Staging of the Axilla Following Neoadjuvant Chemotherapy

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • 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
  • A 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%
        • 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 (SLNB) 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 SLNB 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, et.al. 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.
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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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