Sentinel node biopsy after neoadjuvant chemotherapy in cytologically proven node-positive breast cancer

Feasibility of Sentinel Lymph Node Biopsy in Breast Cancer Patients with Axillary Conversion after Neoadjuvant Chemotherapy-A Single-Tertiary Centre Experience and Review of the Literature

(1) Introduction: Sentinel lymph node biopsy (SLNB) is widely used in breast cancer patients who undergo neoadjuvant chemotherapy (NAC), replacing axillary lymph node dissection. While commonly accepted for cN0 patients, its role in cN1/2 patients remains controversial. Our study aims to investigate the role of SLNB in BC patients who underwent prior NAC and compare our results to those of other studies presented in the literature. (2) Materials and methods: Our retrospective study included 102 breast cancer patients who received NAC before 99mTc-albumin Nanocolloid SLN mapping and SLNB was performed, completed or not with axillary dissection. A review based on the PRISMA statement was also carried out, encompassing 20 studies. (3) Results: The lymphoscintigraphy performed after the administration of NAC presented an identification rate (IR) of 93.13%. IR for SLNB was 94.11%, with a false-negative rate (FNR) of 7.4%. After a median follow-up of 31.3 months, we obtained a distant disease-free survival rate of 98%. The results obtained by other groups were similar to those of our study, presenting IR in the range 80.8-96.8%, with FNR varying from 0 to 22%. (4) Conclusions: on conclusion, SLNB can accurately determine the lymph node status, with an acceptable FNR and maintain its expected prognostic role with low recurrence rates, and our results are comparable to those obtained by other studies.

The value of sentinel lymph-node biopsy in women with node-positive breast cancer at diagnosis and node-negative tumour after neoadjuvant therapy: a systematic review

PURPOSE

To conduct a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) in women with node-positive breast cancer at diagnosis and node-negative tumour after neoadjuvant therapy, compared to axillary lymph-node dissection.

METHODS

The more relevant databases were searched. Main outcomes were false-negative rate (FNR), sentinel lymph-node identification rate (SLNIR), negative predictive value (NPV), and accuracy. We conducted meta-analyses when appropriate.

RESULTS

Twenty studies were included. The pooled FNR was 0.14 (95% CI 0.11-0.17), the pooled SLNIR was 0.89 (95% CI 0.86-0.92), NPV was 0.83 (95% CI 0.79-0.87), and summary accuracy was 0.92 (95% CI 0.90-0.94). SLNB performed better when more than one node was removed and double mapping was used.

CONCLUSIONS

SLNB can be performed in women with a node-negative tumour after neoadjuvant therapy. It has a better performance when used with previous marking of the affected node and with double tracer.

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.

Feasibility and reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patients with positive axillary nodes at initial diagnosis: An up-to date meta-analysis of 3,578 patients

Purpose

Neoadjuvant chemotherapy (NACT) is increasingly adopted in the therapy of breast cancer (BC) patients with positive axillary nodes (cN+), but the reliability and feasibility of sentinel lymph node biopsy (SLNB) following NACT are still controversial. The objective of the present study is to conduct an updated meta-analysis on this issue.

Methods

A literature search was performed using PubMed, Cochrane, Embase, and Web of Science to identify papers published from January 1, 2000 to October 22, 2020 to research SLNB after NACT in BC patients. Studies that met the quality standard were enrolled for this meta-analysis.

Results

A total of 3578 participants from 27 trials were included in this meta-analysis. The pooled estimate of the identification rate (IR) for SLNB was 91 %, and the false negative rate (FNR) was 15 %. The pooled negative prediction value (NPV), accuracy, specificity, and sensitivity were 82 %, 89 %, 97 %, and 85 %, respectively. In subgroup analysis, the application of dual mapping could clearly decrease the FNR. The FNR was significantly high in the luminal types, and it declined as more sentinel lymph nodes (SLNs) were removed.

Conclusion

SLNB following NACT is now technically feasible for BC with cN+. However, it must be emphasized that the FNR is unacceptable high.

•

We performed a meta-analysis to provide a consensus regarding the application of SLNB post-NACT in cN + patients.

•

One comprehensive database search yielded 27 studies (3578 patients).

•

The pooled estimate of IR for SLNB was 91 %, and FNR was 15 %.

•

The application of dual mapping could clearly decrease the FNR.

Enhanced axillary assessment using intradermally injected microbubbles and contrast-enhanced ultrasound (CEUS) before neoadjuvant systemic therapy (NACT) identifies axillary disease missed by conventional B-mode ultrasound that may be clinically relevant

PURPOSE

The purpose of this study is to measure pre-treatment diagnostic yield of malignant lymph nodes (LN) using contrast-enhanced ultrasound (CEUS) in addition to B-mode axillary ultrasound and compare clinicopathological features, response to NACT and long-term outcomes of patients with malignant LN detected with B-mode ultrasound versus CEUS.

METHODS

Between August 2009 and October 2016, NACT patients were identified from a prospective database. Follow-up data were collected until May 2019.

RESULTS

288 consecutive NACT patients were identified; 77 were excluded, 110 had malignant LN identified by B-mode ultrasound (Group A) and 101 patients with negative B-mode axillary ultrasound had CEUS with biopsy of sentinel lymph nodes (SLN). In two cases CEUS failed. Malignant SLN were identified in 35/99 (35%) of B-mode ultrasound-negative cases (Group B). Patients in Group A were similar to those in Group B in age, mean diagnostic tumour size, grade and oestrogen receptor status. More Group A patients had a ductal phenotype. In the breast, 34 (31%) Group A patients and 8 (23%) Group B patients achieved a pathological complete response (PCR). In the axilla, 41 (37%) and 13 (37%) Groups A and B patients, respectively, had LN PCR. The systemic relapse rate was not statistically different (5% and 16% for Groups A and B, respectively).

CONCLUSIONS

Enhanced assessment with CEUS before NACT identifies patients with axillary metastases missed by conventional B-mode ultrasound. Without CEUS, 22 (63%) of cases in Group B (negative B-mode ultrasound) may have been erroneously classed as progressive disease by surgical SLN excision after NACT.

Marking axillary nodes with 4% carbon microparticle suspension before neoadjuvant chemotherapy improves sentinel node identification rate and axillary staging

BACKGROUND AND OBJECTIVES

Marking positive lymph nodes (LNs) before neoadjuvant chemotherapy (NAC) may improve the accuracy of sentinel lymph node biopsy (SLNB). The aim of this study was to determine the feasibility of marking LNs with 4% carbon microparticle suspension (CMS) before NAC and to evaluate if this technique would improve the SLNB identification rate.

METHODS

A prospective study of patients with cT1-T4, cN1-N2 breast cancer who underwent US-guided fine-needle aspiration biopsy (FNAB) of suspected LNs and concomitant marking with 4% CMS was performed. After NAC, LNs marked with 4% CMS and those marked with Patent Blue V dye (PBV) were identified and resected.

RESULTS

Of the 123 patients included, 74 (60.1%) had positive LNs at FNAB. During axillary surgery, 4% CMS was identified in 121 of 123 patients (98.3%) and blue sentinel LNs in 91% (112 of 123 patients) (P = .0103). Comparing isolated results of PBV and 4%CMS + PBV, the association was better in identifying positive LNs (72.2% vs 97.7%) (P = .02).

CONCLUSION

The association of 4% CMS and PBV is feasible and significantly increased the identification rate of positive LNs. 4% CMS may play an important role as a complementary technique in patients submitted to NAC.

Sentinel Lymph Node Biopsy in Locally Advanced Breast Cancer After Neoadjuvant Chemotherapy-an Indian Perspective

Sentinel lymph node biopsy (SLNB) alone in early breast cancer is an established standard of care. However, the same results have not been replicated in locally advanced breast cancer (LABC) after neoadjuvant chemotherapy (NACT). We aim to examine the feasibility of SLNB in LABC patients post NACT to determine identification rates (IR) and false negative rates (FNR). This was a single tertiary cancer center-based prospective study from February 2017 to November 2018. Forty-four patients with LABC (T3, T4 with N0 or N1) were studied and response after NACT was assessed. Only those patients who were N0 or who converted from N1 to N0 after NACT were included. Those patients who remained node positive after NACT directly proceeded with axillary dissection without SLNB and were excluded from the study. Demographic and clinical data is expressed in ratios and percentage and presented in table format. The median age at the time of study was 45.18 years. Most of the patients had T3 and above (97.7%) and N1 (86.3%) disease at the start of neoadjuvant therapy. The mean number of axillary lymph nodes dissected was 13.97. Dual method of sentinel lymph node mapping (methylene blue dye and radiolabeled colloid) was used in 26 (59.1%) patients. At least 1 SLN was identified in 86.4% patients with 100% identification in those patients in whom the dual method of SLN mapping was used. Median of 2 SLN was removed. Overall, false negative rate was 21.4%. FNR was high with the single method of SLN mapping (50% and 33.3% with methylene blue and radioactive colloid respectively) while it was considerably low when both were used simultaneously (11%). An average of 2 (range 0-4) SLN were identified and FNR were zero when 2 or more SLN were identified. Our study shows that SLNB in patients with LABC post NACT though viable cannot be recommended at present due to unacceptable high FNR. However, this should not dissuade us from exploring recurrence-free survival and overall survival associated with such IR and FNR albeit strictly under a clinical trial setting.

Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer: A Systematic Review and Meta-analysis

Objective:

The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND.

Summary of Background Data:

Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity.

Methods:

PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV).

Results:

Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%.

Conclusion:

Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.

Meta-analysis of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initial biopsy-proven node-positive breast cancer

BACKGROUND

Neoadjuvant chemotherapy for breast cancer has the potential to achieve a pathological complete response in up to 40 per cent of patients, converting disease that was initially node-positive to node-negative. This has raised the question of whether sentinel lymph node biopsy could be an alternative to axillary lymph node dissection in these patients. The aim was to undertake a systematic review and meta-analysis of the accuracy and reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initial biopsy-proven node-positive breast cancer.

METHODS

A literature search was conducted using PubMed, Ovid MEDLINE, Embase and Web of Science databases up to 30 April 2017. Inclusion criteria for studies were pathological confirmation of initial node-positive disease, and sentinel lymph node biopsy performed after neoadjuvant chemotherapy followed by axillary lymph node dissection.

RESULTS

A total of 13 studies met the inclusion criteria and were included in the analysis (1921 patients in total). The pooled estimate of identification rate was 90 (95 per cent c.i. 87 to 93) per cent and the false-negative rate was 14 (11 to 17) per cent. In subgroup analysis, the false-negative rate with use of dual mapping was 11 (6 to 15) per cent, compared with 19 (11 to 27) per cent with single mapping. The false-negative rate was 20 (13 to 27) per cent when one node was removed, 12 (5 to 19) per cent with two nodes removed and 4 (0 to 9) per cent with removal of three or more nodes.

CONCLUSION

Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with biopsy-proven node-positive breast cancer is accurate and reliable, but requires careful patient selection and optimal surgical techniques.

The Loss of Lymph Node Metastases After Neoadjuvant Chemotherapy in Patients With Cytology-proven Axillary Node-positive Primary Breast Cancer

BACKGROUND

Axillary lymph node (LN) dissection after neoadjuvant chemotherapy (NAC) still remains a standard treatment of initially LN-positive primary breast cancer because of the difficulty of assessment of LN status. The aim of this study was to assess the LN status after NAC in initially LN-positive primary breast cancer patients who were assessed as clinically LN-negative after NAC (ycN0) and identify factors associated with loss of LN metastasis.

PATIENTS AND METHODS

The study cohort comprised 279 patients with cytology-proven LN-positivity before NAC. LN status was assessed by ultrasonography. Regional recurrence-free survival and overall survival according to pathologic LN after NAC (ypN) status were assessed in patients with ycN0.

RESULTS

Of the 279 patients, 179 patients (64.2%) had ycN0. High nuclear grade, estrogen receptor-negative (ER^-), and human epidermal growth factor receptor 2-positive (HER2⁺), were significant predictors of ycN0/ypN0 (P < .001, .007, and .046, respectively). Metastases persisted in 1 or 2 LNs for 5 (20.0%) of 25 patients with ER^-/HER2⁺ and for 4 (21.1%) of 19 patients with ER^-/HER2^-, and in 3 or more LNs for 0 (0%) of 25 patients with ER^-/HER2⁺ and for 1 (5.3%) of 19 patients with ER^-/HER2^-. Patients with ER⁺ tumors had more numerous residual LN metastases than those with ER^- tumors (P < .001). Among patients with ycN0, ypN status was not associated with regional recurrence-free survival or overall survival.

CONCLUSIONS

Three or more residual LN metastases were rare in patients with ER^- tumors if assessed as ycN0 by ultrasonography. Prospective studies are needed to confirm the prognostic impact of not performing axillary lymph node dissection in such 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.

Synergy of cytological methods in the pathological staging of breast cancer: Axillary fine-needle aspiration and intraoperative scrape cytology of the sentinel lymph node

BACKGROUND

Sentinel lymph node biopsy (SLNB) has become the standard in breast cancer staging, but it is costly and time-consuming. Fine-needle aspiration cytology (FNAC) under ultrasonographic guidance identifies patients who need axillary lymph-node dissection (ALND), thus reducing costs. As an alternative to frozen sections (FS), intraoperative scrape cytology (ISC) for SLNB is an inexpensive, rapid, accurate and safe technique. We evaluated the synergy of FNAC and SLNB in determining the axillary burden and the performance of the ISC method.

METHODS

Over a nine-year period, 894 breast cancer patients were analyzed. Of these, 439 patients with echographic suspicious nodes underwent preoperative FNAC; negative axillary ultrasounds or FNACs resulted in 606 intraoperative SLNB, performed using the ISC technique. The results were compared with histological diagnosis, and sensitivity, specificity, predictive values and accuracy were calculated.

RESULTS

Of the 439 FNACs, 121 were positive and underwent immediate ALND, and 242 negative patients underwent intraoperative SLNB (69% sensitivity, 99% specificity). Positive cases often had multiple nodal involvement (55% pN2-3). Of the 606 SLNB-ISC smears, 510 were true negative; 65 true positives allowed for one-step ALND (71% sensitivity, 99% specificity).

CONCLUSION

Preoperative positive axillary FNAC predicts a higher disease burden and determines the avoidance of SLNB for patients eligible for immediate ALND. ISC instead of FS is a safe and sensitive technique to identify metastases, indicating completion of ALND.

PARTIALLY PRESENTED AT

Joint International Oncology (sentinel node & cancer metastasis) Congress, May 27-29, 2013, San Francisco, California, USA 18 ° International Congress of Cytology (ICC 2013-1161), May 26-30, 2013, Paris, France Convegno Nazionale GISMa - Finalborgo (Savona), Italy,19-20 maggio 2016.

Current Management of the Axilla

Despite advances in estimating prognosis and predicting response to adjuvant systemic therapy, the status of the axillary lymph nodes remains a critical component in initial surgical planning and in determining therapeutic strategies for patients with breast cancer. Buoyed by evidence from multi-institutional randomized clinical trials, the last 2 decades have witnessed remarkable and practice-changing advances in our approach to the axilla. This review concentrates on the current best practice in axillary management for both node-negative and node-positive patients, with particular focus on the evolving management of the axilla in the era of neoadjuvant systemic therapy.

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.

A Nomogram for Predicting the Pathological Response of Axillary Lymph Node Metastasis in Breast Cancer Patients

The value of sentinel lymph node biopsy (SLNB) in post-neoadjuvant chemotherapy (NCT) patients is still controversial. We aimed to identify predictors and construct a nomogram for predicting the pathologically complete response (pCR) of axillary lymph nodes (ALNs) after NCT in node positive breast cancer patients. In total, 426 patients with pathologically proven ALN metastasis before NCT were enrolled, randomized 1:1 and divided into a training set and a validation set. We developed a nomogram based on independent predictors for ALN pCR identified by multivariate logistic regression as well as clinical significant predictors. The multivariate logistic regression analysis showed that hormone receptor (HR) status, human epidermal growth factor 2 (HER2) status and Ki67 index were independent predictors. The nomogram was thereby constructed by those independent predictors as well as tumor size and NCT regimens. The areas under the receiver operating characteristic curve of the training set and the validation set were 0.804 and 0.749, respectively. We constructed a nomogram for predicting ALN pCR in patients who received NCT. Our nomogram can improve risk stratification, accurately predict post-NCT ALN status and avoid unnecessary ALN dissection.

Is sentinel lymph node biopsy a viable alternative to complete axillary dissection following neoadjuvant chemotherapy in women with node-positive breast cancer at diagnosis? An updated meta-analysis involving 3,398 patients

BACKGROUND

The use of sentinel lymph node biopsy (SLNB) following neoadjuvant chemotherapy (NAC) in patients presenting with clinically positive lymph nodes remains controversial.

METHODS

A computer-aided search of the literature regarding SLNB in clinically node-positive breast cancer treated with NAC was carried out to identify the false negative rate (FNR), sentinel lymph node identification rate (IR), and axillary pathological complete response (pCR).

RESULTS

Nineteen articles were used in the analysis yielding 3,398 patients. The pooled estimate of the FNR was 13% and that of the IR was 91%. The adjusted pCR rate was 47%. A trend toward significance was observed with only clinical stage N1 (cN1) disease whereby clinical stage N1 was associated with an increased pCR rate when compared to N2 or N3 disease (P = .06).

CONCLUSIONS

SLNB after NAC in biopsy-proven node-positive patients results in reasonably acceptable FNR and IR, making it a valid alternative management strategy to axillary dissection. More refined patient selection and optimal techniques can improve the FNR and IR in this patient population.

The diagnostic performance of sentinel lymph node biopsy in pathologically confirmed node positive breast cancer patients after neoadjuvant systemic therapy: A systematic review and meta-analysis

PURPOSE

To provide a systematic review and meta-analysis of studies investigating sentinel lymph node biopsy after neoadjuvant systemic therapy in pathologically confirmed node positive breast cancer patients.

METHODS

Pubmed and Embase databases were searched until June 19th, 2015. All abstracts were read and data extraction was performed by two independent readers. A random-effects model was used to pool the proportion for identification rate, false-negative rate (FNR) and axillary pCR with 95% confidence intervals. Subgroup analyses affirmed potential confounders for identification rate and FNR.

RESULTS

A total of 997 abstracts were identified and eventually eight studies were included. Pooled estimates were 92.3% (90.8-93.7%) for identification rate, 15.1% (12.7-17.6%) for FNR and 36.8% (34.2-39.5%) for axillary pCR. After subgroup analysis, FNR is significantly worse if one sentinel node was removed compared to two or more sentinel nodes (23.9% versus 10.4%, p = 0.026) and if studies contained clinically nodal stage 1-3, compared to studies with clinically nodal stage 1-2 patients (21.4 versus 13.1%, p = 0.049). Other factors, including single tracer mapping and the definition of axillary pCR, were not significantly different.

CONCLUSION

Based on current evidence it seems not justified to omit further axillary treatment in every clinically node positive breast cancer patients with a negative sentinel lymph node biopsy after neoadjuvant systemic therapy.

[Axillary pathologic response after neoadjuvant chemotherapy in locally advanced breast cancer with axillary involvement]

AIM

To compare axillary involvement (N+) at initial staging in locally advanced breast cancer (LABC) with axillary lymphadenectomy histologic results after neoadjuvant chemotherapy treatment (NeoChemo).

MATERIAL AND METHODS

Retrospective study between November 2011 and September 2013 of LABC cases treated with neoadjuvant chemotherapy based on docetaxel (associated with trastuzumab in HER2 positive cases and carboplatin/adriamycin in HER2 negative cases). Those clinically or radiologically suspected cases of axillary involvement were histologically confirmed. When there was no suspicion of axillary involvement, sentinel lymph node radioguided biopsy (SLNRB) was performed using intradermal injection of (99m)Tc-nanocolloid albumin prior to neoadjuvant treatment. Axillary lymphadenectomy after NeoChemo was undertaken in all cases with positive axilla. Final pathologic response was classified as complete (pCR) when there was no evidence of tumoral disease and as non-pathologic complete response (no pCR) in the opposite case.

RESULTS

A total of 346 patients treated with docetaxel were reviewed, identifying 105 LABC. Axillary involvement at initial staging was detected in 70 (67%) before starting NeoChemo. From these 70, 73% (n=51) were N+ (fine needle biopsy and/or biopsy) and the remaining 19 (27%) were occult N+ detected by SLNRB. Axillary lymphadenectomy detected pCR in 56% (39/70), increasing up to 84% pCR when initial N+ status was reached using SNLB. On the other hand, when N+ was detected using fine needle biopsy/lymph biopsy, pCR was only 45%.

CONCLUSION

More than 50% of women affected by locally advanced breast cancer with tumoral axillary involvement at initial diagnosis present free metastatic axilla after therapeutic neoadjuvant chemotherapy effect. This increases up to almost 90% in case of occult metastatic axilla detected with sentinel node biopsy prior starting neoadjuvant chemotherapy.

Feasibility and accuracy of sentinel lymph node biopsy in clinically node-positive breast cancer after neoadjuvant chemotherapy: a meta-analysis

Sentinel lymph node biopsy (SLNB) has replaced conventional axillary lymph node dissection (ALND) in axillary node-negative breast cancer patients. However, the use of SLNB remains controversial in patients after neoadjuvant chemotherapy (NAC). The aim of this review is to evaluate the feasibility and accuracy of SLNB after NAC in clinically node-positive patients. Systematic searches were performed in the PubMed, Embase, and Cochrane Library databases from 1993 to December 2013 for studies on node-positive breast cancer patients who underwent SLNB after NAC followed by ALND. Of 436 identified studies, 15 were included in this review, with a total of 2,471 patients. The pooled identification rate (IR) of SLNB was 89% [95% confidence interval (CI) 85-93%], and the false negative rate (FNR) of SLNB was 14% (95% CI 10-17%). The heterogeneity of FNR was analyzed by meta-regression, and the results revealed that immunohistochemistry (IHC) staining may represent an independent factor (P = 0.04). FNR was lower in the IHC combined with hematoxylin and eosin (H&E) staining subgroup than in the H&E staining alone subgroup, with values of 8.7% versus 16.0%, respectively (P = 0.001). Thus, SLNB was feasible after NAC in node-positive breast cancer patients. In addition, the IR of SLNB was respectable, although the FNR of SLNB was poor and requires further improvement. These findings indicate that IHC may improve the accuracy of SLNB.