Swedish prospective multicenter trial on the accuracy and clinical relevance of sentinel lymph node biopsy before neoadjuvant systemic therapy in breast cancer

Fuat Celebioglu,Jan Frisell,Linda Zetterlund,Jana De Boniface,Rimma Axelsson

doi:10.1007/s10549-017-4163-2

Abstract

PurposeThe timing of sentinel lymph node biopsy (SLNB) in the context of neoadjuvant systemic therapy (NAST) in breast cancer is still controversial. SLNB before NAST has been evaluated in few single-institution studies in which axillary lymph node dissection (ALND), however, was commonly not performed in case of a negative SLNB. We investigated the potential clinical relevance of SLNB before NAST by performing ALND in all patients after NAST.MethodsThis national multicenter trial prospectively enrolled clinically node-negative breast cancer patients planned for NAST at 13 recruiting Swedish hospitals between October 2010 and December 2015. SLNB before NAST was followed by ALND after NAST in all individuals. Repeat SLNB after NAST was encouraged but not mandatory.ResultsSLNB before NAST was performed in 224 patients. The identification rate was 100% (224/224). The proportion of patients with a negative SLNB before NAST but positive axillary lymph nodes after NAST was 7.4% (nine of 121 patients, 95% CI 4.0–13.5). Among those with a positive SLNB before NAST, 23.2% (86/112) had further positive lymph nodes after NAST.ConclusionsIn clinically node-negative patients, SLNB before NAST is highly reliable. With this sequence, ALND and regional radiotherapy can be safely omitted in patients with a negative SLNB provided good clinical response to NAST. Additionally, SLNB-positive patients upfront will receive correct nodal staging unaffected by NAST and be consequently offered adjuvant locoregional treatment according to current guidelines pending the results of ongoing randomized trials.

Highlights

Sentinel lymph node biopsy (SLNB) is gold standard for axillary nodal staging in early-stage breast cancer
We investigated the potential clinical relevance of sentinel lymph node biopsy (SLNB) before neoadjuvant systemic therapy (NAST) by performing axillary lymph node dissection (ALND) in all patients after NAST
This is comparable to the False negative rates (FNR) in early-stage breast cancer [27], even though it cannot be ruled out that nodal metastases could have developed during the course of NAST in our trial, and a direct comparison may be difficult

Summary

Introduction

Sentinel lymph node biopsy (SLNB) is gold standard for axillary nodal staging in early-stage breast cancer. Longterm follow-up has not shown any significant difference in survival or regional control when omitting axillary lymph node dissection (ALND) after a negative SLNB [1]. Indications for neoadjuvant systemic therapy (NAST) have been extended to encompass locally advanced and early operable stages of the disease. Only half of patients planned for NAST show nodal involvement at presentation, and an additional 20–40% will be downstaged to node negativity during treatment [3]. ALND is the traditional staging procedure in the neoadjuvant setting but is associated with significant arm morbidity which is further aggravated by regional radiotherapy [4]. SLNB has been studied in several trials outlined below; the timing in relation to NAST, remains controversial

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Discussion

Conclusion