Abstract
BackgroundIn patients who have had axillary nodal metastasis diagnosed prior to neoadjuvant chemotherapy for breast cancer, there is little consensus on how to manage the axilla subsequently. The aim of this study was to explore whether a combination of breast magnetic resonance imaging (MRI) assessed response and primary tumour pathology factors could identify a subset of patients that might be spared axillary node clearance.MethodsA retrospective data analysis was performed of patients with core biopsy-proven axillary nodal metastasis prior to commencement of neoadjuvant chemotherapy (NAC) who had subsequent axillary node clearance (ANC) at definitive breast surgery. Breast tumour and axillary response at MRI before, during and on completion of NAC, core biopsy tumour grade, tumour type and immunophenotype were correlated with pathological response in the breast and the number of metastatic nodes in the ANC specimens.ResultsOf 87 consecutive patients with MRI at baseline, interim and after neoadjuvant chemotherapy who underwent ANC at time of breast surgery, 33 (38%) had no residual macrometastatic axillary disease, 28 (32%) had 1–2 metastatic nodes and 26 (30%) had more than 2 metastatic nodes. Factors that predicted axillary nodal complete response were MRI complete response in the breast (p < 0.0001), HER2 positivity (p = 0.02) and non-lobular tumour type (p = 0.015).ConclusionMRI assessment of breast tumour response to NAC and core biopsy factors are predictive of response in axillary nodes, and can be used to guide decision making regarding appropriate axillary surgery.
Highlights
In the past two decades, sentinel node biopsy (SNB) has become standard practice for surgically staging the axilla in patients having primary surgery for clinically nodenegative breast cancers, replacing the more morbid procedure of axillary node clearance (ANC)
Of 176 patients treated with neoadjuvant chemotherapy (NAC) during the study period, 117 patients had core biopsy-confirmed axillary nodal metastasis prior to treatment
We have shown in this series that 38% of patients will have no residual macrometastatic axillary disease after NAC, which is similar to that of National Surgical Adjuvant Breast Project (NSABP) B-18 and American College of Surgeons Oncology Group trial (ACOSOG Z1071) with 37 and 41% respectively [26], and as such these patients could be spared ANC, with consideration of axillary radiotherapy
Summary
In the past two decades, sentinel node biopsy (SNB) has become standard practice for surgically staging the axilla in patients having primary surgery for clinically nodenegative breast cancers, replacing the more morbid procedure of axillary node clearance (ANC). Al-Hattali et al Cancer Imaging (2019) 19:91 lymph node biopsy after NAC in patients with initial biopsy-proven node-positive breast cancer demonstrated a false-negative rate with use of dual techniques of 11% compared with 19% with single mapping [13]. It confirmed findings from previous studies showing that a higher number of nodes removed improved accuracy (FNR 20% when one node was removed, 12% with two nodes removed and 4% with removal of three or more nodes) [14,15,16,17]. The aim of this study was to explore whether a combination of breast magnetic resonance imaging (MRI) assessed response and primary tumour pathology factors could identify a subset of patients that might be spared axillary node clearance
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