Abstract
PurposeHigh-performing imaging and predictive markers are warranted to minimize surgical overtreatment of the axilla in breast cancer (BC) patients receiving neoadjuvant chemotherapy (NACT). Here we have investigated whether axillary ultrasound (AUS) could identify axillary lymph node (ALN) metastasis (ALNM) pre-NACT and post-NACT for BC. The association of tumor, AUS features and mammographic density (MD) with axillary-pathological complete response (axillary-pCR) post-NACT was also assessed.MethodsThe NeoDense-study cohort (N = 202, NACT during 2014–2019), constituted a pre-NACT cohort, whereas patients whom had a cytology verified ALNM pre-NACT and an axillary dissection performed (N = 114) defined a post-NACT cohort. AUS characteristics were prospectively collected pre- and post-NACT. The diagnostic accuracy of AUS was evaluated and stratified by histological subtype and body mass index (BMI). Predictors of axillary-pCR were analyzed, including MD, using simple and multivariable logistic regression models.ResultsAUS demonstrated superior performance for prediction of ALNM pre-NACT in comparison to post-NACT, as reflected by the positive predictive value (PPV) 0.94 (95% CI 0.89–0.97) and PPV 0.76 (95% CI 0.62–0.87), respectively. We found no difference in AUS performance according to neither BMI nor histological subtype. Independent predictors of axillary-pCR were: premenopausal status, ER-negativity, HER2-overexpression, and high MD.ConclusionBaseline AUS could, to a large extent, identify ALNM; however, post-NACT, AUS was insufficient to determine remaining ALNM. Thus, our results support the surgical staging of the axilla post-NACT. Baseline tumor biomarkers and patient characteristics were predictive of axillary-pCR. Larger, multicenter studies are needed to evaluate the performance of AUS post-NACT.
Highlights
Neoadjuvant chemotherapy (NACT) is the recommended treatment option for breast cancer (BC) patients with axillary lymph node (ALN)-positive disease [1]
The SENTINA trial was designed to evaluate the timing of sentinel lymph node biopsy (SLNB) in the NACT setting and the objective of the Z1071 trial was to determine the false-negative rate (FNR) for sentinel node (SLN) surgery following chemotherapy in women initially presenting with biopsy-proven cN1 BC
The SLN FNR was not different based on axillary ultrasound (AUS) results; using a strategy where only patients with normal AUS undergo SLN surgery reduced the FNR in patients with ≥ two SLNs removed included in the Z1071 trial from 12.6 to 9.8% when preoperative AUS results are considered as part of SLN surgery [8]
Summary
Neoadjuvant chemotherapy (NACT) is the recommended treatment option for breast cancer (BC) patients with axillary lymph node (ALN)-positive disease [1]. The SENTINA trial was designed to evaluate the timing of sentinel lymph node biopsy (SLNB) in the NACT setting and the objective of the Z1071 trial was to determine the false-negative rate (FNR) for sentinel node (SLN) surgery following chemotherapy in women initially presenting with biopsy-proven cN1 BC. In both studies, the primary endpoint was FNR of SLNB after NACT in patients presenting with upfront cN1 disease. The SLN FNR was not different based on axillary ultrasound (AUS) results; using a strategy where only patients with normal AUS undergo SLN surgery reduced the FNR in patients with ≥ two SLNs removed included in the Z1071 trial from 12.6 to 9.8% when preoperative AUS results are considered as part of SLN surgery [8]
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