Abstract
Simple SummaryNeoadjuvant therapy instituted prior to definitive surgery helps to reduce the tumor burden in the breast and axilla. De-escalation of surgery in the axilla may allow removal of just the involved nodes and sentinel nodes for determination of pathological response of previously biopsy proven positive axillary nodes. In order to attain the optimal surgical results with minimum risk of complications, it is important to choose the accurate method of identification of these positive nodes. In this review, we examine the different options to assure identification of the nodes deemed positive before neoadjuvant therapy, at the time of definitive surgery.Increasing use of neoadjuvant therapy in large tumors or node positive disease in breast cancer patients or hormone negative and HER 2 overexpressing cancers often gives rise to complete clinical response, with resolution of disease in the breast and axilla. These results have raised important questions to deescalate loco-regional surgical treatment options with minimum recurrence risk and treatment related morbidity. Although there is excellent prognosis following clinical response, the primary goal of surgery still remains to confirm complete pathological response in the biopsied node that was previously positive and now clinically/radiologically negative (ycN0). Biopsied lymph nodes are often marked with a clip to allow future identification at the time of definitive surgery. The goal of lymph node surgery in oncology is that it should be accurate, hence the significance of localizing the biopsied node. This article aims to review the different options to localize the deemed positive node at the time of definitive surgery, in order to help determine pathological response after neoadjuvant therapy.
Highlights
Neoadjuvant systemic therapy neoadjuvant chemotherapy (NAC) has been traditionally used for locally advanced (Clinical T3N1-N3M0) and inflammatory breast cancer (T4d-N±) to make the tumor more operable
National Comprehensive Cancer Network (NCCN) guidelines for patients with node positive disease prior to NAC, recommends marking the positive biopsied lymph nodes in some form and their subsequent removal, and removing at least 3 sentinel nodes using the dual tracer method, to reduce the false negative rate (FNR) of sentinel lymph node biopsy (SLNB) to
NAC and performing understand the notionmorbidity, that identification lymphmarked nodes after mayisnot surgery with minimal retrievalof ofmetastatic this previously clipped node key.be critical if residual cancer cells are to be killed by adjuvant regional radiation or systemic therapy
Summary
Neoadjuvant systemic therapy neoadjuvant chemotherapy (NAC) has been traditionally used for locally advanced (Clinical T3N1-N3M0) and inflammatory breast cancer (T4d-N±) to make the tumor more operable. Patients who presented with complete clinical axillary response following NAC were subjected to SLNB and ALND, with false negative rate (FNR) ranging from 8.4% (in SN FNAC trial) to 14.2% (in SENTINA trial). All these trials had a pre-specified threshold cut off of FNR to be 10%. National Comprehensive Cancer Network (NCCN) guidelines for patients with node positive disease prior to NAC, recommends marking the positive biopsied lymph nodes in some form (by ink/clip/marker) and their subsequent removal, and removing at least 3 sentinel nodes using the dual tracer method, to reduce the FNR of SLNB to
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