Does ‘fast – track’ axillary node clearance following positive core biopsy lead to overtreatment of axilla?

AimsSentinel lymph node biopsy (SLNB) is the preferred axillary staging procedure, although axillary node clearance (ANC) is still indicated in subgroups of patients. This study aims to review our practice of axillary treatment in node positive cancer, to determine the proportion of patients requiring ANC and to identify if this can be avoided in some patients.MethodsRetrospective data for all breast cancer patients who underwent surgery between 1 January 2017 and 31 December 2018 were included in this study. The histopathology results of ANC were correlated with axillary ultrasound findings, axillary biopsy or SLNB results and effect of neoadjuvant treatment. These were analysed against the available guidelines to evaluate the current practice.Results82 patients out of 520 had ANC (15.7%). Four groups were identified: Group A included 45 patients with nodal infiltration on preoperative biopsy; Group B included 24 patients with nodal infiltration who had neoadjuvant chemotherapy (NACT); Group C included 11 patients with involved nodes on SLNB; Group D included 2 patients with axillary recurrence. 35.5% of patients in Group A had only 1–2 positive nodes following ANC. Complete pathological response was observed in 37.5% patients following NACT. No further nodes were subsequently found in a majority of patients who underwent ANC following positive SLNB (63.6%).Conclusions15.7% of breast cancer patients required ANC. Few patients now require ANC following positive SLNB. The practice of direct (fast-track) ANC after axillary biopsy may lead to overtreatment of the axilla, which needs re-evaluation. Targeted axillary dissection could avoid unnecessary axillary dissection in patients with abnormal nodes and in patients who have received NACT.     

Management of the Axilla in Women With Breast Cancer: Current Clinical Practice and a New Selective Targeted Approach

Background Axillary nodal status is the most important prognostic factor for patients with breast cancer. Clinical assessment and imaging modalities are not always reliable. Surgical removal and histopathological examination of axillary lymph nodes remain essential methods of staging the axilla. However, the optimal management of the axilla remains uncertain. Methods We performed Medline searches to identify relevant systematic reviews, meta-analysis, and nonrandomized and randomized controlled trials for the past 5 years (up to December 2007), as well as important historical articles and clinical guidelines relating to management of the axilla in women with breast cancer. Results Axillary lymph node dissection (ALND) has been the standard surgical approach for many years. It is, however, associated with marked morbidity; survival benefit remains uncertain. Axillary node sampling, widely practiced in the United Kingdom, is a reliable alternative procedure in staging the axilla, with less morbidity. Sentinel lymph node biopsy (SLNB) has become an accurate method for staging the axilla in women with operable, clinically node-negative breast cancer. SLNB alone appears to be a safe and acceptable procedure for patients with uninvolved SLNs. Completion ALND or axillary radiotherapy remains the standard treatment for patients with tumor-involved SLNs. SLNB is associated with less morbidity than ALND. However, long-term follow-up and therapeutic outcomes are being awaited from randomized controlled trials. Conclusions Several procedures are available for staging and treating the axilla. A tailored surgical approach, with careful assessment of risk-benefit and patient preference, is guiding the evolving modern management of the axilla for women with breast cancer.     

Predictors for extensive nodal involvement in breast cancer patients with axillary lymph node metastases

PurposeVarious prediction models have been developed to predict the risk of having no additional axillary metastases in patients with a positive sentinel lymph node biopsy (SLNB), thereby disregarding patients with a positive ultrasound-guided lymph node biopsy (UGLNB). However, in the post-Z0011 trial era it is important to identify all patients with extensive nodal involvement for whom axillary treatment might still be beneficial. Therefore, the aim of this study is to identify factors predicting extensive nodal involvement (≥3 positive nodes) in the axilla, with the emphasis on the method of axillary staging: node positivity by UGLNB versus SLNB.MethodsAll patients diagnosed with invasive breast cancer between January 2006 and December 2011 at the Máxima Medical Center were included. Univariate and multivariate logistic regression analyses were performed.ResultsWe included 302 cases, representing 301 node positive patients, of whom 177 cases had 1 or 2 positive lymph nodes and 125 cases had ≥3 positive lymph nodes. Multivariate analyses showed that a positive UGLNB (OR = 5.10; 95%CI = 2.78–9.36), lymphovascular invasion (OR = 3.60; 95%CI = 1.79–7.23) and a larger tumor size (OR = 1.03 per mm increase; 95%CI = 1.00–1.06) were significantly associated with extensive nodal involvement in patients with invasive breast cancer.ConclusionThis study shows that a positive axilla, determined by UGLNB, is the most important factor for predicting further extensive nodal involvement. Hence, the role of axillary staging by ultrasound should be redefined since it might play an important role in selecting patients who may still benefit from axillary treatment.     

Management of the axilla following neoadjuvant chemotherapy for breast cancer- A change in practice

ObjectivesChemotherapy in the neo adjuvant setting has allowed downsizing of breast tumours thus allowing patients to benefit from breast conservation surgery. The effect of neoadjuvant chemotherapy (NAC) has also been observed in the axilla but most units are still treating the axilla with axillary lymph node dissection (ALND).Materials and methodsA prospective database of breast cancer patients receiving NAC between 2007 and 2016 at a single breast unit was reviewed. The management of the axilla and outcomes was studied.Results165 patients received NAC, 123 (74.5%) were clinically/radiologically node positive and 42 were negative. Median age was 50 years. 26.7% had triple negative disease and 34.5% were HER2 positive. 56/123 (45.5%) patients with positive nodes at the outset responded completely to NAC. 40 patients with positive nodes pre-NAC had post NAC SLNB with 37 requiring adjuvant radiotherapy only. 83/123 went directly to ALND post NAC and of these 27 were node negative and therefore may be considered to have had an unnecessary ALND. Overall mortality was 20.6% (34), local recurrence in the breast or mastectomy scar was 3.6% (6) but there was no recurrence in the axilla (0/165) with a median follow up of 67 months.ConclusionThere is no clear evidence for management of the axilla post NAC. We have used best available evidence to change our practice over the years and our results should encourage others to de-escalate treatment of the axilla in line with the recently published multidisciplinary guidance on axillary surgery following neoadjuvant chemotherapy.     

Is there a requirement for axillary lymph node dissection following identification of micro-metastasis or isolated tumour cells at sentinel node biopsy for breast cancer?

IntroductionRecent decades have seen a significant shift towards conservative management of the axilla. Increasingly, immunohistochemical analysis of sentinel nodes leads to the detection of small tumour deposits, the significance of which remains uncertain. The aims of this study are to examine patients whose sentinel lymph nodes are positive for macro-metastasis, micro-metastasis or isolated tumour cells (ITCs) and to determine the rate of further nodal disease after axillary lymph node dissection (ALND).MethodsA retrospective analysis of all patients undergoing a sentinel lymph node biopsy (SLNB) between January 2007 and December 2010 in a tertiary referral breast unit was performed. Patients who underwent an axillary lymph node dissection for macro-metastasis, micro-metastasis or ITCs were identified. Demographics, histological data and the rate of further axillary disease were examined.ResultsIn total, 664 breast cancer patients attended the symptomatic breast unit during the study period, 360 of whom underwent a SLNB. Seventy patients had a SLNB positive for macro-metastasis. All of these patients underwent ALND. A positive SLNB with either micro-metastasis or ITCs was identified in 58 patients. Only 41 of the 58 patients went on to have an ALND, due primarily to variations in surgeons' preferences. Nineteen patients with micro-metastasis underwent an ALND. Four patients had further axillary disease (21%). Twenty-two patients had ITCs identified, of whom only one had further disease (4.5%). No statistically significant difference was found between the two groups in terms of tumour size, grade, lymphovascular invasion or oestrogen receptor status.ConclusionALND should be considered in patients with micro-metastasis at SLNB. It should rarely be employed in the setting of SLNB positive for ITCs.     

Breast cancer subtypes affect the nodal response after neoadjuvant chemotherapy in locally advanced breast cancer: Are we ready to endorse axillary conservation?

We evaluated the impact of breast cancer subtypes on pathologic complete response (pCR) in 181 patients with positive nodes undergoing neoadjuvant chemotherapy (NAC). After NAC, patients underwent surgery, with sentinel lymph node biopsy (SLNB) or axillary dissection (ALND). In 28.2% of cases a pCR was achieved, with the highest rate in Her2+ and triple negative tumors. Overall, nodal pCR was more frequent than breast pCR (P = 0.003) with higher percentages in Her2+ and LLB‐Her2+ (P < 0.05). In the Her2+ group, nodal pCR was observed only with breast pCR. Thus, in Her2+ tumors, breast pCR predicts node pCR, supporting the use of SLNB in this subgroup to stage the axilla avoiding ALND.     

Reoperative sentinel lymph node biopsy in ipsilateral breast cancer relapse

Sentinel lymph node biopsy (SLNB) is controversial following ipsilateral breast tumour relapse (IBTR) and previous axillary surgery. We retrospectively assessed the feasibility, outcomes and utility of this procedure. Eighteen patients with IBTR who underwent reoperative SLNB were identified. Fifteen women had previously undergone axillary lymph node dissection and three SLNB for breast cancer. Twelve of 16 patients underwent successful lymphoscintigraphy (LSG). Lymphatic drainage patterns varied widely - ipsilateral axilla (5), contralateral axilla (5), and ipsilateral internal mammary (5). Two patients had drainage to more than one nodal basin. Nine of 12 patients demonstrated drainage outside of the ipsilateral axilla. Reoperative SLNB was successful in 12/18 of patients - 4 ipsilateral axilla, 1 ipsilateral internal mammary, 1 ipsilateral intramammary, 4 contralateral axilla. Two patients had sentinel nodes in multiple nodal basins. Positive sentinel node was found in one successful case (contralateral axilla) and isolated tumour cells in two (1 contralateral axilla, 1 ipsilateral internal mammary). In conclusion, reoperative SLNB is feasible. Lymphatic drainage patterns vary widely and preoperative LSG is vital to facilitate identification of sentinel nodes in unusual sites. Its prognostic and therapeutic significance warrants further study.     

Non-sentinel lymph node metastases in breast cancer patients with metastatic sentinel nodes

BACKGROUND: Sentinel lymph node biopsy (SLNB) has been shown to be relatively accurate in axillary nodal staging in breast cancer. In more than half of the patients with metastatic sentinel lymph node (SLN), the SLN was the only lymph node involved in the axilla. Methods: A retrospective analysis was performed for those female Chinese breast cancer patients who underwent SLNB. All patients had axillary dissection after SLNB. Those patients with metastatic SLN were selected for analysis. Various tumour factors and SLN factors were analysed to study the association with residual lymph node metastasis. Results: A total of 139 SLNB was performed. The success rate of SLN localization, false negative rate and accuracy were 92%, 9% and 95%, respectively. Fifty-five patients had metastases in the SLN. In 38 patients (69%), SLN was the only lymph node involved in the axilla. Tumours <3 cm, a single metastatic SLN, presence of micro metastases and the absence of extracapsular spread in the SLN were associated with the absence of metastasis in the non-sentinel lymph nodes. Conclusion: Sentinel lymph node biopsy is accurate in the nodal staging of Chinese breast cancer patients. Several factors such as tumour <3 cm, a single metastatic SLN, micro metastases and the absence of extracapsular spread in the sentinel node(s) are useful predictors for the absence of residual disease in the axilla. With further studies and verification, these factors may prove to be important in determining which patients with metastatic SLN will require further axillary treatment. Until such information is available, axillary dissection should be performed when positive sentinel nodes are found.     

Sentinel Lymph Node Metastasis in Microinvasive Breast Cancer

Background:Ductal carcinoma in situ with microinvasion (DCISM) is a separate pathological entity, distinct from pure ductal carcinoma in situ (DCIS). DCISM is a true invasive breast carcinoma with a well-known metastatic potential. Currently, there is controversy regarding the indication for complete axillary dissection (CAD) to stage the axilla in patients with DCISM. The role of CAD is questioned given its morbidity and reported low incidence of axillary involvement. Sentinel lymph node biopsy (SLNB) may obviate the need for CAD in these patients without compromising the staging of the axilla and the important prognostic information.Methods:From March 1996 to December 2002, 4602 consecutive patients with invasive breast carcinoma underwent SLN biopsy. Of these, 41 patients with DCISM were selected.Results:Metastasis in the SLN were detected in 4 of 41 (9.7%) patients. Two of the 4 patients had only micrometastasis in the SLN. In three patients, the SLN was the only positive node after CAD.Conclusions:SLN biopsy should be considered as a standard procedure in DCISM patients. SLNB can detect nodal micrometastasis and accurately stage the axilla avoiding the morbidity of a CAD. Complete AD may not be mandatory if only the SLN contains micrometastatic disease. Informed consent is very important in the decision not to undergo CAD.     

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??Research hotspots in axillary treatment for early-stage breast cancer WANG Mao-li,WU Ke-jin. Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200011, China
Corresponding author: WU Ke-jin, E-mail: kejinwu@163.com
Abstract Sentinel lymph node biopsy(SLNB) has replaced axillary lymph node dissection(ALND) to stage clinically node-negative breast cancer patients. In the patients with low-volume nodal metastasis, ALND could be safely avoided when treated with breast-conserving therapy eligible for Z0011 or IBCSG 23-01, or radiation considered referring to AMAROS. ALND is still recommended for patients with involved axillary nodes received mastectomy and not planned for radiation. Addition of regional nodal irradiation in subgroups of patients reduces locoregional recurrence significantly and should be recommended taken all clinical and pathologic factors considered for individual patients. For patients with clinically node-negative disease, SLNB following neoadjuvant therapy is considered an acceptable approach.Ultrasound-guided biopsy and localization of suspicious axillary lymph nodes before neoadjuvant therapy are preferred. SLNB may be an option after neoadjuvant therapy in patients with proven positive axillary nodes who achieved clinical complete response, given that usage double tracers, biopsy more than 2 sentinel lymph nodes, evaluation the labelled lymph node before neoadjuvant therapy, and stage N0 (i+) may be regarded as the criteria for ALND. ALND remains the standard-of-care for the subset of patients in clinical practice, unless enrolled on some clinical trials. Staying the current of axillary treatments in early-stage breast cancer helps to make wiser clinical decision and organize further in-depth research, so that safe, effective and moderate axillary treatments can be performed.     

Incidence and Impact of Documented Eradication of Breast Cancer Axillary Lymph Node Metastases Before Surgery in Patients Treated With Neoadjuvant Chemotherapy

OBJECTIVE: To determine the incidence and prognostic significance of documented eradication of breast cancer axillary lymph node (ALN) metastases after neoadjuvant chemotherapy. SUMMARY BACKGROUND DATA: Neoadjuvant chemotherapy is the standard of care for patients with locally advanced breast cancer and is being evaluated in patients with earlier-stage operable disease. METHODS: One hundred ninety-one patients with locally advanced breast cancer and cytologically documented ALN metastases were treated in two prospective trials of doxorubicin-based neoadjuvant chemotherapy. Patients had breast surgery with level I and II axillary dissection followed by additional chemotherapy and radiation treatment. Nodal sections from 43 patients who were originally identified as having negative ALNs at surgery were reevaluated and histologically confirmed to be without metastases. An additional 1112 sections from these lymph node blocks were obtained; half were stained with an anticytokeratin antibody cocktail and analyzed. Survival was calculated using the Kaplan-Meier method. RESULTS: Of 191 patients with positive ALNs at diagnosis, 23% (43 patients) were converted to a negative axillary nodal status on histologic examination (median number of nodes removed = 16). Of the 43 patients with complete axillary conversion, 26% (n = 11) had N1 disease and 74% (n = 32) had N2 disease. On univariate analysis, patients with complete versus incomplete histologic axillary conversion were more likely to have initial estrogen-receptor-negative tumors, smaller primary tumors, and a complete pathologic response in the primary tumor. The 5-year disease-free survival rates were 87% in patients with preoperative eradication of axillary metastases and 51% for patients with residual nodal disease after neoadjuvant chemotherapy. Of the 39 patients with complete histologic conversion for whom nodal blocks were available, occult nodal metastases were found in additional nodal sections in 4 patients (10%). At a median follow-up of 61 months, the 5-year disease-free survival rates were 87% in patients without occult nodal metastases and 75% in patients with occult nodal metastases. CONCLUSIONS: Neoadjuvant chemotherapy can completely clear the axilla of microscopic disease before surgery, and occult metastases are found in only 10% of patients with a histologically negative axilla. The results of this study have implications for the potential use of sentinel lymph node biopsy as an alternative to axillary dissection in patients treated with neoadjuvant chemotherapy.     

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。     

Incidence of Axillary Recurrence in 344 Sentinel Node Negative Breast Cancer Patients after Intermediate Follow-Up. A Prospective Study into the Accuracy of Sentinel Node Biopsy in Breast Cancer Patients

Sentinel lymph node biopsy (SLNB) has been validated in the treatment of breast carcinoma and is considered to stage the axilla adequately in this disease. However, long-term follow-up data are scarce. We evaluated the results of SLNB with respect to loco-regional failures in the axilla in SN-negative patients with invasive breast carcinoma and analysed their causal factors.

Between 1997 and May 2004, 656 patients without clinically palpable lymph nodes were included in our study. Data with regard to demographics, diagnostics, therapy and follow up were gathered prospectively from all patients. Patients treated after May 2004 were excluded from this study to permit at least one year of follow-up.

Out of the 656 patients, 344 patients with a negative sentinel lymph node biopsy did not undergo axillary dissection and were followed up clinically. Median follow up was 43 months. In 3 patients (0.9%) axillary recurrences developed. All three patients subsequently underwent a completion axillary dissection, chemotherapy and radiotherapy.

The low rate of clinical axillary recurrence after an intermediate follow up period suggests that a negative SN biopsy accurately reflects the nodal stage in patients with breast cancer.     

Axillary Staging in the Neoadjuvant Setting

Neoadjuvant chemotherapy (NAC) is increasingly being used in the treatment of locally advanced breast cancer as well as for early breast cancer. Axillary lymph node dissection has been the standard method of staging the axilla in the neoadjuvant setting. Since the sentinel lymph node biopsy was introduced in the early 1990s, less invasive approaches to axillary staging in patients undergoing neoadjuvant therapy have been proposed. In this review, we discuss the effects of NAC, the imaging modalities that have been used to evaluate the axillary lymph nodes, and the role and timing of sentinel lymph node biopsy in the neoadjuvant setting. Finally, we propose a treatment algorithm for patients undergoing NAC on the basis of the current data.     

Sentinel lymph node biopsy in Chinese patients with large operable breast cancer (≥4 cm): A decade's experience from a single institution

BackgroundPerforming sentinel lymph node biopsy (SLNB) in patients with large operable breast cancer is still controversial. Our aim is to find whether or not performing SLNB is feasible and safety in Chinese patients with large operable breast cancer.MethodsWe reviewed the data of patients in our center from 2003 to 2015, a series of 267 patients with large operable breast cancer (≥4 cm) who underwent SLNB were examined. All selected patients recieved preoperative axillary evaluation.ResultsThe successful rate for localizing SLNs was 96.3% (257 of 267). 31.1% (78 of 257) patients were found to have positive sentinel lymph nodes (SLN). The median follow-up was 52 months. 2.2% (4 of 179) SLN-negative patients developed axillary recurrence (AR) as first event. The 5-year axillary recurrence free survival in SLN-negative patients was 96.9% (95%CI, 93.8%–100%). Patients with suspicious nodes on ultrasonography (US) (P = 0.16) and undergoing breast conserving therapy (BCT) (P = 0.057) had a higher trend to be associated with AR. The 5-year recurrence free survival (RFS) was 86.1% (95%CI, 80.8%–93.0%) in SLN-negative patients and 76.3% (95%CI, 68.1%–90.1%) in SLN-positive patients (P = 0.246).ConclusionsSLNB is feasible and safety in patients with large operable breast cancer who underwent preoperative axillary evaluation.     

Sentinel lymph node biopsy before versus after neoadjuvant chemotherapy for breast cancer

Axillary lymph node status is the most important prognostic factor in the treatment of breast cancer. In recent years, sentinel lymph node biopsy (SLNB) has replaced conventional axillary lymph node dissection for predicting axillary lymph node status with higher accuracy. Moreover, neoadjuvant chemotherapy (NAC) is being used increasingly to treat not only patients with locally advanced inoperative breast cancer, but also those with initially operable breast cancer. The application of SLNB has now expanded to include this patient population, who were not previously considered good candidates for SLNB. A number of recent studies have evaluated the feasibility and accuracy of SLNB after NAC in breast cancer patients. Moreover, SLNB has been shown to be accurate in patients scheduled to receive NAC, and repeat SLNB has been performed after NAC for patients with positive nodes detected by the initial SLNB before NAC. Thus, the optimal timing of SLNB for patients with breast cancer in the neoadjuvant setting remains controversial. This article reviews the issues surrounding SLNB before vs. after NAC, according to the published literature and our experience.     

Sentinel Lymph Node Biopsy for Breast Cancer: Current Controversies

Abstract:   Sentinel lymph node biopsy (SLNB) has replaced the routine level I and II axillary lymph node dissection (ALND) for women with clinically node-negative T1 and T2 breast cancer. Studies have shown that SLNB is highly predictive of axillary nodal status with a false-negative of rate less than 10%. Our purpose was to address some of the ongoing controversies about this procedure, including technical issues, use of preoperative lymphoscintigraphy, internal mammary lymph node biopsy, criteria for patient selection (in intraductal carcinoma?), its staging accuracy, and the clinical approach when a SLNB was found to be negative or positive on pathologic examination. After the revision of the American Joint Committee on Cancer (AJCC) staging system for breast cancer in 2002, the evaluation of internal mammary lymph nodes and determination of micrometastases by hematoxylin-eosin or by immunohistochemistry have become increasingly important in staging of patients. Recent guideline recommendations developed by the American Society of Clinical Oncology (ASCO) Expert Panel in 2005 are also discussed. Long-term follow-up results of ongoing studies will provide more accurate assessment of the prognostic significance of SLNB and its value in the prevention of breast cancer-related morbidity in axillary staging compared to ALND.      

Sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a developing alternative to axillary dissection and may prove to be accurate in the detection of micrometastases in lymph nodes of breast cancer patients. Limited studies exist in the use of SLNB after neoadjuvant therapy. This study was undertaken to determine the accuracy of SLNB after neoadjuvant chemotherapy. METHODS: Thirty-one patients with stage I or II breast cancer underwent SLNB after neoadjuvant chemotherapy. RESULTS: Lymphatic mapping was performed by radioisotope, blue dye, or both techniques. Sentinel nodes (SN) were identified in 29 patients (93.5%). The SN was positive in 11 patients (38.0%), and was the only positive node in 5 patients (45.5%). There were no false negative SN by hematoxyin and eosin stain or immunohistochemistry (IHC) studies. CONCLUSIONS: Sentinel node identification rate is similar to that in nonneoadjuvant studies. The sentinel node accurately predicted metastatic disease in the axilla. IHC studies failed to detect any additional micrometastases. This diagnostic technique may provide treatment guidance for patients after neoadjuvant therapy.     

Adequate sentinel node harvest is associated with low false negative rate in breast cancer managed with neoadjuvant chemotherapy and targeted axillary dissection

IntroductionAfter neoadjuvant chemotherapy (NAC) for clinically node-positive breast cancer (NPBC), targeted axillary dissection (TAD) reduces the false negative rate (FNR) of axillary node sampling. Axillary lymph node dissection (ALND) is indicated if the clipped node cannot be identified. Prior studies have indicated that a sentinel lymph node harvest (SLNH) of ≥3 also leads to low FNR. We investigated the performance of SLNH thresholds at inferring the status of the axilla during TAD.MethodsRetrospective review of the Legacy Health System Tumor Registry was performed. We identified NPBC patients between 2011 and 2016 managed with NAC and TAD.ResultsIn 29 patients, the FNR of the SLNB component of TAD was 11% with SLNH of ≥3; with SLNH of ≤2 nodes the FNR was 20%.ConclusionsIn patients with NPBC receiving NAC, adequate SLNH is associated with acceptably low FNR. The decision to pursue ALND for clip identification should be made on a case-by-case basis.     

Management of the axilla in primary breast cancer

Treatment of the axilla with either radiotherapy or surgery remains an integral part of the management of patients with invasive breast cancer. In general, the standard treatment of the axilla involves a partial ALND (surgical clearance of axillary nodes from levels I and II). There is as yet no evidence that axillary treatment improves survival, but the issue remains controversial. Axillary lymph node dissection is an effective staging procedure and is essential for local control of disease in the axilla, although, with increased emphasis on mammographic screening and early detection, the incidence of node-positive breast cancers is decreasing. Today, only about 30% to 40% of all invasive breast cancers are node-positive. Thus, in most cases, the potential morbidity of ALND could be avoided if the status of the axillary nodes were ascertained with a less invasive procedure. The SLNB may eventually prove to be a preferred alternative to routine ALND. It must first be demonstrated, however, that SLNB (without completion ALND) does not adversely affect outcome. Randomized controlled trials must address these concerns, and surgeons must await completion of these studies before accepting SLNB as the standard of care.