Axillary Overtreatment in Patients with Breast Cancer After Neoadjuvant Chemotherapy in the Current Era of Targeted...

In the current era of targeted axillary dissection (TAD), there are still cases where axillary lymph node dissection (ALND) is indicated, but histopathological examination confirms the regression of nodal metastases (ypN0). In this situation, ALND may represent undesirable overtreatment.

A retrospective study at the Comprehensive Cancer Centre was conducted based on a prospectively maintained database. Patients who underwent surgery after neoadjuvant chemotherapy (NAC) between 2020 and 2023 were selected, specifically those for whom ALND was directly indicated after NAC. Subsequently, clinical-pathological characteristics were compared between cases with ypN0 and those with persistent metastases (ypN+). The reasons for indicating ALND in ypN0 cases were extracted from the medical records.

ALND was indicated in 118 cases across 117 patients, of which ypN0 was observed in 44 cases (37%). There were significantly more ypN0 cases for inflammatory carcinomas (68%), the non-luminal HER2-positive phenotype (76%), and carcinomas with histopathological regression of the primary tumor (76%) or the persistence of only the non-invasive component of ypTis (67%). Typical reasons for ALND in ypN0 cases included inflammatory carcinoma (n = 13, 29.5%), locally advanced carcinoma (n = 5, 11.4%), occult carcinoma (n = 2, 4.5%), or persistent lymphadenopathy on ultrasound examination after NAC, especially in the tumor phenotypes HER2-positive and triple-negative breast cancer (TNBC) (n = 8, 18.2%).

Through real-world evidence data analysis, subgroups of breast cancer patients treated with NAC were identified who may experience surgical overtreatment in the axilla. These include patients with inflammatory carcinoma, locally advanced carcinoma, occult carcinoma, or patients with persistent lymphadenopathy on US examination after NAC, particularly in the tumor phenotypes HER2-positive and TNBC.