Is it always necessary to perform an axillary lymph node dissection after neoadjuvant chemotherapy for breast cancer?

Abstract

Introduction Recent prospective studies support the feasibility of performing sentinel lymph node biopsy following neoadjuvant chemotherapy in initially fine-needle aspiration cytology or ultrasound-guided biopsy-proven node-positive breast cancer. The main aid is to identify preoperative features that help us predict a complete axillary response to neoadjuvant chemotherapy in these patients and thus select the candidates for sentinel lymph node biopsy post-neoadjuvant chemotherapy to avoid unnecessary axillary lymphadenectomy. Materials and methods A retrospective observational study with a total of 150 patients, biopsy-proven node-positive breast cancer who underwent neoadjuvant chemotherapy followed by breast surgery and axillary lymphadenectomy were included and retrospectively analysed. A predictive model was generated by a multivariate logistic regression analysis for pathological complete response-dependent variable. Results The response of the primary lesion to neoadjuvant chemotherapy according to post-treatment magnetic resonance imaging, Her2/neu overexpression and a low estrogen receptor expression are associated with a higher rate of nodal pathologically complete response. The multivariant model generated a receiver operating characteristic curve with an area under the curve of 0.79 and a confidence interval of 0.72–0.87 at a 95% level of significance. Conclusions This model could be a helpful tool for the surgeon to help in predicting which cases have a higher likelihood of achieving a pathologically complete response and therefore selecting those who may benefit from a post-neoadjuvant chemotherapy sentinel lymph node biopsy and avoid unnecessary axillary lymphadenectomy.

Is axillary lymph node dissection necessary for positive preoperative aspiration cytology lymph node results?

“…A Spanish study published in 2018 also investigated whether axillary lymph node dissection should be performed after neoadjuvant therapy in cases where an axillary lymph node is considered positive with aspiration cytology. 34 In cases showing a significant presence of the HER2 receptor and low expression of the oestrogen receptor, there is a high chance that complete pathological remission occurs, and in these cases, ALND was not recommended. Our analyses confirmed the same result.…”

The role of magnetic resonance imaging on evaluating response of neoadjuvant therapy for breast cancer

“…But the post-NAT MRI obtained a high negative predictive value (94% and 97.3%, respectively), which means that negative post-NAT MRI can accurately exclude the axillary lymph node diseases [101,102]. Before and during NAT, lymph node pCR can be predicted by negative hormone receptor and positive HER2 receptor status [103][104][105], lower clinical T and N stage [103], higher histological/nuclear grade [103], and treatment response to NAT of breast primary lesions [106,107]. According to the study by Osorio-Silla [77], 59.7% of patients with primary lesions complete response on MRI also achieved complete response on axillary lymph node, and 75.9% of patients with non-complete response of breast primary tumors on MRI had residual lymph node disease after surgery.…”

Role of MRI to Assess Response to Neoadjuvant Therapy for Breast Cancer

“…Several groups have found that adding MRI response of the primary tumor to clinicopathologic data achieves significantly better predictive power. [74][75][76][77] Ha et al trained an artificial intelligence algorithm to predict pCR in the axilla based on pretreatment MRI of the in-breast tumor alone, achieving an overall accuracy of 83%. 78 These models could improve prediction of axillary disease and allow better preoperative planning and patient counseling regarding surgical and radiation options.…”

“…Negative hormone receptor and positive HER2 receptor status, lower clinical T and N stages, high histologic/nuclear grade, and breast tumor response to neoadjuvant therapy are predictors for axillary pCR. Several groups have found that adding MRI response of the primary tumor to clinicopathologic data achieves significantly better predictive power 74–77 . Ha et al trained an artificial intelligence algorithm to predict pCR in the axilla based on pretreatment MRI of the in‐breast tumor alone, achieving an overall accuracy of 83% 78 .…”