How Often Does Neoadjuvant Chemotherapy Avoid Axillary Dissection in Patients With Histologically Confirmed Nodal Metastases? Results of a Prospective Study

Abstract

Background In breast cancer patients with nodal metastases at presentation, false-negative rates <10% have been demonstrated for sentinel node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) when ≥3 negative sentinel nodes (SLNs) are retrieved, but the frequency with which axillary dissection (ALND) can be avoided is uncertain. Methods Among 534 prospectively identified consecutive patients with clinical stage II–III cancer receiving NAC from 11/2013–11/2015, all biopsy-proven node-positive (N+) cases were identified. Patients who were clinically node-negative post-NAC were SLNB-eligible. ALND was indicated for failed mapping, <3 SLNs retrieved, or positive SLNs. Results Of 288 N+ patients, 195 completed surgery. 132/195 (68%) were SLNB-eligible. Of these, median age was 50yrs, 73(55%) were ER+, 21(16%) ER−/HER2+, 38(29%) triple negative. SLNB was deferred intraoperatively in 4 cases. Among 128 SLNB attempts, ≥3 SLNs were retrieved in 110 (86%), 1–2 SLNs in 15(12%), 3 (2%) failed mapping. ALND was indicated in 66 cases: 54(82%) for positive SLNs, 9(14%) for <3 negative SLNs, 3(4%) for failed mapping. 17% with <3 negative SLNs retrieved had persistent disease. 62/128 (48%) had SLNB alone with ≥3 SLNs retrieved. Among 195 N+ patients completing surgery, nodal pathologic complete response (pCR) was achieved in 49%, ranging from 21% in ER+/HER2− to 97% in ER−/HER2+ cases, and was significantly more common than breast pCR in ER+/HER2− and triple-negative cases. Conclusions Nearly 70% of N+ patients were SLNB-eligible post-NAC. ALND was avoided in 48%, supporting the role of NAC in reducing the need for ALND among patients presenting with nodal metastases.

Prospective Clinical Trial of 18F-Fluciclovine PET/CT for Determining the Response to Neoadjuvant Therapy in Invasive Ductal and Invasive Lobular Breast Cancers

“…Only 2 of 6 primary ILC malignancies demonstrated a 100% reduction in 18 F-fluciclovine avidity, and both demonstrated a complete pathologic response. ILC is known to have a lower rate of a pathologic complete response after neoadjuvant therapy than IDC, although this pattern may be secondary to ILC tumors more commonly expressing ER1/HER22 receptor status, a phenotype that has a lower rate of a pathologic complete response (29,30). This pattern appeared in our small dataset.…”

Sentinel lymph node biopsy and neoadjuvant chemotherapy in the management of early breast cancer: Safety considerations and timing

“…hot and/or blue nodes, and must not be randomly sampled. Mamtani et al [16] investigated patients with histologically proven node-positive disease who underwent NACT; 68.0% turned clinically node-negative and were eligible for SLNB. Of 128 SLNB attempts, ≥3 sentinels were identified in 86.0%, and 48.0% were histologically node-negative and spared an ALND.…”

“…Hormone receptor-positive patients are less likely to achieve pCR than those with triple-negative or human epidermal growth factor receptor 2 (HER2)-positive breast cancer, highlighting the importance of patient selection. [15,16] With the addition of targeted therapy in HER2-positive patients, the conversion rates have increased to >70%. [18] Besides the prognostic implications of evaluating response, the use of NACT has the attractive potential to increase axilla-preserving surgical therapy by reducing the need for ALND in patients who are node-negative after NACT.…”

Sentinel lymph node biopsy in breast cancer patients treated with induction chemotherapy should be performed after the completion of chemotherapy

“…It must be remembered that the main objective of preoperative chemotherapy, apart for guaranteeing the possibility of BCT, is to avoid axillary lymphadenectomy. A few studies have shown that the pCR rate within the lymph nodes after preoperative chemotherapy, especially in the following phenotypes: triple--negative and HER2-positive, amounts to 40-50% [16][17][18] (Tab. I).…”

“…I). What is important, axillary lymphadenectomy may be avoided in about 50% of patients with SLN biopsy, confirmed with pCR, after pre-operative chemotherapy especially that the majority of them, an account of the baseline metastatic involvement of the axillary lymph nodes, will undergo radiotherapy of the nodal fields [8,[16][17][18] (www.oncoconferences.ch/BCC). This fits to the generally accepted tendency to limit axillary lymphadenectomies in breast cancer patients [www.oncoconferences.ch/BCC].…”