Neo‐adjuvant chemotherapy and axillary de‐escalation management for patients with clinically node‐negative breast cancer

Abstract

This study aimed to explore the optimal time of sentinel lymph node biopsy (SLNB) and neo‐adjuvant chemotherapy (NAC) and to assess the feasibility of selective elimination of axillary surgery after NAC in clinically node‐negative (cN0) patients. From April 2010 to August 2018, 845 patients undergoing surgery after NAC were included in this retrospective study to analyze the correlation between different clinicopathological characteristics of cN0 patients and negative axillary lymph node after NAC (ypN0). Among the 148 cN0 patients, 83.1% (123/148) were ypN0. The rates of ypN0 in patients with hormone receptor positive (HR+)/HER2−, HR+/HER2+, HR−/HER2+, and triple‐negative (TN) breast cancer were 75.4% (46/61), 82.6% (19/23), 85.2% (23/27), and 94.6% (35/37), respectively (P < 0.001). The rates of ypN0 in TN and HER2+ patients were 94.6% and 95.5%, which were significantly higher than that in HR+/HER2− patients (P < 0.05). Molecular subtypes, clinical stage, radiologic complete response, and pathologic complete response (bpCR) of the breast tumor correlated with ypN0 after full‐course NAC (P < 0.05). Molecular subtypes (OR = 2.374, P = 0.033), clinical stage (OR = 0.320, P = 0.029), and bpCR (OR = 0.454, P = 0.012) were independent predictors for ypN0. The optimal time of SLNB and NAC in cN0 patients might be different among different molecular subtypes: it would be preferable to perform SLNB prior to NAC for HR+/HER2− patients, and SLNB after NAC for TN and HER2+ patients to reduce the risk of axillary lymph node dissection. In view of the high ypN0 rate in cN0 patients, axillary surgical staging might be selectively eliminated, especially for HER2+ and TN patients.

Association between tumor molecular subtype, clinical stage and axillary pathological response in breast cancer patients undergoing complete pathological remission after neoadjuvant chemotherapy: potential implications for de-escalation of axillary surgery

“…Consistent with our findings, they also found molecular subtype (OR = 2.37, p = 0.033) to be an independent predictor for ypN0 after full-course NAT. 22 In our study, both the highest breast pCR and ypN0 rates were found in HER2-positive patients, and the lowest pCR rates were found in the HR-positive/HER2-negative subgroup. Multivariate analysis showed that molecular subtype was significantly associated with ypN status only in breast pCR patients, and not in the breast non-pCR population.…”

“…A similar pattern across tumor subtypes was found in one of our previous studies assessing breast pCR and ypN0 rates separately. 8 In addition, in a cohort of 148 cN0 patients treated with neoadjuvant chemotherapy, Shi et al 22 observed that the ypN0 rates were significantly higher in HER2-positive (95.5%) and triple-negative (94.6%) breast cancer patients, compared with HR-positive/HER2-negative patients ( p < 0.05). Consistent with our findings, they also found molecular subtype (OR = 2.37, p = 0.033) to be an independent predictor for ypN0 after full-course NAT.…”

Axillary management for patients with breast cancer after neoadjuvant chemotherapy: Results of a survey among Brazilian breast surgeons

“…The risk for missing nodal metastasis in these subtypes is lower than in hormone‐positive tumors and concerns about FNR or even avoiding axillary surgery might be considered for hormone‐positive subtypes 20,21 . Patients diagnosed with TN and HER2 positive tumor and clinically negative‐node disease also benefit more from a de‐escalation of axillary surgery after chemotherapy demonstrating lower rates of positive SLNs 19,22 . New studies focusing on the influence of tumor molecular profiling in axilla management after NAC in Brazilian practice might better explain the knowledge of breast surgeons on the subject, and in which cases they are indicating SLNB.…”

Relationship Between Breast and Axillary Pathologic Complete Response According to Clinical Nodal Stage: A Nationwide Study From Korean Breast Cancer Society

“…Compared to HR-positive/HER2-negative disease, NACT is currently recommended in HER2-positive or TNBC cases, even in early BC [ 16 17 ]. Patients with initial cN0 or N1 and TNBC or HER2-positive breast cancer who achieve BpCR at surgery have a low risk of nodal metastasis ( Table 5 ) [ 12 13 18 19 20 21 22 ]. These findings are concordant with the results of the present study.…”