Identification and Resection of Clipped Node Decreases the False-negative Rate of Sentinel Lymph Node Surgery in Patients Presenting With Node-positive Breast Cancer (T0–T4, N1–N2) Who Receive Neoadjuvant Chemotherapy

Abstract

Background The American College of Surgeons Oncology Group Z1071 trial reported a false negative rate (FNR) of 12.6% with sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy in women presenting with node-positive breast cancer. One proposed method to decrease the FNR is clip placement in the positive node at initial diagnosis with confirmation of clipped node resection at surgery. Methods Z1071 was a multi-institutional trial in which women with clinical T0-4,N1-2,M0 breast cancer underwent SLN surgery and axillary dissection (ALND) after neoadjuvant chemotherapy. In cases with a clip placed in the node, the clip location at surgery (SLN or ALND) was evaluated. Results A clip was placed at initial node biopsy in 203 patients. In the 170 (83.7%) patients with cN1 disease and at least 2 SLNs resected, clip location was confirmed in 141 cases. In 107 (75.9%) patients where the clipped node was within the SLN specimen, the FNR was 6.8% (CI:1.9–16.5%). In 34 (24.1%) cases where the clipped node was in the ALND specimen, the FNR was 19.0% (CI:5.4–41.9%). In cases without a clip placed (n=355) and those where clipped node location was not confirmed at surgery (n=29), the FNR was 13.4% and 14.3%, respectively. Conclusion Clip placement at diagnosis of node-positive disease with removal of the clipped node during SLN surgery reduces the FNR of SLN surgery after neoadjuvant chemotherapy. Clip placement in the biopsy-proven node at diagnosis and evaluation of resected specimens for the clipped node should be considered when performing SLN surgery in this setting.

Preoperative Axillary Lymph Node Marking in Patients with Breast Cancer

“…Ve studii Boughey et al [7] byl znovu prozkoumán soubor studie Z1071 stran nalezení klipu v SLN po operaci. Uzliny, kde bylo vysloveno podezření na infiltraci před operací, musely být bio pticky verifikovány, vložení klipu do uzliny však nebylo podmínkou.…”

“…Falešná negativita (tedy podíl případů, kdy byla nalezena infiltrace v jiné než označené uzlině -metoda nebyla kombinována s bio psií SLN) činila 7 %, což je rovněž méně než zmíněných 10 %. Studie se však ve výsledku potý-kala se třemi problémy: tivita metody (tedy že při negativitě uzliny s klipem a SLN byla nalezena infiltrace v uzlině v preparátu z AD) činila ve studii z MD Anderson 4,2 % [11] a ve studii Boughey et al 6,8 % [7]. Možnosti dalšího značení uzlin s klipem jsou rozebrány níže.…”

Axillary Ultrasound Before Neoadjuvant Chemotherapy for Breast Cancer: Don’t Discount the Benefits Yet!

“…For instance, in ACOSOG Z1071, despite the use of dual tracer mapping and excision of at least two SLNs, the false-negative rate (FNR) for SLNB after NAC for previously cN1 patients remained unacceptably high ([10%) unless the axillary lymph node sampled before NAC was resected. 8 If the clipped node was excised, the FNR dropped to 6.8%. These data suggest that AUS should be considered for patients undergoing NAC to improve the accuracy of the subsequent SLNB and to maintain an acceptable FNR.…”

Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy for Patients with Axillary Metastases: Can We Avoid the Unavoidable?

“…While it was not required in the Mamtani et al study, adjuvant findings from Z1071 showed a potential FNR of 9.8 % if axillary ultrasound had been used after NAC, suggesting that axillary ultrasound should be considered to improve accuracy of SLNB in this setting. 10 The group from MSKCC has shown that, in experienced hands, using dual tracers and excising palpably abnormal LNs during SLNB allows for the removal of C3 SLNs in approximately 86 % of qualified patients and, ultimately, an acceptably low FNR (\10 %). Although not used in all studies, clips were placed in 203 patients enrolled in the Z1071 trial.…”