• The ACOSOG Z1071 trial:
    • Was designed to determine the false negative rate (FNR) of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) in women initially presenting with cN1 disease
  • The trial enrolled women from 136 institutions who had clinical T0 through T4, N1 through N2, M0 breast cancer who received neoadjuvant chemotherapy
  • Patients enrolled had pre-chemotherapy axillary nodal disease confirmed by fine-needle aspiration or core needle biopsy
  • Following NAC, patients underwent both SLNB, followed by a back-up axillary lymph node dissection
  • SLNB with dual tracer using both blue dye (isosulfan blue or methylene blue) and a radiolabeled colloid mapping agent was encouraged
  • Rates of detection of at least one SLN were:
    • 92.9% in patients with cN1 disease and 89.5% in patients with cN2 disease
  • Overall, the FNR of SLNB after NAC was 12.6%
  • Bivariable analyses found that the likelihood of a false-negative SLN finding was significantly decreased:
    • When the mapping was performed with the combination of blue dye and radiolabeled colloid (P=.05; FNR, 10.8% combination vs 20.3% single agent) and by removal of at least 3 SLNs (P=.007; FNR, 9.1% for ≥3 SLNs vs 21.1% for 2):
      • A clip was placed at initial node biopsy prior to NAC in 203 patients:
        • In the 170 (83.7%) patients with cN1 disease and at least 2 SLNs resected, clip location was confirmed in 141 cases
        • In 107 (75.9%) patients where the clipped node was within the SLN specimen;
          • The FNR was 6.8% (confidence interval [CI]: 1.9%-16.5%)
      • If the clipped node was found in the ALND specimen:
        • The FNR was 19.0% (CI: 5.4%-41.9%)
      • In cases where a clip was not placed (n = 355) and in those where the clipped node location was not confirmed at surgery (n = 29):
        • The FNR was 13.4% and 14.3%, respectively
  • While the FNR overall exceeded the 10% threshold considered to be clinically acceptable, the authors concluded that with modifications to the SLN technique (i.e., dual tracer mapping and retrieval of at least 3 negative SLNs):
    • To the FNR was less than 10% and supported the use of SLN surgery as an alternative to axillary lymph node dissection in this patient population
  • Subsequently, Caudle et al have reported a separate registry of 191 patients and showed that removing the clipped positive node in addition to SLN had an FNR as low as 2.0%
  • References
    • Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al.; Alliance for Clinical Trials in Oncology. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310(14):1455-1461.
    • Boughey JC, Ballman KV, Le-Petross HT, McCall LM, Mittendorf EA, Ahrendt GM, et al. Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 2016;263(4):802-807.
    • Caudle AS, Yang WT, Krishnamurthy S, Mittendorf EA, Black DM, Gilcrease MZ, et al. Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 2016;34(10):1072-1078.
#Arrangoiz #CancerSurgeon #SurgicalOncologist #BreastSurgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico

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