新辅助化疗后腋窝淋巴结阳性转阴乳腺癌患者前哨淋巴结活检的临床价值

背景与目的：乳腺癌是常见的女性恶性肿瘤,前哨淋巴结活检（SLNB）是早期腋窝淋巴结阴性乳腺癌的标准处理模式,但是经新辅助化疗（NAC）后腋窝淋巴结转阴患者的SLNB存在很大争议,已成为关注焦点。本研究探讨NAC后腋窝淋巴结转阴的乳腺癌患者SLNB的可行性及影响SLNB假阴性率的因素。方法：收集2020年7月—2022年7月海口市人民医院腋窝淋巴结阳性乳腺癌经NAC后腋窝淋巴结降期为阴性的患者45例临床资料,所有患者经染色法行SLNB随后行腋窝淋巴结清除（ALND）,分析前哨淋巴结检出率,假阴性率,准确率等指标,并对可能影响SLNB的假阴性率的因素进行分析。结果：SLNB成功率93.3%,检出前哨淋巴结138枚;准确率90.4%,假阴性率12.5%。肿瘤大小（≤5 cm、>5 cm）与NAC前淋巴结状态（1枚、2枚、≥3枚）对SLNB的成功率、准确率、假阴性率均无明显影响（均P>0.05）;前哨淋巴结检出数目（1枚、2枚、≥3枚）对SLNB准确率（P=0.009）与假阴性率（P=0.002）有明显影响,检出数目越多准确率越高、假阴性率越低。结论：腋窝淋巴结阳性经NAC后转阴的...     

乳腺癌患者Ki-67表达水平对新辅助化疗后病理学完全缓解的预测价值

目的:探讨乳腺癌患者Ki-67表达水平对新辅助化疗(NAC)疗效的影响。方法:收集261例行NAC且临床病理资料相对完整的乳腺癌患者,分析患者Ki-67表达以及其他临床病理因素包括分子分型、激素受体状态等与患者NAC后病理学完全缓解(pCR)的关系。结果:单因素分析结果显示,患者NAC后pCR与孕激素受体(PR)及表皮生长因子受体2(Her-2)状态、分子分型与Ki-67水平明显有关(均P0.05);多因素分析显示,Ki-67表达水平是NAC后pCR独立预测因素(OR=5.476,95%CI=2.637~11.372,P0.05)。此外,在雌激素受体(ER)阳性患者中,Ki-67高表达患者pCR率为低表达患者的4.282倍(OR=4.282,95%CI=1.694~10.825,P=0.002),而PR阳性患者pCR率为阴性患者的0.303倍(OR=0.303,95%CI=0.113~0.810,P=0.017),Her-2阳性者的pCR率是Her-2阴性者的2.607倍(OR=2.607,95%CI=1.023~6.642,P=0.045)。结论:乳腺癌患者Ki-67高表达是NAC后高pCR率的预测因子,同时结合其他激素受体状态,将有助于更好的指导个体化NAC。     

MRI检查预测乳腺癌新辅助化疗后病理完全缓解的准确性分析

目的观察磁共振成像(MRI)预测乳腺癌新辅助化疗(NAC)后病理完全缓解(pCR)的准确性,分析产生预测误差的原因。方法回顾性收集2017年1月至2019年1月期间接受NAC后行手术的157例乳腺癌患者的临床资料,收集NAC前后的MRI参数以及pCR情况,并探索与假阳性和假阴性相关的参数。结果 157例患者中,37例(23.6%)在NAC后获得pCR,33例获得放射完全缓解(rCR,占21.0%)。MRI检查预测pCR的准确率为70.7%(111/157),灵敏度为82.5%(99/120),特异度为32.4%(12/37)。其中未达到rCR而达到pCR者25例(假阳性);达到rCR而未达到pCR者21例(假阴性)。肿瘤直径、肿瘤周围水肿和背景实质强化与MRI的假阳性有关(P0.05),乳腺组织密度和肿瘤边缘强化与MRI的假阴性有关(P0.05)。结论 MRI检查可作为预测乳腺癌NAC后pCR的重要手段,其准确性可能与肿瘤直径、肿瘤周围水肿、背景实质强化、乳腺组织密度和肿瘤边缘强化情况有关。     

乳腺癌前哨淋巴结检测的临床研究

目的通过前哨淋巴结(sentinel lymph node,SLN)活检,了解前哨淋巴结是否能反映乳腺癌腋窝淋巴结转移情况,从而决定是否行腋窝淋巴结清扫(axillary lymph node dissection,ALND). 方法 47例T1、T2、T3临床检查腋窝淋巴结无肿大的乳腺癌患者,术前30 min于乳腺肿块周围腺体注射蓝色染料,术中取蓝染的SLN病理检查,术后将病理检查结果与腋窝淋巴结转移情况进行比较分析. 结果 47例中5例未见淋巴结及淋巴管蓝染,其余42例找到腋窝淋巴结608个,阳性18例168个,阴性24例440个;SLN共78个,阳性16例29个,阴性26例49个.SLN的检出率89.4%,准确性95.2% ,特异性100%,敏感性88.9%,假阴性率11.1%,假阳性率0. 结论 SLN活检反应腋窝淋巴结的肿瘤转移状况,可以用于术中确定是否行ALND.     

Ki-67、P53在Her-2阴性乳腺癌中的表达与ER、腋窝淋巴结转移相关性

目的观察Ki-67、P53在Her-2阴性乳腺癌组织中的表达与ER及腋窝淋巴结转移相关性,探讨其临床意义,提示乳腺癌预后。方法 202例Her-2阴性乳腺患者,根据ER表达情况,将患者分为ER阴性组和ER阳性组,其中ER阴性组99例,ER阳性组103例,研究Ki-67、P53在Her-2阴性乳腺癌组织中的表达与ER及腋窝淋巴结转移相关性。结果 Her-2阴性乳腺癌组织中Ki-67增殖指数在ER阴性组表达明显高于ER阳性组,差异有统计学意义(P0.05),Ki-67增殖指数在腋窝淋巴结阳性组明显高于淋巴结阴性组,差异有统计学意义(P0.05)。P53在ER阴性组表达明显高于ER阳性组,差异有统计学意义(P0.05),P53表达在腋窝淋巴结阳性组和阴性组差异无统计学意义(P0.05)。结论 Her-2阴性乳腺癌组织中Ki-67增殖指数与ER阴性表达正相关,且腋窝淋巴结转移可能性大,P53与ER阴性表达正相关,与腋窝淋巴结转移无明显相关。提示Ki-67、P53可能为Her-2阴性乳腺癌的不良预后因素。     

c-erbB-2基因在乳腺浸润性导管癌及腋窝转移淋巴结中的表达相关性分析

目的:探讨乳腺浸润性导管癌中c-erbB-2的表达及其与腋窝淋巴结等临床病理因素的相关性.方法:采用免疫组织化学方法检测149例乳腺浸润性导管癌患者乳腺原发灶及47例腋淋巴结转移灶中c-erbB-2的表达,结合临床病理因素,分析其相关性.结果:19.46%(29/149)原发灶c-erbB-2高表达,其表达水平与肿瘤大小、腋窝淋巴结转移情况呈正相关,与ER、PR表达呈负相关.47例腋窝淋巴结转移乳腺浸润性导管癌患者中,原发灶c-erbB-2高表达18例(38.30%),腋窝淋巴结转移灶c-erbB-2高表达16例(34.04%),两者差异无统计学意义(P>0.05).5例原发灶c-erbB-2阴性或低表达患者腋窝淋巴结转移呈高表达,7例原发灶c-erbB-2高表达患者淋巴结转移呈阴性或低表达,变化率为25.53%(12/47).结论: c-erbB-2可以作为预测乳腺癌预后的指标,指导术后治疗,但应当考虑c-erbB-2在原发灶和复发转移灶之间的差异,有必要对复发转移灶进行c-erbB-2检测.     

乳腺癌分子亚型在预测新辅助化疗疗效及患者预后中的作用

目的 本研究旨在探讨乳腺癌的分子亚型与乳腺癌的病理完全缓解及患者预后的关系.方法 收集2007年1月-2010年1月在芜湖市第二人民医院接受新辅助治疗的101例乳腺癌患者的病例资料,按照ER、PR及Her-2的免疫组化的结果将其分为4型,单因素与多因素分析临床病理因素与病理完全缓解的关系.结果 19例(18.8％)患者取得病理完全缓解,三阴性乳腺癌是病理完全缓解的独立预测因素(OR=3.35,95％CI:1.25 ～ 9.79,P=0.012),而Her-2丰富型乳腺癌相比较于luminal A型乳腺癌则取得更高的病理完全缓解率(OR =3.11,95％CI:1.09 ～ 10.89,P=0.021).而病理缓解率与无病生存率密切相关(P =0.002).但三阴性乳腺癌的总生存期和无病生存期更短(P =0.008,P=0.0006).结论 三阴性乳腺癌和Her-2丰富型乳腺癌较luminal A型乳腺癌更容易获得新辅助化疗后的病理完全缓解,但三阴性乳腺癌的预后仍然较差,可能与其在治疗后仍有肿瘤残留有关.     

早期乳腺癌腋窝处理研究热点

前哨淋巴结活检（SLNB）替代腋窝淋巴结清扫（ALND）已成为临床腋窝淋巴结阴性早期乳腺癌病人的标准处理方式。有限腋窝淋巴结转移的病人,接受保乳治疗满足美国外科医师协会肿瘤学组（ACOSOG）Z0011、IBCSG 23-01入组条件,可豁免ALND;或参考AMAROS,考虑腋窝放疗替代ALND;接受乳房完全切除无放疗的病人,推荐ALND。区域淋巴结放疗能够降低乳腺癌局部区域复发,在早期乳腺癌病人的腋窝处理中应权衡临床病理指标进行个体化治疗。新辅助治疗初始临床腋窝淋巴结阴性的病人可在新辅助治疗后行SLNB。新辅助治疗前可疑腋窝淋巴结优选超声引导下穿刺明确状态并标记转移淋巴结。选择适宜病人,采用双示踪、活检超过2枚以上前哨淋巴结、评估标记的新辅助治疗前转移淋巴结,并考虑将淋巴结分期N0（i＋）纳为进行ALND的标准,满足上述条件,则初始腋窝淋巴结有转移新辅助治疗后临床完全缓解的病人可谨慎考虑接受SLNB。实践中,除外参与相关临床试验,ALND仍是这部分病人的治疗推荐。     

早期乳腺癌腋窝淋巴结放疗原则

早期乳腺癌病人腋窝淋巴结处理的原则是在有效控制疾病的基础上追求精准与安全。因此,以腋窝放疗替代手术成为近年来的关注焦点。在未行新辅助治疗的人群中,腋窝淋巴结初诊阴性或保乳术后前哨淋巴结（SLN）微转移的病人无须追加腋窝淋巴结清扫（ALND）或完整的腋窝照射;保乳术后SLN 1~2枚宏转移可豁免ALND并行全乳或高切线野照射,SLN转移数目＞2枚或SLN外淋巴结转移风险较高者,豁免ALND后需补充腋窝放疗;乳房切除术后SLN阳性病人中目前证据不足,如未行ALND可考虑补充腋窝放疗;在接受了新辅助全身治疗的病人中,如SLN转阴可豁免ALND并补充腋窝放疗,如SLN未转阴目前依然推荐行ALND。     

102例前哨淋巴结阳性乳腺癌患者腋窝非前哨淋巴结转移相关因素分析

目的:回顾性研究我中心前哨淋巴结(sentinel lymph node,SLN)阳性并续行腋窝淋巴结清扫术(axillary lymph node dissection,ALND)早期乳腺癌患者的临床病理资料,分析腋窝非前哨淋巴结(non-sentinel lymph node,NSLN)转移的相关危险因素,为建立符合本地区的预测模型提供依据。方法:收集温州市人民医院2009年1月—2016年12月102例前哨淋巴结活检阳性并进一步接受腋窝淋巴结清扫术的早期乳腺癌患者临床及病理资料,采用单因素分析及多因素Logistic回归分析方法研究这些临床病理因素与NSLN转移的关系。结果:本研究中共有102例SLN阳性乳腺癌患者进一步接受了ALND,其中36例NSLN发现有转移,NSLN转移检出率是35.3%(36/102)。根据单因素分析结果显示:组织学分级(χ~2=8.8214,P=0.0030)、SLN转移率≥0.5(χ~2=5.2377,P=0.0221)、SLN转移灶最大径 2 mm (χ~2=4.3290,P=0.0370)是NSLN转移的危险因素。多因素Logistic回归分析结果显示:SLN转移率≥0.5(OR=1.63,95%CI:1.29-2.10,P=0.001)、SLN转移灶最大径 2 mm(OR=1.34,95%CI:1.02-2.12,P=0.032)是NSLN转移的独立预测因素。结论:SLN转移率≥0.5、SLN转移灶最大径 2 mm是预测乳腺癌NSLN转移的危险因素,可以作为预测因素,进一步用来构建符合本地区的预测模型。     

Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer: A multicentre study on 1,950 patients

BackgroundType of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized.Patients and methods1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR).ResultsIndependent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75–0.80). After external validation the accuracy of the nomogram was confirmed.ConclusionThe accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients.     

Predictive value of DCE-MRI for early evaluation of pathological complete response to neoadjuvant chemotherapy in resectable primary breast cancer: A single-center prospective study

ObjectiveThis study proposed to establish a predictive model using dynamic enhanced MRI multi-parameters for early predicting pathological complete response (pCR) to neoadjuvant chemotherapy (NAC) in breast cancer.MethodsIn this prospective cohort study, 170 breast cancer patients treated with NAC were enrolled and were randomly grouped into training sample (136 patients) and validation sample (34 patients). DCE-MRI parameters achieved at the end of the first cycle of NAC were screened to establish the predictive model by using multivariate logistic regression model according to pCR status. Receiver operating characteristic curves were conducted to assess the predictive capability. The association between MRI-predicted pCR and actual pCR in survival outcomes was estimated by using the Kaplan–Meier method with log-rank test.ResultsMultivariate analysis showed ΔAreamax and ΔSlopemax were independent predictors for pCR, odds ratio were 0.939 (95%CI, 0.915 to 0.964), and 0.966 (95%CI, 0.947 to 0.986), respectively. A predictive model was established using training sample as “Y = −0.063*ΔAreamax − 0.034*ΔSlopemax”, a cut-off point of 3.0 was determined. The AUC for training and validation sample were 0.931 (95%CI, 0.890–0.971) and 0.971 (95%CI, 0.923–1.000), respectively. MRI-predicted pCR patients showed similar RFS (p = 0.347), DDFS (p = 0.25) and OS (p = 0.423) with pCR patients.ConclusionThe multi-parameter MRI model can be potentially used for early prediction of pCR status at the end of the first NAC cycle, which might allow timely regimen refinement before definitive surgical treatment.     

Sentinel lymph node biopsy after neoadjuvant chemotherapy in a patient with operable breast cancer

PURPOSE: This study was undertaken to assess the feasibility of performing a sentinel lymph node biopsy (SLNB) for a patient with operable breast cancer after undergoing neoadjuvant chemotherapy (NAC). METHOD: Between January 2002 and December 2003, women with primary breast cancer who had a breast tumor measuring larger than 3 cm in unilateral diameter were eligible for NAC. All patients who had completed NAC underwent lymphatic mapping with labeled (99m)Tc phytate on the day before surgery. Sentinel lymph node biopsy followed by a full axillary lymph node (AXLN) dissection (ALND) was performed in all patients. Sentinel lymph nodes (SLN) were sent for a frozen-section examination. RESULTS: The rate of SLN identification was 71%. Both the sensitivity and negative predictive value of SLNB were 100%. The false negative rate was 0%. When candidates for SLNB were restricted to patients with a breast tumor measuring less than 3 cm and clinically negative nodes after NAC, the rate of SLN identification increased to 93% from 71% while still maintaining the 0% false negative rate. CONCLUSION: Sentinel lymph node biopsy after NAC is therefore considered to be a feasible and accurate method to predict the AXLN status in patients who have a breast tumor measuring less than 3 cm in unilateral diameter and a clinically negative AXLN status at the time of surgery after NAC.     

Ultrasound-based prediction of pathologic response to neoadjuvant chemotherapy in breast cancer patients

BackgroundAccuracy in predicting pathologic response to neoadjuvant chemotherapy (NACT) in breast cancer is essential for the determination of therapeutic efficacy and surgical planning. This study aimed to assess the precision of ultrasound (US) for predicting pathologic complete response (pCR = ypT0) after NACT.MethodsThis retrospective mono-center study included 124 invasive breast cancer patients treated with NACT. Patients received US before and after NACT with documentation of clinical partial response (cPR) and clinical complete response (cCR). Post-operatively, the pathologic response was defined as absence of tumor cells (ypT0), presence of non-invasive tumor cells (ypTis) or invasive tumor cells (ypTinv). Sensitivity and specificity of US as well as false negative rate (FNR), negative predictive value (NPV) and positive predictive value (PPV) were analysed for receptor subtypes. A multivariable logistic regression model assessed the influence of patient- and tumor-associated covariates as predictors for pCR.Results50 patients (40.3%) achieved pCR, 39 (78.0%) had a corresponding cCR. Overall sensitivity was 60.8% and specificity 78.0% for US-predicted remission. NPV and FNR differed substantially between subtypes. NPV was highest (75.0%) in triple negative (TN) subtype, while FNR was low (37.5%). Therefore, pathological response was most accurately predicted for TN cancers. NPV for human-epidermal-growth-factor-receptor-2-positive/hormone-receptor-positive (HER2+/HR+) was 55.6%, for HER2+/HR- 64.3% and for HER2-/HR+ 16.7%, FNRs were 40.0%, 71.4% and 32.3%, respectively. Receptor subtypes impacted pCR significantly (p-value: 0.0033), cCR correlated positively with pCR (p-value: 0.0026).ConclusionUS imaging is insufficient to predict pCR with adequate accuracy. Receptor subtypes, however, affect diagnostic precision of US and pathologic outcome.     

Is sentinel lymph node biopsy a viable alternative to complete axillary dissection following neoadjuvant chemotherapy in women with node-positive breast cancer at diagnosis? An updated meta-analysis involving 3,398 patients

BACKGROUND

The use of sentinel lymph node biopsy (SLNB) following neoadjuvant chemotherapy (NAC) in patients presenting with clinically positive lymph nodes remains controversial.

Methods

A computer-aided search of the literature regarding SLNB in clinically node-positive breast cancer treated with NAC was carried out to identify the false negative rate (FNR), sentinel lymph node identification rate (IR), and axillary pathological complete response (pCR).

Results

Nineteen articles were used in the analysis yielding 3,398 patients. The pooled estimate of the FNR was 13% and that of the IR was 91%. The adjusted pCR rate was 47%. A trend toward significance was observed with only clinical stage N1 (cN1) disease whereby clinical stage N1 was associated with an increased pCR rate when compared to N2 or N3 disease (P = .06).

Conclusions

SLNB after NAC in biopsy-proven node-positive patients results in reasonably acceptable FNR and IR, making it a valid alternative management strategy to axillary dissection. More refined patient selection and optimal techniques can improve the FNR and IR in this patient population.     

Diagnosis of complete response to neoadjuvant chemotherapy using diagnostic imaging in primary breast cancer patients

Advances in the therapeutic agents used for neoadjuvant chemotherapy (NAC) have recently achieved higher response rates and induced a greater number of pathologic complete responses (pCR) than ever before. The aim of this study is the diagnosis of pCR after NAC by diagnostic imaging of clinical complete response (cCR) patients. This study included 35 breast cancer patients who demonstrated cCR after receiving NAC with a combination of anthracycline and taxane from May 1998 to August 2003. Surgical treatment included breast-conserving therapy followed by radiotherapy or mastectomy. The identity of post-NAC lesions as either a complete response (CR) or partial response (PR) were made by mammography, ultrasonography, and contrast-enhanced computed tomography (CT). Among the 35 patients, 11 achieved pCR, including the disappearance of both invasive and intraductal components. Of the patients achieving pCR, eight were defined as CR and three were determined to be PR by CT. There was a significant relationship between the pCR and the determination of CR by CT. The determination of CR by ultrasonography was indicative of the disappearance of pathologic invasive components. While mammography appeared to reflect the observed histologic results, we did not observe any statistical differences. A subset of cases exhibited discrepancies between the imaging and pathologic results, likely due to the replacement of destroyed tumor cells by fibrosis and granulomatous tissue. The evaluation of CR by CT was significantly indicative of pCR. The positive predictive value, however, was not large enough to avoid surgical treatment. Further studies will be needed to establish a diagnosis of pCR.     

Early Assessment of Axillary Response with 18F-FDG PET/CT during Neoadjuvant Chemotherapy in Stage II–III Breast Cancer: Implications for Surgical Management of the Axilla

Background

If all initially node-positive patients undergo axillary lymph node dissection (ALND) after neoadjuvant chemotherapy (NAC), overtreatment may occur in patients with complete response. Positron emission tomography–computed tomography (PET/CT) during NAC may predict axillary response and select patients appropriate for less invasive treatment after NAC. We evaluated the value of sequential ¹⁸F fluorodeoxyglucose (FDG) PET/CTs during NAC for axillary response monitoring in stage II–III breast cancer.

Methods

A total of 219 PET/CTs were performed in 80 patients with cytology-proven, node-positive disease at baseline (PET/CT1, n = 80) and twice during NAC (PET/CT2 n = 62, PET/CT3, n = 77). The relative changes in maximum standardized uptake value (SUV_max) of axillary nodes were examined for their ability to assess pathological response. All patients underwent ALND after chemotherapy, and complete axillary response (pCR), defined as absence of isolated tumor cells and of micro- and macrometastases, served as the reference standard.

Results

A total of 32 (40 %) patients experienced axillary pCR. The relative decrease in SUV_max was significantly higher in patients with pCR than in those without, both on PET/CT2 (p < 0.001) and PET/CT3 (p = 0.025). The area under the receiver operating characteristic curve values for PET/CT2 and PET/CT3 were 0.80 (95 % confidence interval 0.68–0.92) and 0.65 (95 % confidence interval 0.52–0.79), respectively. A relative decrease of ≥60 % on PET/CT2 had an excellent specificity (35 of 37, 95 %), a high positive predictive value (12 of 14, 86 %), and a sensitivity of 48 %—that is, it accurately identified histologic pCR in 12 of 25 patients with disease that responded to therapy.

Conclusions

¹⁸F-FDG PET/CT early during NAC is useful for axillary response monitoring in cytology-proven node-positive breast cancer because it identifies pathological response, thus permitting ALND to be spared.     

Predicting nodal status using dynamic contrast-enhanced magnetic resonance imaging in patients with locally advanced breast cancer undergoing neoadjuvant chemotherapy with and without sequential trastuzumab

HYPOTHESIS: Dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) is a reliable and accurate method for monitoring primary tumor response in the breast and can be used as a surrogate to predict final axillary nodal status. DESIGN: Retrospective study (October 1, 2004, through February 28, 2006) of 46 patients with clinically staged locally advanced breast cancer. SETTING: Comprehensive cancer center. PATIENTS: Forty-six patients with locally advanced breast cancer. INTERVENTIONS: Neoadjuvant chemotherapy (NAC), DCE-MRI, mastectomy and lumpectomy, and axillary lymph node dissection. MAIN OUTCOME MEASURES: The DCE-MRI results and pathologic response of the breast and axillary lymph nodes. RESULTS: Forty-six patients underwent NAC with doxorubicin hydrochloride and cyclophosphamide, followed by paclitaxel and carboplatin, with or without trastuzumab based on human epidermal growth factor receptor 2 (HER2/neu) status. Twenty-one patients (46%) had a complete pathologic response. For the HER2/neu-positive patients, the complete pathologic response rate was 70% (14/20). The accuracy, sensitivity, and specificity of the primary tumor response in predicting the axillary nodal status were 78%, 88%, and 72%, respectively. The accuracy, sensitivity, and specificity of the DCE-MRI-measured response in the primary tumor in predicting axillary nodal status were 74%, 62%, and 82%, respectively. For the HER2/neu-positive patients, the accuracy, sensitivity, and specificity improved to 80%, 75%, and 82%, respectively. CONCLUSIONS: The results of DCE-MRI of the primary tumor can be predictive of axillary nodal status, especially in patients receiving trastuzumab who are HER2/neu positive. The HER2/neu-positive patients with a complete clinical response on DCE-MRI are highly unlikely to benefit from an axillary lymph node dissection. For HER2/neu-negative patients, sentinel lymph node sampling is warranted.     

The use of ultrasound in the clinical re-staging of the axilla after neoadjuvant chemotherapy (NACT)

IntroductionUltrasound (US) is the imaging modality of choice for staging the axilla prior to surgery in patients with breast cancer (BC). High pathological complete response rates in the axilla after NACT mean a more conservative approach to surgery can be considered. Radiological re-staging is important in this decision making. After the presentation of results from ACOSOG Z1071 in December 2012, formal ultrasound re-assessment of the axilla after primary therapy was specifically requested in our institution. We report on the accuracy of axillary US (aUS) for identifying residual axillary disease post-NACT.MethodsData were collected on patients who had proven axillary disease prior to NACT and underwent axillary lymph node dissection after NACT between January 2013 and December 2015. Post-chemotherapy aUS reports and axillary pathology reports were classified as positive or negative for abnormal lymph nodes and for residual disease (cCR and pCR respectively).ResultsThe sensitivity and specificity of aUS was 71% and 88% respectively. The negative predictive value (NPV) was 83%. The false negative rate was 29%.ConclusionsAxillary ultrasound provides clinically useful information post-NACT, which will guide surgical decision-making. Patients with aUS-negative axillae are likely to have a lower false negative rate of SLNB after NACT (Boughey et al.). However, aUS does not replace the need to identify and biopsy the nodes which were proven to be positive prior to NACT.     

Lower lymph node yield in axillary lymph node dissection specimens in breast cancer patients receiving neoadjuvant chemotherapy: Quality concern or treatment effect?

Axillary lymph node dissection (ALND) specimens should have at least ten-lymph nodes for examination according to established guidelines. Nonetheless, recent evidence suggests that neoadjuvant chemotherapy (NAC) results in fewer nodes in the specimen. We sought to examine if NAC patients have lower lymph node yield from ALND specimens and whether the number of lymph nodes in the specimen is correlated with pathologic complete response (pCR). Using the National Cancer Database (NCDB), a study cohort of female patients with node-positive, non-metastatic invasive breast cancer diagnosed from 2012 to 2015 was identified. The axillary lymph node retrieval count was compared in NAC and non-NAC patients and then correlated with pCR. A multivariable analysis was performed to identify factors that were associated with less than ten-lymph nodes in the ALND pathologic specimen. Of 56,976 patients identified, 27,197 (48%) received neoadjuvant chemotherapy; 29,779 (52%) did not. NAC patients failed to meet the ten-lymph node minimum in the ALND specimen more often than non-NAC patients (35% vs. 27%, p < 0.001). NAC patients with fewer than ten-lymph nodes were more likely to have a pCR than those with ten or more (22% vs. 16%, p < 0.001). On multivariable analysis, pCR of the primary tumor and receptor status were found to be independent predictors of having fewer than ten-lymph nodes in the ALND specimen. Node-positive breast cancer patients that underwent NAC were more likely to not meet the ten-lymph node standard. However, NAC patients who did not meet the minimum were also more likely to have a pCR compared to NAC patients who did. This suggests lower lymph node yield may not truly be a marker of lower quality surgery but rather a potential marker of NAC treatment effect.