American Society of Breast Surgeons Members

Axillary dissection in patients with preoperative positive nodal cytology: Genuine need or overtreatment?

The ongoing evaluation and evolution of breast cancer surgical care

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