Debating the Optimal Approach to Nodal Management After Pathologic Complete Response to Neoadjuvant Chemotherapy in...

Greater use of neoadjuvant chemotherapy in patients with breast cancer has led surgeons and radiation oncologists to have frequent encounters with women with upfront node-positive disease and a clinical complete response. These cases raise many important questions about what the optimal locoregional management should be to minimize recurrence risk while minimizing treatment-related toxicities. A particular point of debate is whether all patients who are known to have had node-positive disease before neoadjuvant chemotherapy should receive complete axillary lymph node dissection (ALND) if they have had a complete clinical and radiologic response. In this article, we present arguments and evidence in favor of and against axillary dissection after a complete response to neoadjuvant chemotherapy, followed by a brief data-driven review of implications for adjuvant radiotherapy in this context. We conclude that as trials continue to gather more evidence to guide decisions in the future, we must encourage patients to enroll in clinical trials when eligible, and otherwise support them to make decisions that are informed and congruent with their personal values in areas where there is clinical equipoise.