Role of axillary lymph node dissection after tumor downstaging with induction chemotherapy for locally advanced breast cancer

Kuerer, Henry Mark; Newman, Lisa A.; Fornage, Bruno D.; Dhingra, Kapil; Hunt, Kelly K.; Buzdar, Aman U.; Ames, F. C.; Ross, Merrick I.; Feig, Barry W.; Hortobágyi, Gabriel N.; Singletary, S. Eva

doi:10.1007/bf02303476

Cited by 72 publications

(48 citation statements)

References 27 publications

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“…In fact, although we have recently shown that the sensitivity of axillary ultrasonography is significantly better than that of physical examination in detecting residual nodal disease after neoadjuvant chemotherapy, the overall sensitivity and specificity of axillary ultrasound were only 62% and 70%, respectively. 28 One alternative to axillary dissection in patients found to have a clinically negative axilla after neoadjuvant chemotherapy and who are appropriate candidates for breast conservation would be to add an additional radiation field to control subclinical axillary disease. 29 Randomized data from the NSABP B-04 trial established that simple mastectomy plus axillary irradiation is equivalent to radical mastectomy with respect to survival in patients with a clinically negative axilla.…”

Section: Discussionmentioning

confidence: 99%

Incidence and Impact of Documented Eradication of Breast Cancer Axillary Lymph Node Metastases Before Surgery in Patients Treated With Neoadjuvant Chemotherapy

et al. 1999

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ObjectiveTo determine the incidence and prognostic significance of documented eradication of breast cancer axillary lymph node (ALN) metastases after neoadjuvant chemotherapy. Summary Background DataNeoadjuvant chemotherapy is the standard of care for patients with locally advanced breast cancer and is being evaluated in patients with earlier-stage operable disease. MethodsOne hundred ninety-one patients with locally advanced breast cancer and cytologically documented ALN metastases were treated in two prospective trials of doxorubicin-based neoadjuvant chemotherapy. Patients had breast surgery with level I and II axillary dissection followed by additional chemotherapy and radiation treatment. Nodal sections from 43 patients who were originally identified as having negative ALNs at surgery were reevaluated and histologically confirmed to be without metastases. An additional 1112 sections from these lymph node blocks were obtained; half were stained with an anticytokeratin antibody cocktail and analyzed. Survival was calculated using the Kaplan-Meier method. ResultsOf 191 patients with positive ALNs at diagnosis, 23% (43 patients) were converted to a negative axillary nodal status on histologic examination (median number of nodes removed ϭ 16). Of the 43 patients with complete axillary conversion, 26% (n ϭ 11) had N1 disease and 74% (n ϭ 32) had N2 disease. On univariate analysis, patients with complete versus incomplete histologic axillary conversion were more likely to have initial estrogenreceptor-negative tumors, smaller primary tumors, and a complete pathologic response in the primary tumor. The 5-year disease-free survival rates were 87% in patients with preoperative eradication of axillary metastases and 51% for patients with residual nodal disease after neoadjuvant chemotherapy. Of the 39 patients with complete histologic conversion for whom nodal blocks were available, occult nodal metastases were found in additional nodal sections in 4 patients (10%). At a median follow-up of 61 months, the 5-year disease-free survival rates were 87% in patients without occult nodal metastases and 75% in patients with occult nodal metastases. ConclusionsNeoadjuvant chemotherapy can completely clear the axilla of microscopic disease before surgery, and occult metastases are found in only 10% of patients with a histologically negative axilla. The results of this study have implications for the potential use of sentinel lymph node biopsy as an alternative to axillary dissection in patients treated with neoadjuvant chemotherapy.

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Section: Discussionmentioning

confidence: 99%

Incidence and Impact of Documented Eradication of Breast Cancer Axillary Lymph Node Metastases Before Surgery in Patients Treated With Neoadjuvant Chemotherapy

et al. 1999

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“…Kuerer et al showed that, among 30 of 163 patients (19%) treated with PST using FAC (5-fluorouracil, cyclophosphamide, and doxorubicin), 19 (63%) also had pathologically negative axilla compared with 33% or less of those with less than pCR in the breast [39]. They also showed that in those with a positive axillary FNA at diagnosis, 23% were found at surgery after PST to have pCR in the axilla, but the negative predictive value of clinical exam plus ultrasonography after PST was quite limited (~50%) [40,41].…”

Section: Predictive Factorsmentioning

confidence: 99%

Preoperative Therapy in Breast Cancer: Lessons from the Treatment of Locally Advanced Disease

Wolff

Davidson

2002

The Oncologist

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The greater use of screening has changed the stage distribution of breast cancer, and an increasing number of patients are diagnosed with earlier stages of the disease. Still, locally advanced breast cancer (LABC) remains a major clinical problem in the United States and a common presentation in many parts of the world. There is no standard definition of LABC. One commonly used includes patients with large primary tumors greater than 5 cm (T3) or with skin/chest wall involvement (T4), and/or fixed axillary (N2) or ipsilateral internal mammary (N3) lymph node involvement. According to the tumor node metastasis staging, these usually include stage IIIa (T0-2N2 or T3N1-2) and stage IIIb (T4Nx or TxN3) disease. Inflammatory breast cancer (T4d) is included in most classifications despite its distinct clinical behavior and worse prognosis overall, but it serves as an example of combined modality intervention. Historically, the term LABC has been applied to those clinical presentations where the disease is considered inoperable. However, these therapeutic principles (including preoperative or primary systemic therapy [PST]) are increasingly being applied to patients presenting with tumors greater than 5 cm and negative lymph nodes (stage IIb-T3N0) or even smaller tumors, who are considered to have operable disease and a better outcome than those traditionally classified as having LABC. PST is increasingly being used in otherwise operable stage I and II patients aiming at greater rates of breast conservation and earlier efficacy assessment. This article reviews many of these issues and ongoing research questions. The Oncologist 2002;7:239-245 The Oncologist 2002;7:239-245 www.TheOncologist.comCorrespondence: Antonio C. Wolff, M.D., The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Bunting-Blaustein Cancer Research Building, Room 189, 1650 Orleans Street, Baltimore, Maryland 21231-1000 Fax: 410-955-0125; e-mail: awolff@jhmi.edu Received December 21, 2001; accepted for publication February 4, 2002. ©AlphaMed Press 1083-7159/2002 The Oncologist ® Mayo Clinic Hematology/Oncology Reviews LEARNING OBJECTIVESAfter completing this course, the reader will be able to:1. Better understand the current state of the art of managing patients with locally advanced breast cancer.2. Understand how primary, preoperative systemic treatment might be incorporated into the management of patients with early stage breast cancer.3. Understand the status of ongoing and recently completed clinical trials in this important area of multi-modality patient care.Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com CME CME

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“…NAC has also been shown to effectively downstage the axilla [12][13][14]. At present, the use of SLNB after NAC remains highly controversial.…”

Section: Introductionmentioning

confidence: 98%

The feasibility and accuracy of sentinel lymph node biopsy in clinically node‐negative patients after neoadjuvant chemotherapy for breast cancer—a systematic review and meta‐analysis

Tan

Goh

Fook‐Chong

et al. 2011

Journal of Surgical Oncology

116

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The sentinel lymph node biopsy (SLNB) is now an accepted alternative to the axillary lymph node dissection for pathologic evaluation of the axilla in patients with early breast cancer. The use of SLNB after neoadjuvant chemotherapy (NAC) is controversial. This meta-analysis aims to determine the feasibility and the accuracy of SLNB in the population of patients who are clinically node-negative after NAC for breast cancer.

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Role of axillary lymph node dissection after tumor downstaging with induction chemotherapy for locally advanced breast cancer

Cited by 72 publications

References 27 publications

Incidence and Impact of Documented Eradication of Breast Cancer Axillary Lymph Node Metastases Before Surgery in Patients Treated With Neoadjuvant Chemotherapy

Incidence and Impact of Documented Eradication of Breast Cancer Axillary Lymph Node Metastases Before Surgery in Patients Treated With Neoadjuvant Chemotherapy

Preoperative Therapy in Breast Cancer: Lessons from the Treatment of Locally Advanced Disease

The feasibility and accuracy of sentinel lymph node biopsy in clinically node‐negative patients after neoadjuvant chemotherapy for breast cancer—a systematic review and meta‐analysis

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