Axillary Staging after Neoadjuvant Chemotherapy in Breast Cancer

Axillary ultrasound :
- Is frequently useful to assess for lymph node involvement in patients with breast cancer at initial disease presentation:
  - However, normal appearing lymph nodes on ultrasound, before and/or after chemotherapy:
    - Do not obviate the need for surgical axillary staging
Axillary ultrasound with percutaneous biopsy of any suspicious lymph nodes, if present:
- Allows marking of the positive node:
  - To be sure it is removed following treatment with neoadjuvant chemotherapy
Plecha et al. recently published data:
- That show wire localization of marked nodes increases the likelihood of removing the node that was positive prior to neoadjuvant chemotherapy
Boughey et al.:
- Had previously shown that clipping the positive node decreases the false-negative rate of sentinel node biopsy following neoadjuvant chemotherapy
Supraclavicular disease:
- Is classified as N3, stage IIIC disease, not as distant metastatic disease:
  - Supraclavicular involvement can be documented by percutaneous biopsy:
    - Excision is not required prior to chemotherapy
Removal of sentinel lymph nodes prior to neoadjuvant chemotherapy:
- Interferes with assessment of nodal response to chemotherapy
PET/CT scan is not needed to plan nodal staging after neoadjuvant chemotherapy:
- Small volume disease is poorly detected with this modality:
  - So axillary ultrasound is preferred:
    - Regardless of imaging results, surgical staging of the axilla is required
References
- Boughey JC, Ballman KV, Symmans WF, et al. Methods impacting the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0–T4, N1–2) who receive neoadjuvant chemotherapy: results from a prospective trial—ACOSOG Z1071 (Alliance). Poster presented at: San Antonio Breast Cancer Symposium; December 9-13, 2014; San Antonio, TX.
- Plecha D, Bai S, Patterson H, Thompson C, Shenk R. Improving the accuracy of axillary lymph node surgery in breast cancer with ultrasound-guided wire localization of biopsy proven metastatic lymph nodes. Ann Surg Oncol. 2015;22(13):4241-4246.
- Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer-Verlag; 2010.
- Kuerer HM, Sahin AA, Hunt KK, et al. Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy. Ann Surg. 1999;230(1):72-78.
- Hieken TJ, Trull BC, Boughey JC, et al. Preoperative axillary imaging with percutaneous lymph node biopsy is valuable in the contemporary management of patients with breast cancer. Surgery. 2013;154(4):831-838; discussion 838-840.