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The Optimal Treatment Plan to Avoid Axillary Lymph Node Dissection in Early-Stage Breast Cancer Patients Differs by Surgical Strategy and Tumor Subtype

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Strategies to reduce the likelihood of axillary lymph node dissection (ALND) include application of Z0011 or use of neoadjuvant chemotherapy (NAC). Indications for ALND differ by treatment plan, and nodal pathologic complete response rates after NAC vary by tumor subtype. This study compared ALND rates for cT1-2N0 tumors treated with upfront surgery versus those treated with NAC.

Methods

The ALND rates for cT1-2N0 breast cancer patients were compared by tumor subtype among women undergoing upfront surgery to NAC. Multivariable analysis with control for age, cT stage, and lymphovascular invasion, and stratification by subtype was performed.

Results

The study identified 1944 cancers in 1907 women who underwent sentinel lymph node (SLN) biopsy with or without ALND (669 upfront breast-conserving surgeries [BCSs], 1004 upfront mastectomies, 271 NACs). Compared with the NAC group, the ALND rates in the BCS group were lower for estrogen receptor (ER), progesterone receptor-positive (PR+), human epidermal growth factor 2-negative (HER2−) tumors (15 vs 34%; p < 0.001). The ALND rates in the upfront mastectomy group were higher than in the NAC group for HER2+ or TN tumors. In the multivariable analysis, receipt of NAC compared with upfront BCS remained significantly associated with higher odds of ALND in the ER/PR+ HER2− subtype (hazard ratio [HR], 3.35; p < 0.001), whereas NAC versus upfront mastectomy remained significantly associated with lower odds of ALND in the HER2+ and TN subtypes (HR for HER2+, 0.19, p < 0.001; HR for TN, 0.25, p = 0.007).

Conclusion

The study showed that ALND rates differ according to surgery type and tumor subtype secondary to differing ALND indications and nodal response to NAC. These factors can be used to personalize treatment planning to minimize ALND risk for patients with early-stage breast cancer.

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References

  1. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg. 2010;252:426–32; discussion 432–3.

  3. Bear HD, Anderson S, Brown A, et al. The effect on tumor response of adding sequential preoperative docetaxel to preoperative doxorubicin and cyclophosphamide: preliminary results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2003;21:4165–74.

    Article  CAS  PubMed  Google Scholar 

  4. Fisher B, Brown A, Mamounas E, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol. 1997;15:2483–93.

    Article  CAS  PubMed  Google Scholar 

  5. Hunt KK, Yi M, Mittendorf EA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients. Ann Surg. 2009;250:558–66.

    PubMed  Google Scholar 

  6. National Comprehensive Cancer Network. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology, version 2, 2016. Retrieved 28 February at https://www.nccn.org/professionals/physician_gls/f_guidelines_nojava.asp.

  7. Zhang GC, Zhang YF, Xu FP, et al. Axillary lymph node status, adjusted for pathologic complete response in breast and axilla after neoadjuvant chemotherapy, predicts differential disease-free survival in breast cancer. Curr Oncol. 2013;20:e180–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Boughey JC, McCall LM, Ballman KV, et al. Tumor biology correlates with rates of breast-conserving surgery and pathologic complete response after neoadjuvant chemotherapy for breast cancer: findings from the ACOSOG Z1071 (Alliance) Prospective Multicenter Clinical Trial. Ann Surg. 2014;260:608–14; discussion 614–6.

  9. Kim JY, Park HS, Kim S, et al. Prognostic nomogram for prediction of axillary pathologic complete response after neoadjuvant chemotherapy in cytologically proven node-positive breast cancer. Med. Balt. 2015;94:e1720.

    Article  CAS  Google Scholar 

  10. Mamtani A, Barrio AV, King TA, et al. How often does neoadjuvant chemotherapy avoid axillary dissection in patients with histologically confirmed nodal metastases? Results of a prospective study. Ann Surg Oncol. 23(11), 3467–3474 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  11. Ashikaga T, Krag DN, Land SR, et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010;102:111–8.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007;25:3657–63.

    Article  PubMed  Google Scholar 

  13. Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst. 2006;98:599–609.

    Article  PubMed  Google Scholar 

  14. Giuliano AE, Ballman K, McCall L, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial. Ann Surg. 2016;264:413–20.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Dengel LT, Van Zee KJ, King TA, et al. Axillary dissection can be avoided in the majority of clinically node-negative patients undergoing breast-conserving therapy. Ann Surg Oncol. 2014;21:22–7.

    Article  PubMed  Google Scholar 

  16. Xing Y, Foy M, Cox DD, et al. Meta-analysis of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer. Br J Surg. 2006;93:539–46.

    Article  CAS  PubMed  Google Scholar 

  17. van Deurzen CH, Vriens BE, Tjan-Heijnen VC, et al. Accuracy of sentinel node biopsy after neoadjuvant chemotherapy in breast cancer patients: a systematic review. Eur J Cancer. 2009;45:3124–30.

    Article  PubMed  Google Scholar 

  18. Classe JM, Bordes V, Campion L, et al. Sentinel lymph node biopsy after neoadjuvant chemotherapy for advanced breast cancer: results of Ganglion Sentinelle et Chimiotherapie Neoadjuvante, a French prospective multicentric study. J Clin Oncol. 2009;27:726–32.

    Article  PubMed  Google Scholar 

  19. Tan VK, Goh BK, Fook-Chong S, et al. 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. J Surg Oncol. 2011;104:97–103.

    Article  PubMed  Google Scholar 

  20. Kelly AM, Dwamena B, Cronin P, et al. Breast cancer sentinel node identification and classification after neoadjuvant chemotherapy: systematic review and meta analysis. Acad Radiol. 2009;16:551–63.

    Article  PubMed  Google Scholar 

  21. Kuehn T, Bauerfeind I, Fehm T, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013;14:609–18.

    Article  PubMed  Google Scholar 

  22. Boughey JC, Suman VJ, Mittendorf EA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Boileau JF, Poirier B, Basik M, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015;33:258–64.

    Article  PubMed  Google Scholar 

  24. Mamtani A, Patil S, Van Zee KJ, et al. Age and receptor status do not indicate the need for axillary dissection in patients with sentinel lymph node metastases. Ann Surg Oncol. 2016;23:3481–6.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Diego EJ, McAuliffe PF, Soran A, et al. Axillary staging after neoadjuvant chemotherapy for breast cancer: a pilot study combining sentinel lymph node biopsy with radioactive seed localization of pre-treatment positive axillary lymph nodes. Ann Surg Oncol. 2016;23:1549–53.

    Article  PubMed  Google Scholar 

  26. McCartan D, Stempel M, Eaton A, et al. Impact of body mass index on clinical axillary nodal assessment in breast cancer patients. Ann Surg Oncol. 2016;23:3324–9.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Pilewskie M, Jochelson M, Gooch JC, et al. Is preoperative axillary imaging beneficial in identifying clinically node-negative patients requiring axillary lymph node dissection? J Am Coll Surg. 2016;222:138–45.

    Article  PubMed  Google Scholar 

  28. Barrio AV, Mamtani A, Eaton A, et al. Is routine axillary imaging necessary in clinically node-negative patients undergoing neoadjuvant chemotherapy? Ann Surg Oncol. 2017;24:645–51.

    Article  PubMed  Google Scholar 

  29. Tolaney SM, Barry WT, Dang CT, et al. Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer. N Engl J Med. 2015;372:134–41.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Denduluri N, Somerfield MR, Eisen A, et al. Selection of optimal adjuvant chemotherapy regimens for human epidermal growth factor receptor 2 (HER2)-negative and adjuvant targeted therapy for HER2-positive breast cancers: an American Society of Clinical Oncology Guideline Adaptation of the Cancer Care Ontario Clinical Practice Guideline. J Clin Oncol. 2016;34:2416–27.

    Article  CAS  PubMed  Google Scholar 

  31. Galimberti V, Cole BF, Zurrida S, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013;14:297–305.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Mamtani A, Patil S, Stempel M, et al. Axillary micrometastases are not an indication for postmastectomy radiotherapy in stages 1 and 2 breast cancer. Presented at the Society of Surgical Oncology Annual Cancer Symposium, 15–18 March 2017, Seattle Washington.

  33. Gooch J, King TA, Eaton A, et al. The extent of extracapsular extension may influence the need for axillary lymph node dissection in patients with T1–T2 breast cancer. Ann Surg Oncol. 2014;21:2897–903.

    Article  PubMed  PubMed Central  Google Scholar 

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Disclosure

The preparation of this manuscript was funded in part by NIH/NCI Cancer Center Support Grant No. P30 CA008748 to Memorial Sloan Kettering Cancer Center.

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Authors and Affiliations

  1. Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Melissa Pilewskie MD, Anita Mamtani MD, Andrea V. Barrio MD, Michelle Stempel MPH & Monica Morrow MD

  2. Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Emily C. Zabor MS

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  1. Melissa Pilewskie MD
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  2. Emily C. Zabor MS
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  3. Anita Mamtani MD
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Correspondence to Melissa Pilewskie MD.

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Pilewskie, M., Zabor, E.C., Mamtani, A. et al. The Optimal Treatment Plan to Avoid Axillary Lymph Node Dissection in Early-Stage Breast Cancer Patients Differs by Surgical Strategy and Tumor Subtype. Ann Surg Oncol 24, 3527–3533 (2017). https://doi.org/10.1245/s10434-017-6016-y

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  • DOI: https://doi.org/10.1245/s10434-017-6016-y

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