Axillary Staging after Neoadjuvant Chemotherapy in Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • In accordance with National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines:
    • Patients that converted from clinically node positive to negative on both physical exam and imaging after neoadjuvant chemotherapy:
      • Are candidates for targeted axillary dissection (TAD)
  • In order to minimize the false negative rate of TAD:
    • It is important to retrieve the:
      • Clipped malignant axillary lymph node and also perform a sentinel lymph node biopsy (SLNB)
  • Data from ACOSOG Z1071 and MD Anderson Cancer Center:
    • Demonstrated false negative rates greater than approximately 10% to 20% with SLNB alone
    • These rates decreased to nearly 1% to 7%:
      • With the addition of a directed retrieval of the initially malignant axillary lymph node
  • Despite the excellent response to neoadjuvant chemotherapy (NACT) on exam and imaging:
    • There is no data to support non-operative management of the axilla in this patient who presented with regionally advanced invasive breast cancer
  • Unlike with an upfront surgery approach:
    • Any residual disease in the axillary lymph nodes after NACT:
      • Warrants completion level I / II axillary lymph node dissection:
        • In fact, studies have shown rates of additional axillary disease:
          • Ranging from about 30% to 60% in patients with residual micrometastases after NACT
          • These rates are greater than the residual axillary disease rate in ACOSOG Z0011 and also suggest disease that is resistant to systemic therapy and in need of regional control
  • There is no role for random sampling of additional level one axillary lymph nodes
  • Furthermore, while nomograms exist to predict the probability of detecting additional positive non-sentinel lymph nodes in this setting and occasionally special circumstances exist that warrant discussion of results with the patient and one’s colleagues before moving forward:
    • Completion level I / II ALND at the time of the index surgery remains the standard of care
  • The results of Alliance 11202:
    • A randomized phase III trial comparing axillary lymph node dissection to axillary radiation in breast cancer patients (cT1 to cT3, cN1) who have positive sentinel lymph node disease after receiving neoadjuvant chemotherapy will help address the question of whether regional node irradiation is equivalent to cALND plus regional node radiation with respect to recurrence-free survival
  • It should also be noted that the OPBC-04 /Eubreast-06 study:
    • Examined oncologic outcomes following omission of axillary lymph node dissection in node positive patients downstaging to node negative with neoadjuvant chemotherapy
    • Axillary recurrence after omission of ALND in patients who successfully downstage from N+ to ypN0 with NAC is a rare event following both SLNB or TAD, and was not significantly different between those who underwent a TAD versus SLNB
    • The 3-year axillary recurrence rate was less than 1% with TAD or SLNB, while locoregional recurrence at 3 and 5 years was 1.5% and 2.7%, respectively, in all patients and did not differ significantly with the two strategies of lymph node re-staging
  • Furthermore, when the SLNB procedure is optimized with dual tracer and retrieval of ≥ 3 SLNs, the clipped node is an SLN in the majority of cases:
    • Suggesting that failure to retrieve the clipped node should not be an indication for ALND
  • References
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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