Selecting Node-Positive Patients for Axillary Downstaging with Neoadjuvant Chemotherapy
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ORIGINAL ARTICLE – BREAST ONCOLOGY
Selecting Node-Positive Patients for Axillary Downstaging with Neoadjuvant Chemotherapy Giacomo Montagna, MD1, Anita Mamtani, MD1, Andrea Knezevic, MS2, Edi Brogi, MD, PhD3, Andrea V. Barrio, MD1, and Monica Morrow, MD1 1
Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; 2Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY; 3Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
ABSTRACT Background. Axillary lymph node dissection (ALND) can be avoided in node-positive patients who receive neoadjuvant chemotherapy (NAC) if three or more negative sentinel lymph nodes (SLNs) are retrieved. We evaluate how often node-positive patients avoid ALND with NAC, and identify predictors of identification of three or more SLNs and of nodal pathological complete response (pCR). Methods. From November 2013 to July 2019, all patients with cT1-3, biopsy-proven N1 tumors who converted to cN0 after NAC received SLN biopsy (SLNB) with dual mapping and were identified from a prospectively maintained database. Results. 630 consecutive N1 patients were eligible for axillary downstaging with NAC; 573 (91%) converted to cN0 and had SLNB, and 531 patients (93%) had three or more SLNs identified. Lymphovascular invasion (LVI; odds ratio [OR] 0.46, 95% confidence interval [CI] 0.24–0.87; p = 0.02) and increasing body mass index (BMI; OR 0.77, 95% CI 0.62–0.96 per 5-unit increase; p = 0.02) were significantly associated with failure to identify three or more SLNs. 255/573 (46%) patients achieved nodal pCR; 237 (41%) had adequate mapping. Factors associated with ALND avoidance included high grade (OR 2.51, 95% CI 1.6–3.94, p = 0.001) and receptor status (HR?/HER2- [referent]: OR 1.99, 95% CI
Ó Society of Surgical Oncology 2020 First Received: 23 March 2020 M. Morrow, MD e-mail: [email protected]
1.15–3.46 [p = 0.01] for HR-/HER2-, OR 3.93, 95% CI 2.40–6.44 [p \ 0.001] for HR?/HER2?, and OR 8.24, 95% CI 4.16–16.3 [p \ 0.001] for HR-/HER2?). LVI was associated with a lower likelihood of avoiding ALND (OR 0.28, 95% CI 0.18–0.43; p \ 0.001). Conclusions. ALND was avoided in 41% of cN1 patients after NAC. Increased BMI and LVI were associated with lower retrieval rates of three or more SLNs. ALND avoidance rates varied with receptor status, grade, and LVI. These factors help select patients most likely to avoid ALND.
Indications for neoadjuvant chemotherapy (NAC) have evolved over time.1 Currently, in patients who are clinically node positive at presentation, NAC is administered with the aim of achieving nodal pathological complete response (pCR) and de-escalating axillary surgery.2–5 The rate of nodal response depends on tumor biology, with lower rates in hormone receptor positive (HR?)/human epidermal growth factor receptor 2 negative (HER2-) tumors, and higher rates in triple negative (TN) and HER2 positive (HER2?) tumors.3,6,7 Patients who become clinically node negative
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