Axillary Ultrasound After Neoadjuvant Chemotherapy and Its Impact on Sentinel Lymph Node Surgery: Results From the American College of Surgeons Oncology Group Z1071 Trial (Alliance)

Impact of Clipped Node as a Sentinel Lymph Node on Axillary Staging Following Neoadjuvant Chemotherapy in Clinically Node-Positive Breast Cancer

BACKGROUND

Residual disease after neoadjuvant chemotherapy (NAC) is prognostic and informs adjuvant treatment. Targeted axillary dissection (TAD) following NAC has low false-negative rates, facilitating accurate axillary staging. This study evaluates the clipped node status in axillary staging utilizing TAD.

METHODS

Retrospective review identified cN1 breast cancer patients treated with NAC and TAD from July 2013 to June 2023. Nodal ultrasound and biopsy defined cN1 status. Patient, tumor, and treatment characteristics were compared based on clipped node status (sentinel lymph node [SLN] or non-SLN). Multivariate analysis of factors associated with the clipped node as a non-SLN was performed.

RESULTS

A total of 680 patients underwent TAD, 94.6% with dual-tracer mapping. In three patients (0.4%), no SLN was identified. The clipped node was a SLN in 610 patients (90%) and non-SLN in 70 (10.3%). When the clipped node was a non-SLN, 42 (60%) were positive for metastasis. In 22 of 42 patients (52%), the clipped non-SLN was the only positive node. The clipped non-SLN cohort had a higher proportion with >3 suspicious nodes at presentation (p = 0.003), fewer SLNs excised (mean 2.2 vs. 3.5, p ≤ 0.001), and fewer positive SLNs (p ≤ 0.001). On multivariate analysis, > 3 suspicious nodes on ultrasound (odds ratio 3.0, p = 0.001) and tumor size at presentation (odds ratio 0.9, p = 0.02) were significantly associated with the clipped node as a non-SLN.

CONCLUSIONS

When the clipped node was a non-SLN, half of the time it was the only positive node and only residual disease on TAD. Given implications for adjuvant therapy, selective clipped node excision is recommended for precise identification of residual disease after NAC.

Residual Nodal Burden After Neoadjuvant Chemotherapy in cN1 Breast Cancer Patients with Positive Nodes at Targeted Axillary Dissection

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.

Preoperative MRI Features Associated With Axillary Nodal Burden and Disease-Free Survival in Patients With Early-Stage Breast Cancer

OBJECTIVE

To investigate the potential association among preoperative breast MRI features, axillary nodal burden (ANB), and disease-free survival (DFS) in patients with early-stage breast cancer.

MATERIALS AND METHODS

We retrospectively reviewed 297 patients with early-stage breast cancer (cT1-2N0M0) who underwent preoperative MRI between December 2016 and December 2018. Based on the number of positive axillary lymph nodes (LNs) determined by postoperative pathology, the patients were divided into high nodal burden (HNB; ≥3 positive LNs) and non-HNB (<3 positive LNs) groups. Univariable and multivariable logistic regression analyses were performed to identify independent risk factors associated with ANB. Predictive efficacy was evaluated using the receiver operating characteristic (ROC) curve and area under the curve (AUC). Univariable and multivariable Cox proportional hazards regression analyses were performed to determine preoperative features associated with DFS.

RESULTS

We included 47 and 250 patients in the HNB and non-HNB groups, respectively. Multivariable logistic regression analysis revealed that multifocality/multicentricity (adjusted odds ratio [OR] = 3.905, 95% confidence interval [CI]: 1.685-9.051, P = 0.001) and peritumoral edema (adjusted OR = 3.734, 95% CI: 1.644-8.479, P = 0.002) were independent risk factors for HNB. Combined peritumoral edema and multifocality/multicentricity achieved an AUC of 0.760 (95% CI: 0.707-0.807) for predicting HNB, with a sensitivity and specificity of 83.0% and 63.2%, respectively. During the median follow-up period of 45 months (range, 5-61 months), 26 cases (8.75%) of breast cancer recurrence were observed. Multivariable Cox proportional hazards regression analysis indicated that younger age (adjusted hazard ratio [HR] = 3.166, 95% CI: 1.200-8.352, P = 0.021), larger tumor size (adjusted HR = 4.370, 95% CI: 1.671-11.428, P = 0.002), and multifocality/multicentricity (adjusted HR = 5.059, 95% CI: 2.166-11.818, P < 0.001) were independently associated with DFS.

CONCLUSION

Preoperative breast MRI features may be associated with ANB and DFS in patients with early-stage breast cancer.

Development of an Ultrasound-based Nomogram for Predicting Pathologic Complete Response and Axillary Response in Node-Positive Patients with Triple- Negative Breast Cancer

BACKGROUND

The accurate prediction of pathological complete response (pCR) in the breast and axillary lymph nodes (ALN) before neoadjuvant chemotherapy (NAC) is of utmost importance for the development of treatment strategies. We aim to construct a nomogram on ultrasound (US) and clinical-pathologic factors to predict breast and ALN pCR in node-positive triple-negative breast cancers (TNBCs).

METHODS

Patients identified with TNBCs from institution 1 (n = 328) were used for training cohort and those from institution 2 (n = 192) were for validation cohort. US was conducted before and after NAC, and characteristics were obtained from medical records. Univariate and multivariate regression analysis were performed to identify US and clinical-pathologic factors associated with breast and ALN pCR in the training cohort. The assessment of predictive performance was conducted using the receiving operating characteristic curve (ROC), discrimination, and calibration.

RESULTS

Overall, 34.6% of patients achieved breast pCR and 48.1% of patients achieved ALN pCR. The nomogram 1 used for predicting pCR in the breast (AUC, 0.84; 95% CI: 0.79, 0.88) outperformed the clinical (AUC, 0.73; 95% CI: 0.68, 0.78) and US models (AUC, 0.79; 95% CI: 0.74, 0.83). The nomogram 2 used for predicting pCR in the axllia (AUC, 0.83; 95% CI: 0.78, 0.87) also outperformed the clinical (AUC, 0.64; 95% CI: 0.58, 0.69) and US models (AUC, 0.80; 95% CI: 0.75, 0.84). The calibration curve and discrimination curve indicate that the nomogram has good calibration performance and clinical applicability.

CONCLUSION

The nomogram showed promising predictive performance for predicting breast and ALN pCR in patients with TNBCs.

Nomogram Based on US and Clinicopathologic Characteristics: Axillary Nodal Evaluation Following Neoadjuvant Chemotherapy in Patients With Node-Positive Breast Cancer

BACKGROUND

To develop a convenient modality to predict axillary response to neoadjuvant chemotherapy (NAC) in breast cancer patients.

MATERIALS AND METHODS

In this multi-center study, a total of 1019 breast cancer patients with biopsy-proven positive lymph node (LN) receiving NAC were randomly assigned to the training and validation groups at a ratio of 7:3. Clinicopathologic and ultrasound (US) characteristics of both primary tumors and LNs were used to develop corresponding prediction models, and a nomogram integrating clinicopathologic and US predictors was generated to predict the axillary response to NAC.

RESULTS

Axillary pathological complete response (pCR) was achieved in 47.79% of the patients. The expression of estrogen receptor, human epidermal growth factor receptor -2, Ki-67 score, and clinical nodal stage were independent predictors for nodal response to NAC. Location and radiological response of primary tumors, cortical thickness and shape of LNs on US were also significantly associated with nodal pCR. In the validation cohort, the discrimination of US model (area under the curve [AUC], 0.76) was superior to clinicopathologic model (AUC, 0.68); the combined model (AUC, 0.85) demonstrates strong discriminatory power in predicting nodal pCR. Calibration curves of the nomogram based on the combined model demonstrated that substantial agreement can be observed between the predictions and observations. This nomogram showed a false-negative rates of 16.67% in all patients and 10.53% in patients with triple negative breast cancer.

CONCLUSION

Nomogram incorporating routine clinicopathologic and US characteristics can predict nodal pCR and represents a tool to aid in treatment decisions for the axilla after NAC in breast cancer patients.

Comparing shear wave elastography of breast tumors and axillary nodes in the axillary assessment after neoadjuvant chemotherapy in patients with node-positive breast cancer

BACKGROUND

Accurately identifying patients with axillary pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer patients remains challenging.

PURPOSE

To compare the feasibility of shear wave elastography (SWE) performed on breast tumors and axillary lymph nodes (LNs) in predicting the axillary status after NAC.

MATERIALS AND METHODS

This prospective study included a total of 319 breast cancer patients with biopsy-proven positive node who received NAC followed by axillary lymph node dissection from 2019 to 2022. The correlations between shear wave velocity (SWV) and pathologic characteristics were analyzed separately for both breast tumors and LNs after NAC. We compared the performance of SWV between breast tumors and LNs in predicting the axillary status after NAC. Additionally, we evaluated the performance of the most significantly correlated pathologic characteristic in breast tumors and LNs to investigate the pathologic evidence supporting the use of breast or axilla SWE.

RESULTS

Axillary pCR was achieved in 51.41% of patients with node-positive breast cancer. In breast tumors, there is a stronger correlation between SWV and collagen volume fraction (CVF) (r = 0.52, p < 0.001) compared to tumor cell density (TCD) (r = 0.37, p < 0.001). In axillary LNs, SWV was weakly correlated with CVF (r = 0.31, p = 0.177) and TCD (r = 0.29, p = 0.213). No significant correlation was found between SWV and necrosis proportion in breast tumors or axillary LNs. The predictive performances of both SWV and CVF for axillary pCR were found to be superior in breast tumors (AUC = 0.87 and 0.85, respectively) compared to axillary LNs (AUC = 0.70 and 0.74, respectively).

CONCLUSION

SWE has the ability to characterize the extracellular matrix, and serves as a promising modality for evaluating axillary LNs after NAC. Notably, breast SWE outperform axilla SWE in determining the axillary status in breast cancer patients after NAC.

Use of ultrasound and MRI to stage the axilla for breast cancer before and after neoadjuvant chemotherapy prior to targeted sentinel lymphadenectomy

PURPOSE

Prior data from this Center demonstrated that for patients who had biopsy-proven axillary metastases, were ycN0 after neoadjuvant chemotherapy (NAC), and had a wire-directed (targeted) sentinel lymphadenectomy (WD-SLND), 60% were node negative. The hypothesis of this study was that results of axillary imaging either before or after NAC would be predictive of final pathologic status after WD-SLND.

METHODS

For patients treated with NAC between 2015 and 2023, ultrasound and MRI images of the axilla were retrospectively reviewed by radiologists specializing in breast imaging, who were blinded to the surgical and pathology results.

RESULTS

Of 113 patients who fit the clinical criteria, 66 (58%) were ypN0 at WD-SLND and 34 (30%) had a pathologic complete response to NAC. There was no correlation between the number of abnormal lymph nodes on pre-NAC ultrasound or MRI imaging and the final pathologic status of the lymph nodes. The positive predictive value (PPV) of abnormal post-NAC axillary imaging was 48% for ultrasound and 53% for MRI. The negative predictive value (NPV) for normal post-NAC axillary imaging was 67% for ultrasound and 68% for MRI.

CONCLUSION

The results of axillary imaging were not adequate to identify lymph nodes after NAC that were persistently pathologically node positive or those which had become pathologically node negative.

Prediction of the number of positive axillary lymph nodes according to sentinel lymph node involvement and biological subtypes in patients receiving neoadjuvant chemotherapy

BACKGROUND

Sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) for assessing axillary lymph node status in clinically node-negative breast cancer patients. However, the approach to axillary surgery after neoadjuvant treatment is still controversial. In the present study, our objective was to predict the pathological nodal stage based on SLNB results and the clinicopathological characteristics of patients who initially presented with clinical N1 positivity but whose disease status was converted to clinical N0 after neoadjuvant chemotherapy (NAC).

MATERIALS AND METHODS

After NAC, 150 clinically node-negative patients were included. The relationships between clinicopathologic parameters and the number of positive lymph nodes in SLNBs and ALNDs were assessed through binary/multivariate logistic regression analysis.

RESULTS

Among 150 patients, 78 patients had negative SLNBs, and 72 patients had positive SLNBs. According to the ALND data of 21 patients with SLNB1+, there was no additional node involvement (80.8%), 1-2 lymph nodes were positive in 5 patients (19.2%), and no patient had ≥ 3 lymph nodes involved. Following the detection of SLNB1 + positivity, the rate of negative non-sentinel nodes were 75% in the luminal A/B subgroup, 100% in the HER-2-positive subgroup, and 100% in the triple-negative subgroup. Patients with a lower T stage (T1-3 vs. T4), fewer than 4 clinical nodes before NAC (< 4 vs. ≥4), and a decreased postoperative Ki-67 index (< 10% vs. stable/increase) were included. According to both univariate and multivariate analyses, being in the triple-negative or HER2-positive subgroup, compared to the luminal A/B subgroup (luminal A/B vs. HER2-positive/triple-negative), was found to be predictive of complete lymph node response.

CONCLUSION

The number of SLNB-positive nodes, tumor-related parameters, and response to treatment may predict no additional nodes to be positive at ALND.

Contemporary Review of the Management and Treatment of Young Breast Cancer Patients

Approximately 11% of all new breast cancer cases annually are diagnosed in young women, and this continues to be the leading cause of death in women age 20 to 49. Young, premenopausal breast cancer patients present with more advanced stages and with a higher proportion of aggressive subtypes such as triple negative and HER2-enriched tumors. Recently, the United States Preventive Services Task Force (USPSTF) lowered the age threshold to initiate screening mammograms to age 40 to aid in earlier detection. Young age at diagnosis increases the likelihood for a pathogenic mutation, and genetic testing is recommended for all patients age 50 and younger. This population is often underrepresented in landmark clinical trials, and data is extrapolated for the treatment of young women with breast cancer. Despite there being no survival benefit to more extensive surgical treatments, such as mastectomy or contralateral prophylactic mastectomy, many patients opt against breast conservation. Young patients with breast cancer face issues related to treatment toxicities, potential overtreatment of their disease, mental health, sexual health, and fertility preservation. This unique population requires a multidisciplinary care team of physicians, surgeons, genetic counselors, fertility specialists, mental health professionals, physical therapists, and dieticians to provide individualized, comprehensive care. Our aim is to (1) provide a narrative review of retrospective studies, relevant society guidelines, and clinical trials focused on the contemporary treatment and management of YBC patients and (2) discuss important nuances in their care as a guide for members of their multidisciplinary treatment team.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

A nomogram for predicting pathologic node negativity after neoadjuvant chemotherapy in breast cancer patients: a nationwide, multicenter retrospective cohort study (CSBrS-012)

Purpose

This study aimed to investigate the factors associated with pathologic node-negativity (ypN0) in patients who received neoadjuvant chemotherapy (NAC) to develop and validate an accurate prediction nomogram.

Methods

The CSBrS-012 study (2010-2020) included female patients with primary breast cancer treated with NAC followed by breast and axillary surgery in 20 hospitals across China. In the present study, 7,711 eligible patients were included, comprising 6,428 patients in the primary cohort from 15 hospitals and 1,283 patients in the external validation cohort from five hospitals. The hospitals were randomly assigned. The primary cohort was randomized at a 3:1 ratio and divided into a training set and an internal validation set. Univariate and multivariate logistic regression analyses were performed on the training set, after which a nomogram was constructed and validated both internally and externally.

Results

In total, 3,560 patients (46.2%) achieved ypN0, and 1,558 patients (20.3%) achieved pathologic complete response in the breast (bpCR). A nomogram was constructed based on the clinical nodal stage before NAC (cN), ER, PR, HER2, Ki67, NAC treatment cycle, and bpCR, which were independently associated with ypN0. The area under the receiver operating characteristic curve (AUC) for the training set was 0.80. The internal and external validation demonstrated good discrimination, with AUCs of 0.79 and 0.76, respectively.

Conclusion

We present a real-world study based on nationwide large-sample data that can be used to effectively screen for ypN0 to provide better advice for the management of residual axillary disease in breast cancer patients undergoing NAC.

The use of longitudinal CT-based radiomics and clinicopathological features predicts the pathological complete response of metastasized axillary lymph nodes in breast cancer

BACKGROUND

Accurate assessment of axillary status after neoadjuvant therapy for breast cancer patients with axillary lymph node metastasis is important for the selection of appropriate subsequent axillary treatment decisions. Our objectives were to accurately predict whether the breast cancer patients with axillary lymph node metastases could achieve axillary pathological complete response (pCR).

METHODS

We collected imaging data to extract longitudinal CT image features before and after neoadjuvant chemotherapy (NAC), analyzed the correlation between radiomics and clinicopathological features, and developed models to predict whether patients with axillary lymph node metastasis can achieve axillary pCR after NAC. The clinical utility of the models was determined via decision curve analysis (DCA). Subgroup analyses were also performed. Then, a nomogram was developed based on the model with the best predictive efficiency and clinical utility and was validated using the calibration plots.

RESULTS

A total of 549 breast cancer patients with metastasized axillary lymph nodes were enrolled in this study. 42 independent radiomics features were selected from LASSO regression to construct a logistic regression model with clinicopathological features (LR radiomics-clinical combined model). The AUC of the LR radiomics-clinical combined model prediction performance was 0.861 in the training set and 0.891 in the testing set. For the HR + /HER2 - , HER2 + , and Triple negative subtype, the LR radiomics-clinical combined model yields the best prediction AUCs of 0.756, 0.812, and 0.928 in training sets, and AUCs of 0.757, 0.777 and 0.838 in testing sets, respectively.

CONCLUSIONS

The combination of radiomics features and clinicopathological characteristics can effectively predict axillary pCR status in NAC breast cancer patients.

An ultrasound-based nomogram for predicting axillary node pathologic complete response after neoadjuvant chemotherapy in breast cancer: Modeling and external validation

INTRODUCTION

The staging and treatment of axillary nodes in breast cancer have become a focus of research. For breast cancer patients with fine-needle aspiration-or core needle biopsy-confirmed positive nodes, axillary lymph node dissection (ALND) after neoadjuvant chemotherapy (NAC) is still a standard treatment. However, some patients achieve an axillary pathologic complete response (pCR) after NAC. In this study, the authors sought to construct a model to predict axillary pCR in patients with positive axillary lymph nodes (cN+) breast cancer.

METHODS

Data from patients with pathologically proven cN+ breast cancer treated with NAC followed by ALND between January 2010 and April 2019 at the Peking University Cancer Hospital were reviewed. Axillary lymph node status was assessed using ultrasonography before and after NAC. The patient cohort was assigned to the construction and internal validation cohorts according to admission time. A nomogram was constructed based on the significant factors associated with axillary pCR. The predictive performance of the model was externally validated using data from Peking University First Hospital.

RESULTS

This study included 953 and 267 patients from Peking University Cancer Hospital and Peking University First Hospital, respectively. In the construction cohort, 39.7% (238 of 600) of patients achieved axillary pCR after NAC. The result of multivariate logistic regression analysis showed that tumor grade, clinical nodal response, NAC regimen, tumor pCR, lymphovascular invasion, and tumor biologic subtype were significant independent predictors of ypN0 (p < 0.05). The areas under the receiver operating characteristic curves for the construction, validation, and independent testing cohorts were 0.87 (95% confidence interval [CI], 0.84-0.90), 0.83 (95% CI, 0.79-0.87), and 0.84 (0.79-0.89), respectively.

CONCLUSIONS

A nomogram was constructed to predict the pCR of axillary lymph nodes after NAC for breast cancer. Validation of both the internal and external cohorts achieved good predictive performance, indicating that the model has preliminary clinical application prospects.

Can Axillary Ultrasound Identify Node Positive Patients Who can Avoid an Axillary Dissection After Neoadjuvant Chemotherapy?

INTRODUCTION

Axillary lymph node dissection (ALND) is recommended for patients with invasive breast cancer with axillary metastasis treated with neoadjuvant chemotherapy (NAC) who do not have a nodal pathologic complete response (n-pCR). We hypothesized that patients with a single, ultrasound-suspicious, nonpalpable lymph node (LN) at diagnosis, who do not achieve an n-pCR, will have ypN1 disease on surgical pathology.

METHODS

This retrospective study identified breast cancer patients in our institution from 2012 to 2020 with axillary metastasis treated with NAC who did not achieve an n-pCR and had an ALND. Patient's tumor characteristics, axillary ultrasound, and lymph node disease burden at the time of surgery were reviewed.

RESULTS

Fifty five patients met the criteria and 36% had one suspicious LN on ultrasound, 25% had 2, and 38% had >3. After chemotherapy, 64% had ypN1 disease, 29% had ypN2 disease, and 7% had ypN3 disease. Of the 20 patients with one abnormal LN on initial ultrasound, 17 (85%, 95% CI 61-96%) had ypN1 disease. Eleven patients with one abnormal LN on initial ultrasound also had no suspicious LNs on prechemotherapy physical exam; among these patients, 100% had ypN1 disease.

CONCLUSIONS

For breast cancer patients who do not achieve an n-pCR after NAC, pretreatment normal clinical axillary exam and prechemotherapy ultrasound showing only one abnormal LN is associated with ypN1 disease. It may be reasonable to consider omitting completion ALND in this subset of patients while awaiting the results of the Alliance A011202 trial.

Top 100 cited classical articles in sentinel lymph nodes biopsy for breast cancer

Background

The sentinel lymph node biopsy (SLNB) takes on a critical significance in breast cancer surgery since it is the gold standard for assessing axillary lymph node (ALN) metastasis and determining whether to perform axillary lymph node dissection (ALND). A bibliometric analysis is beneficial to visualize characteristics and hotspots in the field of sentinel lymph nodes (SLNs), and it is conducive to summarizing the important themes in the field to provide more insights into SLNs and facilitate the management of SLNs.

Materials and methods

Search terms relating to SLNs were aggregated and searched in the Web of Science core collection database to identify the top 100 most cited articles. Bibliometric tools were employed to identify and analyze publications for annual article volume, authors, countries, institutions, keywords, as well as hotspot topics.

Results

The period was from 1998 to 2018. The total number of citations ranged from 160 to 1925. LANCET ONCOLOGY and JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION were the top two journals in which the above articles were published. Giuliano, AE was the author with the highest number of articles in this field with 15. EUROPEAN INST ONCOL is the institution with the highest number of publications, with 35 articles. Hotspots include the following 4 topics, false-negative SLNs after neoadjuvant chemotherapy; prediction of metastatic SLNs; quality of life and postoperative complications; and lymphography of SLNs.

Conclusion

This study applies bibliometric tools to analyze the most influential literature, the top 100 cited articles in the field of SLNB, to provide researchers and physicians with research priorities and hotspots.

This house believes that: MARI/TAD is better than sentinel node biopsy after PST for cN+ patients

The increasing use and effectiveness of primary systemic treatment (PST) enables tailored locoregional treatment. About one third of clinically node positive (cN+) breast cancer patients achieve pathologic complete response (pCR) of the axilla, with higher rates observed in Human Epidermal growth factor Receptor (HER)2-positive or triple negative (TN) breast cancer subtypes. Tailoring axillary treatment for patients with axillary pCR is necessary, as they are unlikely to benefit from axillary lymph node dissection (ALND), but may suffer complications and long-term morbidity such as lymphedema and impaired shoulder motion. By combining pre-PST and post-PST axillary staging techniques, ALND can be omitted in most cN + patients with pCR. Different post-PST staging techniques (MARI/TAD/SN) show low or ultra-low false negative rates for detection of residual disease. More importantly, trials using the MARI (Marking Axillary lymph nodes with Radioactive Iodine seeds) procedure or sentinel lymph node biopsy (SLNB) as axillary staging technique post-PST have already shown the safety of tailoring axillary treatment in patients with an excellent response. Tailored axillary treatment using the MARI procedure in stage I-III breast cancer resulted in 80% reduction of ALND and excellent five-year axillary recurrence free interval (aRFI) of 97%. Similar oncologic outcomes were seen for post-SLNB in stage I-II patients. The MARI technique requires only one invasive procedure pre-NST and a median of one node is removed post-PST, whereas for the SLNB and TAD techniques two to four nodes are removed. A disadvantage of the MARI technique is its use of radioactive iodine, which is subject to extensive regulations.

Axillary ultrasound for predicting response to neoadjuvant treatment in breast cancer patients-a single institution experience

BACKGROUND

In node-positive breast cancer patients at diagnosis (cN +) that render node-negative after neoadjuvant systemic treatment (NAST), axillary lymph node dissection (ALND) can be avoided in selected cases. Axillary ultrasound (AUS) is most often used for re-staging after NAST. We aimed to determine sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AUS after NAST for predicting nodal response at the Institute of Oncology, Ljubljana.

METHODS

Biopsy-confirmed cN + patients consecutively diagnosed at our institution between 2008 and 2021, who received NAST, followed by surgery were identified retrospectively. Only patients that underwent AUS after NAST were included. AUS results were compared to definite nodal histopathology results. We calculated sensitivity, specificity, PPV and NPV of AUS. We also calculated the proportion of patients with false-positive AUS that results in surgical overtreatment (unnecessary ALND).

RESULTS

We identified 437 cN + patients. In 244 (55.8%) AUS after NAST was performed. Among those, 42/244 (17.2%) were triple negative (TN), 78/244 (32.0%) Her-2 positive (Her-2 +), and 124/244 (50,8%) luminal Her-2 negative cancers. AUS was negative in 179/244 (73.4%), suspicious/positive in 65/244 (26.6%) (11/42 (26.2%) TN, 19/78 (24.4%) Her-2 + , and 35/124 (28.2%) luminal Her-2 negative cancers). On definite histopathology, nodal complete response (pCR) was observed in 89/244 (36.5%) (19/42 (45.2%) TN, 55/78 (70.5%) Her-2 + , and 15/124 (12.1%) luminal Her-2 negative cancers). Among patients with suspicious/positive AUS, pCR was observed in 20/65 (30.8%) (6/11 (54.5%) TN, 13/19 (68.4%) Her-2 + and 1/35 (2.9%) luminal Her-2 negative cancers). Sensitivity was 29.0%, specificity 77,5%, PPV 69.2%, NPV 38.5%. Specificity and PPV in TN was 68.4% and 45.4%, in Her-2 + 76.4% and 31.6%, in luminal Her-2 negative 93,3% and 97,1%, respectively.

CONCLUSION

In approximately half of the patients, AUS falsely predicts nodal response after NAST and may lead to overtreatment in 30% of the cases (ALND). However, AUS has to be interpreted in context with tumor subtype. In luminal Her-2 negative cancers, it has a high PPV and is therefore useful.

Meta-analysis of the application value of indocyanine green fluorescence imaging in guiding sentinel lymph node biopsy for breast cancer

OBJECTIVE

The main objective of this study was to compare the application value of indocyanine green fluorescence imaging (ICGFI) and its combined tracing method with the blue dye method in guiding sentinel lymph node biopsy for breast cancer.

MATERIALS AND METHODS

A computerized search of the Pubmed, Embase, Web of Science, and Cochrane Library databases was conducted to identify all relevant literature on ICGFI compared to the sole methylene blue (MB) tracing method in guiding sentinel lymph node biopsy for breast cancer. The search was performed up until May 2023. After assessing the quality of the included studies, a meta-analysis was conducted using STATA 12.0 software.

RESULTS

A total of 11 relevant studies were included in this research. The analysis results showed that, in terms of the detection rate, the ICGFI group had a higher detection rate to the MB group [odds ratio (OR) = 8.64, 95% CI: 5.46-13.66, P = 0.000], and had a higher quantity compared to the MB group [weighted mean difference (WMD) = 0.72, 95% CI 0.31-1.13, P = 0.001], and it also had a lower false-negative rate [OR = 0.10, 95% CI 0.02-0.43, P = 0.002]. However, there was no statistically significant difference in the positive detection rate, and sensitivity comparison.

CONCLUSION

The indocyanine green fluorescence imaging and tracing method for sentinel lymph node biopsy for breast cancer are simple and effective, and they are well suited for clinical use. A multicenter randomized controlled trial with a large sample size should be conducted in the future for further validation of the method.

The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus

Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy ( ± targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.

Prediction of Residual Axillary Nodal Metastasis Following Neoadjuvant Chemotherapy for Breast Cancer: Radiomics Analysis Based on Chest Computed Tomography

OBJECTIVE

To evaluate the diagnostic performance of chest computed tomography (CT)-based qualitative and radiomics models for predicting residual axillary nodal metastasis after neoadjuvant chemotherapy (NAC) for patients with clinically node-positive breast cancer.

MATERIALS AND METHODS

This retrospective study included 226 women (mean age, 51.4 years) with clinically node-positive breast cancer treated with NAC followed by surgery between January 2015 and July 2021. Patients were randomly divided into the training and test sets (4:1 ratio). The following predictive models were built: a qualitative CT feature model using logistic regression based on qualitative imaging features of axillary nodes from the pooled data obtained using the visual interpretations of three radiologists; three radiomics models using radiomics features from three (intranodal, perinodal, and combined) different regions of interest (ROIs) delineated on pre-NAC CT and post-NAC CT using a gradient-boosting classifier; and fusion models integrating clinicopathologic factors with the qualitative CT feature model (referred to as clinical-qualitative CT feature models) or with the combined ROI radiomics model (referred to as clinical-radiomics models). The area under the curve (AUC) was used to assess and compare the model performance.

RESULTS

Clinical N stage, biological subtype, and primary tumor response indicated by imaging were associated with residual nodal metastasis during the multivariable analysis (all P < 0.05). The AUCs of the qualitative CT feature model and radiomics models (intranodal, perinodal, and combined ROI models) according to post-NAC CT were 0.642, 0.812, 0.762, and 0.832, respectively. The AUCs of the clinical-qualitative CT feature model and clinical-radiomics model according to post-NAC CT were 0.740 and 0.866, respectively.

CONCLUSION

CT-based predictive models showed good diagnostic performance for predicting residual nodal metastasis after NAC. Quantitative radiomics analysis may provide a higher level of performance than qualitative CT features models. Larger multicenter studies should be conducted to confirm their performance.

Combining primary tumor features derived from conventional and contrast-enhanced ultrasound facilitates the prediction of positive axillary lymph nodes in Breast Imaging Reporting and Data System category 4 malignant breast lesions

PURPOSE

To determine whether the primary tumor features derived from conventional ultrasound (US) and contrast-enhanced US (CEUS) facilitate the prediction of positive axillary lymph nodes (ALNs) in breast cancer diagnosed as Breast Imaging Reporting and Data System (BI-RADS) category 4.

METHODS

A total of 240 women with breast cancer who underwent preoperative conventional US, strain elastography, and CEUS between September 2016 and December 2019 were included. The multiple parameters of the primary tumor were obtained, and univariate and multivariate analyses were performed to predict positive ALNs. Then three prediction models (conventional US features, CEUS features, and the combined features) were developed, and the diagnostic performance was evaluated with receiver operating characteristic curves.

RESULTS

On conventional US, the traits of large size and the non-circumscribed margin of the primary tumor were marked as two independent predictors. On CEUS, the features of vessel perforation or distortion and the enhanced range of the primary tumor were marked as two independent predictors for positive ALNs. Three prediction models were then developed: model A (conventional US features), model B (CEUS features), and model C (model A plus B). Model C yielded the highest area under the curve (AUC) of 0.82 [95% confidence interval (CI), 0.75-0.88] compared with model A (AUC 0.74; 95% CI, 0.68-0.81; P = 0.008) and model B (AUC 0.72; 95% CI, 0.65-0.80; P < 0.001) as per the DeLong test.

CONCLUSION

CEUS, as a non-invasive examination technique, can be used to predict ALN metastasis. Combining conventional US and CEUS may produce favorable predictive accuracy for positive ALNs in BI-RADS category 4 breast cancer.

Selective Axillary Dissection after Neoadjuvant Chemotherapy in Patients with Lymph-Node-Positive Breast Cancer (CLYP Study): The Radio-Guided Occult Lesion Localization Technique for Biopsy-Proven Metastatic Lymph Nodes

(1) Background: To help to refine the accuracy of sentinel lymph node biopsy (SLNB) in breast cancer (BC) patients with biopsy-proven nodal disease prior to neoadjuvant chemotherapy (NACT), a method of marking the biopsy-proven positive LN at diagnosis to enable its removal during surgery was proposed. The aim of this study was to evaluate the accuracy of the Radio-Guided Occult Lesion Localization (ROLL) technique of biopsy-proven metastatic LN in nodal staging after NACT among node-positive BC patients. (2) Methods: Patients with invasive BC and biopsy-proven axillary metastases receiving NACT were enrolled. A clip marker was placed on the sampled LN (clipped lymph node, CLN) before NACT. Before surgery, the ROLL procedure (radioactive tracer injection into CLN under ultrasound guidance) was performed, and the CLN was surgically resected. The correspondence between the CLNs and SLNs was evaluated. The pathologic findings of the CLNs and SLN(s) were compared with remaining axillary nodes at ALND to determine false negative rates (FNRs). (3) Results: Seventy-two patients were analyzed. Surgery successfully identified the CLN in 70/72 procedures (97.2%). For 60/72 patients who underwent ALND, the FNRs dropped from 19.35% for SLNB to 3.13% for CLN biopsy. (4) Conclusions: The ROLL procedure got CLNs is accurate in axillary nodal staging after NACT in node-positive BC patients at diagnosis.

Diagnostic accuracy of magnetic resonance imaging to evaluate axillary lymph node status in breast cancer patients receiving neoadjuvant chemotherapy

OBJECTIVES

Axillary lymph node status is an important prognostic factor for breast cancer patients. This study aimed to assess the accuracy of MRI in assessing the axillary nodal status in breast cancer patients receiving neo-adjuvant chemotherapy (NACT).

METHODS

Data were retrospectively collected for 88 patients between 2011 and 2016 from the hospital records. All patients had baseline MRI, followed by the end of neoadjuvant chemotherapy MRI. Patient demographics, cancer type, grade, stage, receptor status, and the number of positive lymph nodes identified on the baseline and preoperative MRI were recorded. The imaging results were compared to post-operative histopathological lymph node findings. The median patient age of the patients was 54 years (32-77 years).

RESULTS

There were 67 (76.1%) patients with histologically proven positive axillary lymph nodes on baseline MRI. The overall conversion from abnormal to normal axillary nodes following chemotherapy (ypN0) was 38.8% (26 patients out of 67). The sensitivity and specificity of MRI for predicting axillary status was 68.85 and 85.71%, respectively, with an overall MRI diagnostic accuracy of 73.07%.

CONCLUSION

MRI has low sensitivity and diagnostic accuracy in predicting axillary nodal status in breast cancer patients receiving neoadjuvant chemotherapy. Given the low NPV of MRI of the axilla, a negative MRI does not obviate the need for definitive axillary surgery.

ADVANCES IN KNOWLEDGE

In its current state, MRI cannot obviate the need for axillary surgery in patients receiving NACT. Long: short axis ratio (L: S) of the axillary lymph node is not a good predictor of axillary metastases.

Axillary ultrasound after neoadjuvant therapy reduces the false-negative rate of sentinel lymph node biopsy in patients with cytologically node-positive breast cancer

OBJECTIVES

This study aimed to determine whether post-neoadjuvant therapy (NAT) axillary ultrasound (AUS) could reduce the false-negative rate (FNR) of sentinel lymph node biopsy (SLNB). We also performed subgroup analyses to identify the appropriate patient for SLNB.

METHODS

A total of 220 patients with cytologically proven axillary node-positive breast cancer who underwent both SLNB and axillary lymph node dissection (ALND) after NAT were included. We calculated the FNR of SLNB. In the case of post-NAT AUS results available, AUS was classified as negative or positive. Then the FNR of post-NAT AUS combined with SLNB was evaluated. Subgroup analyses based on the number of sentinel lymph nodes removed, molecular subtypes, and the clinical N stage were also performed.

RESULTS

The overall axillary lymph node pathological complete response rate was 45.5% (100/220). The FNR of SLNB alone was 15.8% (95%CI: 9.2 to 22.5%). Post-NAT AUS results were available for 181 patients. When combined negative post-NAT AUS results and SLNB, the FNR was reduced to 7.5% (95%CI: 2.4 to 12.7%). Subgroup analyses of the FNR for SLNB alone and negative post-NAT AUS combined with SLNB were shown as follows: in cases patients with less than three sentinel lymph nodes (SLNs) and at least three SLNs removed, the FNR was decreased from 24.5 to 13.2%, and 9.0 to 5.0%, respectively. The FNR was decreased from 20.8 to 10.5% in HR+/HER2+subgroup, 21.4 to 16.7% in HR-/HER2+subgroup, 15.9 to 7.0% in HR+/HER2- subgroup, and 0% in HR-/HER2- subgroup, respectively. For cN1 patients, the FNR was decreased from 18.1 to 12.1% while 17.1 to 3.6% for cN2 patients and 0% for cN3 patients.

CONCLUSION

Using negative post-NAT AUS may help to decrease the FNR and improve patient selection for SLNB.

Non-Invasive and Real-Time Monitoring of the Breast Cancer Metastasis Degree via Metabolomics

Breast cancer (BC) is a serious threat to women's health and metastasis is the major cause of BC-associated mortality. Various techniques are currently used to preoperatively describe the metastatic status of tumors, based on which a comprehensive treatment protocol was determined. However, accurately staging a tumor before surgery remains a challenge, which may lead to the miss of optimal treatment options. More severely, the failure to detect and remove occult micrometastases often causes tumor recurrences. There is an urgent need to develop a more precise and non-invasive strategy for the detection of the tumor metastasis in lymph nodes and distant organs. Based on the facts that tumor metastasis is closely related to the primary tumor microenvironment (TME) evolutions and that metabolomics profiling of the circulatory system can precisely reflect subtle changes within TME, we suppose whether metabolomic technology can be used to achieve non-invasive and real-time monitoring of BC metastatic status. In this study, the metastasis status of BC mouse models with different tumor-bearing times was firstly depicted to mimic clinical anatomic TNM staging system. Metabolomic profiling together with metastasis-related changes in TME among tumor-bearing mice with different metastatic status was conducted. A range of differential metabolites reflecting tumor metastatic states were screened and in vivo experiments proved that two main metastasis-driving factors in TME, TGF-β and hypoxia, were closely related to the regular changes of these metabolites. The differential metabolites level changes were also preliminarily confirmed in a limited number of clinical BC samples. Metabolite lysoPC (16:0) was found to be useful for clinical N stage diagnosis and the possible cause of its changes was analyzed by bioinformatics techniques.

Surgical options of the breast and clinical outcomes of breast cancer patients after neoadjuvant chemotherapy: A single-center retrospective study

Background

Neoadjuvant chemotherapy (NAC) has evolved significantly and has been widely accepted for downstaging disease in early-stage and locally advanced breast cancer patients. Since the optimal surgical intervention for patients receiving NAC remains controversial, we aim to investigate the survival outcome of patients treated with different surgical management.

Methods

A retrospective, nested case-control study was conducted in patients with invasive breast cancer that underwent NAC at Fudan University Shanghai Cancer Center from January 2010 to June 2019. Based on surgical intervention, patients were divided into mastectomy and breast conservation groups. Patients were matched on age at diagnosis, menopausal status, the year of the surgery, post neoadjuvant therapy pathological tumor (ypT) stage, post neoadjuvant therapy pathological node (ypN) stage, molecular subtypes, and axillary surgery by propensity score matching.

Results

A total of 2080 patients were enrolled in this study. Among them, 1819 (87.5%) patients were categorized as mastectomy group, and 261 (12.5%) patients were classed as breast conservation group. Over 9-years of research, the proportion of breast conservation steadily increased in patients after NAC. Data showed that younger (P<0.001) and pre-menopausal (P<0.001) patients with normal BMI (P=0.022) were more likely to receive breast conservation. Patients at advanced ypT stage (P<0.001), ypN stage (P<0.001), and clinical TNM stage (P<0.001) were more often to undergo mastectomy, while breast conservation rate was significantly higher in patients with triple-negative tumors (P=0.023). Compared with the mastectomy group, significant benefits in overall survival were observed in patients who received breast conservation (Hazard ratio 0.41, [95% confidence interval: 0.18-0.97]; p=0.049) in the matched cohort. There was no statistical difference between groups related to disease-free survival and locoregional recurrence.

Conclusions

Tumor biology can significantly impact the surgical decision in patients administrated with NAC. Breast conservation was a safe alternative for mastectomy in the NAC setting without compromising survival outcomes and locoregional control.

Prediction of axillary lymph node pathological complete response to neoadjuvant therapy using nomogram and machine learning methods

Purpose

To determine the feasibility of predicting the rate of an axillary lymph node pathological complete response (apCR) using nomogram and machine learning methods.

Methods

A total of 247 patients with early breast cancer (eBC), who underwent neoadjuvant therapy (NAT) were included retrospectively. We compared pre- and post-NAT ultrasound information and calculated the maximum diameter change of the primary lesion (MDCPL): [(pre-NAT maximum diameter of primary lesion – post-NAT maximum diameter of preoperative primary lesion)/pre-NAT maximum diameter of primary lesion] and described the lymph node score (LNS) (1): unclear border (2), irregular morphology (3), absence of hilum (4), visible vascularity (5), cortical thickness, and (6) aspect ratio <2. Each description counted as 1 point. Logistic regression analyses were used to assess apCR independent predictors to create nomogram. The area under the curve (AUC) of the receiver operating characteristic curve as well as calibration curves were employed to assess the nomogram’s performance. In machine learning, data were trained and validated by random forest (RF) following Pycharm software and five-fold cross-validation analysis.

Results

The mean age of enrolled patients was 50.4 ± 10.2 years. MDCPL (odds ratio [OR], 1.013; 95% confidence interval [CI], 1.002–1.024; p=0.018), LNS changes (pre-NAT LNS – post-NAT LNS; OR, 2.790; 95% CI, 1.190–6.544; p=0.018), N stage (OR, 0.496; 95% CI, 0.269–0.915; p=0.025), and HER2 status (OR, 2.244; 95% CI, 1.147–4.392; p=0.018) were independent predictors of apCR. The AUCs of the nomogram were 0.74 (95% CI, 0.68–0.81) and 0.76 (95% CI, 0.63–0.90) for training and validation sets, respectively. In RF model, the maximum diameter of the primary lesion, axillary lymph node, and LNS in each cycle, estrogen receptor status, progesterone receptor status, HER2, Ki67, and T and N stages were included in the training set. The final validation set had an AUC value of 0.85 (95% CI, 0.74–0.87).

Conclusion

Both nomogram and machine learning methods can predict apCR well. Nomogram is simple and practical, and shows high operability. Machine learning makes better use of a patient’s clinicopathological information. These prediction models can assist surgeons in deciding on a reasonable strategy for axillary surgery.

What Is the Role of Neoadjuvant Endocrine Therapy for Breast Cancer?

There is growing interest in neoadjuvant endocrine therapy (NET) for the treatment of hormone receptor-positive, human epidermal growth factor receptor 2 -negative (HR + HER2-) breast cancer. Expanding the use of genomic assays demonstrates that many patients with HR + HER2-breast cancer do not benefit from chemotherapy, leading to growing interest in NET as a less toxic alternative. Although NET's ability to downsize breast tumors and achieve breast conservation is well-known, axillary surgery algorithms are not well-defined. Here we review primary endocrine therapy, the landmark NET clinical trials, and management of residual nodal disease following NET.

Accuracy and Limitations of Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients with Positive Nodes

Background

Axillary surgical management in patients with node-positive breast cancer at the time of diagnosis converted to negative nodes through neoadjuvant chemotherapy (NAC) remains unclear. Removal of more than two sentinel nodes (SLNs) in these patients may decrease the false negative rate (FNR) of sentinel lymph node biopsies (SLNBs). We aim to analyse the detection rate (DR) and the FNR of SLNB assessment according to the number of SLNs removed.

Methods

A retrospective study was performed from October 2012 to December 2018. Patients with invasive breast cancer who had a clinically node-positive disease at diagnosis and with a complete axillary response after neoadjuvant chemotherapy were selected. Patients included underwent SLNB and axillary lymph node dissection (ALND) after NAC. The SLN was considered positive if any residual disease was detected. Descriptive statistics were used to describe the clinicopathologic features and the results of SLNB and ALND. The DR of SLNB was defined as the number of patients with successful identification of SLN. Presence of residual disease in ALND and negative SLN was considered false negative.

Results

A total of 368 patients with invasive breast cancer who underwent surgery after complete NAC were studied. Of them, 85 patients met the eligibility criteria and were enrolled in the study. The mean age at diagnosis was 50.8 years. Systematic lymphadenectomy was performed in all patients, with an average of 10 lymph nodes removed. The DR of SLNB was 92.9%, and the FNR was 19.1. The median number of SLNs removed was 3, and at least, three SLNs were obtained in 42 patients (53.2%). When at least three sentinel nodes were removed, the FNR decreased to 8.7%.

Conclusions

In this cohort, the SLN assessment was associated with an adequate DR and a high FNR. Removing three or more SLNs decreased the FNR from 19.1% to 8.7%. Complementary approaches may be considered for axillary lymph node staging after neoadjuvant chemotherapy. The study was approved by our institution's ethics committee (Instituto de Investigacion Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain) (https://clinicaltrials.gov/ct2/show/NCEI:20/0048).

Assessment of response of neoadjuvant chemotherapy in carcinoma breast patients by high-frequency ultrasound

Aim

To assess the response of neoadjuvant chemotherapy in carcinoma breast patients by high-frequency ultrasound.

Material and Method

The current single blind, observational study was conducted at rural tertiary healthcare center of Acharya Vinoba Bhave Rural Hospital from October 2018 to Sept 2020. We incorporated breast cancer patients with TNM stages IIIA and IIIB who received neoadjuvant chemotherapy with Cyclophosphamide/Adriamycin/5 FU and Paclitaxel respectively followed by standard surgical procedure modified radical mastectomy. Successive ultrasound examination of the breast malignancy and the axilla was done after 21 days of either of any neoadjuvant chemotherapy for 3 cycles. Assessment of response to neoadjuvant chemotherapy was applied in terms of reduction in the breast tumour volume on ultrasound and percentage of tumour response calculated by Response Evaluation Criteria for Solid Tumours (RECIST). Data were analysed using SPSS version 24.0.

Results

Higher frequency of patients was invasive ductal breast cancer. In our study, Paclitaxel group showed better response in terms of CR and PR than CAF group. Our study noticed a consistent decrement in tumour volume after every cycle of either CAF or Paclitaxel NACT. Axillary ultrasound was able to predict the response of axillary lymph nodes in terms of increase or decrease in number and morphological changes after 3 cycles of NACT with similarity on final histopathology.

Conclusion

It can be concluded from the results of the present study that high-frequency ultrasound is appropriate tool for assessment of response of primary breast malignancy and lymphnode metastasis in the axilla after neoadjuvant chemotherapy.

Accuracy of ultrasonographic changes during neoadjuvant chemotherapy to predict axillary lymph node response in clinical node-positive breast cancer patients

Purpose

To evaluate whether changes in ultrasound features during neoadjuvant chemotherapy (NAC) could predict axillary node response in clinically node-positive breast cancer patients.

Methods

Patients with biopsy-proven node-positive disease receiving NAC between February 2009 and March 2021 were included. Ultrasound (US) images were obtained using a 5-12-MHz linear array transducer before NAC, after two cycles, and at the completion of NAC. Long and short diameter, cortical thickness, vascularity, and hilum status of the metastatic node were retrospectively reviewed according to breast imaging-reporting and data system (BI-RADS). The included population was randomly divided into a training set and a validation set at a 2:1 ratio using a simple random sampling method. Factors associated with node response were identified through univariate and multivariate analyses. A nomogram combining clinical and changes in ultrasonographic (US) features was developed and validated. The receiver operating characteristic (ROC) and calibration plots were applied to evaluate nomogram performance and discrimination.

Results

A total of 296 breast cancer patients were included, 108 (36.5%) of whom achieved axillary pathologic complete response (pCR) and 188 (63.5%) had residual nodal disease. Multivariate regression indicated that independent predictors of node pCR contain ultrasound features in addition to clinical features, clinical features including neoadjuvant HER2-targeted therapy and clinical response, ultrasound features after NAC including cortical thickness, hilum status, and reduction in short diameter ≥50%. The nomogram combining clinical features and US features showed better diagnostic performance compared to clinical-only model in the training cohort (AUC: 0.799 vs. 0.699, P=0.001) and the validation cohort (AUC: 0.764 vs. 0.638, P=0.027).

Conclusions

Ultrasound changes during NAC could improve the accuracy to predict node response after NAC in clinically node-positive breast cancer patients.

Optimal Selection of Imaging Examination for Lymph Node Detection of Breast Cancer With Different Molecular Subtypes

Objective

Axillary lymph node management is an important part of breast cancer surgery and the accuracy of preoperative imaging evaluation can provide adequate information to guide operation. Different molecular subtypes of breast cancer have distinct imaging characteristics. This article was aimed to evaluate the predictive ability of imaging methods in accessing the status of axillary lymph node in different molecular subtypes.

Methods

A total of 2,340 patients diagnosed with primary invasive breast cancer after breast surgery from 2013 to 2018 in Jiangsu Breast Disease Center, the First Affiliated Hospital with Nanjing Medical University were included in the study. We collected lymph node assessment results from mammography, ultrasounds, and MRIs, performed receiver operating characteristic (ROC) analysis, and calculated the sensitivity and specificity of each test. The C-statistic among different imaging models were compared in different molecular subtypes to access the predictive abilities of these imaging models in evaluating the lymph node metastasis.

Results

In Her-2 + patients, the C-statistic of ultrasound was better than that of MRI (0.6883 vs. 0.5935, p=0.0003). The combination of ultrasound and MRI did not raise the predictability compared to ultrasound alone (p=0.492). In ER/PR+HER2- patients, the C-statistic of ultrasound was similar with that of MRI (0.7489 vs. 0.7650, p=0.5619). Ultrasound+MRI raised the prediction accuracy compared to ultrasound alone (p=0.0001). In ER/PR-HER2- patients, the C-statistics of ultrasound was similar with MRI (0.7432 vs. 0.7194, p=0.5579). Combining ultrasound and MRI showed no improvement in the prediction accuracy compared to ultrasound alone (p=0.0532).

Conclusion

From a clinical perspective, for Her-2+ patients, ultrasound was the most recommended examination to assess the status of axillary lymph node metastasis. For ER/PR+HER2- patients, we suggested that the lymph node should be evaluated by ultrasound plus MRI. For ER/PR-Her2- patients, ultrasound or MRI were both optional examinations in lymph node assessment. Furthermore, more new technologies should be explored, especially for Her2+ patients, to further raise the prediction accuracy of lymph node assessment.

ACR Appropriateness Criteria® Imaging of the Axilla

This publication reviews the current evidence supporting the imaging approach of the axilla in various scenarios with broad differential diagnosis ranging from inflammatory to malignant etiologies. Controversies on the management of axillary adenopathy results in disagreement on the appropriate axillary imaging tests. Ultrasound is often the appropriate initial imaging test in several clinical scenarios. Clinical information (such as age, physical examinations, risk factors) and concurrent complete breast evaluation with mammogram, tomosynthesis, or MRI impact the type of initial imaging test for the axilla. Several impactful clinical trials demonstrated that selected patient's population can received sentinel lymph node biopsy instead of axillary lymph node dissection with similar overall survival, and axillary lymph node dissection is a safe alternative as the nodal staging procedure for clinically node negative patients or even for some node positive patients with limited nodal tumor burden. This approach is not universally accepted, which adversely affect the type of imaging tests considered appropriate for axilla. This document is focused on the initial imaging of the axilla in various scenarios, with the understanding that concurrent or subsequent additional tests may also be performed for the breast. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Interventional nuclear medicine's contribution to molecularly targeted precision surgery

The surgical approach to different pathologies, not only oncological, has evolved. As Veronesi's group has coined very graphically, we are moving from "maximum tolerable treatments to minimum effective treatments" and this journey cannot be carried out in any other way than through a multidisciplinary and multimodality approach. Multidisciplinary, because collaboration between surgeons, oncologists, radiologists, nuclear physicians, pathologists, and all those involved in patient follow-up is necessary, and multimodality, because we must move towards precision surgery tailored to each patient in which, on the part of Nuclear Medicine, hybrid imaging (SPECT/CT and PET/CT), bimodal tracers, the use of new allies such as ultrasound or our own adaptation to robotic surgery have a great deal to say. A wide range of possibilities is built on the solid foundation of preoperative scintigraphy, which makes it possible to identify the target tissues and whose knowledge prior to surgery allows the necessary surgical approach to be considered for each patient.

The value of sentinel lymph-node biopsy after neoadjuvant therapy: an overview

PURPOSE

We conducted a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) after the neoadjuvant chemotherapy, compared to axillary lymph-node dissection, in terms of false-negative rate (FNR) and sentinel lymph-node identification rate (SLNIR), sensitivity, negative predictive value (NPV), need for axillary lymph-node dissection (ALND), morbidity, preferences, and costs.

METHODS

MEDLINE, Embase, Scopus, and The Cochrane Library were searched. We assessed the quality of the included systematic reviews using AMSTAR2 tool, and estimated the degree of overlapping of the individual studies on the included reviews.

RESULTS

Six systematic reviews with variable quality were selected. We observed a very high overlapping degree across the included reviews. The FNR and the SLNIR were quite consistent (FNR 13-14%; SLNIR ~ 90% or higher). In women with initially clinically node-negative breast cancer, the FNR was better (6%), with similar SLNIR (96%). The included reviews did not consider the other prespecified outcomes.

CONCLUSIONS

It would be reasonable to suggest performing an SLNB in patients treated with NACT, adjusting the procedure to the previous marking of the affected lymph node, using double tracer, and biopsy of at least three sentinel lymph nodes. More well-designed research is needed. PROSPERO registration number: CRD42020114403.

Combining conventional ultrasound and sonoelastography to predict axillary status after neoadjuvant chemotherapy for breast cancer

OBJECTIVE

To determine the ability of conventional ultrasound (US) combined with shear wave elastography (SWE) to reveal axillary status after neoadjuvant chemotherapy (NAC) in breast cancer patients.

METHODS

From September 2016 to December 2021, 201 patients with node-positive breast cancer who underwent NAC were enrolled in this prospective study. Conventional US features of axillary lymph nodes and SWE characteristics of breast lesions after NAC were analyzed. The diagnostic performances of US, SWE, and their combination were assessed using multivariate logistic regression and receiver operator characteristic curve (ROC) analyses.

RESULTS

The area under the ROC curve (AUC) for the ability of conventional US features to determine axillary status after NAC was 0.82, with a sensitivity of 85.23%, a specificity of 67.39%, and an accuracy of 76.11%. Shear wave velocity (SWV) displayed moderate performance for predicting axilla status after NAC with SWV_mean demonstrating an AUC of 0.85. Cortical thickness and shape of axillary nodes and SWV_mean of breast tumors were independently associated with axillary nodal metastasis after NAC. Compared to conventional US, the combination of conventional US of axillary lymph nodes with SWE of breast lesions achieved a significantly higher AUC (0.90 vs 0.82, p < 0.01, Delong's test) with a sensitivity of 87.50%, improved specificity of 82.61% and accuracy of 85.00%.

CONCLUSIONS

Breast SWE was independently associated with residual metastasis of axillary node after NAC in patients with initially diagnosed positive axilla. Combining SWE with conventional US showed good diagnostic performance for axillary node disease after NAC.

KEY POINTS

• Breast SWE can serve as a supplement to axilla US for the evaluation of the axilla after NAC. • The combination of axilla US with breast SWE may be a promising method to facilitate less-invasive treatment in patients receiving NAC.

Neoadjuvant approach in patients with early breast cancer: patient assessment, staging, and planning

Neoadjuvant treatment (NAT) has become an option in early stage (stage I-II) breast cancer (EBC). New advances in systemic and targeted therapies have increased rates of pathologic complete response increasing the number of patients undergoing NAT. Clear benefits of NAT are downstaging the tumor and the axillary nodes to de-escalate surgery and to evaluate response to treatment. Selection of patients for NAT in EBC rely in several factors that are related to patient characteristics (i.e, age and comorbidities), to tumor histology, to stage at diagnosis and to the potential changes in surgical or adjuvant treatments when NAT is administered.

Imaging and histologic confirmation is performed to assess extent of disease y to confirm diagnosis. Besides mammogram and ultrasound, functional breast imaging MRI has been incorporated to better predict treatment response and residual disease. Contrast enhanced mammogram (CEM), shear wave elastography (SWE), or Dynamic Optical Breast Imaging (DOBI) are emerging techniques under investigation for assessment of response to neoadjuvant therapy as well as for predicting response. Surgical plan should be delineated after NAT taking into account baseline characteristics, tumor response and patient desire.

In the COVID era, we have witnessed also the increasing use of NAT in patients who may be directed to surgery, unable to have it performed as surgery has been reserved for emergency cases only.

Pathological Response in the Breast and Axillary Lymph Nodes after Neoadjuvant Systemic Treatment in Patients with Initially Node-Positive Breast Cancer Correlates with Disease Free Survival: An Exploratory Analysis of the GeparOcto Trial

Simple Summary

The extent of axillary surgery has been reduced in recent years to minimize side effects. However, a negative impact of reduced surgery on outcome must be avoided. We investigated for whom the extent of surgery can be safely reduced by examining early-stage breast cancer patients converting from lymph node (LN)-positive to LN-negative disease after neoadjuvant systemic treatment (NAST). Of 242 initially LN-positive patients treated within the GeparOcto trial, 54.5% were classified as LN-negative after NAST, 31.8% as LN-positive, and for 13.6% data were missing. Overall, 92.1% of patients underwent complete axillary LN dissection, with 6.6% undergoing sentinel LN dissection only. At surgery, 55.4% of patients had no signs of cancer in the LN, 45.0% had no signs of cancer in the breast (of those 8.3% had involved LN), and 41.3% had no signs of cancer at all. Patients with involved LN still had a bad prognosis. Conversion from LN-positive to LN-negative after NAST is of highest prognostic value. Surgical axillary staging after NAST is essential in these patients to offer tailored treatment.

Abstract

Background: The conversion of initially histologically confirmed axillary lymph node-positive (pN+) to ypN0 after neoadjuvant systemic treatment (NAST) is an important prognostic factor in breast cancer (BC) patients and may influence surgical de-escalation strategies. We aimed to determine pCR rates in lymph nodes (pCR-LN), the breast (pCR-B), and both (tpCR) in women who present with pN+ BC, to assess predictors for response and the impact of pCR-LN, pCR-B, and tpCR on invasive disease-free survival (iDFS). Methods: Retrospective, exploratory analysis of 242 patients with pN+ at diagnosis from the multicentric, randomized GeparOcto trial. Results: Of 242 patients with initially pN+ disease, 134 (55.4%) had a pCR-LN, and 109 (45.0%) a pCR-B. Of the 109 pCR-B patients, 9 (8.3%) patients had involved LN, and 100 (41.3%) patients had tpCR. Those with involved LN still had a bad prognosis. As expected, pCR-B and intrinsic subtypes (TNBC and HER2+) were identified as independent predictors of pCR-LN. pCR-LN (ypN0; hazard ratio 0.42; 95%, CI 0.23–0.75; p = 0.0028 for iDFS) was the strongest independent prognostic factor. Conclusions: In initially pN+ patients undergoing NAST, the conversion to ypN0 is of high prognostic value. Surgical axillary staging after NAST is still essential in these patients to offer tailored treatment.

Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer: A multicentre study on 1,950 patients

BACKGROUND

Type of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized.

PATIENTS AND METHODS

1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR).

RESULTS

Independent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75-0.80). After external validation the accuracy of the nomogram was confirmed.

CONCLUSION

The accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients.

To Look or Not to Look? Yes to Nodal Ultrasound!

Knowledge of axillary nodal status is highly important for correct staging and treatment planning in patients with breast cancer. Axillary US is a recognized highly specific and cost-effective tool for assessing nodal status and guiding appropriate treatment. Axillary US imaging with US-guided biopsy is routinely performed throughout the world. However, because of recent developments in the surgical management of the axilla in patients with newly diagnosed breast cancer (American College of Surgeons Oncology Group [ACOSOG] Z0011 trial) and in patients with breast cancer receiving neoadjuvant systemic therapy (ACOSOG Z1071, SENTinel NeoAdjuvant [SENTINA] and Sentinel Node biopsy aFter NeoAdjuvant Chemotherapy [SN FNAC] trials), some have questioned the utility of axillary US for nodal staging. Here, we review the evidence to date supporting the additional value of axillary US for patients with breast cancer. Nodal US in patients with newly diagnosed breast cancer is useful for staging; in a significant proportion of patients, nodal US identifies additional axillary level II or level III nodal disease, which allows for appropriate treatment of disease. Furthermore, ongoing clinical trials may show that axillary surgery can be omitted in patients with negative findings on axillary US. In patients with lymph node-positive disease undergoing neoadjuvant systemic therapy, nodal US can guide the approach to axillary surgery. A more personalized patient approach, taking into the account tumor biology, among other factors, may help to mitigate the controversy surrounding the role of axillary US in breast cancer patients.

Clinical Value of Three Combined Ultrasonography Modalities in Predicting the Risk of Metastasis to Axillary Lymph Nodes in Breast Invasive Ductal Carcinoma

Objective

The present study aimed to assess the clinical value of conventional ultrasound (C-US), ultrasound elastography (UE), percutaneous contrast-enhanced ultrasound (P-CUES), and the combination of these three ultrasonography modalities for evaluating the risk of axillary lymph node (ALN) metastasis in breast invasive ductal carcinoma (IDC).

Methods

This retrospective analysis included 120 patients with pathologically confirmed IDC who underwent sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). Based on the gold standard of postoperative pathology, ALN pathology results were evaluated and compared with findings obtained using C-US, UE, P-CUES, and the three modalities combined.

Results

(1) There was a statistically significant difference between the histological grade of the tumor and the pathological condition of ALNs. (2) The difference between C-US parameters and UE score were statistically significant. The accuracy of P-CEUS localization of SLNs was 100% (96/96) when compared with localization guided by methylene blue. The difference in the distribution of the four SLN enhancement patterns was statistically significant. (3) The sensitivity, specificity, positive predictive value, and negative predictive value of C-US and UE were 75%, 71%, 58%, and 89%, and 71%, 72%, 50%, and 86%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of P-CUES were 91%, 82%, 78%, 92%, respectively. When all three modalities were combined, the sensitivity, specificity, positive predictive value, and negative predictive value were 94%, 89%, 86%, and 95%, respectively. In the detection of ALN metastasis, there was a good correlation between histopathological results and evaluations based on the three combined ultrasonography modalities (kappa: 0.82, p<0.001).

Conclusions

When compared to C-US, UE, or P-CEUS alone, the combination of the three ultrasonography modalities was found to be superior in distinguishing metastatic and non-metastatic ALNs. This combined strategy may aid physicians in determining the most appropriate approach to ALN surgery as well as the prognosis of breast IDC.

Breast cancer subtypes affect the ultrasound performance for axillary lymph node status evaluation after neoadjuvant chemotherapy: a retrospective analysis

PURPOSE

The aim of our study was to investigate the effect of breast cancer subtypes on the diagnostic value of axillary ultrasound for node status evaluation after neoadjuvant chemotherapy.

PATIENTS AND METHODS

Pathologic node-positive breast cancer patients underwent axillary ultrasound imaging after neoadjuvant chemotherapy were retrospectively reviewed. The enrolled patients were classified into four subtypes: Luminal A, Luminal B, human epidermal growth factor receptor 2-enriched and triple-negative. Ultrasound images of axillary nodes were reviewed and were evaluated as normal or abnormal and were associated with final pathologic results. Diagnostic value of axillary ultrasound was assessed in four subtypes based on sensitivity, specificity, positive predictive value and negative predictive value. The diagnostic value of axillary ultrasound as well as clinical and pathological characteristics was compared between four breast cancer subtypes using chi-square test or fisher's exact test.

RESULT

Luminal A subtype had highest positive predictive value (92.1%), lowest sensitivity (43.8%) and lowest negative predictive value (11.8%). Triple-negative subtype had lowest positive predictive value (73.2%), highest sensitivity (76.9%) and highest negative predictive value (59.1%) (P < 0.05). Luminal B and human epidermal growth factor receptor 2-enriched subtypes had medium sensitivity, positive predictive value and negative predictive value.

CONCLUSION

The diagnostic value of axillary ultrasound for node residue disease assessment after neoadjuvant chemotherapy is different between four breast cancer subtypes.

Surgical Management of the Axilla of HER2+ Breast Cancer in the Z1071 Era: A Propensity-Score-Matched Analysis of the NCDB

INTRODUCTION

We aim to analyze survival outcomes for sentinel lymph node biopsy (SLNB) versus axillary lymph node dissection (ALND) in human epidermal growth factor receptor (HER2)+ infiltrative ductal carcinoma (IDC) that demonstrate complete clinical response (cCR) to neoadjuvant systemic therapy (NAST) after initial presentation with clinical N1 (cN1) disease.

METHODS

NCDB 2004-2017 was utilized for the analysis. Female patients with unilateral HER2+ IDC, stage cT1-T4 cN1, who demonstrated cCR to NAST with reported definitive axillary surgical management were included. Patients were propensity score matched, and overall survival (OS) was compared. Cox regression analysis was used to identify survival predictors.

RESULTS

6453 patients were selected, of whom 2461 (38.1%) had SLNB and 3992 (69.1%) had ALND as definitive axillary surgical management. The trend of SLNB utilization increased from 20% in 2012 to 50% in 2017. A total of 2454 patients were matched from each group with adequate adjustment for all variables. There was no difference in OS between SLNB versus ALND (84.03 ± 0.36 versus 84.62 ± 0.42 months; p = 0.522). Cox regression identified age, cT stage, primary tumor response to NAST, ypN+, and endocrine therapy as significant OS predictors. In subgroup analysis of patients with ypN+ who had SLNB as a definitive procedure, primary tumor response to NAST and continuation of adjuvant chemotherapy were associated with improved OS.

CONCLUSION

In cN1 HER2+ IDC patients who demonstrate cCR to NAST, SLNB is a reasonable definitive procedure for axillary management with comparable OS outcomes to ALND. However, higher-level data are required to determine the appropriate management in the case of ypN+.

Ultrasound guided needle biopsy of axilla to evaluate nodal metastasis after preoperative systemic therapy in cohort of 106 breast cancers enriched with BRCA1/2 pathogenic variant carriers

BACKGROUND

Aim of the study is to evaluate the role of ultrasound guided fine needle aspiration cytology (FNAC) in the restaging of node positive breast cancer after preoperative systemic therapy (PST).

METHODS

From January 2016 - October 2020 106 node positive stage IIA-IIIC breast cancer cases undergoing PST were included in the study. 18 (17 %) were carriers of pathogenic variant in BRCA1/2. After PST restaging of axilla was performed with ultrasound and FNAC of the marked and/or the most suspicious axillary node. In 72/106 cases axilla conserving surgery and in 34/106 cases axillary lymph node dissection (ALND) was performed.

RESULTS

False Positive Rate (FPR) of FNAC after PST in whole cohort and BRCA1/2 positive subgroup is 8 and 0 % and False Negative Rate (FNR) - 43 and 18 % respectively. Overall Sensitivity - 55 %, specificity- 93 %, accuracy 70 %.

CONCLUSION

FNAC after PST has low FPR and is useful to predict residual axillary disease and to streamline surgical decision making regarding ALND both in BRCA1/2 positive and negative subgroups. FNR is high in overall cohort and FNAC alone are not able to predict ypCR and omission of further axillary surgery. However, FNAC performance in BRCA1/2 positive subgroup is more promising and further research with larger number of cases is necessary to confirm the results.