Avoiding axillary lymphadenectomy in n+ triple-negative, her2-positive breast cancer after neoadjuvant chemotherapy
Journal: Advances in Medicine and Engineering Interdisciplinary Research DOI: 10.32629/ameir.v3i4.4851
Abstract
To evaluate the omission of the axillary lymphadenectomy in patients with N1 breast cancer negative triple and HER2-positive who showed an axillary response after neoadjuvant chemotherapy, and identify the axillary response in relation to the molecular subtypes. It is a description of the technique and the presentation of our experience. Method: A descriptive, retrospective study of 100 patients with cT1-T3/N1/M0 stage who received primary systemic therapy between January 2020 and January 2024; 72 of them received chemotherapy and/or anti-HER2 therapy and 28 hormonal therapies; biopsy and marking of the suspicious lymph node with nitinolÒ clips (maximum 3) was performed. In the surgery, a harpoon was placed in the axillary node + BSGC with 99mTc and methylene blue. Results: An axillary response was achieved in 52/100 cases (52 %), in 34/52 (65.3 %) it was a complete pathological response pCR and in 18/52 isolated tumor cells or micro metastases. Macrometastasis was observed in 48/100 (48 %) and therefore axillar lymphadenectomy (33) or axillary radiation therapy (15) was performed. The axillary response occurred in: Luminal A: 26 %, Luminal B: 42 %, HER2-positive 87 % and triple negative 77 %. The mean lymph node was 3.05. Conclusions: The 52 % of the cohort had an axillary response, thus avoiding the lymphadenectomy. Luminal A is scarce, the intention to negativize the armpit is controversial. The target axillary dissection is an oncological safe procedure; not less than the axillar lymphadenectomy.
Keywords
cancer; breast; neoadjuvant; chemotherapy; target axillary dissection; primary systemic treatment
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[2] Sociedad Española de Oncología Médica. SEOM. Las cifras de cáncer de España. (consultado 09 de agosto 2023), Disponible en: URL: www.seom.org.
[3] Giuliano A, Kirgan D, Guenther M, Morton D. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994; 220(3):391-401.
[4] Giuliano A. The evolution of sentinel node biopsy for breast cancer: Personal experience. Breast J. 2020;26(1):17-21.
[5] Krag D, Weaver D, Ashikaga T, Moffat F, Klimberg V, Shriver C, et al. The sentinel node in breast cancer - a multicenter validation study. N EnglJ Med. 1998;339:941-946.
[6] Fisher B, Brown B, Mamounas E, Wieand S, Robidoux A, Margolese RG, 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: 2483-2493.
[7] Mansel RE, Fallowfield L, Kissin A, Goyal RG, Newcombe J, Dixon M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANACH trial. J Natl Cancer Inst. 2006;98:599-609.
[8] Ashikaga T, Krag DN, Land SR, Julian TB, Anderson SJ, Brown AM, et al. Morbidity results of the NASBP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010;102:111-118.
[9] Veronesi U, Paganelli G, Viale A, Luini S, Zurrida V. Galimberti V, et al. A randomized comparison of sentinel node biopsy with routine axillary dissection in breast cancer. N EnglJ Med. 2003;349:546-553.
[10] Giuliano A, Ballman K, McCall L, Beitsch PD, Brennan MB, Kelemen PR, et al. Effect of axillary dissection vs. no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis. The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017;318(10):918-926.
[11] García-Etienne C, Mansel R, Tomatis M, Heil J, Bingazoil L, Ferrari A, et al. Trends in axillary node dissection for early-stage breast cancer in Europe: Impact of evidence on practice. Breast. 2019;45:89-96.
[12] Galimberti V, Cole BF, Viale G, Veronesi P, Vicini E, Intra M, et al. International Breast Cancer Study Group Trial 23-01. Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol. 2018;19(10):1385-1393.
[13] Budzar AU, Valero V, Ibrahim NK, Francis D, Broglio KR, RTheriault RL, et al. Neoadjuvant therapy with paclitaxel followed by 5-fluorouracil, epirubicin, and cyclophosphamide chemotherapy and concurrent trastuzumab in human epidermal growth factor receptor 2-positive operable breast cancer: An update of the initial randomized study population and data of additional patients treated with the same regimen. Clin. Cancer Res. 2007;13:228-233.
[14] Mamtani AV, Barrio TA, King KJ, VanZee G, Plitas M, Pilewskie, et al. How often does neoadjuvant chemotherapy avoid axillary dissection in patients with histologically confirmed nodal metastasis ? Results ofa prospective study. Ann Surg Oncol. 2016;23:3467-3474.
[15] Hennessy BT, Hortobagyi GN, Rouzier R, Kuerer H, N. Sneige A,Budzar U, et al.Outcome after pathological complete eradication of cytologically proven breast cancer node metastases following primary chemotherapy. J Clin Oncol. 2005;23:9304-9311.
[16] Cortazar P, Zhang L, Untch M, Mehta K, Costantino JP, Wolmark N, et al. Pathological complete response and long-term clinical benefit in breast cancer: The CTNeoBC pooled analysis. Lancet. 2014;384:164-172.
[17] Mamounas EP, Brown A, Anderson S, Smith R, Julian T, Miller B, Bear HD, 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.
[18] Kuehn T, Bauerfeind I, Fehm T, Fleige B, Hausschild M, Helms G, 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;14:609-618.
[19] Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: The ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455-1461.
[20] Donker M, Straver ME, Wesseling J, Loo CE, Schot M, Drukker CA, et al. Making axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients: The MARI procedure. Ann Surg. 2015;261(2):378-382.
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[22] Moo TA, Edelweiss M, Hajiyeva S, Stempel M, Raiss M, Zabor EC, et al. Is low-volume gisease in the sentinel node after neoadjuvant chemotherapy an indication for axillary dissection? Ann Surg Oncol. 2018;25(6):1488-1494.
[23] Tinterri C, Canavese G, Bruzzi P, Dozin B. NEONOD 2: Rationale and design of a multicenter non- inferiority trial to assess the effect of axillary surgery omission on the outcome of breast cancer patients presenting only micrometastasis in the sentinel lymph node after neoadjuvant chemotherapy. Contemp Clin Trials Commun. 2019;23;17:100496.
[24] Peg V, Sansano I, Vieites B, Bernet L, Cano R, Córdoba A, et al. Role of total tumour load of sentinel lymph node on survival in early breast cancer patients. Breast. 2017;33:8-13.
[25] Van Nijnatten TJ, SimonsJM, MoossdorffM, de Munck L, Lobbes MB, van der Pol CC, et al. Prognosis of residual axillary disease after neoadjuvant chemotherapy in clinically node-posiIve breast cancer patients: Isolated tumor cells and micrometastases carry a beter prognosis than macrometastases. Breast Cancer Res Treat. 2017;163(1):159-166.
[26] Galimberti V, Ribeiro Fontana SK, Vicini E, Morigi C, Sargenti M, et al. "This house believes that: Sentinel node biopsy alone is better than TAD after NACT for cN+ patients". Breast. 2023;67:21-25.
[27] Barrio AV, Montagna G, Mamtani A, Sevilimedu V, Edelweiss M, Capko D, et al. Nodal recurrence in patients with node-positive breast cancer treated with sentinel node biopsy alone after neoadjuvant chemotherapy-a rare event. JAMA Oncol. 2021;7(12):1851-1855.
[28] Moral P, Delgado S, Ballester H, Ponce J, Martin T, Peiró G. Biopsia del ganglio centinela y disección axilar dirigida en mujeres con cáncer de mama y axila positiva en el momento del diagnóstico: caminando hacia el futuro. Revista de Senología y Patología Mamaria. 2023;(36): 100402.
[29] Piltin MA, Hoskin TL, Day CN, Davis J Jr, Boughey JC. Oncologic outcomes of sentinel lymph node surgery after neoadjuvant chemotherapy for node-positive breast cancer. Ann Surg Oncol. 2020 ;27(12):4795-4801.
[30] Vento G, Fuster C, Maisto V, Rios A, Gavilá J, Guerrero A, et al. Disección axilar dirigida tras tratamiento sistémico primario en cáncer de mama N1. Validación de la técnica y experiencia a los 4 años. Rev Senol Patol Mamar. 2024;37(3):100605.
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