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Axillary ultrasound for prediction of response to neoadjuvant therapy in the context of surgical strategies to axillary dissection in primary breast cancer: a systematic review of the current literature

Abstract

Purpose

Data on the optimal treatment strategy for patients undergoing neoadjuvant therapy (NAT) who initially presented with metastatic nodes and convert to node-negative disease (cN+ → ycN0) are limited. Since NAT leads to axillary downstaging in 20–60% of patients, the question arises whether these patients might be offered less-invasive procedures than axillary dissection, such as sentinel node biopsy or targeted removal of lymph nodes marked before therapy.

Methods

We performed a systematic review of clinical studies on the use of axillary ultrasound for prediction of response to NAT and ultrasound-guided marking of metastatic nodes for targeted axillary dissection.

Results

The sensitivity of ultrasound for prediction of residual node metastasis was higher than that of clinical examination and MRI/PET in most studies; specificity ranged in large trials from 37 to 92%. The diagnostic performance of ultrasound after NAT seems to be associated with tumor subtype: the positive predictive value was highest in luminal, the negative in triple-negative tumors. Several trials evaluated the usefulness of ultrasound for targeted axillary dissection. Before NAT, nodes were most commonly marked using ultrasound-guided clip placement, followed by ultrasound-guided placement of a radioactive seed. After chemotherapy, the clip was detected on ultrasound in 72–83% of patients; a comparison of sonographic visibility of different clips is lacking. Detection rate after radioactive seed placement was ca. 97%.

Conclusion

In conclusion, ultrasound improves prediction of axillary response to treatment in comparison to physical examination and serves as a reliable guiding tool for marking of target lymph nodes before the start of treatment. High quality and standardization of the examination is crucial for selection of patients for less-invasive surgery.

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MB-P: project development, data collection, data analysis, manuscript writing. IVG: data analysis, manuscript writing. AH: manuscript editing. PP: data collection, data analysis, manuscript writing. NK: data collection, data analysis, manuscript writing. MM: manuscript editing. SB: manuscript editing. MH: project development, data analysis, manuscript writing

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Banys-Paluchowski, M., Gruber, I.V., Hartkopf, A. et al. Axillary ultrasound for prediction of response to neoadjuvant therapy in the context of surgical strategies to axillary dissection in primary breast cancer: a systematic review of the current literature. Arch Gynecol Obstet 301, 341–353 (2020). https://doi.org/10.1007/s00404-019-05428-x

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  • DOI: https://doi.org/10.1007/s00404-019-05428-x

Keywords

  • Axillary ultrasound
  • Neoadjuvant therapy
  • Breast cancer
  • Therapy response
  • Targeted axillary dissection
  • Clipped lymph node