Axillary Lymph Node Status, Adjusted for Pathologic Complete Response in Breast and Axilla after Neoadjuvant Chemotherapy, Predicts Differential Disease-Free Survival in Breast Cancer

Zhang, G.C.; Zhang, Y.F.; Xu, Fangping; Qian, Xin; Guo, Zi-Bai; Ren, Chen; Yao, Min

doi:10.3747/co.20.1294

Cited by 50 publications

(37 citation statements)

References 23 publications

(23 reference statements)

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“…Rates of nodal pCR with NAC differ based on tumor subtype 18 , ranging from 40% to 60% overall, and approaching 70% to 80% among patients with triple-negative and HER2 amplified tumors (Table 5). 26, 27, 29, 30, 48, 54 cN0 patients with these subtypes, even when undergoing breast-conserving surgery, may have a higher likelihood of avoiding ALND with definitive axillary staging following NAC, a concept that warrants further study. In cN+ patients, it is clear that NAC offers the only possibility of avoiding ALND.…”

Section: Neoadjuvant Therapy Versus Initial Surgery: Selecting the Opmentioning

confidence: 99%

Axillary Nodal Management Following Neoadjuvant Chemotherapy

2017

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Importance The increasing use of neoadjuvant chemotherapy (NAC) for operable breast cancer has raised questions about optimal local therapy for the axilla. Observations Sentinel lymph node biopsy (SLNB) after NAC in patients presenting with clinically negative nodes has an accuracy similar to upfront SLNB and reduces the need for axillary lymph node dissection (ALND) compared to SLNB prior to NAC. In patients presenting with node-positive disease, clinical trials demonstrate that SLNB after NAC is accurate when ≥3 sentinel nodes are obtained, but long-term outcomes are lacking. The relative importance of pre- and post-NAC stage in predicting risk of locoregional recurrence remains an area of controversy. Conclusion and Relevance NAC reduces the need for ALND, and SLNB is an accurate method of determining nodal status post NAC.

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Section: Neoadjuvant Therapy Versus Initial Surgery: Selecting the Opmentioning

confidence: 99%

Axillary Nodal Management Following Neoadjuvant Chemotherapy

2017

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“…6 Following NAC, ALND is performed for any nodal metastasis, regardless of tumor deposit size. 6 While NAC is associated with the potential for axillary nodal downstaging, rates of a nodal pathologic complete response (pCR) differ substantially by tumor subtype 7–10 and, therefore, the likelihood of minimizing the extent of axillary surgery differs by tumor biology. Given these options, the optimal treatment plan to avoid ALND in early-stage breast cancer patients remains unclear.…”

Section: Introductionmentioning

confidence: 99%

The Optimal Treatment Plan to Avoid Axillary Lymph Node Dissection in Early-Stage Breast Cancer Patients Differs by Surgical Strategy and Tumor Subtype

et al. 2017

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Background Strategies to reduce the likelihood of axillary lymph node dissection (ALND) include application of Z0011 or use of neoadjuvant chemotherapy (NAC). Indications for ALND differ by treatment plan and nodal pathologic complete response rates following NAC vary by tumor subtype. ALND rates in patients with cT1-2N0 tumors undergoing upfront surgery were compared to those treated with NAC. Methods ALND rates among cT1-2N0 breast cancer patients were compared by tumor subtype among women undergoing upfront surgery to NAC. Multivariable analysis controlling for age, cT stage, lymphovascular invasion, and stratified by subtype was performed. Results 1944 cancers in 1907 women who underwent SLN biopsy +/− ALND were identified (669 upfront breast-conserving surgery [BCS], 1004 upfront mastectomy, 271 NAC). Compared to the NAC group, ALND rates in the BCS group were lower for ER/PR+ HER2− tumors (15% versus 34%, p<.001). ALND rates in the upfront mastectomy group were higher than the NAC group among HER2+ or TN tumors. On multivariable analysis, receipt of NAC compared to upfront BCS remained significantly associated with higher odds of ALND in the ER/PR+, HER2− subtype (HR 3.35, p<.001), while NAC versus upfront mastectomy remained significantly associated with lower odds of ALND in the HER2+ and TN subtypes (HR HER2+ 0.19, p<.001; HR TN 0.25, p=0.007). Conclusion ALND rates differ according to surgery type and tumor subtype secondary to differing ALND indications and nodal response to NAC. These factors can be used to personalize treatment planning in order to minimize ALND risk in early-stage breast cancer patients.

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“…Thus, administering neoadjuvant chemotherapy to grade 3 patients of all stages may significantly affect the rate of pCR and concomitant outcomes, although additional clinical trials investigating the efficacy of neoadjuvant chemotherapy in early-stage patients are required. In addition, there is increasing evidence that a certain subset of women with axillary disease at diagnosis require adjuvant systemic therapy, regardless of their local response to neoadjuvant treatment, as demonstrated on operative pathology (18). In our cohort, a total of 5 patients recurred, 3 of whom did so within 18 months of definitive surgical treatment; none of these 5 patients received adjuvant chemotherapy.…”

Section: Discussionmentioning

confidence: 87%