Leveraging Neoadjuvant Chemotherapy to Minimize the Burden of Axillary Surgery: a Review of Current Strategies and Surgi
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LOCAL-REGIONAL EVALUATION AND THERAPY (A KONG, SECTION EDITOR)
Leveraging Neoadjuvant Chemotherapy to Minimize the Burden of Axillary Surgery: a Review of Current Strategies and Surgical Techniques Alison Laws 1
&
Michelle C. Specht 1
Accepted: 16 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review Axillary nodal disease is significantly less likely in both clinically node-negative (cN0) and node-positive (cN+) breast cancer patients after neoadjuvant chemotherapy (NAC). There have thus been significant efforts to “de-escalate” axillary surgery in this setting. This review discusses modern axillary surgical paradigms and techniques after NAC. Recent Findings In cN0 patients, the accuracy and feasibility of sentinel lymph node biopsy (SLNB) after NAC is wellestablished, with prospective evidence supporting its oncologic safety. SLNB is also acceptable in select cN+ patients when certain criteria are met. There is mounting “real-world” evidence for the technical feasibility of this approach, including various methods of localizing and excising biopsy-proven nodes, with the ability to avoid axillary lymph node dissection in a substantial proportion of patients. However, outcome data is limited to small retrospective series. Summary In appropriately selected patients, there is increasing opportunity to leverage the benefits of NAC to minimize the burden of axillary surgery. Keywords Breast cancer . Neoadjuvant chemotherapy . Sentinel lymph node biopsy . Targeted axillary dissection . Axillary localization . Oncologic outcomes
Introduction Increasingly, neoadjuvant chemotherapy (NAC) is used for treatment of breast cancer and has numerous advantages [1, 2]. Response to NAC, particularly attaining a pathologic complete response (pCR), has important prognostic implications [3–5], and recent trials have demonstrated a survival advantage to tailoring therapy in the adjuvant setting based on this response [6, 7]. From a locoregional therapy perspective, patients with large tumors may be down-sized to facilitate breast conservation [4, 5, 8, 9]. The likelihood of disease eradication in the axilla is even greater than in the breast; in the early NSABP B-18 and B-27 trials comparing neoadjuvant versus adjuvant chemotherapy, nodal disease was significantly less
likely in both clinically node-negative (cN0) and nodepositive (cN+) patients [4, 5]. With modern chemotherapy, axillary pCR in cN+ patients are approximately 35–40% overall [10, 11, 12••, 13]. As a result, there have been significant efforts to “de-escalate” axillary surgery after NAC, by identifying patients with no residual nodal disease who may avoid the morbidity of axillary lymph node dissection (ALND). As compared to ALND, sentinel lymph node biopsy (SLNB) carries less risk of wound infections and seromas, shoulder mobility deficits, paresthesias, and lymphedema [14, 15]. However, attempts to minimize the burden of axillary surgery must balance the need to maintain accurate axillary staging and oncolog
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