Surgical Management of the Axilla in Clinically Node-Positive Patients Receiving Neoadjuvant Chemotherapy: A National Cancer Database Analysis
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The feasibility of sentinel lymph node biopsy (SLNB) in patients with clinically node-positive (cN+) disease who convert to clinically node-negative (cN0) disease following neoadjuvant chemotherapy (NAC) has been evaluated in several large clinical trials, but it remains unclear whether the approach has been broadly adopted in the United States.
The National Cancer Database was used to identify women diagnosed with cN+ breast cancer who received NAC followed by surgery between 2012 and 2015. Trends in axillary surgery were evaluated and multivariable logistic regression analyses performed to determine factors associated with receipt of SLNB.
Of 12,965 women cN+ at baseline, the use of SLNB increased from 31.8% in 2012 to 49% in 2015 (p < 0.001). Using axillary pCR as a surrogate for patients who convert to cN0 following NAC, among 5127 (39.5%) ypN0 patients, SLNB increased from 38.2 to 58.4% over the study period (p < 0.001), resulting in avoidance of axillary dissection in 42.2% of ypN0 patients by 2015. In adjusted analyses, factors significantly associated with SLNB attempt included cN1 disease, age < 45 years, treatment facility type, triple-negative and HER2-positive subtypes, and year of diagnosis. In women with residual isolated tumor cells (ITCs), micrometastases, and ypN1 disease, SLNB was the only axillary procedure performed in 36.9%, 23.6%, and 13.0% of cases.
The use of SLNB in cN+ patients receiving NAC increased significantly between 2012 and 2015. SLNB alone was performed in more than 10% of patients with ypN1 disease, 20% with micrometastases, and 35% with ITCs; the oncologic safety of omitting axillary dissection in these patients requires further evaluation.
The authors have no relevant conflicts of interest to disclose. This study was supported by the Breast Cancer Research Foundation.
- 10.Boughey JC, Ballman KV, Le-Petross HT, et al. Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 2016;263:802–7.CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Caudle AS, Bedrosian I, Milton DR, et al. Use of sentinel lymph node dissection after neoadjuvant chemotherapy in patients with node-positive breast cancer at diagnosis: practice patterns of American Society of Breast Surgeons Members. Ann Surg Oncol. 2017;24:2925–34.CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Caudle AS, Yang WT, Krishnamurthy S, et al. Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 2016;34:1072–8.CrossRefPubMedPubMedCentralGoogle Scholar
- 19.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.CrossRefPubMedGoogle Scholar
- 21.van Nijnatten TJA, Simons JM, Smidt ML, et al. A novel less-invasive approach for axillary staging after neoadjuvant chemotherapy in patients with axillary node-positive breast cancer by combining radioactive iodine seed localization in the axilla with the sentinel node procedure (RISAS): A Dutch Prospective Multicenter Validation Study. Clin Breast Cancer. 2017;17:399–402.CrossRefPubMedGoogle Scholar
- 23.Mamounas EP, White JR, Bandos H, et al. NSABP B-51/RTOG 1304: Randomized phase III clinical trial evaluating the role of postmastectomy chest wall and regional nodal XRT (CWRNRT) and post-lumpectomy RNRT in patients (pts) with documented positive axillary (Ax) nodes before neoadjuvant chemotherapy (NC) who convert to pathologically negative Ax nodes after NC. J Clin Oncol. 2014;32:TPS1141-1.Google Scholar
- 27.NCCN Guidelines Version 3.2018 Breast Cancer. Published October 25, 2018. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed 11 Nov 2018.