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Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using
Abigail S Caudle1, Wei T Yang1, Savitri Krishnamurthy1
1All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
Purpose:
Placing clips in nodes with biopsy-confirmed metastasis before initiating neoadjuvant therapy allows for evaluation of response in breast cancer. Our goal was to determine if pathologic changes in clipped nodes reflect the status of the nodal basin and if targeted axillary dissection (TAD), which includes sentinel lymph node dissection (SLND) and selective localization and removal of clipped nodes, improves the false-negative rate (FNR) compared with SLND alone.
Methods:
A prospective study of patients with biopsy-confirmed nodal metastases with a clip placed in the sampled node was performed. After neoadjuvant therapy, patients underwent axillary surgery and the pathology of the clipped node was compared with other nodes. Patients undergoing TAD had SLND and selective removal of the clipped node using iodine-125 seed localization. The FNR was determined in patients undergoing complete axillary lymphadenectomy (ALND).
Results:
Of 208 patients enrolled in this study, 191 underwent ALND, with residual disease identified in 120 (63%). The clipped node revealed metastases in 115 patients, resulting in an FNR of 4.2% (95% CI, 1.4 to 9.5) for the clipped node. In patients undergoing SLND and ALND (n = 118), the FNR was 10.1% (95% CI, 4.2 to 19.8), which included seven false-negative events in 69 patients with residual disease. Adding evaluation of the clipped node reduced the FNR to 1.4% (95% CI, 0.03 to 7.3; P = .03). The clipped node was not retrieved as an SLN in 23% (31 of 134) of patients, including six with negative SLNs but metastasis in the clipped node. TAD followed by ALND was performed in 85 patients, with an FNR of 2.0% (1 of 50; 95% CI, 0.05 to 10.7).
Conclusion:
Marking nodes with biopsy-confirmed metastatic disease allows for selective removal and improves pathologic evaluation for residual nodal disease after chemotherapy.
Insights
Clipping breast cancer nodes with metastasis before neoadjuvant therapy and using targeted axillary dissection (TAD) significantly reduces the false-negative rate (FNR) for nodal staging. This approach improves accuracy in evaluating residual disease after chemotherapy.
Area of Science:
- Oncology
- Surgical Pathology
- Breast Cancer Research
Background:
- Accurate staging of breast cancer nodal metastasis is crucial for treatment planning.
- Neoadjuvant therapy is increasingly used, necessitating reliable methods to assess treatment response in lymph nodes.
- Sentinel lymph node dissection (SLND) alone can have a significant false-negative rate (FNR).
Purpose of the Study:
- To evaluate if pathologic changes in clipped nodes correlate with overall nodal basin status after neoadjuvant therapy.
- To determine if targeted axillary dissection (TAD), incorporating SLND and clipped node removal, improves the FNR compared to SLND alone.
- To assess the utility of clip placement in biopsy-confirmed metastatic nodes for guiding axillary surgery.
Main Methods:
- Prospective study involving patients with biopsy-confirmed nodal metastases and a placed clip in the sampled node.
- Post-neoadjuvant therapy, patients underwent axillary surgery, comparing clipped node pathology with other nodes.
- Targeted axillary dissection (TAD) involved SLND and selective removal of the clipped node using iodine-125 seed localization.
- False-negative rates were calculated in patients undergoing complete axillary lymphadenectomy (ALND).
Main Results:
- Of 191 patients undergoing ALND, 120 (63%) had residual disease. The clipped node identified metastases in 115 patients (FNR 4.2%).
- In patients undergoing SLND and ALND (n=118), the FNR was 10.1%. Incorporating clipped node evaluation reduced the FNR to 1.4% (P=.03).
- The clipped node was not retrieved as an SLN in 23% of patients, highlighting its importance for targeted removal. TAD followed by ALND yielded an FNR of 2.0%.
Conclusions:
- Marking biopsy-confirmed metastatic nodes with clips enables selective removal and enhances pathologic assessment of residual nodal disease post-chemotherapy.
- Targeted axillary dissection, including evaluation of clipped nodes, significantly lowers the false-negative rate in breast cancer nodal staging.
- Clip placement is a valuable tool for improving the accuracy of axillary staging after neoadjuvant therapy.
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