Targeted Axillary Dissection Reduces Residual Nodal Disease in Clinically Node- Positive Breast Cancer After Neoadjuvant Chemotherapy

Overview

Journal World J Surg Oncol

Publisher Biomed Central

Specialties General Surgery
Oncology

Date 2024 Jul 6

PMID 38971793

Authors

Neslihan Cabioglu

Hasan Karanlik

Ravza Yilmaz

Selman Emiroglu

Mustafa Tukenmez

Suleyman Bademler

Duygu Has Simsek

Tarik Recep Kantarci

Inci Kizildag Yirgin

Aysel Bayram

Memduh Dursun

Affiliations

Soon will be listed here.

Abstract

Background: Any advantage of performing targeted axillary dissection (TAD) compared to sentinel lymph node (SLN) biopsy (SLNB) is under debate in clinically node-positive (cN+) patients diagnosed with breast cancer. Our objective was to assess the feasibility of the removal of the clipped node (RCN) with TAD or without imaging-guided localisation by SLNB to reduce the residual axillary disease in completion axillary lymph node dissection (cALND) in cN+ breast cancer.

Methods: A combined analysis of two prospective cohorts, including 253 patients who underwent SLNB with/without TAD and with/without ALND following NAC, was performed. Finally, 222 patients (cT1-3N1/ycN0M0) with a clipped lymph node that was radiologically visible were analyzed.

Results: Overall, the clipped node was successfully identified in 246 patients (97.2%) by imaging. Of 222 patients, the clipped lymph nodes were non-SLNs in 44 patients (19.8%). Of patients in cohort B (n=129) with TAD, the clipped node was successfully removed by preoperative image-guided localisation, or the clipped lymph node was removed as the SLN as detected on preoperative SPECT-CT. Among patients with ypSLN(+) (n=109), no significant difference was found in non-SLN positivity at cALND between patients with TAD and RCN (41.7% vs. 46.9%, p=0.581). In the subgroup with TAD with axillary lymph node dissection (ALND; n=60), however, patients with a lymph node (LN) ratio (LNR) less than 50% and one metastatic LN in the TAD specimen were found to have significantly decreased non-SLN positivity compared to others (27.6% vs. 54.8%, p=0.032, and 22.2% vs. 50%, p=0.046).

Conclusions: TAD by imaging-guided localisation is feasible with excellent identification rates of the clipped node. This approach has also been found to reduce the additional non-SLN positivity rate to encourage omitting ALND in patients with a low metastatic burden undergoing TAD.

References

Caudle A, Yang W, Mittendorf E, Black D, Hwang R, Hobbs B . Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg. 2014; 150(2):137-43. PMC: 4508192. DOI: 10.1001/jamasurg.2014.1086. View

Trinh L, Miyake K, Dirbas F, Kothary N, Horst K, Lipson J . CT-Guided Wire Localization for Involved Axillary Lymph Nodes After Neo-adjuvant Chemotherapy in Patients With Initially Node-Positive Breast Cancer. Breast J. 2016; 22(4):390-6. DOI: 10.1111/tbj.12597. View

Hellingman D, Donswijk M, Winter-Warnars G, de Koekkoek-Doll P, Pinas M, Budde-van Namen Y . Feasibility of radioguided occult lesion localization of clip-marked lymph nodes for tailored axillary treatment in breast cancer patients treated with neoadjuvant systemic therapy. EJNMMI Res. 2019; 9(1):94. PMC: 6811805. DOI: 10.1186/s13550-019-0560-3. View

Barron A, Hoskin T, Boughey J . Predicting Non-sentinel Lymph Node Metastases in Patients with a Positive Sentinel Lymph Node After Neoadjuvant Chemotherapy. Ann Surg Oncol. 2018; 25(10):2867-2874. DOI: 10.1245/s10434-018-6578-3. View

Cho N, Moon W, Han W, Park I, Cho J, Noh D . Preoperative sonographic classification of axillary lymph nodes in patients with breast cancer: node-to-node correlation with surgical histology and sentinel node biopsy results. AJR Am J Roentgenol. 2009; 193(6):1731-7. DOI: 10.2214/AJR.09.3122. View

Bedi D, Krishnamurthy R, Krishnamurthy S, Edeiken B, Le-Petross H, Fornage B . Cortical morphologic features of axillary lymph nodes as a predictor of metastasis in breast cancer: in vitro sonographic study. AJR Am J Roentgenol. 2008; 191(3):646-52. DOI: 10.2214/AJR.07.2460. View

Banys-Paluchowski M, Gasparri M, de Boniface J, Gentilini O, Stickeler E, Hartmann S . Surgical Management of the Axilla in Clinically Node-Positive Breast Cancer Patients Converting to Clinical Node Negativity through Neoadjuvant Chemotherapy: Current Status, Knowledge Gaps, and Rationale for the EUBREAST-03 AXSANA Study. Cancers (Basel). 2021; 13(7). PMC: 8037995. DOI: 10.3390/cancers13071565. View

Simons J, van Nijnatten T, van der Pol C, Luiten E, Koppert L, Smidt M . Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer: A Systematic Review and Meta-analysis. Ann Surg. 2018; 269(3):432-442. PMC: 6369968. DOI: 10.1097/SLA.0000000000003075. View

Donker M, Straver M, Wesseling J, Loo C, Schot M, Drukker C . Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients: the MARI procedure. Ann Surg. 2014; 261(2):378-82. DOI: 10.1097/SLA.0000000000000558. View

10.

Garcia-Moreno J, Benjumeda-Gonzalez A, Amerigo-Gongora M, Landra-Dulanto P, Gonzalez-Corena Y, Gomez-Menchero J . Targeted axillary dissection in breast cancer by marking lymph node metastasis with a magnetic seed before starting neoadjuvant treatment. J Surg Case Rep. 2019; 2019(11):rjz344. PMC: 6893002. DOI: 10.1093/jscr/rjz344. View

11.

Erbil Y, Sari S, Agcaoglu O, Ersoz F, Bayraktar A, Salmaslioglu A . Radio-guided excision of metastatic lymph nodes in thyroid carcinoma: a safe technique for previously operated neck compartments. World J Surg. 2010; 34(11):2581-8. DOI: 10.1007/s00268-010-0714-y. View

12.

Nguyen T, Hoskin T, Day C, Degnim A, Jakub J, Hieken T . Decreasing Use of Axillary Dissection in Node-Positive Breast Cancer Patients Treated with Neoadjuvant Chemotherapy. Ann Surg Oncol. 2018; 25(9):2596-2602. DOI: 10.1245/s10434-018-6637-9. View

13.

Weiss A, King C, Grossmith S, Portnow L, Raza S, Nakhlis F . How Often Does Retrieval of a Clipped Lymph Node Change Adjuvant Therapy Recommendations? A Prospective, Consecutive, Patient Cohort Study. Ann Surg Oncol. 2022; 29(6):3764-3771. DOI: 10.1245/s10434-022-11324-7. View

14.

Al-Hilli Z, Hoskin T, Day C, Habermann E, Boughey J . Impact of Neoadjuvant Chemotherapy on Nodal Disease and Nodal Surgery by Tumor Subtype. Ann Surg Oncol. 2017; 25(2):482-493. DOI: 10.1245/s10434-017-6263-y. View

15.

Boileau J, Poirier B, Basik M, Holloway C, Gaboury L, Sideris L . Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2014; 33(3):258-64. DOI: 10.1200/JCO.2014.55.7827. View

16.

Cabioglu N, Karanlik H, Kangal D, Ozkurt E, Oner G, Sezen F . Improved False-Negative Rates with Intraoperative Identification of Clipped Nodes in Patients Undergoing Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy. Ann Surg Oncol. 2018; 25(10):3030-3036. DOI: 10.1245/s10434-018-6575-6. View

17.

Caudle A, Yang W, Krishnamurthy S, Mittendorf E, Black D, Gilcrease M . Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection. J Clin Oncol. 2016; 34(10):1072-8. PMC: 4933133. DOI: 10.1200/JCO.2015.64.0094. View

18.

Untch M, Gerber B, Harbeck N, Jackisch C, Marschner N, Mobus V . 13th st. Gallen international breast cancer conference 2013: primary therapy of early breast cancer evidence, controversies, consensus - opinion of a german team of experts (zurich 2013). Breast Care (Basel). 2014; 8(3):221-9. PMC: 3728634. DOI: 10.1159/000351692. View

19.

Mamtani A, Barrio A, King T, Van Zee K, Plitas G, Pilewskie M . How Often Does Neoadjuvant Chemotherapy Avoid Axillary Dissection in Patients With Histologically Confirmed Nodal Metastases? Results of a Prospective Study. Ann Surg Oncol. 2016; 23(11):3467-3474. PMC: 5070651. DOI: 10.1245/s10434-016-5246-8. View

20.

Balasubramanian R, Morgan C, Shaari E, Kovacs T, Pinder S, Hamed H . Wire guided localisation for targeted axillary node dissection is accurate in axillary staging in node positive breast cancer following neoadjuvant chemotherapy. Eur J Surg Oncol. 2019; 46(6):1028-1033. DOI: 10.1016/j.ejso.2019.12.007. View