Incidence and Impact of Documented Eradication of Breast Cancer Axillary Lymph Node Metastases Before Surgery in Patients Treated With Neoadjuvant Chemotherapy

Abstract

ObjectiveTo determine the incidence and prognostic significance of documented eradication of breast cancer axillary lymph node (ALN) metastases after neoadjuvant chemotherapy. Summary Background DataNeoadjuvant chemotherapy is the standard of care for patients with locally advanced breast cancer and is being evaluated in patients with earlier-stage operable disease. MethodsOne hundred ninety-one patients with locally advanced breast cancer and cytologically documented ALN metastases were treated in two prospective trials of doxorubicin-based neoadjuvant chemotherapy. Patients had breast surgery with level I and II axillary dissection followed by additional chemotherapy and radiation treatment. Nodal sections from 43 patients who were originally identified as having negative ALNs at surgery were reevaluated and histologically confirmed to be without metastases. An additional 1112 sections from these lymph node blocks were obtained; half were stained with an anticytokeratin antibody cocktail and analyzed. Survival was calculated using the Kaplan-Meier method. ResultsOf 191 patients with positive ALNs at diagnosis, 23% (43 patients) were converted to a negative axillary nodal status on histologic examination (median number of nodes removed ϭ 16). Of the 43 patients with complete axillary conversion, 26% (n ϭ 11) had N1 disease and 74% (n ϭ 32) had N2 disease. On univariate analysis, patients with complete versus incomplete histologic axillary conversion were more likely to have initial estrogenreceptor-negative tumors, smaller primary tumors, and a complete pathologic response in the primary tumor. The 5-year disease-free survival rates were 87% in patients with preoperative eradication of axillary metastases and 51% for patients with residual nodal disease after neoadjuvant chemotherapy. Of the 39 patients with complete histologic conversion for whom nodal blocks were available, occult nodal metastases were found in additional nodal sections in 4 patients (10%). At a median follow-up of 61 months, the 5-year disease-free survival rates were 87% in patients without occult nodal metastases and 75% in patients with occult nodal metastases. ConclusionsNeoadjuvant chemotherapy can completely clear the axilla of microscopic disease before surgery, and occult metastases are found in only 10% of patients with a histologically negative axilla. The results of this study have implications for the potential use of sentinel lymph node biopsy as an alternative to axillary dissection in patients treated with neoadjuvant chemotherapy.

Sentinel lymph node metastasis after neoadjuvant treatment in breast cancer: Any size matters?

“…There is clear evidence that NAC downstages posi tive axillary nodes in a proportion of patients. Early studies have shown that NAC can completely clear axillary metastases in approximately 23% of patients with locally advanced breast cancer [6] , rates that have increased to 40%60% with the use of targeted therapies [7] . Axillary complete downstaging after NAC has been correlated with better prognosis and assessment of residual disease after NAC is important not only in determining the prognostic information but also in selecting candidates for further systemic and radiation therapy treatment [7,8] .…”

“…The number of residual metastastic axillary nodes after NAC has been established as an important prog nostic factor for disease free survival [6] . Axillary response after NAC is a better prognostic factor than response of the primary tumor [6,8,27] .…”

“…Axillary response after NAC is a better prognostic factor than response of the primary tumor [6,8,27] . Because most of these studies included patients with ALND, ITC in the axillary nodes are not reported.…”

Study on the role of primary systemic chemotherapy with anthracycline combination schedule in locally advanced breast cancer: long term follow up data

“…There is enough evidence to show the benefit from Anthracycline combination chemotherapy. [8][9][10][11][12] Data from RCTs show that the rate of breast conserving surgery and pathologic complete response was significantly higher for patients receiving taxanes (Docetaxel). [13][14][15][16][17][18][19] No consensus exists whether anthracycline and taxanes can be used in combination or in sequence.…”

Sentinel node biopsy in breast cancer patients undergoing induction chemotherapy should be performed prior to chemotherapy

“…In that respect, pre-chemotherapy sentinel node biopsy is revealed as advantageous. We know that chemotherapy will result in the complete remission of axillary lymph node metastases in 20-40% of patients diagnosed with lymph node involvement prior to treatment [3]. Radiotherapy should later be offered to those patients, even if there has been complete remission of the axillary lymph node lesions.…”