Comprehensive Axillary Evaluation in Neoadjuvant Chemotherapy Patients With Ultrasonography and Sentinel Lymph Node Biopsy

Abstract

Background: There is ongoing debate regarding the optimal sequence of sentinel lymph node (SLN) biopsy and neoadjuvant chemotherapy (CTX) for breast cancer. We report the accuracy of comprehensive pre-neoadjuvant CTX and post-neoadjuvant CTX axillary staging via ultrasound imaging, fine-needle aspiration (FNA) biopsy, and SLN biopsy. Results: Axillary staging was pathologically negative by pre-neoadjuvant CTX SLN biopsy in 53 cases (58%); these patients had no further axillary surgery. In 38 cases (42%), axillary metastases were confirmed at presentation by either ultrasound-guided FNA or SLN biopsy. These 38 patients underwent completion axillary lymph node dissection (ALND) after delivery of neoadjuvant CTX. Follow-up lymphatic mapping was attempted in 33 of these cases, and the SLN was identified in 32 (identification rate, 97%). One third of these cases were completely node negative on ALND. Residual metastatic disease was identified in 22 cases, and the SLN was falsely negative in 1 (4.5%).Conclusions: Patients receiving neoadjuvant CTX can have accurate axillary nodal staging by ultrasound-guided FNA or SLN biopsy. In cases of documented axillary metastasis at presentation, repeat axillary staging with SLN biopsy can document the post-neoadjuvant CTX nodal status. This strategy optimizes pre-neoadjuvant CTX and post-neoadjuvant CTX staging information by distinguishing the patients who are node negative at presentation from those who have been downstaged to node negativity and offers the potential for avoiding unnecessary ALNDs in both of these patient subsets.

Current applications and future prospects of fine‐needle aspiration biopsy of locoregional lymph nodes in the management of breast cancer

“…54 Many reports have described the role of US-guided FNA biopsy of axillary lymph nodes in directing the surgical treatment of patients with early stage breast cancer; however, only a few reports have illustrated its utility in patients selected to receive neoadjuvant chemotherapy. Khan et al 51 reported the value of a comprehensive approach to staging, including the evaluation of axillary and nonaxillary lymph nodes (including supraclavicular, infraclavicular, and internal mammary chain lymph nodes), before neoadjuvant chemotherapy. 51 Although preneoadjuvant lymph node staging cannot determine the full extent of axillary lymph node disease, it provides useful information for medical oncologists in planning chemotherapy regimens.…”

“…Khan et al 51 reported the value of a comprehensive approach to staging, including the evaluation of axillary and nonaxillary lymph nodes (including supraclavicular, infraclavicular, and internal mammary chain lymph nodes), before neoadjuvant chemotherapy. 51 Although preneoadjuvant lymph node staging cannot determine the full extent of axillary lymph node disease, it provides useful information for medical oncologists in planning chemotherapy regimens.…”

Evaluation of axillary status in patients with breast cancer using thin-section CT

“…[1][2][3] For the evaluation of axillary lymph node metastases, various approaches and examination techniques have been proposed to improve the diagnostic accuracy of ultrasound (US), CT, positron emission tomography (PET), and other diagnostic modalities. [4][5][6][7][8][9][10][11][12][13][14][15] However, no defi nitive criteria have yet been established. Mammary gland CT can be performed with the patient in nearly the same position as that during surgery, and it is beginning to attract attention as a modality that permits the extent of the primary lesion and axillary lymph node metastases to be evaluated simultaneously.…”

Sentinel lymph node biopsy before versus after neoadjuvant chemotherapy for breast cancer

“…Khan et al reported the results of repeat SLNB for patients initially found to be node-positive by SLNB before NAC, indicating that the identifi cation rates and false-negative rates of repeat SLNB were 97% and 4.5%, respectively. 34 They reported that one-third of patients who were initially node-positive were subsequently proven to be node-negative, allowing for the avoidance of ALND. Consequently, it is possible that a signifi cant number of patients whose axillary diseases were eradicated by NAC can be spared ALND during defi nitive surgery after NAC.…”