Selecting Node-Positive Patients for Axillary Downstaging with Neoadjuvant Chemotherapy

Montagna, Giacomo; Mamtani, Anita; Knežević, Andrea; Brogi, Edi; Barrio, Andrea V.; Morrow, Monica

doi:10.1245/s10434-020-08650-z

Cited by 61 publications

(44 citation statements)

References 38 publications

(51 reference statements)

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“…60 In a single-institution study, three or more negative sentinel lymph nodes were retrieved and axillary lymph node dissection was avoided in 237 (42%) of 573 patients who became cN0 after neoadjuvant therapy. 61 Another approach to decrease false negative rates of sentinel lymph node biopsy after primary systemic treatment is targeted axillary dissec tion. 62 Rates of nodal recurrence after sentinel lymph node biopsy alone in patients presenting initially as cN-positive are not yet available.…”

Section: Early Breast Cancer: Neoadjuvant Treatment Conceptmentioning

confidence: 99%

Breast cancer

et al. 2021

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Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.

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Section: Early Breast Cancer: Neoadjuvant Treatment Conceptmentioning

confidence: 99%

Breast cancer

et al. 2021

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“…One advantage of neoadjuvant therapy in the treatment of breast cancer is the potential to downstage the axilla and reduce the extent of morbid axillary surgery [1][2][3][4][5][6] . The nodal response to neoadjuvant therapy can impact both surgical planning and the appropriate duration and type of neoadjuvant therapy.…”

Section: Introductionmentioning

confidence: 99%

Accuracy of breast MRI in evaluating nodal status after neoadjuvant therapy in invasive lobular carcinoma

et al. 2021

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Neoadjuvant therapy in breast cancer can downstage axillary lymph nodes and reduce extent of axillary surgery. As such, accurate determination of nodal status after neoadjuvant therapy and before surgery impacts surgical management. There are scarce data on the diagnostic accuracy of breast magnetic resonance imaging (MRI) for nodal evaluation after neoadjuvant therapy in patients with invasive lobular carcinoma (ILC), a diffusely growing tumor type. We retrospectively analyzed patients with stage 1–3 ILC who underwent pre-operative breast MRI after either neoadjuvant chemotherapy or endocrine therapy at our institution between 2006 and 2019. Two breast radiologists reviewed MRIs and evaluated axillary nodes for suspicious features. All patients underwent either sentinel node biopsy or axillary dissection. We evaluated sensitivity, specificity, negative and positive predictive values, and overall accuracy of the post-treatment breast MRI in predicting pathologic nodal status. Of 79 patients, 58.2% received neoadjuvant chemotherapy and 41.8% neoadjuvant endocrine therapy. The sensitivity and negative predictive value of MRI were significantly higher in the neoadjuvant endocrine therapy cohort than in the neoadjuvant chemotherapy cohort (66.7 vs. 37.9%, p = 0.012 and 70.6 vs. 40%, p = 0.007, respectively), while overall accuracy was similar. Upstaging from clinically node negative to pathologically node positive occurred in 28.0 and 41.7%, respectively. In clinically node positive patients, those with an abnormal post-treatment MRI had a significantly higher proportion of patients with ≥4 positive nodes on pathology compared to those with a normal MRI (61.1 versus 16.7%, p = 0.034). Overall, accuracy of breast MRI for predicting nodal status after neoadjuvant therapy in ILC was low in both chemotherapy and endocrine therapy cohorts. However, post-treatment breast MRI may help identify patients with a high burden of nodal disease (≥4 positive nodes), which could impact pre-operative systemic therapy decisions. Further studies are needed to assess other imaging modalities to evaluate for nodal disease following neoadjuvant therapy and to improve clinical staging in patients with ILC.

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“…In a separate single institution series of 630 cN1 patients without clipping of the positive node, 91% converted to cN0 post NACT and proceeded to SLNB (117,118). Three or more SLNs were mapped in 93% of cases, regarded as adequate mapping, with 7% having less than 3 nodes identified and complete failure in 2%.…”

Section: Management Of the Axillamentioning

confidence: 99%

Neoadjuvant Chemotherapy for Breast Cancer: Moving Beyond Pathological Complete Response in the Molecular Age

Provenzano

2021

ama

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This review focuses on neoadjuvant chemotherapy for breast cancer which introduces practical issues for pathologists, including predicting response, optimising specimen handling, size measurement and assessment of residual disease, and recent advances in management of the axilla. The role of neoadjuvant chemotherapy in breast cancer is increasing, and it has become standard of care for high risk Human Epidermal Growth Factor Receptor 2 positive and triple negative breast cancers. The benefits of the neoadjuvant approach extend beyond pathological complete response to tumour downstaging permitting conservative surgi- cal options in the breast and axilla, and assessment of response provides valuable prognostic information to enable escalation and de-escalation of adjuvant therapy to optimise oncological outcomes. Hence histopathologists play a vital role in patient management in the neoadjuvant setting. Optimal patient selection for neoadjuvant chemotherapy requires consideration of pre- treatment histopathological and molecular tumour characteristics. Post chemotherapy, tumour staging can be challenging, and changes in criteria for measurement of primary tumour and metastases in the 7th and 8th editions of the TNM have led to confu- sion amongst pathologists. This review offers practical guidance on specimen handling and measurement of lesion size. Mov- ing forwards more detailed information on degree of response will be required for adjuvant therapy decision making, and the Residual Cancer Burden is emerging as the preferred method for quantifying residual disease not just within clinical trials but in routine practice. Recent advances in management of the axilla are discussed, including the significance of minimal residual disease in the form of isolated tumour cells and micrometastases which portend a worse prognosis in the neoadjuvant setting.Conclusion. Neoadjuvant chemotherapy now forms part of routine breast cancer management, and detailed histopathological assessment and an understanding of the importance of molecular tumour biology is essential for clinical decision making.

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Selecting Node-Positive Patients for Axillary Downstaging with Neoadjuvant Chemotherapy

Cited by 61 publications

References 38 publications

Breast cancer

Breast cancer

Accuracy of breast MRI in evaluating nodal status after neoadjuvant therapy in invasive lobular carcinoma

Neoadjuvant Chemotherapy for Breast Cancer: Moving Beyond Pathological Complete Response in the Molecular Age

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