Feasibility of Sentinel Lymph Node Biopsy in Breast Cancer Patients with Initial Axillary Lymph Node Metastasis after Primary Systemic Therapy

Abstract

PurposePrimary systemic therapy (PST) downstages up to 40% of initial documented axillary lymph node (ALN) metastases in breast cancer. The current surgical treatment after PST consists of breast tumor resection and axillary lymph node dissection (ALND). This strategy, however, does not eliminate unnecessary ALND in patients with complete remission of axillary metastases. The aim of this study was to examine the accuracy of sentinel lymph node biopsy (SLNB) after PST among patients with documented ALN metastasis at presentation and to identify the rate of pathologic complete-remission (CR) with ALN after PST.MethodsWe analyzed 66 patients with ALN metastasis that was pathologically proven preoperatively who underwent SLNB and concomitant ALND after PST. Axillary ultrasound (AUS) was used to evaluate the clinical response of initially documented ALN metastasis after PST. Intraoperative lymphatic mapping was performed using blue dye with or without radioisotope.ResultsAfter PST, 34.8% of patients had clinical CR of ALN on AUS and 28.8% patients had pathologic CR of ALN. The overall success rate of SLNB after PST was 87.9%, and the sentinel lymph node identification rate in patients with clinical CR was 95.7%. In patients with successful lymphatic mapping, 70.7% of patients had residual axillary metastases. The overall accuracy and false-negative rate were 87.9% and 17.1% in all patients: 95.5% and 10.0% in patients with clinical CR of ALN, and 83.3% and 19.4% in patients with residual axillary disease after PST.ConclusionOur findings suggest that SLNB may be feasible in patients with initial documented ALN metastasis who have clinical CR for metastatic ALN after PST. Further investigation in a prospective setting should be performed to confirm our results.

Contrast Enhanced Ultrasound (CEU) Using Microbubbles for Sentinel Lymph Node Biopsy in Breast Cancer: a Systematic Review

“…Various studies reported that the SLN identification rate after neo-adjuvant chemotherapy was over 90% while the false-negative rate was almost 10% (30,31). Regardless of the present data, there is concern on the hypothesis that SLN biopsy after neo-adjuvant chemotherapy might increase the number of the false-negative biopsies due to multiple factors such as fibrosis, distorted lymphatic drainage, tissue scarring and not always uniform response of the patients to treatment (32).…”

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

“…In 20 studies, the axillary staging procedure was always followed by ALND as part of trial protocol. A total of 17 trials investigated accuracy of SLNB, [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] 1 trial investigated ML, 8 and 2 trials investigated a combination procedure. 6,32 Studies validating the combination procedure were scarce, yet several studies did report on cohorts of patients in whom a combination procedure was performed without routine cALND.…”

Lymphoscintigraphy and Sentinel Nodes

“…This approach is sometimes used even in cases of confirmed axillary metastasis. Such disease has been successfully downstaged in up to 40% of patients (29).…”

“…When this is done, patients receive two surgical interventions: the SLNB before chemotherapy and a lumpectomy or mastectomy after chemotherapy (15,29).…”