Sentinel lymph node biopsy in breast cancer patients after neoadjuvant chemotherapy

BACKGROUND AND OBJECTIVES: Sentinel lymph node biopsy (SLNB) is an accurate method for axillary staging in patients with early breast cancer. The aim of this study was to evaluate the accuracy and the feasibility of SLNB in breast cancer patients who had received preoperative (neoadjuvant) chemotherapy. METHODS: Patients with advanced breast cancer stage II or III who were treated with neoadjuvant chemotherapy were included in the study. Sentinel lymph node (SLN) identification and biopsy was attempted and performed, and axillary lymph node dissection (ALND) was performed in the same surgical procedure after SLNB. The histopathologic examination of the SLNs and the dissected axillary lymph nodes was performed and nodal status was compared. RESULTS: Thirty patients were included in the study. After peritumoural injection of technetium-99m labelled human albumin and subareolar subcutaneous injection of blue dye, the SLNs could be identified in 26/30 patients (identification rate 86.7%). In 4/30 patients (13.3%) SLNs could not be identified. In 25/26 patients (96.2%) SLNs accurately predicted the axillary status. Eleven patients had negative SLNs and negative nodes in ALND. Six patients had positive SLNs and positive nodes in ALND. In eight patients SLNs only were positive and nodes in ALND were negative. One patient had a false-negative SLNB, calculating a false-negative rate of 6.7% (1/15). CONCLUSIONS: SLNB is a well introduced technique for axillary staging in patients with early breast cancer. The accuracy of SLNB after neoadjuvant chemotherapy is similar to patients with primary surgery. SLNB could be an alternative to ALND in a subgroup of patients after neoadjuvant chemotherapy, and therefore could reduce morbidity due to surgery in those patients. Due to small numbers of patients, further evaluation in this subset of patients is required.     

The feasibility and accuracy of sentinel lymph node biopsy in clinically node-negative patients after neoadjuvant chemotherapy for breast cancer--a systematic review and meta-analysis

The sentinel lymph node biopsy (SLNB) is now an accepted alternative to the axillary lymph node dissection for pathologic evaluation of the axilla in patients with early breast cancer. The use of SLNB after neoadjuvant chemotherapy (NAC) is controversial. This meta-analysis aims to determine the feasibility and the accuracy of SLNB in the population of patients who are clinically node-negative after NAC for breast cancer.     

乳腺癌新辅助化疗后腋窝淋巴结转移综合预测模型的建立

目的:建立乳腺癌新辅助化疗后淋巴结转移的综合预测模型,评估新辅助化疗后淋巴结转移情况,指导临床手术方案选择。方法:回顾分析2015年1月至2018年12月143例乳腺癌新辅助化疗患者的临床、病理及影像资料,并根据术后淋巴结病理分为转移组与无转移组。采用χ2/t检验对两组指标进行单因素分析;将P<0.05的指标纳入多因素Logistic回归分析。用多因素分析有统计学意义(P<0.05)的指标构建乳腺癌新辅助化疗后淋巴结转移综合预测模型的列线图,并应用受试者工作特征（receiver operation characteristic,ROC)曲线评价此模型的性能。结果:单因素分析表明化疗方案、化疗前淋巴结穿刺病理、术前查体、术前彩超、术前CT/MRI、RECIST分级对腋窝淋巴结转移有预测作用;多因素分析表明,化疗前淋巴结穿刺病理、术前彩超、RECIST分级是新辅助化疗后腋窝淋巴结转移的独立预测因素。乳腺癌新辅助化疗后淋巴结转移的预测模型的曲线下面积为0.785,特异度为85.4%,敏感度为59.8%。结论:乳腺癌新辅助化疗后淋巴结转移的综合预测模型对腋窝淋巴结有较好的预测能力,可为选择合适的手术方式提供临床指导。     

临床腋窝淋巴结阳性乳腺癌患者内乳区前哨淋巴结活检术研究*

目的：评估临床腋窝淋巴结阳性乳腺癌患者行内乳区前哨淋巴结活检术（IM-SLNB）的临床意义。方法：2013年6 月至2014年10月对山东省肿瘤医院乳腺病中心就诊的64例临床腋窝淋巴结阳性的原发性乳腺癌患者行前瞻性单臂入组研究,采取腋窝淋巴结清扫术,同时均应用新的核素注射技术进行IM-SLNB。结果：64例患者中内乳区前哨淋巴结（IM-SLN）显像为38例,显像率为59.4%（38/ 64）。 38例IM-SLN 显像患者中IM-SLNB 成功率为100%（38/ 38）,并发症发生率为7.9%（3/ 38）,IM-SLN 转移率为21.1%（8/ 38）。 肿瘤位于内上象限和腋窝淋巴结转移数目较多的患者,其IM-SLN 转移率较高（P < 0.001 和P = 0.017）。 患者临床获益率为59.4%（38/ 64）,其中12.5%（8/ 64）另接受了内乳区放疗、46.9%（30/ 64）避免了不必要的内乳区放疗。结论：临床腋窝淋巴结阳性的乳腺癌应进行IM-SLNB,尤其对于肿瘤位于内上象限及怀疑存在较多腋窝淋巴结转移数目的患者,以获得内乳区淋巴结的转移状态,指导乳腺癌患者内乳区放疗。     

Axillary sentinel lymph node biopsy after neoadjuvant chemotherapy for carcinoma of the breast

BACKGROUND:

The timing and accuracy of axillary sentinel lymph node biopsy (SLNB) in patients who are receiving neoadjuvant chemotherapy (NACT) for breast cancer are controversial. To examine the accuracy of SLNB after NACT, the authors performed SLNB after chemotherapy on all of patients who received NACT at their institution starting in January 1997.

METHODS:

Seventy‐nine women who underwent NACT between 1997 and 2008 comprised this study and were divided as follows: 4 women had stage I disease, 60 women had stage II disease, and 15 women had stage III disease, including 10 women who had multicentric disease. Thirty‐nine women (49.4%) had clinical evidence of axillary metastasis (N1‐N2) at the time of diagnosis. The regimen, the duration of treatment, and the number of cycles of NACT depended on clinical response. The choice of breast conservation therapy or mastectomy was based on the patient's response to treatment and patient preference. All patients underwent SLNB after NACT.

RESULTS:

Seventy‐three patients underwent breast conservation therapy, and 6 patients underwent mastectomy. Sentinel lymph nodes were identified in 98.7% of patients (in 1 patient, SLNB failed to capture 1 proven axillary metastasis), and 29 patients underwent full axillary lymph node dissection. Fourteen patients (17.7%) had no residual carcinoma (invasive or ductal carcinoma in situ) in their breast, 5 patients (6.3%) had residual ductal carcinoma in situ (only), and 60 patients (75.9%) had residual invasive carcinoma. One false‐negative SLNB was reported in the group of 23 patients who underwent full axillary dissection after a negative SLNB. No patient had a subsequent axillary recurrence.

CONCLUSIONS:

SLNB after NACT was feasible in virtually all patients and accurately selected patients who required complete level I and II axillary dissection. NACT frequently downstaged the axilla, converting patients with N1‐N2 lymph node status to N0 status and also avoiding full axillary dissection in these patients. Cancer 2010. © 2010 American Cancer Society.     

Sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy

BACKGROUND:

Sentinel lymph node biopsy (SLNB) is a widely used staging method for patients with early breast cancer. Neoadjuvant chemotherapy modifies the anatomical conditions in the breast and axilla, and thus SLNB remains controversial in patients treated preoperatively. The aim of this study was to demonstrate the reliability and accuracy of this procedure in this particular group of patients.

METHODS:

The retrospective study analyzed medical records of patients diagnosed with primary breast cancer between the years 2005 and 2009. Of the patients treated by neoadjuvant therapy, 343 underwent lymphatic mapping to identify sentinel lymph nodes, and these were included in the analysis.

RESULTS:

The overall detection rate of sentinel lymph nodes was 80.8%. It was strongly influenced by clinical lymph node status (significantly higher success rate in lymph node‐negative patients); higher detection rates were also associated with age <50 years, estrogen receptor positivity, lower proliferation index, and absent lymphovascular space invasion. The false‐negative rate was 19.5% and was only marginally significantly dependent on lymphovascular space invasion. The overall accuracy of the method was 91.5%.

CONCLUSIONS:

By using the present technique, sentinel lymph node biopsy cannot be recommended as a reliable predictor of axillary lymph node status when performed at the authors' institution after neoadjuvant chemotherapy. Infrequent use of blue dye for lymphatic mapping, low number of resected sentinel lymph nodes, and absence of any selection among patients included in the study could be the main factors responsible for the low detection rate and high false‐negative rate. Cancer 2011;. © 2011 American Cancer Society.     

Histopathologic examination of axillary sentinel lymph nodes in breast carcinoma patients

The axillary sentinel lymph node biopsy (SLNB) has gained increasing popularity as a novel surgical approach for staging patients with breast carcinoma and for guiding the choice of adjuvant therapy with minimal morbidity. Patients with negative SLNB represent a subset of breast carcinoma patients with definitely better prognosis, because their pN0 status is based on a very thorough examination of the sentinel lymph nodes (SLNs), with a very low risk of missing even small micrometastatic deposits, as compared with routine examination of the 20 or 30 lymph nodes obtained by the traditional axillary clearing. The histopathologic examination of the SLNs may be performed after fixation and embedding in paraffin, or intraoperatively on frozen sections. Whatever is the preferred tracing technique and surgical procedure, the histopathologic examination of each SLN must be particularly accurate, to avoid a false-negative diagnosis. Unfortunately, because of the lack of standardised guidelines or protocols for SLN examination, different institutions still adopt their own working protocols, which differ substantially in the number of sections cut and examined, in the cutting intervals (ranging from 50 to more than 250 microm), and in the more or less extensive use of immunohistochemical assays for the detection of micrometastatic disease. Herein, a very stringent protocol for the examination of the axillary SLN is reported, which is applied either to frozen SLN for the intraoperative diagnosis, and to fixed and embedded SLN as well.     

Factors predicting one or two sentinel lymph nodes to be accepted for sentinel lymph node biopsy alone after neoadjuvant therapy in initially node-positive breast cancer patients

BackgroundCurrent guidelines recommend harvesting ≥3 sentinel nodes if sentinel lymph node biopsy (SLNB) alone is considered after neoadjuvant therapy (NAT) for initially node-positive (cN+) breast cancer. We attempted to investigate factors predicting one or two sentinel lymph nodes harvested to be accepted for SLNB alone after NAT in initially cN + patients.MethodsOverall, 157 patients who received NAT (clinically T1–3/N1–2/M0) and underwent SLNB were identified from a prospectively maintained database. Significant factors were identified using a multiple logistic regression model.ResultsThe overall SLN identification rate was 83.4%. Failed SLN identification was associated with a 2-day protocol using a single tracer (odds ratio: 0.331 [95% confidence interval {CI}: 0.132–0.830], p = 0.018), age >52 years (0.345 [0.131–0.913], p = 0.032), and lobular histology (0.156 [0.026–0.944], p = 0.043). The overall false-negative SLNB rate was 14.7%. Its increased risk was associated with radioactivity count >530 for any SLN during SLNB (96.4 [4.00–2320], p = 0.005), age ≥57 years (34.2 [1.92–610], p = 0.016), and taxane use (105 [1.02–10700], p = 0.049); its decreased risk was associated with more harvested SLNs (0.191 [0.054–0.669], p = 0.01) and dual tracers (0.101 [0.012–0.843], p = 0.034). A predictive model using these factors achieved an area under the curve of 0.935 (95% CI: 0.878–0.991).ConclusionWhen taxane was administered during NAT, the false-negative rate was predicted at <5% for patients aged <57 years, if 1–2 SLNs were harvested using dual tracers, and when the count of every SLN was lower than 530 after NAT in cN + breast cancer.     

乳腺癌新辅助化疗后前哨淋巴结活检意义的前瞻性研究

目的:探讨乳腺癌患者新辅助化疗(NAC)后腋窝前哨淋巴结活检的可行性.方法:采用99Tc硫胶体联合亚甲蓝示踪法对60例NAC后达到临床腋淋巴结阴性的乳腺癌患者和60例临床腋淋巴结阴性的早期乳腺癌患者进行腋窝前哨淋巴结活检术(SLNB),评估SLNB的检出率和准确性,比较两组患者SLNB的检出率和假阴性率,并分析NAC后SLNB检出率和假阴性率与患者及肿瘤特点的关系.结果:60例NAC后患者的前哨淋巴结(SLN)检出率为90%,SLNB的敏感度为90%,特异度为93.33%,准确性为91.67%,假阴性率为10%.其检出率和假阴性率与早期乳腺癌组比较,差异均无统计学意义(P=0.743,P=1.000).NAC组化疗前临床分期T3或N2以上者,腋淋巴结的检出率均显著下降,差异有统计学意义(P=0.030,P=0.000),分期N2以上者假阴性率显著增高,差异有统计学意义,P=0.001.结论:对NAC后达到临床淋巴结阴性的乳腺癌患者,腋窝SLN的检出率和假阴性率与早期乳腺癌SLNB差异无统计学意义,化疗前的TN分期是SLNB检出率和假阴性影响因素.     

乳腺癌SLN阳性与残余腋淋巴结阳性的预测因素

目的明确前哨淋巴结(SLN)阳性乳腺癌中不同的临床病理特点,并确定非SLN(NSLN)发生转移的预测因素。方法回顾分析726例成功确定了SLN的0~Ⅱ期乳腺癌病例,SLN阳性的185例患者接受腋窝淋巴结清除(ALND)。根据NSLN有无转移,将该185例分为两组,残余腋窝淋巴结有转移组(NSLN )81例,残余腋窝淋巴结无转移组(NSLN-)104例。结果多变量分析显示,原发肿瘤较大(>2.0cm)、淋巴管浸润、阳性SLN较大(>2mm)、所获得的SLN全部阳性4项均与NSLN阳性相关。在4项因素均存在的病例中,73%(30/41)存在NSLN阳性。结论4项独立的预测因素与NSLN转移有关。     

Histologic changes associated with false‐negative sentinel lymph nodes after preoperative chemotherapy in patients with confirmed lymph node‐positive breast cancer before treatment

BACKGROUND:

A wide range of false‐negative rates has been reported for sentinel lymph node (SLN) biopsy after preoperative chemotherapy. The purpose of this study was to determine whether histologic findings in negative SLNs after preoperative chemotherapy are helpful in assessing the accuracy of SLN biopsy in patients with confirmed lymph node‐positive disease before treatment.

METHODS:

Eighty‐six patients with confirmed lymph node‐positive disease at presentation underwent successful SLN biopsy and axillary dissection after preoperative chemotherapy at a single institution between 1994 and 2007. Available hematoxylin and eosin‐stained sections from patients with negative SLNs were reviewed, and associations between histologic findings in the negative SLNs and SLN status (true negative vs false negative) were evaluated.

RESULTS:

Forty‐seven (55%) patients had at least 1 positive SLN, and 39 (45%) patients had negative SLNs. The false‐negative rate was 22%, and the negative predictive value was 67%. The negative SLNs from 17 of 34 patients with available slides had focal areas of fibrosis, some with associated foamy parenchymal histiocytes, fat necrosis, or calcification. These histologic findings occurred in 15 (65%) of 23 patients with true‐negative SLNs and in only 2 (18%) of 11 patients with false‐negative SLNs (P = .03, Fisher exact test, 2‐tailed). The lack of these histologic changes had a sensitivity and specificity for identifying a false‐negative SLN of 82% and 65%, respectively.

CONCLUSIONS:

Absence of treatment effect in SLNs after chemotherapy in patients with lymph node‐positive disease at initial presentation has good sensitivity but low specificity for identifying a false‐negative SLN. Cancer 2010. © 2010 American Cancer Society.     

Clinical implications of sentinel nodes outside the axilla and internal mammary chain in patients with breast cancer

PURPOSE: The aim of this study was to determine the incidence, location, surgical identification rate, tumor status, and clinical implications of sentinel nodes outside the axilla and internal mammary chain. PATIENTS AND METHODS: In 785 breast cancer patients, pre-operative lymphoscintigraphy was performed after intratumoral injection of 116 MBq 99mTc-labeled nanocolloid (0.2 ml; 3.1 mCi). Sentinel nodes were pursued using a gamma-ray detection probe and vital blue dye. RESULTS: Lymphoscintigraphy visualized sentinel nodes outside the axilla and internal mammary chain in 91 of the 785 patients (12%). Sentinel nodes (106) were identified in 80 patients. These nodes were found in the following locations: 50 in the breast, 31 in the infraclavicular fossa, 19 between the pectoral muscles, and 6 within the supraclavicular bed. Eighteen nodes contained a metastasis (17%) and were removed from 16 patients. The treatment strategy was adjusted in 12 of them with the addition of adjuvant local or systemic therapy. Two additional patients with an unusually situated tumor-negative sentinel node were spared an axillary node dissection that would otherwise have been performed. CONCLUSION: Unusually situated sentinel nodes were visualized in 12% of the patients. The treatment was adjusted in 18% of patients in whom these nodes were identified.     

乳腺癌新辅助化疗后内乳区前哨淋巴结活检研究

目的：新辅助化疗（neoadjuvant chemotherapy,NAC）目前已成为局部晚期乳腺癌患者的标准治疗模式。本研究旨在评估乳腺癌患者在NAC后接受内乳区前哨淋巴结活检（internal mammary sentinel lymph node biopsy,IMSLNB）的临床获益。方法：回顾性分析2014年4月—2018年4月山东大学附属山东省肿瘤医院乳腺病中心收治的202例接受NAC的原发性乳腺癌患者的临床资料并进行统计分析,入组患者术前均采用“新型注射技术”注射核素示踪剂。术前哨位淋巴结显像和（或）术中γ探测仪发现内乳区前哨淋巴结（internal mammary sentinel lymph node,IMSLN）显像者行经肋间IMSLNB。根据目前的指南评估NAC后接受IMSLNB的临床获益。结果：入组202例患者,NAC后IMSLN显像率为34.2%(69/202),且与临床肿瘤分期相关（P=0.017）,IMSLN显像患者中,临床淋巴结阴性和临床淋巴结阳性（clinical lymph node-positive,cN⁺）患者分别占11.6% (8/69)和88.4%(61/69)。NAC后IMSLNB的成功率为98.6%（68/69）,IMSLN的检出率为33.7%(68/202),转移率为11.8% (8/68),8例IMSLN转移患者,术后淋巴结分期发生了改变,其中1例患者不伴腋窝淋巴结（axillary lymph node,ALN）转移（pN₀至pN_1b）,2例伴1~3枚ALN转移（pN_1a至pN_1c）,4例伴4~9枚ALN转移（pN_2a至pN_3b）,1例伴≥10枚ALN转移（pN_3a至pN_3b）,术后病理学分期也发生了改变（0期至ⅠB期,ⅡA/ⅢA期至ⅢC期）,这8例IMSLN转移患者术后均接受了内乳区放疗（internal mammary node irradiation,IMNI）。结论：NAC后IMSLN有显像的患者,尤其是cN⁺患者,NAC后应接受IMSLNB,以期获得完整的淋巴结分期。IMSLNB能够进一步完善淋巴结病理完全缓解的定义并指导IMNI。     

Low locoregional failure rates in selected breast cancer patients with tumor-positive sentinel lymph nodes who do not undergo completion axillary dissection

BACKGROUND: The role for completion axillary dissection (CLND) in patients with breast cancer who have tumor-positive sentinel lymph nodes (SLN) has been questioned. The objective of this study was to examine the long-term safety of avoiding CLND in selected patients with positive SLNs. METHODS: Patients with invasive breast cancer who underwent SLN biopsy at the authors' institution between 1993 and July 2005 were reviewed. Of 3366 total patients, 750 patients had a positive SLN. There were 196 patients with a positive SLN who did not undergo CLND based on clinician and patient preference. Clinicopathologic variables and treatment patterns were analyzed along with locoregional, distant recurrence, and survival. RESULTS: Most tumors were infiltrating ductal carcinomas (74%), estrogen receptor-positive tumors (82%), progesterone receptor-positive tumors (70%), HER-2/neu-negative tumors (78.6%), and tumors were classified predominantly as either T1 or T2 (95.4%). The median number of SLNs removed was 3, and the median number of positive SLNs was 1. The median size of the tumor deposit in the SLN was 1.0 mm (range, 0.1-12.9 mm). Most SLNs were positive by on hematoxylin and eosin staining (64.3%), whereas 35.7% of SLNs were positive only by immunohistochemistry. Most patients underwent breast conservation (68.9%), radiation (58.2%), and chemotherapy (neoadjuvant in 14.3%, adjuvant in 55.6%). With a median follow-up of 29.5 months, no patients had an axillary recurrence, 1 patient had a supraclavicular lymph node recurrence, and 3 patients developed distant metastases. The median time to recurrence was 32 months. CONCLUSIONS: In selected patients who had positive SLNs, the locoregional failure rate was low without CLND. Prospective studies will be valuable to corroborate these results and to refine further the optimal selection criteria for this approach.     

乳腺癌新辅助化疗后腋窝及内乳前哨淋巴结活检研究

背景与目的：临床新辅助化疗(neoadjuvant chemotherapy,NAC)后腋窝淋巴结(axillary lymph node,ALN)转阴的患者腋窝前哨淋巴结活检(axillary sentinel lymph node biopsy, ASLNB)能否替代腋窝淋巴结清扫(axillary lymph node dissection,ALND)尚存在争议,且此前研究只评估ALN病理状况而未评估内乳淋巴结(internal mammary lymph node,IMLN)状况。本研究旨在评估NAC后乳腺癌患者接受ASLNB和内乳前哨淋巴结活检(internal mammary sentinel lymph node biopsy,IM-SLNB)的临床意义。方法：回顾性分析2012年1月—2014年12月山东省肿瘤医院乳腺病中心原发性乳腺癌(cT_1-4N_0-3M₀)60例患者的临床资料,将患者分为3组：A组初始cN₀且NAC后为ycN₀,B组初始cN+且NAC后为ycN₀,C组NAC后为ycN₊。术前接受核素注射。术中A组和B组联合亚甲蓝行ASLNB。A组仅对腋窝前哨淋巴结(axillary sentinel lymph node,ASLN)阳性者行ALND;B组行ASLNB后转行ALND;C组直接行ALND。术前淋巴显像和(或)γ探测仪发现内乳前哨淋巴结(internal mammary sentinel lymph node,IM-SLN)的患者行IM-SLNB。结果：A组、B组和C组分别收集6例、45例和9例。A组ASLNB成功率为100%(6/6),仅1例ASLN阳性转行ALND。B组ASLNB成功率为100%(45/45),假阴性率为17.9%(5/28)。其中检出1枚、2枚和＞2枚ASLN的假阴性率分别为27.3%(3/11)、20.0%(2/10)和0%(0/7)。C组所有患者ALN均有转移。IM-SLN总体显像率为63.3%(38/60)。IM-SLNB的总体成功率为97.4%(37/38),转移率为8.1%(3/37),并发症发生率为5.3%(2/38)。结论：对初始cN₀且NAC后为ycN₀者ASLN阴性时ASLNB可替代ALND;对初始cN₊且NAC后为ycN₀者,联合双示踪剂且检出＞2枚ASLN可满足临床可接受的假阴性率(<10%);对NAC后仍为ycN₊者应行ALND。NAC后IM-SLN显像者应行IM-SLNB,以获得完整分期、评估预后并指导术后放疗,有望完善病理完全缓解(pathological complete response,pCR)定义。     

A risk score model predictive of the presence of additional disease in the axilla in early-breast cancer patients with one or two metastatic sentinel lymph nodes

Background

Axillary lymph node dissection (ALND) in early-breast cancer patients with positive sentinel node (SLN+) may not always be necessary.

Aims

To predict the finding of ≥1 metastatic axillary node in addition to SLN+(s); to discriminate between patients who would or not benefit from ALND.

Methods

Records of 397 consecutive patients with 1-2 SLN+s receiving ALND were reviewed. Clinico-pathological features were used in univariate and multivariate analyses to develop a logistic regression model predictive of the risk of ≥1 additional axillary node involved. The discrimination power of the model was quantified by the area under the receiver operating characteristic curve (AUC) and validated using an independent set of 83 patients.

Results

In univariate analyses, the risk of ≥1 additional node involved was correlated with tumor size, grade, HER-2 and Ki-67 over-expression, number of SLN+s. All factors, but Ki-67, retained in multivariate regressions were used to generate a predictive model with good discriminating power on both the training and the validation sets (AUC 0.73 and 0.75, respectively). Three patient groups were defined based on their risk to present additional axillary burden.

Conclusions

The model identifies SLN+-patients at low risk (≤15%) who could reasonably be spared ALND and those at high risk (>75%) who should receive ALND. For patients at intermediate risk, ALND appropriateness could be individually evaluated based on other clinico-pathological parameters.     

Management of the axilla in patients with breast cancer and positive sentinel lymph node biopsy: An evidence-based update in a European breast center

The surgical approach to the axilla in breast cancer has been a controversial issue for more than three decades. Data from recently published trials have provided practice-changing recommendations in this scenario. However, further controversies have been triggered in the surgical community, resulting in heterogeneous diffusion of these recommendations.The development of clinical guidelines for the management of the axilla in patients with breast cancer is a work in progress. A multidisciplinary team discussion was held at the research hospital Policlinico San Matteo from the Università degli Studi di Pavia with the aim to update recommendations for the management of the axilla in patients with breast cancer. An evidence-based approach is presented.Our multidisciplinary panel determined that axillary dissection after a positive sentinel lymph node biopsy may be avoided in cN0 patients with micro/macrometastasis to ≤2 sentinel nodes, with age ≥40y, lesions ≤3 cm, who have not received neoadjuvant chemotherapy and have planned breast conservation (BCS) with whole breast radiotherapy (WBRT). Cases with gross (>2 mm) ECE in SLNs are evaluated on individual basis for completion ALND, axillary radiotherapy or omission of both. Patients fulfilling the criteria listed above who undergo mastectomy, may also avoid axillary dissection after multidisciplinary discussion of individual cases for consideration of axillary irradiation. Women 70 years or older with hormone receptors positive invasive lesions ≤3 cm, clinically negative nodes, and serious or multiple comorbidities who undergo BCS with WBRT, may forgo axillary staging/surgery (if mastectomy or larger tumor, comorbidities and life expectancy are taken into account).