Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer

Abstract

Objective: The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND. Summary of Background Data: Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity. Methods: PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV). Results: Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%. Conclusion: Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.

Excision of both pretreatment marked positive nodes and sentinel nodes improves axillary staging after neoadjuvant systemic therapy in breast cancer

“…In patients with clinically node‐positive (cN+) disease, axillary lymph node dissection (ALND) is still performed frequently, providing both regional control and information for adjuvant therapy recommendations. Neoadjuvant systemic therapy (NST) is often given to patients with cN+ disease, leading to a pathological complete response (pCR) in the axilla in approximately one‐third of patients. Patients with an axillary pCR do not benefit from ALND, yet do suffer from both short‐ and long‐term side‐effects of the operation.…”

“…Various less invasive procedures have been proposed for axillary staging after NST in patients with cN+ tumours before treatment. However, neither the sentinel lymph node (SLN) nor the marking of the axilla with a radioactive iodine seed (MARI) procedure have low enough false‐negative rates (FNRs) for these techniques to comfortably replace ALND. Based on the negative predictive values (NPVs) of these procedures, residual axillary disease may be missed in at least one in six patients with cN+ disease in whom an axillary pCR is suggested.…”

Reply to: Sentinel node biopsy after neoadjuvant chemotherapy for breast cancer in patients with pre-treatment node-positive: Recommendation to optimize the performance

“…We agree with Franceschini that removing SLNs together with a marked node seems crucial to accurate staging of the axilla. Our group performed a systemic review and meta-analysis to evaluate the diagnostic accuracy of currently available less invasive staging procedures [1]. In this review, we compared the diagnostic accuracy of SLNB, MARI and of procedures in which SLNB and MARI are combined (i.e.…”

Sentinel Node Biopsy After Neoadjuvant Systemic Therapy for Breast Cancer: The Method Matters

“…More recently, techniques for marking the needle biopsy-positive nodes and verification that they are removed, combined with SLN mapping and removal, can reduce the FNR to as low as 2%. [27][28][29][30][31] These methods have included placing a clip in the node at the time of biopsy, identification of the clip by intraoperative ultrasound and specimen radiograph, 125 I seeds placed at the time of biopsy or before surgery, or tattooing positive nodes with India ink. 27,28,32 Nonradioactive marker options, such as using magnetic, radiofrequency, or radar technology markers, are additional options.…”