Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: the GANEA 2 study

Use of superparamagnetic iron oxide for sentinel lymph node detection following neoadjuvant systemic therapy. A systematic review and meta-analysis

Superparamagnetic iron oxide(SPIO) is used increasingly in sentinel lymph node(SLN) identification in breast cancer patients. Identification ratios in the upfront setting are comparable to that of radioisotope and blue dye(RI/BD). However, its use in the neoadjuvant(NACT) setting remains under debate. The aim of this study was to assess the outcomes of SPIO in breast cancer patients receiving NACT followed by surgery. A systematic review of major databases was performed. Studies examining SPIO compared to standard of care(RI/BD) for SLN detection after NACT were included. Primary outcomes included individual detection rate(nodal detection) and nodal detection rate (number of nodes detected). Trial Sequential Analysis (TSA) was performed to assess results certainty. Study quality was assessed using the MINORS tool for observational studies. Five studies involving 374 patients were included. Regarding individual detection rate, SPIO was successful in 308/314 patients and RI in 297/314 patients. Pooled individual detection rates for SPIO and RI were 98.1 % vs 94.6 %(weighted Risk Ratio 1.02,95 % CI 0.99,1.05,p = 0.18; I2 = 24.3 %). Four studies examined nodal detection rates. Within these studies, a total of 625 SLNs were retrieved with 569 detected with SPIO and 468 with RI(mean: 2.26 SLN for SPIO and 1.86 for RI) with a respective nodal detection rate of 91.0 % vs 74.9 %(weighted Risk Ratio:1.25,95 % CI 1.06,1.47,p < 0.001; I2 = 89.6). The median MINORS score was 19/24(range 14-24), denoting good quality. In patients treated with NACT, SPIO performed comparably to RI, but seems to identify more SLNs. Routine use of SPIO in the neoadjuvant setting should be considered safe and effective.

Omission of axillary dissection after neoadjuvant systemic treatment in initially node-positive HER2-overexpressed and triple-negative breast cancer patients: SENATURK OTHER-NAC study

BACKGROUND

More data is needed for those patients with aggressive tumor biology with a high recurrence risk for de-escalating axillary surgery in clinically N+ breast cancer. We, therefore, investigated the outcome in cN+ patients with HER2+ or triple-negative breast cancer who were treated with sentinel lymph node biopsy alone following neoadjuvant systemic treatment.

MATERIAL AND METHODS

Clinically N+ patients (cT1-4N1-3M0) with HER2+ and triple-negative breast cancer at admission and downstaged to cN0 with neoadjuvant systemic treatment were included in the study. All patients were treated with sentinel node biopsy alone without further axillary dissection but followed by regional nodal irradiation.

RESULTS

Of 259 patients, the pathologic complete response rate was 47.1 %. Overall, 171 (66 %) patients had HER2+ and 88 (34 %) had triple-negative cancer. Of 56 ypN+ patients, the lymph node metastases were macrometastases in 24 (42.9 %) patients. After a median follow-up of 46 months, irrespective of ypN status, isolated axillary, locoregional, and distant recurrence rates were 0.8 %, 2.7 %, and 7.7 %, respectively. Recurrence and disease-specific death rates were not different between HER2+ and triple-negative cancer as well as ypN+ and ypN0 patients. Advanced cT stage (cT3-4) was the only significant factor associated with poor disease-free and disease-specific survivals.

CONCLUSION

Irrespective of the final ypN status and tumor subtype, omission of axillary dissection resulted with low axillary recurrence rate in initially cN+ HER2+ and triple-negative breast cancer patients who were downstaged to cN0 with neoadjuvant systemic treatment and did not receive axillary dissection.

Radar reflectors for marking of target lymph nodes in initially node-positive patients receiving neoadjuvant chemotherapy for breast cancer-a subgroup analysis of the prospective AXSANA (EUBREAST-03) trial

BACKGROUND

Surgical staging procedures of the axilla in initially clinically node-positive (cN +) breast cancer patients receiving neoadjuvant chemotherapy (NACT) vary across countries. Different procedures such as axillary lymph node dissection, sentinel lymph node biopsy, target lymph node biopsy and targeted axillary dissection are currently in use. To date, data on radar reflectors as a non-wire and non-radioactive technique for marking target lymph nodes are limited. The present study aims at examining the detection rate, the rate of lost markers, and magnetic resonance imaging artifacts after TLN marking using a radar reflector before NACT in the largest available cohort of breast cancer patients enrolled in the international prospective AXSANA study.

METHODS

AXSANA (EUBREAST-03) is an international prospective cohort study including cN + patients managed with different surgical axillary staging techniques after NACT. Eligible patients have cT1-4c cN + breast cancer and receive neoadjuvant chemotherapy. Patients are followed up for 5 years. In the present subgroup analysis, only patients with a TLN marked by a radar reflector were included.

RESULTS

A TLN was marked by radar reflector insertion in 158 patients prior to NACT. Of these, 136 had final surgery results available at the time of analysis, and in 135 out of these 136 patients, localization of TLN was attempted. All radar markers were successfully removed. While lymphoid tissue corresponding to the TLN was identified in 132 patients (97.8%), no lymphoid tissue was detected on histopathology in three patients. It remains unclear whether the TLN was excised in these cases or not. In 1 out of 27 patients (3.7%) who underwent preoperative MRI, image assessment was compromised due to artifacts after radar marker placement.

CONCLUSION

To the best of our knowledge, this is the largest prospective series of patients receiving a radar reflector for the marking of a TLN prior to NACT for breast cancer. Our data demonstrate that radar reflectors are a reliable tool for marking target lymph nodes before neoadjuvant treatment.

TRIAL REGISTRATION NUMBER

NCT04373655 (date of registration May 4, 2020).

National Variation in Implementation of Sentinel Lymph Node Biopsy for Clinically Node-Positive Patients Undergoing Neoadjuvant Therapy

BACKGROUND

Sentinel lymph node biopsy (SLNB) is feasible in women with clinically node-positive breast cancer following neoadjuvant chemotherapy and a nodal pathologic complete response. Acceptable false negative rates are achieved through technical considerations such as removing three or more sentinel lymph nodes (SLNs); however, the variation that exists in adherence to this technique is unclear.

OBJECTIVE

This study aimed to evaluate recent trends in axillary surgery in women with cN1-cN2 disease who received neoadjuvant chemotherapy, adherence to removing three or more SLNs, and variation in SLN yield.

METHODS

We performed a cohort study using the National Cancer Database of women aged ≥18 years with cN1-cN2 disease who received neoadjuvant chemotherapy, including those without a pathologic complete response, from 2012 to 2020. Trends in axillary surgery and lymph node yield obtained during SLNB were evaluated.

RESULTS

The cohort included 67,365 women (median age 54 years). The number of patients receiving SLNB alone increased from 14 to 39%; SLNB with completion axillary lymph node dissection (ALND) increased from 17 to 30%; and ALND alone decreased from 69 to 27%. The rates of obtaining three or more SLNs during SLNB remained the same over time at 66%, while facility-level variation in obtaining three or more nodes ranged from 40 to 86%.

CONCLUSIONS

There has been de-escalation of axillary surgery with fewer patients undergoing ALND; however, overall there has been no significant change in the rates of obtaining three or more lymph nodes during SLNB following neoadjuvant chemotherapy, with significant facility-level variation observed.

Performance of sentinel lymph node biopsy after neoadjuvant chemotherapy in clinically node-positive breast cancer patients: systematic review and meta-analysis

BACKGROUND

The reliability of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NACT) in patients with initially node-positive breast cancer is still controversial. This meta-analysis is conducted to investigate the feasibility and accuracy of SLNB after NACT in patients with initially positive axillary nodes.

METHODS

We conducted a literature search using Medline, PubMed, Embase, Central, and SCOPUS up until April 2021 for studies on the performance of SLNB following NACT. We included prospective studies including breast cancer patients with positive lymph nodes at diagnosis and received NACT before undergoing SLNB irrespective of their molecular subtypes or stage. Our main outcomes of interest were the identification rate (IR) and the false negative rate (FNR) of SLNB.

RESULTS

We included an aggregate of 33 studies in this meta-analysis enrolling 4624 patients. The reported IR ranged from a minimum of 77.6% to a maximum of 100% and resulted in a pooled IR of 88% (95% confidence interval [CI]: 86-90, I2 : 80.9%). The FNR reported in the studies ranged from a minimum of 5.1% to a maximum of 43% and showed a pooled FNR of 13% (95% CI: 11-15, I2 : 72.31%). The subgroup analysis demonstrated that the usage of dual mapping technique could decrease the FNR and increase the IR. Moreover, the number of lymph nodes retrieved inversely correlated with FNR ( P < 0.01).

CONCLUSIONS

Our findings support the feasibility and accuracy of SLNB after NACT in initially node-positive breast cancer patients, that converted to clinically node-negative when performed in properly selected cases. SLNB offers a less invasive approach in selected patients sparing them the morbidity associated with ALND. This approach aligns with efforts to de-escalate surgical management in breast cancer and reinforces that SLNB post-NACT should be incorporated into clinical practice, provided that stringent patient selection and procedural standards are maintained.

De-Escalation of Nodal Surgery in Clinically Node-Positive Breast Cancer

Importance

Increasing evidence supports the oncologic safety of de-escalating axillary surgery for patients with breast cancer after neoadjuvant chemotherapy (NAC).

Objective

To evaluate the oncologic outcomes of de-escalating axillary surgery among patients with clinically node (cN)-positive breast cancer and patients whose disease became cN negative after NAC (ycN negative).

Design, Setting, and Participants

In the NEOSENTITURK MF-1803 prospective cohort registry trial, patients from 37 centers with cT1-4N1-3M0 disease treated with sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) alone or with ypN-negative or ypN-positive disease after NAC were recruited between February 15, 2019, and January 1, 2023, and evaluated.

Exposure

Treatment with SLNB or TAD after NAC.

Main Outcomes and Measures

The primary aim of the study was axillary, locoregional, or distant recurrence rates; disease-free survival; and disease-specific survival. Number of axillary lymph nodes removed was also evaluated.

Results

A total of 976 patients (median age, 46 years [range, 21-80 years]) with cT1-4N1-3M0 disease underwent SLNB (n = 620) or TAD alone (n = 356). Most of the cohort had a mapping procedure with blue dye alone (645 [66.1%]) with (n = 177) or without (n = 468) TAD. Overall, no difference was found between patients treated with TAD and patients treated with SLNB in the median number of total lymph nodes removed (TAD, 4 [3-6] vs SLNB, 4 [3-6]; P = .09). Among patients with ypN-positive disease, those who underwent TAD were more likely to have a lower median lymph node ratio (TAD, 0.28 [IQR, 0.20-0.40] vs SLNB, 0.33 [IQR, 0.20-0.50]; P = .03). At a median follow-up of 39 months (IQR, 29-48 months), no significant difference was found in the rates of ipsilateral axillary recurrence (0.3% [1 of 356] vs 0.3% [2 of 620]; P ≥ .99) or locoregional recurrence (0.6% [2 of 356] vs 1.1% [7 of 620]; P = .50) between the TAD and SLNB groups, with an overall locoregional recurrence rate of 0.9% (9 of 976). The initial clinical tumor stage, pathologic complete response, and use of blue dye alone as a mapping procedure were not associated with the outcome. Even though patients with TAD demonstrated an increased disease-free survival rate compared with the SLNB group, this difference did not reach statistical significance (94.9% vs 92.6%; P = .07). Factors associated with decreased 5-year disease-specific survival were cN2-3 axillary stage (cN1, 98.7% vs cN2-3, 96.8%; P = .03) and nonluminal type tumor pathologic characteristics (luminal, 98.9% vs nonluminal, 96.9%; P = .007).

Conclusions and Relevance

The short-term results suggest very low rates of axillary and locoregional recurrence in a select group of patients with cN-negative disease after NAC treated with TAD alone or SLNB alone followed by regional nodal irradiation regardless of the SLNB technique or nodal pathology. Whether TAD might provide a clear survival advantage compared with SLNB remains to be proven in studies with longer follow-up.

Risk of Surgical Overtreatment in cN1 Breast Cancer Patients who Become ypN0 After Neoadjuvant Chemotherapy: SLNB Versus TAD

BACKGROUND

Two surgical approaches have emerged for axillary staging in cN1 breast cancer patients after neoadjuvant chemotherapy (NAC): sentinel lymph node biopsy (SLNB) and targeted axillary dissection (TAD). Direct comparisons of technical and oncological outcomes with SLNB versus TAD are lacking.

METHODS

We routinely performed SLNB from 2017 to 2018 for cN1 breast cancer patients who converted to cN0 after NAC, then adopted TAD from 2019 to 2022. To minimize the false-negative rate (FNR), we required retrieval of ≥3 sentinel lymph nodes (SLN) (2017-2018) or retrieval of the clipped node (CN) and ≥2 SLN (2019-2022). In ypN0 cases meeting these criteria, axillary lymph node dissection (ALND) was omitted. We compared the rate of per-protocol required ALND due to technical failure of SLNB versus TAD and reported axillary recurrence rates.

RESULTS

Among 191 cN1 ypN0 patients, 77 underwent SLNB and 114 underwent TAD. The overall rate of required ALND due to technical failure was 14.7% and did not differ between SLNB versus TAD (16.9% vs. 13.2%, p = 0.38). The most common technical failure with SLNB was retrieving <3 SLN (10.4%); for TAD, it was not retrieving the CN (7.1%). Median follow-up was 3.9 years for SLNB patients and 1.7 years for TAD patients; there were 1 (1.3%) and 0 (0.0%) axillary recurrences, respectively.

CONCLUSIONS

Sentinel lymph node biopsy and TAD for cN1 patients after NAC showed equivalent technical failure rates and low axillary recurrence rates. When applying strict criteria to minimize FNR of axillary staging surgery, approximately 15% of ypN0 patients may be overtreated with ALND.

Identifying subgroups of ypN1 breast cancer patients who may exempt from axillary lymph node dissection after neoadjuvant chemotherapy: insights from a large cohort study

BACKGROUND

In patients with breast cancer staged ypN1 after neoadjuvant chemotherapy (NAC), there is limited evidence-based guidance regarding exemption from axillary lymph node dissection (ALND).

METHODS

This study analyzed ypN1 breast cancer patients post-NAC from the Surveillance, Epidemiology, and End Results databases. Patients were categorized into the breast-conserving surgery (BCS) group and the total mastectomy (TM) group, and further divided by the number of positive lymph nodes (LNs). The effects of three axillary management strategies, ALND, sentinel lymph node biopsy combined with radiotherapy (SLNB + RT), and ALND + RT were compared. The overall survival (OS) and breast cancer-specific survival (BCSS) of all subgroups and their independent risk factors were analyzed. Independent prognostic factors selected from multivariate Cox analysis were utilized to create nomograms for predicting OS and BCSS.

RESULTS

A total of 3641 patients were involved, with 1331 in the BCS group and 2310 in the TM group. In the TM group, patients with 3 residual positive LNs exhibited significant improvements in OS and BCSS when treated with ALND + RT. For patients with 1 or 2 residual positive LNs in the TM group and all BCS patients, no significant survival differences in survival outcomes were observed among the three axillary management methods. The accuracy of the nomograms was validated via calibration curves, receiver operating characteristic curves, and decision curve analysis curves.

CONCLUSION

For TM group patients with 3 residual positive LNs after NAC, ALND + RT is recommended. For other subgroups of ypN1 patients, SLNB + RT can be considered an alternative to ALND. The nomogram developed to predict OS and BCSS in ypN1 breast cancer patients demonstrated excellent predictive ability.

Nodal Burden and Oncologic Outcomes in Patients With Residual Isolated Tumor Cells After Neoadjuvant Chemotherapy (ypN0i+): The OPBC-05/ICARO Study

PURPOSE

The nodal burden of patients with residual isolated tumor cells (ITCs) in the sentinel lymph nodes (SLNs) after neoadjuvant chemotherapy (NAC) (ypN0i+) is unknown, and axillary management is not standardized. We investigated rates of additional positive lymph nodes (LNs) at axillary lymph node dissection (ALND) and oncologic outcomes in patients with ypN0i+ treated with and without ALND.

METHODS

The Oncoplastic Breast Consortium-05/ICARO cohort study (ClinicalTrials.gov identifier: NCT06464341) retrospectively analyzed data from patients with stage I to III breast cancer with ITCs in SLNs after NAC from 62 centers in 18 countries. The primary end point was the 3-year rate of any axillary recurrence. The rate of any invasive recurrence was the secondary end point.

RESULTS

In total, 583 patients were included, of whom 182 (31%) had completion ALND and 401 (69%) did not. The median age was 48 years. Most patients (74%) were clinically node-positive at diagnosis and 41% had hormone receptor-positive/human epidermal growth factor receptor 2-negative tumors. The mean number of SLNs with ITCs was 1.2. Patients treated with ALND were more likely to present with cN2/3 disease (17% v 7%, P < .001), have ITCs detected on frozen section (62% v 8%, P < .001), have lymphovascular invasion (38% v 24%, P < .001), and receive adjuvant chest wall (89% v 78%, P = .024) and nodal radiation (82% v 75%, P = .038). Additional positive nodes were found at ALND in 30% of patients, but only 5% had macrometastases. The 3-year rates of any axillary and any invasive recurrence were 2% (95% CI, 0.95 to 3.6) and 11% (95% CI, 8 to 14), respectively, with no statistical difference by type of axillary surgery.

CONCLUSION

The nodal burden in patients with ypN0(i+) was low, and axillary recurrence after ALND omission was rare in patients selected for this approach. These results do not support routine ALND in all patients with ypN0(i+).

Axillary lymph node metastasis in breast cancer: from historical axillary surgery to updated advances in the preoperative diagnosis and axillary management

Axillary lymph node status, which was routinely assessed by axillary lymph node dissection (ALND) until the 1990s, is a crucial factor in determining the stage, prognosis, and therapeutic strategy used for breast cancer patients. Axillary surgery for breast cancer patients has evolved from ALND to minimally invasive approaches. Over the decades, the application of noninvasive imaging techniques, machine learning approaches and emerging clinical prediction models for the detection of axillary lymph node metastasis greatly improves clinical diagnostic efficacy and provides optimal surgical selection. In this work, we summarize the historical axillary surgery and updated perspectives of axillary management for breast cancer patients.

Trends in Surgical Axillary Staging and Clinical Outcomes Among Breast Cancer Patients With Neoadjuvant Therapy: A Population-Based Cohort Study

OBJECTIVES

Surgical management of the axilla with neoadjuvant treatment has been a significant research focus over the past decade, resulting in numerous publications. The trends in surgical choices based on lymph node status and survival outcomes in large populations were previously unclear.

METHODS

Breast cancer patients who underwent neoadjuvant therapy were identified from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2021 and categorized into 2 cohorts: LN- (no lymph node metastasis) and LNm (1-2 sentinel node metastases). We analyzed the trends in surgical axillary staging and compared the 10-year overall survival between sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND).

RESULTS

Among 26,320 patients, 18,548 were in the LN- cohort (16,607 with SLNB and 1,941 with ALND) and 7,772 were in the LNm cohort (3,601 with SLNB and 4,171 with ALND). The proportion of patients undergoing SLNB increased from 76.4% in 2010 to 93.8% in 2021 in the LN- cohort and doubled from 25.2% in 2010 to 55.0% in 2021 in the LNm cohort. ALND was identified as a favorable factor over SLNB in the LNm cohort (hazard ratio [HR] 0.84; 95% CI, 0.73-0.96; P = .014).

CONCLUSION

Omission of ALND for patients with 1 to 2 node metastases after neoadjuvant therapy has doubled since 2010. SLNB is an efficient and safe approach of surgical axillary staging for the LN- cohort but not for patients with residual axillary cancer, even with low-volume disease.

Breast Cancer Recurrence in Initially Clinically Node-Positive Patients Undergoing Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in the NEOSENTITURK-Trials MF18-02/18-03

BACKGROUND

This study aims to identify factors predicting recurrence and unfavorable prognosis in cN+ patients who have undergone sentinel lymph node biopsy (SLNB) following neoadjuvant chemotherapy (NAC).

METHODS

The retrospective multi-centre "MF18-02" and the prospective multi-centre cohort registry trial "MF18-03" (NCT04250129) included patients with cT1-4N1-3M0 with SLNB+/- axillary lymph node dissection (ALND) post-NAC.

RESULTS

A total of 2407 cN+ patients, who later achieved cN0 status after NAC and subsequently underwent SLNB, were studied. The majority had cT1-2 (79.1%) and N1 (80.7%). After a median follow-up time of 41 months, the rates of locoregional recurrence and axillary recurrence (AR) were 1.83% and 0.37%, respectively. No significant difference in locoregional recurrence or AR rates was observed between the SLNB/targeted axillary dissection-only (n = 1470) and ALND (n = 937) groups. Factors significantly linked with AR included age younger than 45 years, nonpathological complete response (non-pCR) in the breast, and nonluminal pathology. Locoregional recurrences were associated with nonluminal or HER2(+) pathology, non-pCR in the breast, and ALND. Poor prognostic factors for disease-free survival (DFS) included having cT3-T4, no breast pCR (non-pCR), ypN(+), and nonluminal pathology. No significant difference was found in DFS or disease-specific survival (DSS) rates among ypN0, ypN-isolated tumour cells, ypNmic, and ypN1. However, significant decreases in DFS and DSS rates were observed when comparing ypN2 or ypN3 disease with ypN0.

CONCLUSIONS

The present large registry data indicate that younger patients (<45), those with nonluminal pathology, and those who only partially respond in the breast are more susceptible to axillary and locoregional recurrences.

Is Axillary Lymph Node Dissection Needed? Clinicopathological Correlation in a Series of 224 Neoadjuvant Chemotherapy-Treated Node-Positive Breast Cancers

BACKGROUND

Axillary lymph node status is valuable in determining systemic and radiation therapy. Following neoadjuvant therapy for patients with clinically involved axillary nodes, the role of axillary lymph node dissection (ALND) following a positive sentinel lymph node biopsy (SLNB) is a subject of controversy.

MATERIALS AND METHODS

We retrospectively analyzed 224 neoadjuvant chemotherapy-treated node-positive breast cancer cases and evaluated the role of ALND in optimizing staging accuracy and treatment outcomes.

RESULTS

About 63 (27.8%) underwent ALND based on post neoadjuvant persistent positive lymph nodes on exam /imaging. SLNBs were performed in 161 (71.9%) patients as initial surgical planning; 67 (41.6%) patients had positive SLNB results, and 51 (76.1%) underwent further ALND. In patients with 1 positive sentinel lymph node, follow-up ALND yielded additional positive lymph nodes in 10.5% of cases, whereas in patients with 2 or more positive sentinel lymph nodes, follow-up ALND yielded additional positive lymph nodes in 87.5% of cases. The presence of 2 positive macro-metastatic sentinel lymph nodes significantly predicts additional nodal involvement, especially in patients without a pathologic complete response.

CONCLUSION

De-escalation of axillary surgery to SLNB alone in this context may be safely considered in neoadjuvant-treated clinical node positive patient with <2 positive sentinel lymph nodes. Our findings help guide surgeons to appropriately select patients who can potentially benefit from ALND for locoregional control and recommendation for adjuvant radiation.

Significance of Residual Nodal Disease in Clinically Node-Negative Breast Cancer After Neoadjuvant Chemotherapy

BACKGROUND

Trials evaluating omission of axillary dissection (ALND) in patients with cN0 breast cancer with positive sentinel lymph nodes (SLNs) have excluded neoadjuvant chemotherapy (NACT). It remains unclear whether the data can be extrapolated to cN0 patients undergoing NACT. This study sought to identify factors associated with positive SLNs and additional disease on ALND in cT1-2N0 disease after NACT.

METHODS

The authors queried their database for cT1-2N0 patients treated with NACT followed by SLN biopsy from 1996 to 2022. Physical examination and ultrasound determined clinical nodal status. Multivariable logistic regression identified factors associated with positive SLNs and disease on ALND.

RESULTS

Of 1930 patients, 234 (12.1%) had positive SLNs. Positive SLNs were predicted by hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) status (odds ratio [OR] 2.5; p < 0.0001), lobular histology (OR 1.8; p = 0.007), multifocality (OR 2; p = 0.001), grade 1 tumors (OR 2.5; p = 0.002), and cT2 category (OR 1.9; p = 0.004). Of the 234 patients with positive SLNs and known SLN metastasis size, 148 (63.2%) underwent ALND, and 39 (26.4%) had additional positive nodes. Increasing patient age predicted disease on ALND (OR 1.03; p = 0.02). No additional positive nodes on ALND were identified in patients with only isolated tumor cells compared with 12.3% who had micrometastases and 37.6% who had macrometastases (p = 0.01). During a 5-year median follow-up period of the SLN-positive patients, three (1.3%) experienced axillary recurrence and two of the three underwent ALND at the initial surgery with no additional positive nodes.

CONCLUSIONS

In cT1-2N0 breast cancer, HR+/HER2- status, lobular histology, multifocality and cT2 category predicted positive SLNs after NACT. Older age predicted positive nodes on ALND. Patients with positive SLNs had low axillary recurrence rates. These findings support investigation into omission of ALND in cN0 breast cancer and a low volume of SLN disease after NACT.

Who still needs surgical staging of the axilla for invasive breast cancer?

Sentinel lymphadenectomy may be safely omitted for postmenopausal patients with low-risk estrogen-receptor-positive cancers who have a negative pretreatment axillary ultrasound. Surgical staging should still be done for patients who are premenopausal or postmenopausal with high-risk estrogen receptor-positive cancers, for those having neoadjuvant chemotherapy, or those with estrogen-receptor-negative or human epidermal growth factor receptor-positive cancers.

Indocyanine Green Fluorescence Plus Blue Dye for Sentinel Lymph Node Biopsy in Patients Undergoing Neoadjuvant Chemotherapy for Breast Cancer: A Multicenter, Prospective Cohort Study

BACKGROUND

Sentinel lymph node biopsy (SLNB) using radioisotope tracer plus blue dye is the gold standard after neoadjuvant chemotherapy (NAC) in initially cN1 breast cancer patients, but clinical use still has limitations. This study aims to examine diagnostic performance of dual indocyanine green (ICG) and methylene blue tracing for SLNB in patients who have completed NAC for breast cancer with initially cN1 disease.

METHODS

Adult women (20-80 years of age) scheduled to undergo NAC for biopsy-proven cT0-3N1M0 primary invasive breast cancer were consecutively enrolled in this prospective, multicenter, cohort study. Upon the completion of NAC, SLNB was conducted using ICG and methylene blue, followed by axillary lymph node dissection. The primary outcome was the detection rate (DR); secondary outcomes included the false-negative rate (FNR) and adverse events associated with the use of tracers.

RESULTS

A total of 156 patients were enrolled; all underwent SLNB after NAC. The median number of lymph nodes retrieved during SLNB was 3 (range: 0-11). The DR was 97.4% (152/156; 95% CI, 93.6%-99.0%). The FNR was 6.7% (4/60; 95% CI, 2.6%-15.9%). Negative predictive value was 95.7% (88/92; 95% CI, 89.4%-98.3%). In the subgroup analysis stratified by ycN status, FNR was 4.0% (1/25; 95% CI, 0.7%-19.5%) and 8.6% (3/35; 95% CI, 3.0%-22.4%) in the ycN0 and ycN+ subgroups, respectively. No allergic reaction was reported.

CONCLUSIONS

SLNB with ICG plus methylene blue achieved a high DR and a very low FNR in breast cancer patients with initially cN1 disease.

TRIAL REGISTRATION

ClinicalTrials.gov (https://www.

CLINICALTRIALS

gov/), NCT02869815.

Axillary lymph node management strategies in cN + breast cancer patients after neoadjuvant chemotherapy

With the widespread use of neoadjuvant chemotherapy (NAC), the optimal management strategy for axillary lymph nodes following chemotherapy has become a hot topic of discussion. For patients with clinically positive axillary lymph nodes (cN +) (defined as axillary lymph nodes confirmed positive by pathology before NAC), axillary lymph node dissection (ALND) remains the current standard treatment. However, there is still no consensus on whether sentinel lymph node biopsy (SLNB) and other local axillary treatments following NAC can safely replace ALND to reduce injury and complications. This article provides a narrative review of strategies for managing axillary lymph nodes in this patient population.

Sentinel Node Biopsy in Post-neoadjuvant Chemotherapy Breast Cancer Patients Using Pre-chemotherapy Breast Tattooing

The role of sentinel lymph node biopsy (SLNB) in locally advanced breast cancer (LABC) post-neoadjuvant chemotherapy (NACT) is debatable. We conducted a novel pilot study in which pre-NACT tattooing of breast lumps in LABC patients resulted in black tattoos being deposited in the axillary node. We hypothesized that this black node was the sentinel node. The identification rate (IR) of the black node in our pilot study was 100%, and the false-negative rate (FNR) was 0%. This study aims to evaluate our hypothesis that the black node is the sentinel node in post-NACT LABC patients after pre-NACT breast tattooing. This is a cross-sectional study of prospectively collected data of women with LABC undergoing surgery after NACT. Patients underwent tattooing of breast primarily using black tattoo ink prior to NACT. Women who progressed on NACT were excluded. All patients underwent axillary dissection. Intraoperatively identified black nodes were sent separately for pathological evaluation. The accuracy of the black nodes was assessed using IR and FNR. Of the 214 patients, a complete clinical response was present in 36%. Black node IR was 88.8% and FNR was 17.4%. In pre-NACT cN0 and cN1 patients, IR was 100% and 96.6%, and FNR was 0% and 4.63%, respectively. SLNB using pre-NACT tattooing in LABC patients has a high IR and FNR. In the subset with low pre-NACT axillary burden (cN0 or cN1), SLNB by pre-NACT breast tattooing has a high IR and low FNR.

Neoadjuvant chemotherapy for breast cancer in Italy: A Senonetwork analysis of 37,215 patients treated from 2017 to 2022

BACKGROUND

Adoption of neoadjuvant chemotherapy (NACT) in the "real world" has been poorly investigated. Aim of this study was to examine the rate of NACT in Italy, trends over time and determinants of therapeutic choices.

METHODS

Senonetwork, the recognized network of Breast Centers in Italy, has developed a voluntary national data warehouse with the aim to monitor and improve treatments quality. A retrospective analysis was conducted among 58,661 breast cancer (BC) patients treated between 2017 and 2022 by 24 high-volume Breast Centers participating in the project.

RESULTS

After subset exclusion, 37,215 primary BC patients were analysed, 32,933 underwent primary-breast-surgery and 4,282 underwent NACT. From 2017 to 2022, the overall NACT incidence increased particularly for HR-/HER2+, Triple-Negative, and HR+/HER2+ BC (p < 0.001). In cN + patients the recommendation to axillary lymph-node dissection after NACT decreased over time along with an increase of <4 lymph-nodes removed (p < 0.001). Immediate breast reconstruction and indication for nipple sparing mastectomy increased significantly over time (OR = 1.10, p = 0.011 and OR 1.14, p < 0.001, respectively). On multivariate analysis, there was a trend towards an increased adoption of conservative treatment for HR-/HER2+ (p = 0.01) and Triple Negative tumors (p = 0.06). Implementation of NACT varied significantly among Breast-Centers from 3.8 to 17.7 % (p < 0.001).

CONCLUSION

The impact of NACT on the subsequent surgical management is substantial and continues to evolve over time, resulting in less-extensive surgery. Even among high-volume Centers NACT implementation rate is still highly variable. Although we registered a significant increase in its use during the study period, these results need to be further improved.

Guidance for Canadian Breast Cancer Practice: National Consensus Recommendations for Clinical Staging of Patients Newly Diagnosed with Breast Cancer

The accurate staging of breast cancer is fundamental for guiding treatment decisions and predicting patient outcomes. However, there can be considerable variation in routine clinical practice based on individual interpretation of guidelines and depending on the healthcare provider initially involved in working up patients newly diagnosed with breast cancer, ranging from primary care providers, triage nurses, surgeons, and/or oncologists. The optimal approach for clinical staging, particularly in asymptomatic patients presenting with intermediate-risk disease, remains a topic of dialogue among clinicians. Given this area of uncertainty, the Research Excellence, Active Leadership (REAL) Canadian Breast Cancer Alliance conducted a modified Delphi process to assess the level of agreement among Canadian expert clinicians on various staging recommendations. In total, 20 items were drafted covering staging based on biological status, the utilization of localization clips, both for the axilla during diagnosis and primary surgical site for margins and radiation therapy planning, and the use of advanced imaging for the investigation of distant metastases. Overall, the consensus threshold among all participants (i.e., ≥75% agreement) was reached in 20/20 items. Differences in clinical practice and recent findings from the literature are provided in the discussion. These consensus recommendations are meant to help standardize breast cancer staging practices in Canada, ensuring accurate diagnosis and optimal treatment planning.

Albumin-To-Alkaline Phosphatase Ratio as a New Early Predictive Marker of Axillary Response in Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy: A Pilot Study

Background and Objectives: The Albumin-to-Alkaline Phosphatase ratio (AAPR) is an easily applicable and cost-effective marker investigated as an outcome predictor in solid cancers. Preliminary evidence in breast cancer suggests that a low AAPR correlates with a poor response to neoadjuvant chemotherapy (NAC) in primary tumors. However, data regarding the axillary response are lacking. This study aims to evaluate whether the AAPR can predict the axillary response in initially nodal-positive (cN+) breast cancer patients undergoing NAC. Materials and Methods: Clinical and biochemical variables of cN+ breast cancer patients undergoing NAC were collected. Pre-NAC albumin and alkaline phosphatase serum values were utilized in the AAPR calculation. Fisher's exact test was performed to identify differences between the two groups of patients (high and low AAPR according to the cut-off reported in the literature). The primary outcome was the nodal pathologic complete response (pCR) rate in the two groups of patients. Results: Nodal pCR was achieved in 20/45 (44.4%) patients. A total of 36/45 (80%) patients had an AAPR > 0.583. Among patient and tumor characteristics, the only statistically significant difference between the two groups was the axillary pCR between the low and high AAPR groups (p-value = 0.03, OR = 0.129, 95% CI = 0.00-0.835). Conclusions: This pilot study suggests that the pre-treatment AAPR might be an early predictor of axillary response in cN+ breast cancer patients undergoing NAC. This result justifies further investigation in larger prospective trials to validate this finding.

Breast and axillary marking in the neoadjuvant setting: survey results from experts of the Brazilian society of mastology

Introduction/objectives

The precise location of the tumor site is essential for the success of surgical treatment. Neoadjuvant chemotherapy (NAC) is a challenge for preoperative tumor and node localization. Thus, the knowledge and attitudes of the affiliated members of the Brazilian Society of Mastology (SBM) regarding breast and axilla marking were evaluated and a consensus regarding management and treatment was reached.

Methods

This was an online survey conducted between June and December 2022. All 1,742 active mastologists affiliated to the SBM were invited anonymously. The online form contained 28 objective questions, of which 22 were formulated on a Likert scale. These questions addressed relevant aspects related to breast and axilla marking in the neoadjuvant setting. Responses that reached 70% agreement were considered consensual. Statistical analysis was performed using the SPSS program version 26.0. Post hoc analysis was performed when appropriate and the significance level was set at p < 0.05. Polychoric regression analyses were conducted using `VGAM` package.

Results

In total, 468 mastologists answered the questionnaire (26.8%), with a predominance of professionals aged between 40-49 years (32.1%). Most professionals were board-certified (84,8%). The indication of tumor marking in the breast prior to NAC was consensual (96.4%) and the metal clip was the preferred method (69.7%). There was no consensus regarding the indication of pre-NAC histologically positive lymph node marking (49.8% disagree and 42.8% agree). However, there was consensus that the clinical and imaging evaluation was insufficient for staging the axilla as N1 (71.6%). The contraindication of breast and node marking in T4b tumors (71.2%) was consensual. There was consensus on the indication of sentinel lymph node biopsy (SLNB) for initially cN1 (92.3%) or cN2 (72.7%) tumors that became cN0 after NAC, with 67.5% opting for dual staining with technetium and patent blue. When <3 lymph nodes were retrieved 41.0% of mastologists performed axillary lymphadenectomy. Among the 28 questions, consensus was reached on only 11 (39.3%).

Conclusion

The indication of pre-NAC breast marking is consensual among Brazilian mastologists, although axillary nodal marking is not. There is a great divergence of attitudes among Brazilian surgeons in relation to the many issues related to pre-NAC breast and axilla marking.

Contemporary Axillary Surgical Management in Patients with Pathologically Node Positive Disease After Neoadjuvant Chemotherapy: A Survey of Members of the American Society of Breast Surgeons

BACKGROUND

Axillary lymph node dissection (ALND) is increasingly omitted for breast cancer patients with pathologic nodal disease after neoadjuvant chemotherapy (NAC). This study aimed to understand when and why surgeons consider omitting ALND after NAC.

METHODS

The American Society of Breast Surgeons membership was surveyed, and responses were tabulated. To identify patterns, multiple correspondence analyses followed by cluster analysis on coordinates provided by the former were performed. Chi-squared analyses determined whether cluster characteristics were significantly (P < 0.05) associated with omission of ALND.

RESULTS

Of members, 328/2172 (15.1%) completed the survey. Most (60.7%) always offer sentinel lymph node surgery to cN1 patients who respond to NAC, and many (43.9%) sometimes omit ALND in the setting of residual nodal disease. Respondents less often consider omitting ALND with increasing volume of pathologic nodal disease after NAC and are less likely to omit ALND among patients with cN1 disease at presentation than cN0 (P < 0.05 across all volumes). Respondents cited radiation administration (74.1%) and belief that ALND would not improve locoregional (48.2%), distant recurrence or survival (47.6%) outcomes when axillary radiation is administered as reasons to omit ALND. The respondent group comprising male private practice surgeons, practicing ≥ 21 years, consider omitting ALND significantly more frequently.

CONCLUSIONS

Surgeons sometimes consider ALND omission for patients with pathologic nodal disease after NAC but are more likely to do so in cN0 patients and patients with smaller volumes of nodal disease. These decisions are largely based on perceived lack of oncologic benefit despite absence of prospective data supporting this deescalation.

Prediction of non-sentinel lymph node metastases in T1-2 sentinel lymph node-positive breast cancer patients undergoing mastectomy following neoadjuvant therapy

BACKGROUND

Axillary lymph node dissection (ALND) is the standard axillary management for breast cancer patients with positive sentinel lymph node biopsy (SLNB) after neoadjuvant therapy. Nevertheless, when that happens, the frequency of additional positive nodes is not properly evaluated. We aim to develop a prediction model to assess the frequency of additional nodal disease after a positive sentinel lymph node following neoadjuvant therapy.

METHODS

We retrospectively analyzed the ultrasound and clinicopathological characteristics of breast cancer patients with 1-3 positive sentinel lymph nodes (SLN) undergoing mastectomy after neoadjuvant therapy (NAT) at our institution, and performed univariate and multivariate logistic analyses to confirm the factors affecting non-SLN metastasis. These factors were included to establish a nomogram, and the area under receiver operating characteristic curve (AUC) and decision curve analysis (DCA) were utilized to assess the validity of this model.

RESULTS

A total of 126 breast cancer patients were ultimately included in our study, 38 (53.5%) patients were diagnosed with non-SLN metastases of all 71 patients in training set. The results of multifactorial logistic analysis suggested that lymph node metastasis ratio (LNR), short axis of lymph node and progesterone receptor (PR) were strongly associated with non-SLN metastasis. We established a nomogram using the above three variables as predictors, which yielded an area under the curve of 0.795, and validated with a favorable AUC of 0.876.

CONCLUSION

The nomogram we constructed can accurately predict the likelihood of non-SLN metastasis in our patients with 1-3 positive SLN after NAT, which may help guide decision making regarding axillary management.

Shifting the Paradigm: The Transformative Role of Neoadjuvant Therapy in Early Breast Cancer

The use of neoadjuvant systemic therapy (NST) has become increasingly important in the treatment of breast cancer because of its various advantages. These include the ability to downstage tumors without compromising locoregional control and the potential to obtain valuable information about clinical and biological response to therapy with implications for individual prognoses. Surgical response assessment paves the way for response-adapted therapy, and pathological complete response (pCR; defined as ypT0/is ypN0) serves as an additional endpoint for drug development trials. Recommended NST regimens commonly consist of anthracyclines and taxane, with dose-dense anthracyclines and weekly paclitaxel often preferred, whenever feasible. For patients with human epidermal growth factor receptor-2 (HER2)-positive tumors, dual anti-HER2 therapy (trastuzumab and pertuzumab) is indicated together with NST in case of elevated risk of recurrence. For patients with triple-negative breast cancer (TNBC), adding carboplatin to NST correlates with improved pCR and survival rates, as does the addition of immune checkpoint inhibitors. For hormone receptor (HR)-positive/HER2-negative cancers, emerging data on NST including immune checkpoint inhibitors may elevate the significance of NST in high-risk luminal breast cancer. Here, we present a synthesis of the results from neoadjuvant clinical trials that aim at optimizing treatment options for patients with high-risk breast cancer.

Surgery paradigm for locally advanced breast cancer following neoadjuvant systemic therapy

Locally advanced breast cancer (LABC) remains a significant clinical challenge, particularly in developing countries. While neoadjuvant systemic therapy (NST) has improved the pathological complete response (pCR) rates, particularly in HER2-positive and triple-negative breast cancer patients, surgical management post-NST continues to evolve. The feasibility of omitting surgery and the increasing consideration of breast-conserving surgery, immediate reconstruction in LABC patients are important areas of exploration. Accurate assessment of tumor response to NST through advanced imaging and minimally invasive biopsies remains pivotal, though challenges persist in reliably predicting pCR. Additionally, axillary lymph node management continues to evolve, with emerging strategies aiming to minimize the extent of surgery in patients who achieve nodal downstaging post-NST. Minimizing axillary lymph node dissection in favor of less invasive approaches is gaining attention, though further evidence is needed to establish its oncological safety. The potential for personalized treatment approaches, reducing surgical morbidity, and improving quality of life are key goals in managing LABC, while maintaining the priority of achieving favorable long-term outcomes.

Retrieval of the Clipped Axillary Lymph Node and Its Impact on Treatment Decisions

We examined clinically node-positive (cN+) breast cancer patients undergoing neoadjuvant chemotherapy and clipped lymph node (CLN) localization to determine the rate of CLN = non-sentinel lymph node (SLN), the factors associated with cN+ to pN0 conversion, and the treatment impact. We conducted a single institution review of cN+ patients receiving NAC from 2016 to 2022 with preoperative CLN localization (N = 81). Demographics, hormone receptor (HR) and HER2 status, time to surgery, staging, chemotherapy regimen, localization method, pathology, and adjuvant therapy were analyzed. Pathologic complete response (pCR) of the CLN was observed in 41 patients (50.6%): 18.8% HR+/HER2-, 75% HR+/HER2+, 75% HR-/HER2+, and 62.5% triple-negative breast cancer (p-value = 0.006). CLN = SLN in 68 (84%) patients, while CLN = non-SLN in 13 (16%). In 14 (17.3%) patients, the final treatment was altered based on +CLN status: 11 patients underwent axillary lymph node dissection (ALND), and 3 had systemic treatment changes. pCR rates varied, with the highest conversion rates observed in HER2+ disease and the lowest in HR+/HER2- disease. In 2 (2.5%) patients, adjuvant therapy changes were made based on a non-sentinel CLN, while in 97.5% of patients, a SLN biopsy alone represented the status of the axilla. This demonstrates that a +CLN often alters final plans and that, despite also being a SLN in most cases, a subset of patients will be undertreated by SLN biopsy alone.

De-escalation of Axillary Surgery After Neoadjuvant Therapy

Surgical de-escalation of the axilla has evolved over the past 28 years since the emergence of sentinel lymph node surgery. Well-documented complications of the once standard of care axillary lymph node dissection (ALND), including lymphedema, led physician scientists towards a progressive push to study and incorporate less invasive techniques in the axilla. Many trials have justified oncologic safety of axillary de-escalation in patients who are spared neoadjuvant treatment. The applicability in the neoadjuvant setting, however, is less clear and axillary surgical approaches in this patient population have evolved at a slower pace. This review aims to analyze current data in axillary management for patients undergoing neoadjuvant treatment and to discuss current surgical approaches based on nodal pathologic response.

Sentinel lymph node biopsy before and after neoadjuvant chemotherapy in cN0 breast cancer patients: impact on axillary morbidity and survival-a propensity score cohort study

PURPOSE

In patients with clinically lymph node-negative (cN0) breast cancer, performing sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NACT) has been preferentially embraced in comparison to before NACT. However, survival outcomes associated with both strategies remain understudied. We aimed to compare the axillary lymphadenectomy (ALND) rate, disease-free survival (DFS), and overall survival (OS), between two strategies.

METHODS

We included 310 patients in a retrospective observational study. SNLB was performed before NACT from December 2006 to April 2014 (107 cases) and after NACT from May 2014 to May 2020 (203 patients). An inverse probability of treatment weighting (IPTW) method was applied to homogenize both groups. Hazard ratios (HR) and odd ratios (OR) are reported with 95% confidence intervals (95%CI).

RESULTS

The lymphadenectomy rate was 29.9% before NACT and 7.4% after NACT (p < 0.001), with an OR of 5.35 95%CI (2.7-10.4); p = .002. After 4 years of follow-up, SLNB after NACT was associated with lower risk for DFS, HR 0.42 95%CI (0.17-1.06); p = 0.066 and better OS, HR 0.21 CI 95% (0.07-0.67); p = 0.009 than SLNB before NACT. After multivariate analysis, independent adverse prognostic factors for OS included SLNB before NACT, HR 3.095 95%CI (2.323-4.123), clinical nonresponse to NACT, HR 1.702 95% CI (1.012-2.861), and small tumors (cT1) with high proliferation index, HR 1.889 95% (1.195-2.985).

CONCLUSION

Performing SLNB before NACT results in more ALND and has no benefit for patient survival. These findings support discontinuing the practice of SLNB before NACT in patients with cN0 breast cancer.

The Role of Level III Dissection in Locally Advanced Breast Cancer following Neoadjuvant Chemotherapy-A Prospective Study

Nisha Prasannan Breast cancer is the most common female cancer in India, with a significant number presenting as locally advanced breast cancer (LABC). Level III clearance is routinely performed in our institute in LABC following neoadjuvant chemotherapy (NACT). In our previous retrospective study, level III positivity rate was 15.5%. We aim to prospectively assess level III positivity rate in LABC patients post-NACT. This is a prospective study of female patients with LABC (defined as cT3N1-3M0 or cT4N0-3M0 or cT any N2,3M0) who received NACT and underwent surgery including level III dissection from November 2019 to October 2021. Data collected included age, menopausal status, TNM stage at presentation, grade, hormone receptor and HER2 status, treatment response, ycT and ycN stage, and final histopathology. Univariate and multivariate analysis was undertaken. p -Value less than or equal to 0.05 was considered significant. Study recruited 598 patients. Level III node positivity rate was 8.4%. The clinical complete response rate (cCR) was 36% (215/598). On univariate analysis, significant association was present between level III node and cCR ( p  < 0.01), ycT0 stage ( p  = 0.001), ycN0 stage ( p  = 0.028), level II node positivity ( p  = 0.001), ypT stage ( p  = 0.001), and ypN stage ( p  = 0.001). On multivariate analysis, significant association was present between level III node and ycT stage ( p  < 0.001), ypT stage ( p  = 0.001), and ypN stage ( p  = 0.001). Level III positivity rate in LABC post-NACT is high. In patients with advanced ycT stage, it would be advisable to offer complete axillary dissection including level III. Level III dissection may be avoided in patients with ycT0 or ycN0 or with cCR.

Assessing the Efficacy of Radioactive Iodine Seed Localisation in Targeted Axillary Dissection for Node-Positive Early Breast Cancer Patients Undergoing Neoadjuvant Systemic Therapy: A Systematic Review and Pooled Analysis

Targeted axillary dissection (TAD), employing marked lymph node biopsy (MLNB) alongside sentinel lymph node biopsy (SLNB), is increasingly recognised for its efficacy in reducing false negative rates (FNRs) in node-positive early breast cancer patients receiving neoadjuvant systemic therapy (NST). One such method, 125I radioactive seed localisation (RSL), involves implanting a seed into a biopsy-proven lymph node either pre- or post-NST. This systematic review and pooled analysis aimed to assess the performance of RSL in TAD among node-positive patients undergoing NST. Six studies, encompassing 574 TAD procedures, met the inclusion criteria. Results showed a 100% successful deployment rate, with a 97.6% successful localisation rate and a 99.8% retrieval rate. Additionally, there was a 60.0% concordance rate between SLNB and MLNB. The FNR of SLNB alone was significantly higher than it was for MLNB (18.8% versus 5.3%, respectively; p = 0.001). Pathological complete response (pCR) was observed in 44% of cases (248/564). On average, the interval from 125I seed deployment to surgery was 75.8 days (range: 0-272). These findings underscore the efficacy of RSL in TAD for node-positive patients undergoing NST, enabling precise axillary pCR identification and facilitating the safe omission of axillary lymph node dissection.

Omission of Breast Surgery in Exceptional Responders

Breast cancer management has transformed significantly over the last decades, primarily through the integration of neoadjuvant systemic therapy (NST) and the evolving understanding of tumor biology, enabling more tailored treatment strategies. The aim of this review is to critically present the historical context and contemporary evidence surrounding the potential of omission of surgery post-NST, focusing on exceptional responders who have achieved a pathologic complete response (pCR). Identifying these exceptional responders before surgery remains a challenge, however standardized image-guided biopsy may allow optimized patient selection. The safety and feasibility of omitting breast and axillary surgeries in these exceptional responders are explored in ongoing clinical trials and the reported preliminary results appear promising. Moreover, understanding patient and physician perspectives regarding the potential elimination of surgery post-NST is integral. While some patients express a preference to omit or minimize surgery, the majority of healthcare providers are intrigued by the prospect of avoiding surgical interventions and endorse further research in this field.

Is my patient an appropriate candidate for sentinel node biopsy? Less axillary surgery, for the right patients. Critical review and grades of recommendation

INTRODUCTION

While general conclusions of historical trials are widely recognized, the nuances regarding precise indications of Sentinel Node Biopsy (SNB) in breast cancer in complex clinical scenarios often remain a source of debate and require further elucidation.

METHODS

Two reviewers (JFB and GNM) independently searched electronic databases for studies including SNB as the main intervention. Filters were applied to retrieve only clinical trials (randomized or experimental non-randomized); non-oncological outcomes were excluded. The selected studies were considered to construct a narrative review focused on inclusion criteria and survival outcomes, followed by recommendations.

RESULTS

Fourteen (n = 14) trials were selected, including eleven (n = 11) randomized trials for upfront surgery, and three (n = 3) single-group clinical trials for surgery following neoadjuvant therapy. All trials for upfront surgery provided long-term survival data for SNB, that was equivalent or non-inferior to axillary dissection, in tumors without palpable adenopathy (caution for larger T3 and T4 tumors) - Grade of recommendation: A. In tumors up to 5 cm, complete axillary dissection is not necessary if up to two sentinel nodes are positive for macrometastasis, and radiation therapy is planned - Grade of recommendation: A. If there are more than two sentinel nodes positive for macrometastasis, or a positive node other than the sentinel one, complete axillary dissection is recommended - Grade of recommendation: A. Following neoadjuvant chemotherapy, considering 10% as an acceptable false negative rate, SNB might be offered for cN0 patients who have remained negative, and for cN1 (caution for cN2) patients become clinically negative; complete axillary dissection might not be necessary if at least two sentinel lymph nodes are retrieved, and there is no residual disease - Grade of recommendation: B.

CONCLUSION

SNB can be performed in most cases of clinically negative nodes. After neoadjuvant chemotherapy, SNB is feasible and may have acceptable performance for cN0 and cN1 tumors, although prospective survival data is still awaited.

Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy

The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.

Axillary Surgery for Breast Cancer in 2024

Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous 'one size fits all' radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.

Prognostic Importance of Axillary Lymph Node Response to Neoadjuvant Systemic Therapy on Axillary Surgery in Breast Cancer-A Single Center Experience

Neoadjuvant systemic treatment (NST) is the standard treatment for HER2+, triple-negative (TN), and highly proliferative luminal HER2- early breast cancer. Pathologic complete response (pCR) after NST is associated with improved outcomes. We evaluated the predictive factors for axillary-pCR (AXpCR) and its impact on the extent of axillary node surgery. This retrospective study included 92 patients (median age of 50.4 years) with an initially node-positive disease. Patients were treated with molecular subtype-specific NST (4.3% were luminal A-like, 28.3% luminal HER2-, 26.1% luminal HER2+, 18.5% HER2+ non-luminal, and 22.8% TN). Axillary-, breast- and total-pCR were achieved in 52.2%, 48.9%, and 38% of patients, respectively. In a binary logistic regression model for the whole population, the only independent factor significantly associated with AXpCR was breast-pCR (OR 7.4; 95% CI 2.6-20.9; p < 0.001). In patients who achieved breast-pCR, aggressive subtypes (HER2+ and TN; OR 11.24) and clinical tumor stage (OR 0.10) had a significant impact on achieving AXpCR. Axillary lymph node dissection was avoided in 53.3% of patients. In conclusion, in node-positive patients with HER2+ and TN subtypes, who achieved breast-pCR after NST, de-escalation of axillary surgery could be considered in most cases.

[Can we avoid axillary lymph node dissection in patients with node positive invasive breast carcinoma?]

OBJECTIVES

The indications and modalities of breast and axillary surgery are undergoing profound change, with the aim of personalizing surgical management while avoiding over-treatment. To update best practices for axillary surgery, four questions were selected by the Senology Commission of the Collège National des Gynécologues et Obstétriciens Français (CNGOF), focusing on, firstly, the definition and evaluation of targeted axillary dissection (TAD) techniques; secondly, the possibility of surgical de-escalation in case of initial lymph node involvement while performing initial surgery; thirdly, in case of surgery following neo-adjuvant systemic therapy (NAST), and fourthly, contra-indications to de-escalation of axillary surgery to allow access to particular adjuvant systemic therapies.

METHODS

The Senology Commission based its responses primarily on an analysis of the international literature, clinical practice recommendations and national and international guidelines.

RESULTS

Firstly, TAD is a technique that combines excision of clipped metastatic axillary node(s) and the axillary sentinel lymph nodes (ASLNs). The detection rate and sensitivity are increased but it still needs to be standardized and practices better evaluated. Secondly, TAD represents an alternative to axillary clearance in cases of metastatic involvement of a single node that can be resected. Thirdly, neither TAD nor ASLN alone is recommended in France after NAST outside of clinical trials, although it is used in several countries in cases of complete pathological response in the lymph nodes, and when at least three lymph nodes have been removed. Fourthly, as some adjuvant targeted therapies are indicated in cases of lymph node invasion of more than three lymph nodes, the place of TAD in this context remains to be defined.

CONCLUSION

Axillary surgical de-escalation can limit the morbidity of axillary clearance. Having proved that TAD does not reduce patient survival, it will most probably replace axillary clearance in well-defined indications. This will require prior standardization of the method and its indications and contra-indications, particularly to enable the use of new targeted therapies.

The Role of Human Epidermal Growth Factor Receptor 2 (HER2)-Targeted Therapies in Early-Stage Breast Cancer: Current Practices, Treatment De-escalation, and Future Prospects

Human epidermal growth factor receptor 2 (HER2)-targeted therapy has transformed the treatment paradigm for early-stage HER2-positive breast cancer, providing personalized and effective interventions. This comprehensive review delves into the current state of HER2-targeted therapies, emphasizing pivotal clinical trials that have demonstrated their substantial impact on long-term outcomes. Combination therapies that integrate HER2-targeted agents with chemotherapy exhibit enhanced tumor responses, particularly in neoadjuvant settings. Neoadjuvant chemotherapy (NACT) is explored for its role in tumor downsizing, facilitating breast-conserving surgery (BCS), and incorporating oncoplastic solutions to address both oncologic efficacy and aesthetic outcomes. Innovative axillary management post-NACT, such as targeted axillary dissection (TAD), is discussed for minimizing morbidity. The review further explores the delicate balance between maximal therapy and de-escalation, reflecting recent trends in treatment approaches. The therapeutic landscape of HER2-low breast cancer is examined, highlighting considerations in HER2-positive breast cancer with BReast CAncer gene (BRCA) mutations. Emerging immunotherapeutic strategies, encompassing immune checkpoint inhibitors and chimeric antigen receptor (CAR) T-cell therapy, are discussed in the context of their potential integration into treatment paradigms. In conclusion, the evolving landscape of HER2-positive early-stage breast cancer treatment, characterized by targeted therapies and multidisciplinary approaches, underscores the need for ongoing research and collaborative efforts. The aim is to refine treatment strategies and enhance patient outcomes in this dynamic and rapidly evolving field.

Axillary lymph node dissection in triple-negative or HER2-positive breast cancer patients with clinical N2 achieving pathological complete response after neoadjuvant therapy: Is it necessary?

AIM

This study aims to identify suitable candidates for axillary sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) among clinical N2 (cN2) triple-negative (TN) or HER2 positive (HER2+）breast cancer patients following neoadjuvant therapy（NAT）.

BACKGROUND

Despite the substantial axillary burden in cN2 breast cancer patients, high pathological response rates can be achieved with NAT in TN or HER2+ subtypes, thus enabling potential downstaging of axillary surgery.

METHODS

A retrospective analysis was conducted on data from the CSBrS-012 study, screening 709 patients with initial cN2, either HER2+ or TN subtype, from January 1, 2010 to December 31, 2020. The correlation between axillary pathologic complete response (pCR) (yPN0) and breast pCR was examined.

RESULTS

Among the 177 cN2 patients who achieved breast pCR through NAT, 138 (78.0 %) also achieved axillary pCR. However, in the 532 initial clinical N2 patients who did not achieve breast pCR, residual axillary lymph node metastasis persisted in 77.4 % (412/532) of cases. The relative risk of residual axillary lymph node metastasis in patients who did not achieve breast pCR was 12.4 (8.1-19.1), compared to those who did achieve breast pCR, P < 0.001.

CONCLUSION

For cN2 TN or HER2+ breast cancer patients who achieve breast pCR following NAT, consideration could be given to downstaging and performing an axillary SLNB or TAD.

Prognostic analysis of cT1-3N1M0 breast cancer patients who have responded to neoadjuvant therapy undergoing various axillary surgery and breast surgery based on propensity score matching and competitive risk model

Background

Sentinel lymph node biopsy (SLNB) in breast cancer patients with positive clinical axillary lymph nodes (cN1+) remains a topic of controversy. The aim of this study is to assess the influence of various axillary and breast surgery approaches on the survival of cN1+ breast cancer patients who have responded positively to neoadjuvant therapy (NAT).

Methods

Patients diagnosed with pathologically confirmed invasive ductal carcinoma of breast between 2010 and 2020 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. To mitigate confounding bias, propensity score matching (PSM) analysis was employed. Prognostic factors for both overall survival (OS) and breast cancer-specific survival (BCSS) were evaluated through COX regression risk analysis. Survival curves were generated using the Kaplan-Meier method. Furthermore, cumulative incidence and independent prognostic factors were assessed using a competing risk model.

Results

The PSM analysis matched 4,890 patients. Overall survival (OS) and BCSS were slightly worse in the axillary lymph node dissection (ALND) group (HR = 1.10, 95% CI 0.91-1.31, p = 0.322 vs. HR = 1.06, 95% CI 0.87-1.29, p = 0.545). The mastectomy (MAST) group exhibited significantly worse OS and BCSS outcomes (HR = 1.25, 95% CI 1.04-1.50, p = 0.018 vs. HR = 1.37, 95% CI 1.12-1.68, p = 0.002). The combination of different axillary and breast surgery did not significantly affect OS (p = 0.083) but did have a significant impact on BCSS (p = 0.019). Competing risk model analysis revealed no significant difference in the cumulative incidence of breast cancer-specific death (BCSD) in the axillary surgery group (Grey's test, p = 0.232), but it showed a higher cumulative incidence of BCSD in the MAST group (Grey's test, p = 0.001). Multivariate analysis demonstrated that age ≥ 70 years, black race, T3 stage, ER-negative expression, HER2-negative expression, and MAST were independent prognostic risk factors for both OS and BCSS (all p < 0.05).

Conclusion

For cN1+ breast cancer patients who respond positive to NAT, the optimal surgical approach is combining breast-conserving surgery (BCS) with SLNB. This procedure improves quality of life and long-term survival outcomes.

Radiographic identification of a positive clipped axillary lymph node in a mastectomy specimen following neoadjuvant chemotherapy

Sentinel lymph node biopsies are recommended for staging in node-positive breast cancer patients who become clinically node-negative after neoadjuvant therapy. Current guidelines support the omission of an axillary lymph node dissection if 3 negative sentinel nodes are retrieved during surgery. Consequently, the utility of routine clip placement in biopsied nodes prior to neoadjuvant chemotherapy and the necessity of targeted removal of these clipped nodes is in question. There are various methods for retrieving clipped nodes. We describe a case in which an intraoperative radiograph of a mastectomy specimen identified a clipped node that had not been localized with targeted axillary dissection in a patient with breast cancer. Pathology revealed persistent nodal positivity after neoadjuvant therapy, resulting in an escalation in care and a complete axillary dissection. We review the current literature on nodal clipping, and discuss the importance of localizing clipped nodes and the impact it can have on management.

Performance and oncologic safety of sentinel lymph node biopsy after neoadjuvant chemotherapy: Results from a tertiary care center in Lebanon

BACKGROUND

The feasibility of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NACT) in initially node-positive patients is still controversial. We aim to evaluate the oncologic outcomes of SLNB after NACT and further compare the results between those who were initially node-negative and node-positive.

METHODS

This is a retrospective cohort that included patients diagnosed with invasive breast cancer and had surgical management between January 2010 and December 2016. Survival and recurrence data after 3-5 years were collected from patients' records. We divided patients into Group A who were initially node-negative and had SLNB ± axillary lymph node dissection (ALND) and Group B who were node-positive and had SLNB ± ALND.

RESULTS

Among initially node-negative patients, 43 out of 63 patients did SLNB (Group A). However, among initially node-positive patients only 28 out of 123 patients did SLNB (Group B). Out of the 71 patients who did SLNB after NACT, 26 patients had positive SLNs with only 14 patients who further underwent ALND. The identification rate of SLNB was 100% in Group A and 96.4% in Group B. The survival curves by nodal status showed no significant difference between overall survival and recurrence-free survival at 5 years between patients in Group A versus Group.

CONCLUSION

The results suggest that in properly selected patients, SLNB can be feasible after NACT. Our results resemble the reported literature on accuracy of SLNB after NACT and adds to the growing pool of data on this topic.

What's new in surgical oncology breast

It is on the backdrop of advances in tumor biology and systemic therapy for breast cancer, that progress in locoregional treatment has focused on management of the breast for invasive cancer, imaging for staging and therapeutic decision-making, and de-escalation in the management of the axilla.

Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy

Background

The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer.

Summary

Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement.

Key Messages

Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.

Understanding breast cancer complexity to improve patient outcomes: The St Gallen International Consensus Conference for the Primary Therapy of Individuals with Early Breast Cancer 2023

The 18th St Gallen International Breast Cancer Conference held in March 2023, in Vienna, Austria, assessed significant new findings for local and systemic therapies for early breast cancer with a focus on the evaluation of multimodal treatment options. The emergence of more effective, innovative agents in both the preoperative (primary or neoadjuvant) and post-operative (adjuvant) settings has underscored the pivotal role of a multidisciplinary approach in treatment decision making, particularly when selecting systemic therapy for an individual patient. The importance of multidisciplinary discussions regarding the clinical benefits of interventions was explicitly emphasized by the consensus panel as an integral part of developing an optimal treatment plan with the 'right' degree of intensity and duration. The panelists focused on controversies surrounding the management of common ductal/no special type and lobular breast cancer histology, which account for the vast majority of breast tumors. The expert opinion of the panelists was based on interpretations of available data, as well as current practices in their professional environments, personal and socioeconomic factors affecting patients, and cognizant of varying reimbursement and accessibility constraints around the world. The panelists strongly advocated patient participation in well-designed clinical studies whenever feasible. With these considerations in mind, the St Gallen Consensus Conference aims to offer guidance to clinicians regarding appropriate treatments for early-stage breast cancer and assist in balancing the realistic trade-offs between treatment benefit and toxicity, enabling patients and clinicians to make well-informed choices through a shared decision-making process.

Impact of axillary surgery on outcome of clinically node positive breast cancer treated with neoadjuvant chemotherapy

PURPOSE

Axillary Lymph Node Dissection (ALND) is recommended for breast cancer patients who present with clinically node positive disease (cN1) especially if they have residual nodal disease (ypN+) following neoadjuvant therapy (NAT). It is unknown whether axillary dissection improves outcome for these patients.

METHODS

A prospectively maintained database was used to identify all patients who were diagnosed with cTis-T4N1M0 breast cancer treated with NAT.

RESULTS

In our study, of 292 cN1 breast cancer patients who received NAT, we compared ALND with targeted axillary surgery (TAS) in ypN+ patients. ALND was performed in 75% of the ypN+ subgroup, while 25% underwent TAS. Axillary recurrence occurred in four ALND patients, but no recurrence was observed in the TAS group (p = 0.21). Five-year axillary recurrence-free survival was 100% for TAS and 90% for ALND (p = 0.21). Overall survival at five years was 97% for TAS and 85% for ALND (p = 0.39). Disease-free survival rates at five years were 51% for TAS and 61% for ALND (p = 0.9). Clinicopathological variables were similar between the groups, although some differences were noted. ALND patients had smaller clinical tumor size, larger pathological tumor size, more lymph nodes retrieved, larger tumor deposits, higher rates of extranodal extension, and greater prevalence of macrometastatic nodal disease. Tumor subtype and size of lymph node tumor deposit independently predicted survival.

CONCLUSION

Axillary recurrence is infrequent in cN1 patients treated with NAT. Our study found that ALND did not reduce the occurrence of axillary recurrence or enhance overall survival. It is currently uncertain which patients benefit from axillary dissection.