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Annals of Surgical Oncology

, Volume 26, Issue 12, pp 3846–3855 | Cite as

Impact of Residual Nodal Disease Burden on Technical Outcomes of Sentinel Lymph Node Biopsy for Node-Positive (cN1) Breast Cancer Patients Treated with Neoadjuvant Chemotherapy

  • Alison Laws
  • Melissa E. Hughes
  • Jiani Hu
  • William T. Barry
  • Laura Dominici
  • Faina Nakhlis
  • Thanh Barbie
  • Margaret Duggan
  • Anna Weiss
  • Esther Rhei
  • Katharine Carter
  • Suniti Nimbkar
  • Stuart J. Schnitt
  • Tari A. KingEmail author
Breast Oncology

Abstract

Background

Recent trials have demonstrated the feasibility of sentinel lymph node biopsy (SLNB) for cN1 breast cancer patients after neoadjuvant chemotherapy (NAC). This study evaluated the technical outcomes of SLNB by residual nodal disease volume.

Methods

From a prospective database, cT1-3 cN1 patients receiving NAC and surgery from 2016 to 2017 were identified. Performance measures of post-NAC physical exam and imaging-based axillary assessment were compared. For the patients who converted to cN0 and underwent SLNB, adequate mapping (defined as ≥ 3 SLN) and the false-negative rate (FNR) of intraoperative SLN evaluation were assessed by residual nodal disease volume (ypN1-3 vs ypN0[i+]/ypN1mi vs ypN0).

Results

Of 156 cT1-3 cN1 patients, 96 converted to cN0 and underwent SLNB. Adequate mapping was achieved for 64 patients (66.7%) and was not associated with nodal volume (p = 0.12). The FNR of the intraoperative SLN evaluation was 37.8%, and smaller nodal volume was associated with FNR (p < 0.01). Of 36 patients (37.5%) who achieved an axillary pathologic complete response, 24 (66.7%) had three or more negative SLNs and were safely spared axillary lymph node dissection (ALND). The positive predictive values of physical exam versus imaging-based post-NAC nodal assessment were respectively 88% and 69.8%.

Conclusions

This study showed SLNB to be an effective tool for minimizing axillary surgery in cN1 patients treated with NAC. However, important technical limitations exist, such as inability to identify three SLNs in more than two-thirds of patients and high-false negative rates for intraoperative SLN evaluation, particularly for patients with small residual nodal volumes. Preoperative counseling should include realistic assessment of the potential need for ALND in this population.

Notes

Disclosure

There are no conflict of interest.

Supplementary material

10434_2019_7515_MOESM1_ESM.docx (17 kb)
Supplementary material 1 (DOCX 17 kb)

References

  1. 1.
    Cortazar P, Zhang L, Untch M, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet. 2014;384:164–72.CrossRefGoogle Scholar
  2. 2.
    Alvarado R, Yi M, Le-Petross H, et al. The role for sentinel lymph node dissection after neoadjuvant chemotherapy in patients who present with node-positive breast cancer. Ann Surg Oncol. 2012;19:3177–84.CrossRefGoogle Scholar
  3. 3.
    Boughey JC, Suman VJ, Mittendorf EA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455–61.CrossRefGoogle Scholar
  4. 4.
    Mamtani A, Barrio AV, King TA, et al. How often does neoadjuvant chemotherapy avoid axillary dissection in patients with histologically confirmed nodal metastases? Results of a prospective study. Ann Surg Oncol. 2016;23:3467–74.CrossRefGoogle Scholar
  5. 5.
    Dominici LS, Negron Gonzalez VM, Buzdar AU, et al. Cytologically proven axillary lymph node metastases are eradicated in patients receiving preoperative chemotherapy with concurrent trastuzumab for HER2-positive breast cancer. Cancer. 2010;116:2884–9.CrossRefGoogle Scholar
  6. 6.
    Fisher B, Bryant J, Wolmark N, et al. Effect of preoperative chemotherapy on the outcome of women with operable breast cancer. J Clin Oncol. 1998;16:2672–85.CrossRefGoogle Scholar
  7. 7.
    Bear HD, Anderson S, Smith RE, et al. Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2006;24:2019–27.CrossRefGoogle Scholar
  8. 8.
    Boileau JF, Poirier B, Basik M, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015;33:258–64.CrossRefGoogle Scholar
  9. 9.
    Kuehn T, Bauerfeind I, Fehm T, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013;14:609–18.CrossRefGoogle Scholar
  10. 10.
    Chang JM, Kosiorek HE, Wasif N, et al. The success of sentinel lymph node biopsy after neoadjuvant therapy: a single-institution review. Am J Surg. 2017;214:1096–101.CrossRefGoogle Scholar
  11. 11.
    Galimberti V, Ribeiro Fontana SK, Maisonneuve P, et al. Sentinel node biopsy after neoadjuvant treatment in breast cancer: five-year follow-up of patients with clinically node-negative or node-positive disease before treatment. Eur J Surg Oncol. 2016;42:361–8.CrossRefGoogle Scholar
  12. 12.
    Kang YJ, Han W, Park S, et al. Outcome following sentinel lymph node biopsy-guided decisions in breast cancer patients with conversion from positive to negative axillary lymph nodes after neoadjuvant chemotherapy. Breast Cancer Res Treat. 2017;166:473–80.CrossRefGoogle Scholar
  13. 13.
    Nguyen TT, Hoskin TL, Day CN, Degnim AC, Jakub JW, Hieken TJ, Boughey JC. Decreasing use of axillary dissection in node-positive breast cancer patients treated with neoadjuvant chemotherapy. Ann Surg Oncol. 2018;25:2596–602.CrossRefGoogle Scholar
  14. 14.
    King TA, Morrow M. Surgical issues in patients with breast cancer receiving neoadjuvant chemotherapy. Nat Rev Clin Oncol. 2015;12:335–43.CrossRefGoogle Scholar
  15. 15.
    Krag DN, Anderson SJ, Julian TB, et al. Technical outcomes of sentinel lymph node resection and conventional axillary lymph node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 2007;8:881–8.CrossRefGoogle Scholar
  16. 16.
    Liu LC, Lang JE, Lu Y, et al. Intraoperative frozen section analysis of sentinel lymph nodes in breast cancer patients: a meta-analysis and single-institution experience. Cancer. 2011;117:250–8.CrossRefGoogle Scholar
  17. 17.
    Veronesi U, Paganelli G, Galimberti V, et al. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet. 1997;349:1864–7.CrossRefGoogle Scholar
  18. 18.
    Chao C, Wong SL, Ackermann D, et al. Utility of intraoperative frozen section analysis of sentinel lymph nodes in breast cancer. Am J Surg. 2001;182:609–15.CrossRefGoogle Scholar
  19. 19.
    Weiser MR, Montgomery LL, Susnik B, Tan LK, Borgen PI, Cody HS. Is routine intraoperative frozen-section examination of sentinel lymph nodes in breast cancer worthwhile? Ann Surg Oncol. 2000;7:651–5.CrossRefGoogle Scholar
  20. 20.
    Comparison of axillary lymph node dissection with axillary radiation for patients with node-positive breast cancer treated with chemotherapy (ALLIANCE A011202) www.clinicaltrials.gov. Retrieved 22 February 2019 at https://clinicaltrials.gov/ct2/show/NCT01901094.
  21. 21.
    Boughey JC, Ballman KV, Hunt KK, et al. Axillary ultrasound after neoadjuvant chemotherapy and its impact on sentinel lymph node surgery: results from the American College of Surgeons Oncology Group Z1071 trial (Alliance). J Clin Oncol. 2015;33:3386–93.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Alison Laws
    • 1
  • Melissa E. Hughes
    • 2
    • 3
  • Jiani Hu
    • 4
  • William T. Barry
    • 4
  • Laura Dominici
    • 3
    • 5
  • Faina Nakhlis
    • 3
    • 5
  • Thanh Barbie
    • 3
    • 5
  • Margaret Duggan
    • 3
    • 5
  • Anna Weiss
    • 3
    • 5
  • Esther Rhei
    • 3
    • 5
  • Katharine Carter
    • 3
    • 5
  • Suniti Nimbkar
    • 3
    • 5
  • Stuart J. Schnitt
    • 6
  • Tari A. King
    • 3
    • 5
    Email author
  1. 1.University of CalgaryCalgaryCanada
  2. 2.Department of Medical OncologyDana-Farber Cancer InstituteBostonUSA
  3. 3.Breast Oncology ProgramDana-Farber/Brigham and Women’s Cancer CenterBostonUSA
  4. 4.Department of Data SciencesDana-Farber Cancer InstituteBostonUSA
  5. 5.Division of Breast Surgery, Department of SurgeryBrigham and Women’s HospitalBostonUSA
  6. 6.Department of PathologyBrigham and Women’s HospitalBostonUSA

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