Is Preoperative Axillary Imaging Beneficial in Identifying Clinically Node-Negative Patients Requiring Axillary Lymph Node Dissection?

Pilewskie, Melissa; Jochelson, Maxine S.; Gooch, Jessica C.; Patil, Sujata; Stempel, Michelle

doi:10.1016/j.jamcollsurg.2015.11.013

Cited by 74 publications

(39 citation statements)

References 26 publications

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“…We have previously published on rates of ALND among women with cN0 disease with abnormal axillary imaging when treated according to Z0011 and found that ALND was only required in 30% of those with an abnormal axillary ultrasound. 27 This is in contrast to data published by Barrio et al 28 who reported on cN0 patients with abnormal axillary imaging who underwent NAC and found that 40% of those with an upfront abnormal axillary ultrasound required ALND post-NAC. In addition, 23% of women who were cN0 without abnormal axillary imaging prior to NAC were pathologically node positive following NAC.…”

Section: Discussionmentioning

confidence: 70%

The Optimal Treatment Plan to Avoid Axillary Lymph Node Dissection in Early-Stage Breast Cancer Patients Differs by Surgical Strategy and Tumor Subtype

et al. 2017

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Background Strategies to reduce the likelihood of axillary lymph node dissection (ALND) include application of Z0011 or use of neoadjuvant chemotherapy (NAC). Indications for ALND differ by treatment plan and nodal pathologic complete response rates following NAC vary by tumor subtype. ALND rates in patients with cT1-2N0 tumors undergoing upfront surgery were compared to those treated with NAC. Methods ALND rates among cT1-2N0 breast cancer patients were compared by tumor subtype among women undergoing upfront surgery to NAC. Multivariable analysis controlling for age, cT stage, lymphovascular invasion, and stratified by subtype was performed. Results 1944 cancers in 1907 women who underwent SLN biopsy +/− ALND were identified (669 upfront breast-conserving surgery [BCS], 1004 upfront mastectomy, 271 NAC). Compared to the NAC group, ALND rates in the BCS group were lower for ER/PR+ HER2− tumors (15% versus 34%, p<.001). ALND rates in the upfront mastectomy group were higher than the NAC group among HER2+ or TN tumors. On multivariable analysis, receipt of NAC compared to upfront BCS remained significantly associated with higher odds of ALND in the ER/PR+, HER2− subtype (HR 3.35, p<.001), while NAC versus upfront mastectomy remained significantly associated with lower odds of ALND in the HER2+ and TN subtypes (HR HER2+ 0.19, p<.001; HR TN 0.25, p=0.007). Conclusion ALND rates differ according to surgery type and tumor subtype secondary to differing ALND indications and nodal response to NAC. These factors can be used to personalize treatment planning in order to minimize ALND risk in early-stage breast cancer patients.

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Section: Discussionmentioning

confidence: 70%

The Optimal Treatment Plan to Avoid Axillary Lymph Node Dissection in Early-Stage Breast Cancer Patients Differs by Surgical Strategy and Tumor Subtype

et al. 2017

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“…21 However, the role of axillary imaging in cN0 patients meeting ACOSOG Z0011 criteria has been questioned. We have previously demonstrated that the identification of abnormal nodes on preoperative imaging 22 or even a positive needle biopsy 23 does not reliably identify a group of patients who require ALND when ACOSOG Z0011 eligibility criteria are otherwise met. While BMI has been not been shown to impact the sensitivity of axillary ultrasound 24-26 , our data suggest that obesity itself is not an indication for additional axillary evaluation.…”

Section: Discussionmentioning

confidence: 99%

Impact of Body Mass Index on Clinical Axillary Nodal Assessment in Breast Cancer Patients

et al. 2016

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Background Over one-third of American adults are obese, and an elevated body mass index (BMI) has been postulated to reduce the sensitivity of the clinical evaluation of the axilla. Clinical nodal exam is important in allocating breast cancer patients to appropriate axillary management. We sought to determine whether BMI influences the rate of nodal positivity in women designated clinically node negative (cN0) by physical examination. Methods Breast cancer patients deemed cN0 who underwent sentinel lymph node biopsy (SLNB) from 2/2006–12/2011 were identified from a prospectively maintained database. Clinicopathologic features including BMI and axillary surgery results were recorded and compared among pathologically node-negative and node-positive patients. Results Overall, 5142 cN0 patients underwent 5262 SLNB procedures during the study period. Nearly one-third (28%) of patients were obese (BMI>30kg/m2). A positive SLN was identified in 25% of patients; 84% proceeded to axillary lymph node dissection. Predictors of SLN positivity included younger age, larger tumor size, high nuclear grade, multifocality, and lymphovascular invasion. An increased BMI did not correlate with a higher likelihood of SLN positivity (p=0.6). The likelihood of cN0 patients having a high burden of axillary metastases (>3 positive nodes) was 4% overall and, similarly, did not differ according to BMI (p=0.4). Conclusion Elevated BMI was not associated with a higher likelihood of SLN positivity or heavy nodal disease burden among women staged as cN0 by physical exam. These findings indicate that physical examination is appropriate and sufficient for preoperative axillary evaluation in women undergoing initial surgery regardless of patient BMI.

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“…Nonetheless, a judicious use of, as well as interpretation of, US-guided axillary staging is required when deciding on the surgical management of the axilla. As established by the ACOSOG Z0011 trial, further treatment is not required in certain patients with one or two positive axillary nodes, and the mere presence of abnormal nodes on imaging in clinically node-negative patients is not a reliable indicator of the need for ALND (12). …”

Section: Invasive Breast Cancer Clinically Node Positivementioning

confidence: 99%

Current Management of the Axilla

McCartan

Gemignani²

2016

Clinical Obstetrics &Amp; Gynecology

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Despite advances in estimating prognosis and predicting response to adjuvant systemic therapy, the status of the axillary lymph nodes remains a critical component in initial surgical planning and in determining therapeutic strategies for patients with breast cancer. Buoyed by evidence from multi-institutional randomized clinical trials, the last two decades have witnessed remarkable and practice-changing advances in our approach to the axilla. This review concentrates on the current best practice in axillary management for both node-negative and node-positive patients with particular focus on the evolving management of the axilla in the era of neoadjuvant systemic therapy.

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Is Preoperative Axillary Imaging Beneficial in Identifying Clinically Node-Negative Patients Requiring Axillary Lymph Node Dissection?

Cited by 74 publications

References 26 publications

The Optimal Treatment Plan to Avoid Axillary Lymph Node Dissection in Early-Stage Breast Cancer Patients Differs by Surgical Strategy and Tumor Subtype

The Optimal Treatment Plan to Avoid Axillary Lymph Node Dissection in Early-Stage Breast Cancer Patients Differs by Surgical Strategy and Tumor Subtype

Impact of Body Mass Index on Clinical Axillary Nodal Assessment in Breast Cancer Patients

Current Management of the Axilla

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