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Surgical Management of the Axilla in Node-Negative and Node-Positive Disease at Diagnosis

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Management of the Breast and Axilla in the Neoadjuvant Setting

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Abstract

Neoadjuvant systemic therapy (NST) is increasingly used in early-stage breast cancer to downstage the extent of surgery in both breast and axilla. Neoadjuvant systemic therapy refers to neoadjuvant chemotherapy (NAC), neoadjuvant endocrine therapy (NET), and/or biological targeted and non-targeted agents. De-escalating axillary surgery is of particular interest because it may minimize associated morbidities such as lymphedema. Axillary surgical management following NAC is well studied, and there are several ongoing studies focusing on this topic. The bulk of this chapter will be focused on discussing axillary surgical management following NAC. Sentinel lymph node biopsy (SLNB) following NAC can be done accurately with false negative rates (FNR) comparable to upfront surgery for those patients who are clinically node negative (cN0) at presentation. SLNB following NAC is also accurate for patients who are clinically node positive (cN+) at presentation, when >2 lymph nodes are removed, along with some other surgical technique modifications reviewed in detail in this chapter. The long-term oncologic outcome following SLNB without axillary lymph node dissection (ALND) for cN+ patients following NAC is not known. Unlike the topic of axillary surgical management following NAC, where there is robust data and interest, the role of NET in axillary management is not well studied. Additionally, the oncologic significance of residual axillary disease following NET is not known. Further investigation is warranted to help answer these questions.

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References

  1. Giuliano AE, 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(6):569–75.

    Article  CAS  Google Scholar 

  2. Galimberti V, 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(4):297–305.

    Article  Google Scholar 

  3. Donker M, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014;15(12):1303–10.

    Article  Google Scholar 

  4. Fisher B, 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(7):2483–93.

    Article  CAS  Google Scholar 

  5. Bear HD, 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(22):4165–74.

    Article  CAS  Google Scholar 

  6. Rastogi P, et al. Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project Protocols B-18 and B-27. J Clin Oncol. 2008;26(5):778–85.

    Article  Google Scholar 

  7. Hunt KK, 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(4):558–66.

    Article  Google Scholar 

  8. Masuda N, et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017;376(22):2147–59.

    Article  CAS  Google Scholar 

  9. von Minckwitz G, et al. Trastuzumab emtansine for residual invasive HER2-positive breast cancer. N Engl J Med. 2019;380(7):617–28.

    Article  Google Scholar 

  10. Ellis MJ, et al. Randomized phase II neoadjuvant comparison between letrozole, anastrozole, and exemestane for postmenopausal women with estrogen receptor-rich stage 2 to 3 breast cancer: clinical and biomarker outcomes and predictive value of the baseline PAM50-based intrinsic subtype–ACOSOG Z1031. J Clin Oncol. 2011;29(17):2342–9.

    Article  CAS  Google Scholar 

  11. Montagna G, et al. How effective is neoadjuvant endocrine therapy (NET) in downstaging the axilla and achieving breast-conserving surgery? Ann Surg Oncol. 2020;27(12):4702–10.

    Article  Google Scholar 

  12. Stafford A, et al. Axillary response in patients undergoing neoadjuvant endocrine treatment for node-positive breast cancer: systematic literature review and NCDB analysis. Ann Surg Oncol. 2020;27(12):4669–77.

    Article  Google Scholar 

  13. Kantor O, et al. Prognostic significance of residual nodal disease after neoadjuvant endocrine therapy for hormone receptor-positive breast cancer. NPJ Breast Cancer. 2020;6:35.

    Article  CAS  Google Scholar 

  14. King TA, Morrow M. Surgical issues in patients with breast cancer receiving neoadjuvant chemotherapy. Nat Rev Clin Oncol. 2015;12(6):335–43.

    Article  Google Scholar 

  15. Mamounas EP, et al. Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2005;23(12):2694–702.

    Article  Google Scholar 

  16. Pilewskie M, Morrow M. Axillary nodal management following neoadjuvant chemotherapy: a review. JAMA Oncol. 2017;3(4):549–55.

    Article  Google Scholar 

  17. Mamounas EP, et al. Predictors of locoregional recurrence after neoadjuvant chemotherapy: results from combined analysis of National Surgical Adjuvant Breast and Bowel Project B-18 and B-27. J Clin Oncol. 2012;30(32):3960–6.

    Article  Google Scholar 

  18. Classe JM, 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(5):726–32.

    Article  Google Scholar 

  19. Classe JM, et al. Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: the GANEA 2 study. Breast Cancer Res Treat. 2019;173(2):343–52.

    Article  Google Scholar 

  20. de Munck L, Sonke GS, van Dalen T, van Diest PJ, van den Bongard HJ, Peeters PH, Rutgers EJ. Population based study on sentinel node biopsy before or after neoadjuvant chemotherapy in clinically node negative breast cancer patients: identification rate and influence on axillary treatment. Eur J Cancer. 2015;51(8):915–21.

    Article  Google Scholar 

  21. Dauphine C, et al. Axillary recurrence after sentinel lymph node biopsy for breast cancer. Am Surg. 2010;76(10):1127–9.

    Article  Google Scholar 

  22. Boughey JC, 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(4):608–14. discussion 614-6

    Article  Google Scholar 

  23. Boughey JC, 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(14):1455–61.

    Article  CAS  Google Scholar 

  24. Boughey JC, et al. Abstract P2-01-02: methods impacting the false negative rate of sentinel lymph node surgery in patients presenting with node positive breast cancer (T0-T4,N1-2) who receive neoadjuvant chemotherapy – results from a prospective trial – ACOSOG Z1071 (Alliance). Cancer Res. 2015;75(9 Supplement):P2. -01-02-P2-01-02

    Google Scholar 

  25. Boughey JC, et al. Axillary ultrasound after neoadjuvant chemotherapy and its impact on sentinel lymph node surgery: results from the American College of Surgeons Oncology Group Z1071 Trial (Alliance). J Clin Oncol. 2015;33(30):3386–93.

    Article  CAS  Google Scholar 

  26. Kuehn 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(7):609–18.

    Article  Google Scholar 

  27. Boileau JF, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015;33(3):258–64.

    Article  Google Scholar 

  28. Boughey JC, et al. Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 2016;263(4):802–7.

    Article  Google Scholar 

  29. Caudle AS, et al. Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 2016;34(10):1072–8.

    Article  CAS  Google Scholar 

  30. Caudle AS, et al. Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg. 2015;150(2):137–43.

    Article  Google Scholar 

  31. Diego EJ, 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(5):1549–53.

    Article  Google Scholar 

  32. National Comprehensive Cancer Network (NCCN). Breast cancer (Version 6.2020). Accessed 27 Nov 2020. Available from: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

  33. Caudle AS, et al. Use of sentinel lymph node dissection after neoadjuvant chemotherapy in patients with node-positive breast cancer at diagnosis: practice patterns of American Society of Breast Surgeons Members. Ann Surg Oncol. 2017;24(10):2925–34.

    Article  Google Scholar 

  34. Wong SM, et al. Surgical management of the axilla in clinically node-positive patients receiving neoadjuvant chemotherapy: a national cancer database analysis. Ann Surg Oncol. 2019;26(11):3517–25.

    Article  Google Scholar 

  35. Liu J, et al. The role of postmastectomy radiotherapy in clinically node-positive, stage II-III breast cancer patients with pathological negative nodes after neoadjuvant chemotherapy: an analysis from the NCDB. Oncotarget. 2016;7(17):24848–59.

    Article  Google Scholar 

  36. Cho WK, et al. The benefit of post-mastectomy radiotherapy in ypN0 patients after neoadjuvant chemotherapy according to molecular subtypes. J Breast Cancer. 2019;22(2):285–96.

    Article  Google Scholar 

  37. A011202 trial. Accessed 23 Jan 2021. Available from: https://clinicaltrials.gov/ct2/show/NCT01901094

  38. ATNEC trial. Accessed 23 Jan 2021. Available from: https://clinicaltrials.gov/ct2/show/NCT04109079

  39. TAXIS trial. Accessed 23 Jan 2021. Available from: https://clinicaltrials.gov/ct2/show/NCT04109079

  40. NSABP B-51/RTOG 1304 trial. Accessed 23 Jan 2021. Available from: https://clinicaltrials.gov/ct2/show/NCT01872975

  41. NEONOD2 trial. Accessed 23 Jan 2021. Available from: https://clinicaltrials.gov/ct2/show/NCT04019678

  42. Cortazar P, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet. 2014;384(9938):164–72.

    Article  Google Scholar 

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Authors and Affiliations

  1. Breast Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA

    Joanna S. Lee, Priscilla F. McAuliffe & Ronald R. Johnson

Authors
  1. Joanna S. Lee
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  2. Priscilla F. McAuliffe
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  3. Ronald R. Johnson
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Corresponding author

Correspondence to Ronald R. Johnson .

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Editors and Affiliations

  1. Breast Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Atilla Soran

  2. Dana-Farber Harvard Cancer Centar, Brigham and Women’s Hospital, Boston, MA, USA

    Faina Nakhlis

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Lee, J.S., McAuliffe, P.F., Johnson, R.R. (2022). Surgical Management of the Axilla in Node-Negative and Node-Positive Disease at Diagnosis. In: Soran, A., Nakhlis, F. (eds) Management of the Breast and Axilla in the Neoadjuvant Setting. Springer, Cham. https://doi.org/10.1007/978-3-030-88020-0_10

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  • DOI: https://doi.org/10.1007/978-3-030-88020-0_10

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-88019-4

  • Online ISBN: 978-3-030-88020-0

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