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

Abstract

Purpose: Neoadjuvant chemotherapy (NACT) is increasingly adopted in the therapy of breast cancer (BC) patients with positive axillary nodes (cNþ), but the reliability and feasibility of sentinel lymph node biopsy (SLNB) following NACT are still controversial. The objective of the present study is to conduct an updated meta-analysis on this issue. Methods: A literature search was performed using PubMed, Cochrane, Embase, and Web of Science to identify papers published from January 1, 2000 to October 22, 2020 to research SLNB after NACT in BC patients. Studies that met the quality standard were enrolled for this meta-analysis. Results: A total of 3578 participants from 27 trials were included in this meta-analysis. The pooled estimate of the identification rate (IR) for SLNB was 91 %, and the false negative rate (FNR) was 15 %. The pooled negative prediction value (NPV), accuracy, specificity, and sensitivity were 82 %, 89 %, 97 %, and 85 %, respectively. In subgroup analysis, the application of dual mapping could clearly decrease the FNR. The FNR was significantly high in the luminal types, and it declined as more sentinel lymph nodes (SLNs) were removed. Conclusion: SLNB following NACT is now technically feasible for BC with cNþ. However, it must be emphasized that the FNR is unacceptable high.

Improved false-negative rates using a novel patient selection flowchart in initially biopsy-proven node-positive breast cancer undergoing blue-dye alone guided sentinel lymph node biopsy after neoadjuvant chemotherapy

“…Moreover, the result of the ACOSOG Z1071 trial, which supported increasing the number of SLNs to improve the FNR, incentivizes surgeons to remove as many SLNs as possible to reduce FNR in real clinical practice. [10,47,49,50] Although our study has achieved an acceptable FNR (9.9%) for blue-dye guided SLNB, it is a single-center study with a small number of cases and lack of external veri cation.…”

“…[21,22] Although, the IR is a crucial determining factor re ecting the ability to identify the SLNs for SLNB, a recent meta-analysis showed that there is no signi cant difference in IR when the SLN was tagged using the different mapping methods (p = 0.55). [47] A prior study at the Memorial Sloan Kettering Cancer Center supported that it was mostly the nodal status pre-NAC, not the SLNB technique, which affect the retrieval number of SLNs.…”

Axillary Management after Neoadjuvant Chemotherapy; A Review of How and When?

“…These findings correlated with a study by Kuemmel et al [24] about targeted axillary dissection (TAD; SLN combines with excision target lymph node that marked before NAC biopsy) improved FNR to 4.3%. An updated meta analysis in 2021 by Siyang Caol et al [25] included 27 trials summarized pool IR 91%and FNR 15% and established that dual mapping can decrease FNR to 10%. They suggested removal of the targeted node in combination with SLN (TAD) to decrease FNR.…”

“…As mentioned previously, targeted node dissection reduces FNR of SLN after NAC [3,24,25] but the localization technique is still limited by the accuracy and the cost of technology. There are multiple studies describing the accuracy of each technique to localize clinically positive lymph nodes before NAC.…”

Options to Determine Pathological Response of Axillary Lymph Node Metastasis after Neoadjuvant Chemotherapy in Advanced Breast Cancer

“…Additionally, using dual tracers for SLN identification yielded more sentinel nodes and lowered the FNR. Thus, the more morbid complete ALND is being potentially avoided in a large number of node positive patients if the nodes can be accurately proven negative by more limited node surgery after NAC [11][12][13]. Post-NAC axillary staging poses unique challenges in identification of previously positive node(s) in the axilla.…”