Sentinel Lymph Node Biopsy in Breast Cancer Patients With Pathological Complete Response in the Axillary Lymph Node After Neoadjuvant Chemotherapy

Abstract

Purpose Sentinel lymph node biopsy (SLNB) alone following neoadjuvant chemotherapy (NAC) remains controversial in patients with breast cancer who are initially lymph node-positive. The present study aimed to evaluate the impact of SLNB and axillary lymph node dissection (ALND) on breast cancer recurrence and survival in patients who converted from lymph node-positive to pathological node-negative (ypN0) after NAC. Methods This single-center retrospective study included 223 patients who converted to axillary lymph node-negative status after NAC and underwent breast and axillary surgery between January 2006 and December 2015. This study compared the overall survival (OS), disease-free survival (DFS), ipsilateral axillary lymph node recurrence rates and incidence of postoperative complications, especially, arm lymphedema and shoulder stiffness between SLNB and ALND. Results This study included 223 patients with axillary pathological complete response (pCR) after NAC and surgery. The SLNB and ALND groups included 94 and 129 patients, respectively. The median follow-up time was 57 (range, 6–155) in the SLNB group and 99 (range 2–159) months in the ALND group. The corresponding 5-year OS and DFS rates were 96.3% and 94.2% ( p = 0.392), and 89.2% and 86.4% ( p = 0.671), respectively. Four patients (4.3%) in the SLNB group and nine (7.0%) in the ALND group developed locoregional recurrences. Ipsilateral axillary lymph node recurrence and distant metastasis were observed in one (1.1%) and three (2.3%) patients, and in 10 (10.6%) and 11 (8.5%) patients, respectively. Patients in the ALND group were more likely than their SLNB counterparts to experience complications, such as shoulder stiffness (9 [7.0%] vs. 4 [4.3%] patients, p = 0.57). The rate of lymphedema in the ALND group was three times that in the SLNB group (35 [27.1%] vs. 8 [8.5%] patients, p < 0.001). Conclusion As an alternative to ALND, SLNB has oncological safety in patients with axillary pathological complete response after NAC.

Axillary lymph node recurrence following wire‐directed sentinel lymph node dissection for breast cancer patients with biopsy‐proven axillary metastases prior to neoadjuvant chemotherapy at a safety net medical center

“…These findings confirm those of four previously published retrospective studies in which pre‐NAC biopsies were obtained demonstrating the presence of axillary lymph node metastases 8,10–12 (Table 4). Our findings are in agreement with another three studies where pretreatment axillary lymph node biopsies were not done, but the patients were ycN0 before SLND after NAC 9 or ypN0 at the time of SLND 13,14 . Of the 1631 patients presented in Table 4, including the 62 from the current series, 793 (49%) were ypN0 post‐NAC and had SLND alone.…”

“…6,7 More recent retrospective studies have shown that these patients have low levels of axillary lymph node recurrence when treated with SLND alone, suggesting that for many patients treated with NAC, completion ALND may not improve clinical outcomes. [8][9][10][11][12][13][14] The primary aim of this study was to determine the rate of axillary lymph node recurrence for patients who had pretreatment biopsy-proven axillary node metastases, were clinically nodenegative (ycN0) after NAC and had wire-directed (WD) SLND. The hypothesis was that patients rendered pathologically nodenegative (ypN0) by NAC do not benefit from a completion ALND to minimize the posttreatment risk of recurrence in ipsilateral axillary lymph nodes.…”

“…The FNR was reduced with the use of image guidance and dual tracers during SLND 6,7 . More recent retrospective studies have shown that these patients have low levels of axillary lymph node recurrence when treated with SLND alone, suggesting that for many patients treated with NAC, completion ALND may not improve clinical outcomes 8–14 …”

Oncologic outcomes in breast cancer patients with metastatic nodes and pathological nodal response following neoadjuvant chemotherapy without axillary dissection: a literature review

“…Radiotherapy details were not explicitly reported in some studies and if reported, it was unclear in 4 studies ( 11 , 21 , 22 , 24 ) how many of these patients specifically received axillary radiotherapy.…”

“…After excluding these 7 studies, 15 studies with 1,515 eligible patients (range, 29-242 patients) (10,11,(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) were analysed in this review (Table 2). All studies were retrospective in nature except for a study which was prospective (26).…”