Excision of both pretreatment marked positive nodes and sentinel nodes improves axillary staging after neoadjuvant systemic therapy in breast cancer

Abstract

Background: Marking the axilla with radioactive iodine seed and sentinel lymph node (SLN) biopsy have been proposed for axillary staging after neoadjuvant systemic therapy in clinically node-positive breast cancer. This study evaluated the identification rate and detection of residual disease with combined excision of pretreatment-positive marked lymph nodes (MLNs) together with SLNs. Methods: This was a multicentre retrospective analysis of patients with clinically node-positive breast cancer undergoing neoadjuvant systemic therapy and the combination procedure (with or without axillary lymph node dissection). The identification rate and detection of axillary residual disease were calculated for the combination procedure, and for MLNs and SLNs separately. Results: At least one MLN and/or SLN(s) were identified by the combination procedure in 138 of 139 patients (identification rate 99⋅3 per cent). The identification rate was 92⋅8 per cent for MLNs alone and 87⋅8 per cent for SLNs alone. In 88 of 139 patients (63⋅3 per cent) residual axillary disease was detected by the combination procedure. Residual disease was shown only in the MLN in 20 of 88 patients (23 per cent) and only in the SLN in ten of 88 (11 per cent), whereas both the MLN and SLN contained residual disease in the remainder (58 of 88, 66 per cent).

Targeted Axillary Dissection in Node-Positive Breast Cancer: A Retrospective Study and Cost Analysis

“…Recently, Simons et al published a multicentric retrospective study on the combination of the MARI procedure and SLND in four hospitals in the Netherlands [ 19 ]. We noted important differences in the procedure compared to our study.…”

“…We noted important differences in the procedure compared to our study. First, there was a variability in the methodology: a guide wire was inserted in 51.1% of patients rather than an iodine-125 seed [ 19 ]. Second, the node was marked with either a clip or a seed only if proven metastatic, implying an additional procedure for all patients.…”

“…Simons et al reported differences in practices for the SLND procedure [ 19 ]. A dual-tracer method (technetium-99 and a blue dye) was not always used: one site performed SLND with technetium-99 or blue dye alone [ 19 ].…”

“…Simons et al reported differences in practices for the SLND procedure [ 19 ]. A dual-tracer method (technetium-99 and a blue dye) was not always used: one site performed SLND with technetium-99 or blue dye alone [ 19 ]. In the present study, we used a dual-tracer method, which is known to decrease the FNR of the procedure [ 11 ].…”

“…In the present study, we used a dual-tracer method, which is known to decrease the FNR of the procedure [ 11 ]. Also, we obtained a radiography of the specimen to ensure proper removal of the targeted node, whereas this was not routinely performed by Simons et al [ 19 ]. Lastly, immunohistochemistry was obtained in all cases in our study based on evidence showing increased detection of micrometastases [ 9 ].…”