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Lee J, Park S, Bae SJ, Ji J, Kim D, Kim JY, Park HS, Ahn SG, Kim SI, Park BW, Jeong J. Micrometastases in axillary lymph nodes in breast cancer, post-neoadjuvant systemic therapy. Breast Cancer Res 2024; 26:120. [PMID: 39085833 PMCID: PMC11293213 DOI: 10.1186/s13058-024-01874-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/21/2024] [Indexed: 08/02/2024] Open
Abstract
INTRODUCTION The significance of minimal residual axillary disease, specifically micrometastases, following neoadjuvant systemic therapy (NST) remains largely unexplored. Our study aimed to elucidate the prognostic implications of micrometastases in axillary and sentinel lymph nodes following NST. METHODS This retrospective study analyzed primary breast cancer patients who underwent surgery after NST from September 2006 through February 2018. All patients received axillary lymph node dissection (ALND), either with or without sentinel lymph node biopsy. Recurrence-free survival (RFS)-associated variables were identified using a multivariate Cox proportional hazard model. RESULTS Of the 978 patients examined, 438 (44.8%) exhibited no pathologic lymph node involvement (ypN0) after NST, while 89 (9.1%) had micrometastases (ypN1mi) and 451 (46.7%) had macrometastases (ypN+). Notably, 51.1% of the patients with sentinel lymph node micrometastases (SLNmi) had additional metastases, nearly triple that of SLN-negative patients (P < 0.001), and 29.8% of SLNmi patients were upstaged with the ALND. Although ypN1mi was not associated with RFS in patients post-NST (HR, 1.02; 95% CI, 0.42-2.49; P = 0.958), SLNmi patients experienced significantly worse RFS compared to SLN-negative patients (hazard ratio [HR], 2.23; 95% confidence intervals [CI], 1.12-4.46; P = 0.023). Additional metastases in SLNmi were more prevalent in patients with larger residual breast disease greater than 20 mm, HR-positive/HER2-negative subtype, and low Ki-67 LI (< 14%). CONCLUSIONS SLNmi is a negative prognostic factor significantly associated with additional non-SLN metastases, while ypN1mi does not influence the prognosis compared to ypN0. Hence, additional ALND may be warranted to confirm axillary nodal status in patients with SLNmi.
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Affiliation(s)
- Janghee Lee
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University, Dongtan, Republic of Korea
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Seho Park
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Junghwan Ji
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dooreh Kim
- Department of Surgery, College of Medicine, Seoul St. Marys's Hospital, The Catholic University of Seoul, Seoul, Republic of Korea
| | - Jee Ye Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyung Seok Park
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Il Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byeong-Woo Park
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Moore AM, Caudle AS, Sun SX, Yi M, Smith BD, Valero V, Yang W, Kuerer HM, Hunt KK, Teshome M. Residual Nodal Burden After Neoadjuvant Chemotherapy in cN1 Breast Cancer Patients with Positive Nodes at Targeted Axillary Dissection. Ann Surg Oncol 2024:10.1245/s10434-024-15797-6. [PMID: 39044106 DOI: 10.1245/s10434-024-15797-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 06/25/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Targeted axillary dissection (TAD) facilitates nodal staging in cN1 breast cancer after neoadjuvant chemotherapy (NAC). Completion axillary node dissection (cALND) remains the standard of care for TAD-positive patients. This study investigated factors associated with additional positive nodes at cALND (cALND+) and the impact on the residual cancer burden (RCB). METHODS Retrospective review of cN1 breast cancer patients treated with NAC and TAD was conducted from July 2013 to June 2023. The review defined cN1 status by ultrasound (US) and biopsy. Patient, tumor, and treatment characteristics were evaluated. Multivariate analysis was performed to identify factors associated with cALND+, and RCB was calculated. RESULTS Of 902 patients who underwent TAD, 554 (61.4%) were TAD-positive. 457 underwent cALND, and 124 (27%) were cALND+ (average 4.1 additional +nodes). The cALND+ patients had larger primary tumors at diagnosis (4 vs 3.5 cm; p = 0.04), more than three suspicious nodes on initial US (30% vs 13%; p ≤ 0.0001), larger residual primary tumors on pathology (median, 3 vs 2.1 cm; p = 0.0004), and more positive TAD nodes (median, 2 vs 1; p ≤ 0.0001). In the multivariate analysis, the factors associated with cALND+ were more than three suspicious nodes on initial US (odds ratio [OR], 2.9; p ≤ 0.0001), more positive TAD nodes (OR, 1.1; p ≤ 0.0001), larger clipped node metastasis (OR, 1.1; p ≤ 0.0001), and larger residual tumor on pathology (OR, 1.1; p = 0.006). Of 65 cALND+ patients with RCB class I or II, 29 (45%) had an increase in RCB based on cALND. CONCLUSION Of cN1 breast cancer patients treated with NAC who are TAD-positive, approximately 25% will have additional nodal disease on cALND. In these patients, positive cALND is associated with greater disease burden, which has potential implications for RCB status and prognosis.
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Affiliation(s)
- Alexandra M Moore
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Abigail S Caudle
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susie X Sun
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Min Yi
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benjamin D Smith
- Department of Breast Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vicente Valero
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei Yang
- Department of Breast Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Department of Surgery, Division of Surgical Oncology, University of California Los Angeles, Los Angeles, CA, USA
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Weiss A, Colugnati F, Mitchell M, Li Y, Marin C, Gergelis KR, O'Sullivan CC, Boughey JC. 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. Ann Surg Oncol 2024:10.1245/s10434-024-15705-y. [PMID: 38976157 DOI: 10.1245/s10434-024-15705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/10/2024] [Indexed: 07/09/2024]
Abstract
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.
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Affiliation(s)
- Anna Weiss
- Division of Surgical Oncology, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
| | - Fernando Colugnati
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Melissa Mitchell
- Department of Breast Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yue Li
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Chelsea Marin
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Kimberly R Gergelis
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
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Weiss A, Jin Q, Waks AG, Yardley D, Spring LM, Wrabel E, Tayob N, Viale G, Krop IE, King TA, Metzger-Filho O. Axillary Nodal Response to Neoadjuvant T-DM1 Combined with Pertuzumab in a Prospective Phase II Multi-Institution Clinical Trial. J Am Coll Surg 2024; 238:303-311. [PMID: 38047578 DOI: 10.1097/xcs.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
BACKGROUND Patients with ERBB2 (HER2)-positive breast cancer experience high pathologic complete response (pCR) rates after standard neoadjuvant anti-HER2 systemic therapy. We examined axillary pathologic nodal response to neoadjuvant dual HER2-targeted therapy alone, based on breast pathologic response, in a multi-institution clinical trial. STUDY DESIGN Patients with HER2-positive breast cancer were enrolled to a phase II single-arm trial, which administered 6 cycles of neoadjuvant trastuzumab emtansine (T-DM1) plus pertuzumab. Rates of pathologic nodal disease (ypN) in patients who were clinically node-negative (cN0) and node-positive (cN1) were analyzed, by residual breast disease (pCR and residual cancer burden [RCB] I to III). RESULTS One hundred fifty-eight patients completed preoperative treatment and proceeded to surgery. Of 92 patients who were cN0, 48 (52.2%) and 10 (10.9%) experienced breast pCR and RCB I, respectively. Of these, 100% were ypN0. Of 34 with RCB II to III, 26 (76.5%) were ypN0. Of 30 patients who were cN1 with breast pCR, 100% were ypN0; of the 12 patients who were cN1 with RCB I, 66.7% were ypN0; and of the 24 patients who were cN1 with RCB II to III, 25% were ypN0. ypN0 rates were significantly different between patients who did and did not experience a pCR, in both cN0 (p = 0.002) and cN1 (p < 0.001) subgroups. CONCLUSIONS Patients with HER2-positive breast cancer treated with dual HER2-targeted therapy who experienced a breast pCR or RCB I response were frequently ypN0. These findings support future trials considering omission of axillary surgical staging for patients with HER2-positive breast cancer in neoadjuvant trials of active HER2-targeted regimens, particularly if they experience breast pCR or RCB I.
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Affiliation(s)
- Anna Weiss
- From the Division of Surgical Oncology, Department of Surgery, University of Rochester, Rochester, NY (Weiss)
| | - Qingchun Jin
- Department of Data Science (Jin, Tayob), Dana-Farber Cancer Institute Boston, MA
| | - Adrienne G Waks
- Division of Medical Oncology (Waks, Metzger-Filho), Dana-Farber Cancer Institute Boston, MA
- Harvard Medical School, Boston, MA (Waks, Tayob, King, Metzger-Filho)
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA (Waks, Wrabel, King, Metzger-Filho)
| | - Denise Yardley
- Sarah Cannon Research Institute and Tennessee Oncology, Nashville, TN (Yardley)
| | | | - Eileen Wrabel
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA (Waks, Wrabel, King, Metzger-Filho)
| | - Nabihah Tayob
- Department of Data Science (Jin, Tayob), Dana-Farber Cancer Institute Boston, MA
- Harvard Medical School, Boston, MA (Waks, Tayob, King, Metzger-Filho)
| | - Giuseppe Viale
- Division of Pathology, European Institute of Oncology, IRCCS and University of Milan, Milan, Italy (Viale)
| | - Ian E Krop
- Yale Cancer Center, New Haven, CT (Krop)
| | - Tari A King
- Harvard Medical School, Boston, MA (Waks, Tayob, King, Metzger-Filho)
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA (Waks, Wrabel, King, Metzger-Filho)
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA (King)
| | - Otto Metzger-Filho
- Division of Medical Oncology (Waks, Metzger-Filho), Dana-Farber Cancer Institute Boston, MA
- Harvard Medical School, Boston, MA (Waks, Tayob, King, Metzger-Filho)
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA (Waks, Wrabel, King, Metzger-Filho)
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Loonis AST, Chesebro AL, Bay CP, Portnow LH, Weiss A, Chikarmane SA, Giess CS. Positive predictive value of axillary lymph node cortical thickness and nodal, clinical, and tumor characteristics in newly diagnosed breast cancer patients. Breast Cancer Res Treat 2024; 203:511-521. [PMID: 37950089 DOI: 10.1007/s10549-023-07155-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/30/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Axillary lymph nodes (LNs) with cortical thickness > 3 mm have a higher likelihood of malignancy. To examine the positive predictive value (PPV) of axillary LN cortical thickness in newly diagnosed breast cancer patients, and nodal, clinical, and tumor characteristics associated with axillary LN metastasis. METHODS Retrospective review of axillary LN fine needle aspirations (FNAs) performed 1/1/2018-12/31/2019 included 135 axillary FNAs in 134 patients who underwent axillary surgery. Patient demographics, clinical characteristics, histopathology, and imaging features were obtained from medical records. Hypothesis testing was performed to identify predictors of axillary LN metastasis. RESULTS Cytology was positive in 72/135 (53.3%), negative in 61/135 (45.2%), and non-diagnostic in 2/135 (1.5%). At surgery, histopathology was positive in 84 (62.2%) and negative in 51 (37.8%). LN cortices were thicker in metastatic compared to negative nodes (p < 0.0001). PPV of axillary LNs with cortical thickness ≥ 3 mm, ≥ 3.5 mm, ≥ 4 mm and, ≥ 4.25 mm was 0.62 [95% CI 0.53, 0.70], 0.63 [0.54, 0.72], 0.67 [0.57, 0.76] , and 0.74 [0.64, 0.83], respectively. At multivariable analysis, abnormal hilum (OR = 3.44, p = 0.016) and diffuse cortical thickening (OR = 2.86, p = 0.038) were associated with nodal metastasis. CONCLUSION In newly diagnosed breast cancer patients, increasing axillary LN cortical thickness, abnormal fatty hilum, and diffuse cortical thickening are associated with nodal metastasis. PPV of axillary LN cortical thickness ≥ 3 mm and ≥ 3.5 mm is similar but increases for cortical thickness ≥ 4 mm. FNA of axillary LNs with cortex < 4 mm may be unnecessary for some patients undergoing sentinel LN biopsy.
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Affiliation(s)
- Anne-Sophie T Loonis
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Allyson L Chesebro
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
| | - Camden P Bay
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Takeda Pharmaceuticals, Cambridge, MA, USA
| | - Leah H Portnow
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Anna Weiss
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Division of Surgical Oncology, Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Sona A Chikarmane
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Catherine S Giess
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
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