Internal Mammary Lymph Node and SNLB After Neoadjuvant Chemotherapy

  • As reported by Veronesi in 1999,:
    • 737 patients were randomized to either undergo:
      • Halsted mastectomy or extended mastectomy with IM node dissection:
        • After 30 years of follow-up, there was no difference in overall survival or disease-specific survival:
          • For the patients eligible with T1, T2, T3, N0, and N1 disease who underwent IM node dissection vs. no IM dissection
  • 2019 retrospective review of 95 breast cancer patients with clinically detected IM nodes (IMNs) at diagnosis:
    • Were treated with surgery and radiation:
      • With median follow-up of 43 months
    • 77 received neoadjuvant chemotherapy:
      • With IMN normalization in 67.5%, and partial IMN response in 24.6%
    • The 5-year IMN failure-free survival, disease-free survival, and overall survival were:
      • 96%, 70%, and 84%, respectively
    • IMN failure-free survival was significantly affected by:
      • Resection margin status
      • Size of IMN
      • Receipt of IMN boost radiation
  • A recently published meta-analysis in the Annals of Surgery found that axillary staging following neoadjuvant chemotherapy:
    • Is best performed with a combination approach of:
      • Sentinel lymph node biopsy with excision of the pre-chemotherapy-marked positive node:
        • With a false negative rate of 2% to 4%:
          • The identification rate was 100%
      • ACOSOG Z1071 reported an overall false negative rate of 12.6%:
        • When sentinel node biopsy was performed after neoadjuvant chemotherapy with documented node-positive disease prior to treatment
        • The false-negative rate decreased to 6.8%:
          • When both sentinel node(s) and the clipped node were retrieved at the time of surgery
  • References
    • Veronesi U, Marubini E, Mariani L, Valagussa P, Zucali R. The dissection of internal mammary nodes does not improve the survival of breast cancer patients. 30-year results of a randomised trial. Eur J Cancer. 1999;35(9):1320-1325.
    • Kim J, Chang JS, Choi SH, Radiotherapy for initial clinically positive internal mammary nodes in breast cancer. Radiat Oncol J. 2019;37(2):91-100.
    • Simons JM, van Nijnatten TJA, van der Pol CC, Luiten EJT, Koppert LB, Smidt ML. 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. 2019;269(3):432-442.
    • Boughey JC, Ballman KV, Le-Petross HT, et al. Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with nodepositive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 2016;263(5):802-807.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncology #BreastCancer #CASO #Miami #CenterforAdvancedSurgicalOncology

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