Timing of sentinel lymph node biopsy in patients receiving neoadjuvant chemotherapy for breast cancer

The Feasibility and Reliability of Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Breast Cancer Patients With Negative Axillary Lymph Nodes-A Meta-analysis

Background

The application of sentinel lymph node biopsy (SLNB) has expanded from early breast cancer to locally advanced breast cancer with neoadjuvant chemotherapy (NAC). For patients with negative axillary lymph nodes, performing SLNB before or after NAC remains controversial.

Objectives

To evaluate the diagnostic feasibility and reliability of SLNB after NAC in breast cancer patients with negative axillary nodes at initial diagnosis.

Design

To calculate pooled identification rate (IR) and false negative rate (FNR) of SLNB after NAC on breast cancer patients with initially negative axillary nodes by enrolling relevant studies and perform subgroup analysis by the type of tracer and the number of biopsied sentinel lymph nodes in average.

Data sources and methods

The PubMed, Embase, Cochrane, Web of Science, and Scopus databases from January 1, 2002, to March 1, 2022, were searched for studies. The QUADAS-2 tool and MINORS item were employed to evaluate the quality of the included studies. I2 and Q tests were used to evaluate the heterogeneity among the studies. Random-effects model and fixed-effects model were employed to calculate the pooled IR, FNR, and 95% confidence interval (CI). Publication bias was evaluated, and sensitivity analysis was performed. Subgroup analysis was performed according to the type of tracer (single/double) and the number of biopsied sentinel lymph nodes in average (⩽2/>2).

Results

A total of 21 studies covering 1716 patients were enrolled in this study (IR = 93%, 95% CI = 90-96; FNR = 8%, 95% CI = 6-11).

Conclusion

The SLNB after NAC can serve as a feasible and reliable approach in breast cancer patients with negative axillary lymph node. In our study, no significant impact of tracer was found on the IR and FNR of SLNB, and the number of biopsy nodes >2 leads to the decreased FNR of SLNB.

Outcomes of Sentinel Node Biopsy for Women with Breast Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis of Real-World Data

BACKGROUND

Evidence on the accuracy of sentinel lymph node biopsy (SLNB) after neoadjuvant therapy (NAT) for patients with breast cancer is inconclusive. This study reviewed the real-world data to determine the acceptability of SLNB after NAT.

METHODS

The study searched for articles in the PubMed, EMBASE, and Cochrane Library databases. The primary outcomes were the identification rate for sentinel lymph nodes (SLNs) and the false-negative rate (FNR) for SLNB. The study also evaluated the FNR in subgroups defined by tumor stage, nodal stage, hormone receptor status, human epidermal growth factor receptor-2 status, tumor response, mapping technique, and number of SLNs removed.

RESULTS

The study retrieved 61 prospective and 18 retrospective studies with 10,680 initially cN± patients. The pooled estimate of the identification rate was 0.906 (95 % confidence interval [CI], 0.891-0.922), and the pooled FNR was 0.118 (95 % CI, 0.103-0.133). In subgroup analysis, the FNR was significantly higher for the patients with estrogen receptor (ER)-negative status and fewer than three SLNs removed. The FNR did not differ significantly between the patients with and those without complete tumor response. Among the patients with initial clinical negative axillary lymph nodes, the incidence of node metastasis was 26.8 % (275/1041) after NAT.

CONCLUSION

Real-world evidence indicates that the FNR of SLNB after NAT in breast cancer is 11.8 %, exceeding only slightly the commonly adopted threshold of 10 %. The FNR is significantly higher for patients with ER-negative status and removal of fewer than three SLNs. Using a dual tracer and removing at least three SLNs may increase the accuracy of SLNB after NAT.

Management of the Axilla in Early-Stage Breast Cancer: Ontario Health (Cancer Care Ontario) and ASCO Guideline

PURPOSE

To provide recommendations on the best strategies for the management and on the best timing and treatment (surgical and radiotherapeutic) of the axilla for patients with early-stage breast cancer.

METHODS

Ontario Health (Cancer Care Ontario) and ASCO convened a Working Group and Expert Panel to develop evidence-based recommendations informed by a systematic review of the literature.

RESULTS

This guideline endorsed two recommendations of the ASCO 2017 guideline for the use of sentinel lymph node biopsy in patients with early-stage breast cancer and expanded on that guideline with recommendations for radiotherapy interventions, timing of staging after neoadjuvant chemotherapy (NAC), and mapping modalities. Overall, the ASCO 2017 guideline, seven high-quality systematic reviews, 54 unique studies, and 65 corollary trials formed the evidentiary basis of this guideline.

RECOMMENDATIONS

Recommendations are issued for each of the objectives of this guideline: (1) To determine which patients with early-stage breast cancer require axillary staging, (2) to determine whether any further axillary treatment is indicated for women with early-stage breast cancer who did not receive NAC and are sentinel lymph node-negative at diagnosis, (3) to determine which axillary strategy is indicated for women with early-stage breast cancer who did not receive NAC and are pathologically sentinel lymph node-positive at diagnosis (after a clinically node-negative presentation), (4) to determine what axillary treatment is indicated and what the best timing of axillary treatment for women with early-stage breast cancer is when NAC is used, and (5) to determine which are the best methods for identifying sentinel nodes.Additional information is available at www.asco.org/breast-cancer-guidelines.

Management of the Axilla after Neoadjuvant Systemic Therapy

OPINION STATEMENT

As the use of neoadjuvant systemic therapy (NAST) increases, the optimal management of the axilla has become increasingly complex. Consensus among professional organizations is that those patients with clinically negative axillary nodes who are being considered for NAST should undergo a sentinel lymph node (SLN) biopsy following NAST. If a positive SLN is subsequently identified, an axillary lymph node dissection (ALND) is the current standard of care. For patients with clinically node-positive disease, SLN biopsy is a reasonable option for those with a good response to NAST. Patients should undergo SLN mapping with a dual dye technique. Additionally, at least 2 lymph nodes should be removed, including the previously biopsied and marked lymph node with cancer. In this setting, the identification and false negative rates are acceptable. Patients found to have a negative SLN at this time may be spared the morbidity associated with ALND. Patients found to have persistently positive lymph nodes following NAST, either clinically or pathologically, should undergo a complete ALND.

Heterogeneous Responses of Axillary Lymph Node Metastases to Neoadjuvant Chemotherapy are Common and Depend on Breast Cancer Subtype

BACKGROUND

The objective of this study was to analyze heterogeneous responses of axillary lymph node metastasis to neoadjuvant chemotherapy and to determine to what extent they differ between tumor subtypes (TN, HER2+, HR+/HER2-).

METHODS

This retrospective, monocenter study included 72 consecutive, histologically node-positive breast cancers (cT1-4 cN1-3 cM0) diagnosed in the period from January 2015 to December 2016, who had received axillary lymph node dissection following neoadjuvant chemotherapy. All individual lymph node specimens were re-evaluated for the presence of tumor cells and chemotherapy effects to assess their response to neoadjuvant chemotherapy on an individual lymph node level according to the Sataloff classification.

RESULTS

Heterogeneous axillary responses to neoadjuvant chemotherapy occurred in 47.2% of the included 72 patients. The partial response rate was significantly higher in HR+/HER2- tumors (74.2%) than in TN (28.6%) and HER2+ tumors (25.0%) (p < 0.001). The presence of at least one negative, completely responding lymph node in the axillary lymph node dissection specimen had a false-negative rate of 48.8% in predicting ypN0. It dropped below 10% if at least four completely responding negative lymph nodes were identified.

CONCLUSIONS

Our study shows that axillary heterogeneous response rates differ significantly between tumor subtypes.

Assessment of sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer in two subgroups: Initially node negative and node positive converted to node negative - A systemic review and meta-analysis

BACKGROUND

Neoadjuvant chemotherapy (NAC) is increasingly used to treat patients with breast cancer, but the reliability of sentinel lymph node biopsy (SLNB) following chemotherapy is in doubt. In this meta-analysis, we aimed to evaluate studies that examine the results of SLNB after NAC to assess identification rate (IR) and false-negative rate (FNR).

MATERIALS AND METHODS

Systemic searches were performed in the PubMed, ISI Web of Sciences, Scopus, and Cochrane databases from January 1, 2000, to November 30, 2016, for studies of SLNB after NAC for breast cancer and followed by axillary lymph node (LN) dissection in two subgroups: initially node negative and node positive converted to node negative. Two reviewers independently review quality of included studies. A random-effects model was used to pool IR and FNR with 95% confidence intervals (CI), and heterogeneity among studies was assessed by I 2 and Q-test.

RESULTS

A total of 23 studies with 1521 patients in the initially node-negative subgroup and 13 studies with 1088 patients in the node-positive converted to node-negative subgroup, were included in this meta-analysis with IR and FNR of 94% (95% CI: 92-96) and 7% (95% CI: 5-9) in the initially node-negative subgroup and 89% (95% CI: 85-94) and 13% (95% CI: 7-18) in the node-positive converted to node-negative subgroup, respectively.

CONCLUSION

Our meta-analysis showed acceptable IR and FNR in initially node-negative group and it seems feasible in these patients, but these parameters did not reach to predefined value in node-positive converted to node-negative group, and thus, it is not recommended in these patients.

[Risk of axillary recurrence after sentinel lymph node biopsy before neoadjuvant chemotherapy in breast cancer]

OBJECTIVES

In case of large breast cancer, neoadjuvant chemotherapy (NAC) can be performed to reduce the size of the tumor and thus perform a conservative surgery. The place of the sentinel lymph node biopsy (SLNB) in case of NAC is still debated. The main aim of this study is to assess the risk of axillary recurrence after negative SLNB before NAC.

METHODS

It is a retrospective, observational and uni-centric study. We included 18 to 80-year-old patients with unilateral breast cancer requiring a NAC and with a negative SLNB before NAC. Our primary endpoint was axillary recurrence.

RESULTS

Between August 2006 and October 2016, 64 patients had a negative GS performing before a NAC and did not benefit from axillary dissection after NAC. The average duration of follow-up was 37 months. During our follow-up, we did not find any cases of axillary recurrence.

CONCLUSION

This study supports the reliability of lymph node status assessment using the SLNB before CNA.

The Usefulness of Photodynamic Eye for Sentinel Lymph Node Identification in Patients with Cervical Cancer

Aims and background

We studied the potential use of sentinel lymph node identification using a near-infrared fluorescence imaging technique in the treatment of cervical cancer.

Methods and study design

Directly before the start of the operation, 0.2 ml of 5 mg/ml indocyanine green was prepared and injected into 4 sites in the cervix using a 26-gauge standard needle, at 3, 6, 9 and 12 o'clock positions. When the operation was advanced to the pelvis, near-infrared fluorescence imaging was performed using photodynamic eye (Hamamatsu Photonics Co., Japan). The sentinel lymph nodes and other dissected lymph nodes were histologically examined to find any metastases.

Results

Twelve patients were examined. Their ages ranged from 36 to 68 years (median, 58). Sentinel lymph nodes were identified in 10 patients (83%), and all were bi-laterally identified. The median maximum tumor diameter of dissected cervical tumors was 35 mm (22–65); histology was squamous cell carcinoma in 8 patients and adenocarcinoma in 2 patients. Capillary lymphatic space involvement was found in 8 of the 10 patients. The site of the sentinel lymph node was the right external iliac node in 8 patients, the right obturator node in 8, the left external iliac node in 9, and the left obturator node in 8. Lymph node metastasis was found in 2 of the 12 patients, and all were sentinel lymph nodes. No metastasis from lymph nodes other than sentinel lymph nodes was observed.

Conclusions

Photodynamic eye achieved a detection rate similar to that obtained with the blue dye and radioisotope method. It is also easier to use than the other two methods. Free full text available at www.tumorionline.it

Selective Sentinel Lymph Node Biopsy and Primary Systemic Therapy in Breast Cancer

Aims and background

Sentinel lymph node biopsy has become an ordinary method for breast cancer staging. Neoadjuvant chemotherapy has been considered one of the contraindications for sentinel lymph node biopsy due to potential secondary fibrosis and lymphatic distortion. Timing and influence on sentinel lymph node biopsy result by primary systemic therapy are current and controversial topics.

Methods and study design

The experience in the medical literature is reviewed. A search was performed in the following databases: Medline (through Pubmed), EMBASE, Tripdatabase and Cochrane Library, between January 1998 and December 2008.

Results and conclusions

After analyzing the conclusions from 42 series and waiting for the end of related prospective trials, it could be concluded that sentinel lymph node biopsy is a useful diagnostic tool that should be integrated in the algorithm for the management of breast cancer patients when primary systemic therapy is needed.

Identification of the sentinel lymph node using hemosiderin in locally advanced breast cancer

OBJECTIVE

to verify the agreement rate in the identification of sentinel lymph node using an autologous marker rich in hemosiderin and 99 Technetium (Tc99) in patients with locally advanced breast cancer.

METHODS

clinical trial phase 1, prospective, non-randomized, of 18 patients with breast cancer and clinically negative axilla stages T2=4cm, T3 and T4. Patients were submitted to sub-areolar injection of hemosiderin 48 hours prior to sentinel biopsy surgery, and the identification rate was compared at intraoperative period to the gold standard marker Tc99. Agreement between methods was determined by Kappa index.

RESULTS

identification rate of sentinel lymph node was 88.9%, with a medium of two sentinel lymph nodes per patients. The study identified sentinel lymph nodes stained by hemosiderin in 83.3% patients (n=15), and, compared to Tc99 identification, the agreement rate was 94.4%.

CONCLUSION

autologous marker rich in hemosiderin was effective to identify sentinel lymph nodes in locally advanced breast cancer patients.

Is it time to relook the management of axilla in post-neoadjuvant breast cancer cases in a re-evolving era of current axillary management?

Aim: Axillary node dissection (AND) is an established practice, recently a conservative approach to axilla has resurged but there is reluctance to pass this benefit to neoadjuvant chemotherapy (NAC) cases, even in complete responders. Present study aims to look whether this approach is applicable to post-NAC cases. Patients & methods: Prospective study of 100 cases of NAC for breast cancer. Results: The core positive axillary nodes at diagnosis (66) after NAC had AND, 25 (38%) showed pathological complete response (pCR) in axillary nodes and 41 (62%) have residual disease. While, 34 with radiologically normal nodes, incidence of positive sentinel lymph node biopsy after NAC is lower as compared with patients without NAC. Conclusion: We conclude that it is time to re-examine axillary management in post-NAC cases with pCR, and possibly avoiding AND in 30–40% cases. Also, there is no place for upfront sentinel lymph node biopsy which offers no gain.

Sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer: retrospective comparative evaluation of clinically axillary lymph node positive and negative patients, including those with axillary lymph node metastases confirmed by fine needle aspiration

Background

To evaluate the accuracy of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) in breast cancer patients with axillary lymph node (ALN) metastasis.

Methods

A total of 122 patients with operable breast cancer were enrolled in this single-center retrospective study. Eighty patients were clinically diagnosed with a positive axillary lymph node (ALN) via imaging or physical examination (including 66 patients with biopsy-proven metastasis). The other 42 cases had a clinically negative ALN. After four sessions of neoadjuvant chemotherapy, patients were assigned to an ALN-positive or -negative group. The identification rate (IR) and false negative rate (FNR) were determined in the ALN-negative group.

Results

ALN changed from positive to negative after NAC in 48 patients. Among them, 46 had at least one SLN resected (total IR = 95.8 %). Eight of the 46 SLN-negative patients had pathologically confirmed metastasis of at least one non-SLN (FNR = 36 %). Fifty-five of the 56 patients with a biopsy-proven negative ALN remained ALN negative. Furthermore, 54 of the 56 patients had at least one SLN resected (IR =98.2 %). Three SLN-negative patients of the 54 had at least one positive non-SLN (FNR = 10.7 %).

Conclusions

Due to its high FNR, post-NAC SLNB is not recommended for breast cancer patients with ALN metastasis confirmed by biopsy, though their ALN may become negative after NAC. However, for operable breast cancer with negative ALN, post-NAC SLNB is feasible if the ALN remains clinically negative after NAC.

Trial registration

Retrospective evaluation.

The Feasibility and Accuracy of Sentinel Lymph Node Biopsy in Initially Clinically Node-Negative Breast Cancer after Neoadjuvant Chemotherapy: A Systematic Review and Meta-Analysis

Background

With the increased use of neoadjuvant chemotherapy (NAC) in breast cancer, the timing of sentinel lymph node biopsy (SLNB) has become increasingly important. In this study, we aimed to evaluate the feasibility and accuracy of SLNB for initially clinically node-negative breast cancer after NAC by conducting a systematic review and meta-analysis.

Methods

We searched PubMed, Embase, and the Cochrane Library from January 1, 1993 to November 30, 2015 for studies on initially clinically node-negative breast cancer patients who underwent SLNB after NAC followed by axillary lymph node dissection (ALND).

Results

A total of 1,456 patients from 16 studies were included in this review. The pooled identification rate (IR) for SLNB was 96% [95% confidence interval (CI): 95%-97%], and the false negative rate (FNR) was 6% (95% CI: 3%-8%). The pooled sensitivity, negative predictive value (NPV) and accuracy rate (AR) were 94% (95% CI: 92%-97%, I² = 27.5%), 98% (95% CI: 98%-99%, I² = 42.7%) and 99% (95% CI: 99%-100%, I² = 32.6%), respectively. In the subgroup analysis, no significant differences were found in either the IR of an SLNB when different mapping methods were used (P = 0.180) or in the FNR between studies with and without immunohistochemistry (IHC) staining (P = 0.241).

Conclusion

Based on current evidence, SLNB is technically feasible and accurate enough for axillary staging in initially clinically node-negative breast cancer patients after NAC.

[Assessment of sentinel lymph node biopsy in patients receiving neoadjuvant chemotherapy in breast cancer: before or after?]

The main goal of preoperative chemotherapy is to reduce the size of the tumor and allow conservative treatment. Neoadjuvant treatment can affect axillary status with a downstaging in one third of the cases. For these patients, the benefit of axillary node dissection is questioned and the sentinel node biopsy (SLNB) seems to be a relevant option. However, the timing of performing SLNB is still debated especially for clinical negative patients with negative axillary ultrasound before preoperative chemotherapy. For axillary positive nodes proved by biopsy/cytology before preoperative chemotherapy, SLNB can be an option if there is a good clinical and radiological response.

The use of isotope injections in sentinel node biopsy for breast cancer: are the 1- and 2-day protocols equally effective?

Sentinel lymph nodes are mapped using ^99mTechnetium, injected on day of surgery (1-day protocol) or day before (2-day protocol). This retrospective cohort study compares efficacy between the two protocols. Histopathology for all unilateral sentinel lymph node biopsies (March 2012–March 2013) in a single centre were reviewed. Number of sentinel lymph nodes, non-sentinel lymph nodes and pathology was compared. 2/270 (0.7 %) in 1-day protocol and 8/192 (4 %) in 2-day protocol had no sentinel lymph nodes removed (p = 0.02). The median (range) number of sentinel lymph nodes removed per patient was 2 (0–7) and 1 (0–11) in the 1- and 2-day protocols respectively (p = 0.08). There was a trend for removing more non-sentinel lymph nodes in 2-day protocol [1-day: 52/270 (19 %); 2-day: 50/192 (26 %), p = 0.07]. Using 2-day, sentinel lymph node identification failure rate is higher, although within acceptable rates. The 1 and 2 day protocols are both effective, therefore choice of protocol should be driven by patient convenience and hospital efficiency. However, this study raises the possibility that 1-day may be preferable when higher sentinel lymph node count is beneficial, for example following neoadjuvant chemotherapy.

Impact of neoadjuvant chemotherapy on locoregional surgical treatment of breast cancer

Preoperative (neoadjuvant) chemotherapy (NC) has become the standard of care for patients with locally advanced breast cancer and is being increasingly used in those with large operable disease. Its main clinical advantages from a surgical therapy standpoint include the potential for conversion of patients requiring mastectomy to breast-conservation candidates, the potential for improving the cosmetic outcome following lumpectomy by decreasing the size of the primary breast tumor even if the patient is a lumpectomy candidate at presentation, and the potential for converting patients who present with positive axillary nodes and who would initially require axillary lymph node dissection to candidates for sentinel lymph node biopsy alone. Important steps are required from the time of diagnosis until the time of surgical resection to ensure successful locoregional therapy outcomes in patients treated with NC. They include accurate assessment of the location and extent of the primary breast tumor and determination of axillary nodal status before and after NC. This information is critical for successful execution of the surgical plan and to optimize the use of adjuvant radiotherapy following NC. In the future, development of more active neoadjuvant chemotherapy regimens and novel molecular and imaging techniques will undoubtedly lead to further individualization of breast cancer surgical management following NC, including the possibility of avoiding surgical resection in cases with a high likelihood of achieving a pathological complete response.

Locoregional therapy of locally advanced breast cancer: a clinical practice guideline

QUESTIONS

In female patients with locally advanced breast cancer (labc) and good response to neoadjuvant chemotherapy (nact), including endocrine therapy, what is the role of breast-conserving surgery (bcs) compared with mastectomy?In female patients with labc, is radiotherapy (rt) indicated for those who have undergone mastectomy?does locoregional rt, compared with breast or chest wall rt alone, result in a higher survival rate and lower recurrence rates?is rt indicated for those achieving a pathologic complete response (pcr) to nact?In female patients with labc who receive nact, is the most appropriate axillary staging procedure sentinel lymph node biopsy (slnb) or axillary dissection? Is slnb indicated before nact rather than at the time of surgery?How should female patients with labc that does not respond to initial nact be treated?

METHODS

This guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care (pebc) and the Breast Cancer Disease Site Group (dsg). A systematic review was prepared based on literature searches conducted using the medline and embase databases for the period 1996 to December 11, 2013. Guidelines were located from that search and from the Web sites of major guideline organizations. The working group drafted recommendations based on the systemic review. The systematic review and recommendations were then circulated to the Breast Cancer dsg and the pebc Report Approval Panel for internal review; the revised document underwent external review. The full three-part evidence series can be found on the Cancer Care Ontario Web site.

RECOMMENDATIONS

For most patients with labc, modified radical mastectomy should be considered the standard of care. For some patients with noninflammatory labc, bcs can be considered on a case-by-case basis when the surgeon deems that the disease can be fully resected and the patient expresses a strong preference for breast preservation.For patients with labc, rt after mastectomy is recommended.It is recommended that, after bcs or mastectomy, patients with labc receive locoregional rt encompassing the breast or chest wall and local node-bearing areas.It is recommended that postoperative rt remain the standard of care for patients with labc who achieve pcr to nact.It is recommended that axillary dissection remain the standard of care for axillary staging in labc, with the judicious use of slnb in patients who are advised of the limitations of the current data.Although slnb either before or after nact is technically feasible, the data are insufficient to make any recommendation about the optimal timing of slnb with respect to nact. Limited data suggest higher sentinel lymph node identification rates and lower false negative identification rates when slnb is conducted before nact; however, those data must be balanced against the requirement for two operations if slnb is not performed at the time of resection of the main tumour.It is recommended that patients receiving neoadjuvant anthracycline-taxane-based therapy (or other sequential regimens) whose tumours do not respond to the initial agent or agents, or who experience disease progression, be expedited to the next agent or agents of the regimen.For patients who, in the opinion of the treating physician, fail to respond or progress on first-line nact, several therapeutic options can be considered, including second-line chemotherapy, hormonal therapy (if appropriate), rt, or immediate surgery (if technically feasible). Treatment should be individualized through discussion at a multidisciplinary case conference, considering tumour characteristics, patient factors and preferences, and risk of adverse effects.It is recommended that prospective randomized clinical trials be designed for patients with labc who fail to respond to nact so that more definitive treatment recommendations can be developed.

Selective sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer: results of the GEICAM 2005-07 study

INTRODUCTION

A controversial aspect of breast cancer management is the use of sentinel lymph node biopsy (SLNB) in patients requiring neoadjuvant chemotherapy (NCT). This paper discusses the detection rate (DT) and false negatives (FN) of SLNB after NCT to investigate the influence of initial nodal disease and the protocols applied.

METHODS

Prospective observational multicenter study in women with breast cancer, treated with NCT and SLNB post-NCT with subsequent lymphadenectomy. DT and FN rates were calculated, both overall and depending on the initial nodal status or the use of diagnostic protocols pre-SLNB.

RESULTS

No differences in DT between initial node-negative cases and positive cases were found (89.8 vs. 84.4%, P=.437). Significant differences were found (94.1 vs. 56.5%, P=0,002) in the negative predictive value, which was lower when there was initial lymph node positivity, and a higher rate of FN, not significant (18.2 vs. 43.5%, P=.252) in the same cases. The axillary study before SLNB and after the NCT, significantly decreased the rate of FN in patients with initial involvement (55.6 vs 12.5, P=0,009).

CONCLUSIONS

NCT means less DT and a higher rate of FN in subsequent SLNB, especially if there is initial nodal involvement. The use of protocols in axillary evaluation after administering the NCT and before BSGC, decreases the FN rate in these patients.

Assessing the impact of neoadjuvant chemotherapy on the management of the breast and axilla in breast cancer

BACKGROUND

Nodal status is a sensitive prognostic indicator in breast cancer. Axillary metastases may be an indication for neoadjuvant systemic therapy. The aims of this study were to compare pathologic response rates to neoadjuvant chemotherapy (NAC) in the breast and axilla across different molecular subtypes of breast cancer and to compare the predictive value of axillary assessment before and after chemotherapy in determining final nodal status in this cohort of patients.

PATIENTS AND METHODS

The cohort comprised patients undergoing NAC from 2003 to November 2012. Data regarding patient and tumor characteristics, management, and outcomes were obtained from a prospectively maintained database and analyzed using PASW Statistics, version 18 (SPSS Inc, Chicago, IL).

RESULTS

Two hundred two cancers were identified in 196 patients. One hundred thirty-one (65%) diagnostic axillary procedures were performed, 105 (80%) before NAC, of which 93 (89%) were positive. In 28 (30%), downstaging was noted before NAC. Human epidermal growth factor receptor 2 (HER2) subtypes had the highest rate of complete pathologic response (n = 11 [61%]) and negative axillary clearance (AXCn) (n = 11 [69%]). Of 177 AXCns, 68 (38%) were negative before NAC.

CONCLUSION

AXCn in patients undergoing NAC remains controversial. HER2 subtypes are less likely to have axillary involvement after NAC and may demand different management.

Past, present and future of primary systemic treatment in breast cancer

Primary systemic treatment is a fundamental part of breast cancer therapy, and it is applied to non-surgical and locally advanced tumours as well as surgical tumours to increase the likelihood of conservative treatment. Its aim is to achieve the best possible survival with better cosmetic results and with the lowest number of treatment-related secondary effects. Before treatment is started, it is necessary to attain the best knowledge of the biological features and locoregional extension of the tumour. To do so, it is necessary to obtain a biopsy of the lesion with a wide bore needle, as well as good radiological knowledge of the disease. Therefore, currently, the use of a dynamic magnetic resonance imaging (MRI) of the breast should be included in all cases. In addition, before it is started, especially in those tumours in which conservative treatment is considered, one or several radiopaque markers should be put into place to make it possible to locate the area to be treated if there is a considerable or complete response. Systemic treatment is mainly based on combined chemotherapy with anthracyclins and taxanes, in addition to some biological agents with demonstrated efficiency for increasing the likelihood of complete disease response (trastuzumab in patients with Her-2/neu overexpression). However, there is room for neoadjuvant hormone treatment, in patients with hormone receptor overexpression, especially in those cases in which chemotherapy is contraindicated as well as in elderly patients with a relatively short life expectancy. The assessment of preoperative treatment should be based on adequate radiological tests, and nowad these should include MRI before taking decisions about adequate surgical treatment. The objective of primary treatment is to be able to increase survival and improve the chances of local treatment in the case of locally advanced treatment, achieving results that are at least equal to those of adjuvant treatment in the case of surgical tumours, but with greater chances of conservative surgery. Although the objective is survival, achieving complete pathological response seems to be a reasonable related objective, although these are more closely linked in some tumour subtypes.

Timing of the sentinel lymph node biopsy in breast cancer patients receiving neoadjuvant therapy - recommendations for clinical guidance

Neoadjuvant chemotherapy (NAC) is an increasingly important component in the treatment of both locally advanced and early-stage breast cancer. With this, a debate on the timing of the sentinel lymph node biopsy (SLNB) has emerged. At the end of the last century, the SLNB was introduced as an axillary staging modality, and this paper aims to further elucidate this issue in the context of NAC. We compiled available data on the SLNB after NAC and provide clinical guidance for timing the SLNB in this context. On the basis of our findings, we recommend that the SLNB can be performed after NAC in all cases. In patients with a clinically node-negative (cN0) status prior to NAC, the SLNB should be performed after NAC, and in case of a histologically confirmed negative SLNB, a completion axillary lymph node dissection (ALND) has no added value and can be omitted. In patients with clinically positive nodal involvement (cN+) prior to NAC, all axillary surgery can also be performed after NAC.

Fine-needle aspirates CYFRA 21-1 is a useful tumor marker for detecting axillary lymph node metastasis in breast cancer patients

Introduction

To assess whether the value of CYFRA21-1 in the aspirates of ultrasonography-guided fine-needle aspiration biopsy (US-FNAB) can contribute to improving the performances of US-FNAB in the diagnosis of axillary lymph node (LN) metastasis in breast cancer patients.

Methods

US-FNAB was performed in 156 axillary LNs in 152 breast cancer patients (mean age: 51.4 years, range: 17–92 years). Concentrations of CYFRA21-1 were measured from washouts of the syringe used during US-FNAB. Tumor marker concentrations, US-FNAB, intraoperative sentinel node biopsy (SNB), and surgical pathology results were reviewed and analyzed. For comparison, the values of CEA and CA15-3 were also measured from washouts.

Results

Among the 156 LNs, 75 (48.1%) were benign, and 81 (51.9%) were metastases. Mean concentrations of CYFRA21-1 were significantly higher in metastasis compared to benign LNs (P<0.001). US-FNAB combined to CYFRA21-1 showed significantly higher sensitivity, NPV, and accuracy compared to US-FNAB alone (all values P<0.05). All diagnostic indices of US-FNAB combined to CYFRA21-1 were significantly higher compared to US-FNAB combined with CEA or CA15-3 (all P<0.001). Of the 28 metastatic LNs which showed metastasis on SNB, CYFRA21-1 showed higher positive rate of 75.0% (CEA or CA15-3∶60.7%, P = 0.076).

Conclusion

Measuring CYFRA 21-1 concentrations from US-FNAB aspirates improves sensitivity, NPV, and accuracy of US-FNAB alone, and may contribute to reducing up to 75.0% of unnecessary intraoperative SNB. Compared to CEA or CA15-3, CYFRA21-1 shows significantly higher performances when combined to US-FNAB in the preoperative diagnosis of LN metastasis in breast cancer patients.

A central review of histopathology reports after breast cancer neoadjuvant chemotherapy in the neo-tango trial

Background:

Neo-tAnGo, a National Cancer Research Network (NCRN) multicentre randomised neoadjuvant chemotherapy trial in early breast cancer, enroled 831 patients in the United Kingdom. We report a central review of post-chemotherapy histopathology reports on the surgical specimens, to assess the presence and degree of response.

Methods:

A central independent two-reader review (EP and HME) of histopathology reports from post-treatment surgical specimens was performed. The quality and completeness of pathology reporting across all centres was assessed. The reviews included pathological response to chemotherapy (pathological complete response (pCR); minimal residual disease (MRD); and lesser degrees of response), laterality, the number of axillary metastases and axillary nodes, and the type of surgery. A consensus was reached after discussion.

Results:

In all, 825 surgical reports from 816 patients were available for review. Out of 4125 data items there were 347 discrepant results (8.4% of classifications), which involved 281 patients. These involved grading of breast response (169 but only 9 involving pCR vs MRD); laterality (6); presence of axillary metastasis (35); lymph node counts (108); and type of axillary surgery (29). Excluding cases with pCR, only 45% of reports included any comment regarding response in the breast and 30% in the axillary lymph nodes.

Conclusion:

We found considerable variability in the completeness of reporting of surgical specimens within this national neoadjuvant breast cancer trial. This highlights the need for consensus guidelines among trial groups on histopathology reporting, and the participation of histopathologists throughout the development and analysis of neoadjuvant trials.

Sentinel node biopsy for breast cancer: past, present, and future

Sentinel node biopsy has replaced axillary lymph node dissection as the standard of care in early breast cancers. Sentinel node biopsy represents a highly accurate and less-morbid axillary staging, which allows most patients to avoid unnecessary axillary lymph node dissection and its morbidity. This review provides information including several issues which are still under debate, such as clinical significance of micrometastases, avoidance of axillary lymph node dissection for patients with positive sentinel nodes, accuracy and timing of sentinel node biopsy in patients undergoing neoadjuvant chemotherapy, and how many sentinel nodes are sufficient for removal. Finally, a new topic is introduced: superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging for the detection of metastases in sentinel nodes localized by computed tomography (CT)-lymphography (CT-LG) in patients with breast cancer. SPIO-enhanced MR imaging is a useful method of detecting metastases in sentinel nodes localized by CT-LG in patients with breast cancer. Patients with clinically negative nodes may be spared even sentinel node biopsy when the sentinel node is diagnosed as disease free using SPIO-enhanced MR imaging.

Preoperative needle biopsy of sentinel lymph nodes using intradermal microbubbles and contrast-enhanced ultrasound in patients with breast cancer

OBJECTIVE

The purpose of this study was to assess whether sentinel lymph nodes (SLNs) that undergo targeted needle biopsy after identification by contrast-enhanced ultrasound (CEUS) using intradermally injected microbubbles results in more node-positive breast cancer patients being diagnosed preoperatively. Furthermore, we sought to determine whether the addition of CEUS to gray-scale sonography of the axilla reduces the number of patients having axillary lymph node (ALN) dissection as a second procedure.

SUBJECTS AND METHODS

Intradermal microbubble injection was performed in 136 breast cancer patients who had no abnormal ALNs on routine gray-scale axillary sonography. When an enhancing ALN was visualized, percutaneous sonography-guided fine-needle aspiration cytology or core needle biopsy was performed. Depending on the biopsy results, patients underwent SLN biopsy or ALN dissection. If the putative SLN biopsy was positive or a biopsy tract was seen in the excised SLN, the procedure was defined as successful.

RESULTS

SLNs were identified and biopsied in 126 of the 136 cases (93%). Seventeen patients had positive sonography-guided biopsy results (13%) and were treated with immediate ALN dissection. In seven patients, the biopsied node was the only positive node. The remaining 109 patients underwent SLN biopsy. In nine cases (8%), a positive lymph node was identified. Four of these false-negative cases had only micrometastases.

CONCLUSION

SLNs can be identified and biopsied using CEUS to increase the accuracy of preoperative axillary staging. If the needle biopsy result is negative, conventional SLN biopsy is indicated.

Accuracy and axilla sparing potentials of sentinel lymph node biopsy with methylene blue alone performed before versus after neoadjuvant chemotherapy in breast cancer: a single institution experience

INTRODUCTION

The timing of sentinel lymph node biopsy (SLNB) of breast cancer in the neoadjuvant setting is still controversial. We retrospectively analyzed a Chinese patient cohort with neoadjuvant chemotherapy (NAC) to evaluate the accuracy and axilla sparing potentials of different SLNB timings with methylene blue alone for lymphatic mapping.

MATERIALS AND METHODS

Patients with NAC and axillary lymph node dissection (ALND) and either pre- or post-NAC SLNB were eligible. Clinicopathological characteristics, identification rate (IR), false-negative rate (FNR), accuracy, and positive-predictive value were calculated and compared between the pre- and post-NAC SLNB group using appropriate statistical methods. Axilla sparing potentials of different SLNB timings were evaluated and compared.

RESULTS

One hundred and fifteen eligible cases were included, and 58 had pre-NAC SLNB while the other 57 had post-NAC SLNB. Both groups were comparable in clinicopathological characteristics, neoadjuvant treatments and pathologic complete response rate. IR, FNR, and accuracy of SLNB, as pre-NAC versus post-NAC, were 100 versus 98.2 % (P = 0.496), 0 versus 8.0 % (P = 0.181), and 100 versus 96.4 % (P = 0.239), respectively. Post-NAC SLNB had significantly higher positive-predictive value for ALNs than pre-NAC SLNB (70.0 vs. 36.4 %, P = 0.014), suggesting as high as 63.6 % of ALND performed in the pre-NAC group could have been avoided while only 30 % of ALND in the post-NAC group were theoretically unnecessary.

CONCLUSIONS

Both SLNB timings of breast cancer patients with NAC were feasible and accurate. Although pre-NAC SLNB tends to be better in accuracy, post-NAC SLNB is significantly superior in terms of axilla sparing.

Is optimal timing of sentinel lymph node biopsy before neoadjuvant chemotherapy in patients with breast cancer? A literature review

BACKGROUND

Twenty five percent of women with breast cancer who undergo preoperative chemotherapy do not have axillary metastases. These patients need to withstand sentinel lymph node biopsy (SLNB). The optimal timing of SLNB in patients with neoadjuvant chemotherapy has not yet been defined.

METHODS

We systematically reviewed the literature for studies concerning the efficacy of sentinel lymph node biopsy before neoadjeuvant chemotherapy. A literature search was performed for the years 1993 through 2011 using the databases MEDLINE and EMBASE. Data that assessed the reliability of sentinel lymph node biopsy before chemotherapy were collected.

RESULTS

We identified 10 high-quality studies from 387 papers, which are analyzed further in this review. The identification rates reported ranged from 97% to 100%. The sensitivities of sentinel lymph node biopsy were 100%, and the false negative rates were 0%. Use an isotope combined with blue dye was associated with a higher probability of identification than that of using an isotope or blue dye alone (99.5% vs 98.5%). Only two studies compared data based on different timing for the sentinel lymph node biopsy. They achieved a lower false negative rate (0% vs 15.8%) and higher success rate (100% vs 81%) in patients with sentinel lymph node biopsy prior to neoadjuvant chemotherapy.

CONCLUSION

Sentinel lymph node biopsy prior to chemotherapy potentially gives a more accurate evaluation of axillary status, because it is unaffected by any previous therapeutic intervention.

The feasibility and accuracy of sentinel lymph node biopsy in clinically node-negative patients after neoadjuvant chemotherapy for breast cancer--a systematic review and meta-analysis

The sentinel lymph node biopsy (SLNB) is now an accepted alternative to the axillary lymph node dissection for pathologic evaluation of the axilla in patients with early breast cancer. The use of SLNB after neoadjuvant chemotherapy (NAC) is controversial. This meta-analysis aims to determine the feasibility and the accuracy of SLNB in the population of patients who are clinically node-negative after NAC for breast cancer.

Preoperative sentinel node identification with ultrasound using microbubbles in patients with breast cancer

OBJECTIVE

Sentinel lymph node (SLN) biopsy is the standard procedure for axillary staging in early breast cancer. Lymphatic imaging after peritumoral microbubble injection has been described in animal models. The aim of this study was to identify and localize SLNs preoperatively by contrast-enhanced sonography after intradermal injection of microbubbles in patients with breast cancer.

SUBJECTS AND METHODS

Eighty consecutive consenting patients with primary breast cancer were recruited. Patients received a periareolar intradermal injection of microbubble contrast agent. Breast lymphatics were visualized by sonography and followed to the axilla to identify SLNs. A guidewire was deployed to localize the SLN. The next day, patients underwent standard tumor excision and SLN biopsy.

RESULTS

In 71 (89%) of the 80 patients, SLNs were identified and guidewires were inserted. In these patients, operative findings using conventional radioisotope and blue dye techniques confirmed that the wired nodes were SLNs. Fourteen patients were found to have metastases in SLNs. In these patients, the SLNs were identified correctly and were localized with guidewires before surgery.

CONCLUSION

SLNs may be identified and localized before surgery using contrast-enhanced sonography after injection of microbubbles.

A further survey of surgical management of the axilla in UK breast cancer patients

INTRODUCTION

The aims of this study were to investigate the practice of axillary lymph node management within different units throughout the UK, and to assess changes in practice since our previous survey in 2004.

SUBJECTS AND METHODS

A structured questionnaire was sent to 350 members of the British Association of Surgical Oncology.

RESULTS

There were 177 replies from respondents who managed more than 100 patients a year with breast cancer. Of these: 12 did not perform axillary ultrasound at all in their centre; 17 (10%) employed axillary node clearance (ANC) on all patients; 122 (69%) performed sentinel node biopsy (SNB) with dual localisation; and 111 respondents had attended the New Start Course. Radioisotope was most frequently injected 2 h or more before operation. Just 13 surgeons were convinced of the value of dissecting internal mammary nodes visualised on a scan. Reasons for not using dual localisation included lack of nuclear medicine facilities, no local ARSAC licence holder, no probe, and no funding. Sixty-six surgeons stated that, if they had an ARSAC licence and could inject the radioactivity in theatre, this would be a major improvement. In addition, 83 (47%) did not perform SLNB in patients receiving neo-adjuvant chemotherapy.

CONCLUSIONS

Despite significant changes since 2004, substantial variation remains in management of the axilla. A number of surgeons are practicing outwith current guidelines.

Sentinel lymph node biopsy before or after neoadjuvant chemotherapy: pros and cons

This article summarizes the relative pros and cons surrounding the timing of sentinel lymph node (SLN) biopsy in patients undergoing neoadjuvant chemotherapy. Several institutions initiated prospective trials of SLN biopsy performed after neoadjuvant chemotherapy in conjunction with a completion axillary lymph node dissection, with the goal of ultimately showing that SLN biopsy could be safely and accurately performed after the patient completed systemic therapy. Other institutions adopted a policy of performing SLN biopsy before initiation of chemotherapy. This avoided the issue surrounding the accuracy of SLN biopsy after chemotherapy and potentially provided information that might influence adjuvant therapy decisions. This article addresses the clinical questions regarding the 2 approaches including the accuracy of the procedure and the prognostic information gleaned.

What's new in neoadjuvant therapy for breast cancer?

Neoadjuvant treatment of breast cancer is currently being used in patients with advanced disease as well as with increasing application in those that present with initially operable breast cancer. The current clinical benefits of the use of NAC include: NAC increases the possibility of the use of BCS, the safety of NAC is comparable with that of adjuvant chemotherapy, and pCR may be predictive of overall survival. Although there are still unresolved clinical questions regarding the use of neoadjuvant therapy in initially operable breast cancer, there appears to be equivalent survival to the standard of care. Future research should be aimed at tailoring treatment to individual patients using specific tumor characteristics that may predict response to different types of chemotherapy, molecular targeted therapy, and endocrine therapy.

Sentinel lymph node biopsy in breast cancer: a comprehensive literature review

Sentinel lymph node biopsy has emerged as the new standard of care for nodal staging in early-stage breast disease. In the this review, the procedure of SLNB in breast cancer will be examined in greater detail with the aim of understanding techniques that may improve results and of identifying future research questions in this field.

Accuracy of sentinel node biopsy after neoadjuvant chemotherapy in breast cancer patients: a systematic review

BACKGROUND

As neoadjuvant chemotherapy (NAC) is increasingly used to downstage patients with breast cancer, the timing of the sentinel node (SN) biopsy has become an important issue. This review was conducted to determine the accuracy of SN biopsy following NAC.

METHODS

We searched Medline, Embase and Cochrane databases from 1993 to February 2009 for studies on patients with invasive breast cancer who underwent SN biopsy after NAC followed by an axillary lymph node dissection (ALND).

RESULTS

Of 574 eligible studies, 27 were included in this review with a total study population of 2148 patients. The pooled SN identification rate was 90.9% (95% confidence interval (CI)=88.0-93.1%) and the false-negative rate was 10.5% (95% CI=8.1-13.6%). Negative predictive value and accuracy after NAC were 89.0% (95% CI=85.1-92.1%) and 94.4% (95% CI=92.6-95.8%), respectively. The reported SN success rates were heterogeneous and several variables were reported to be associated with decreased SN accuracy, i.e. initially positive clinical nodal status.

CONCLUSIONS

There is a potential role for SN biopsy following NAC which could be considered on an individual basis. However, there is insufficient evidence to recommend this as a standard procedure. Further research with subgroup analysis using variables reported to be associated with decreased SN accuracy is required in order to clearly define its value in the subgroups of breast cancer patients.

Current surgery for breast cancer

Surgeons retain the central role in the multidisciplinary care of the breast cancer patient. While technical details of the operations for these patients remain important, effective evidence-based decision making may be even more so. Advances in the methods of breast cancer diagnosis, localization techniques and surgical therapies, as well as the expanded role of the surgeon in breast cancer prevention, radiation therapy and the treatment of distant disease, requires surgeons to stay up to date with the available evidence. Herein, we present a review of the current surgical therapy of invasive breast cancer.