A comparison of sentinel node biopsy before and after neoadjuvant chemotherapy: Timing is important

Department of Surgical Oncology, Massachusetts General Hospital, 55 Fruit St., Yawkey Building, 7th Floor, Boston, MA 02114, USA.
The American Journal of Surgery (Impact Factor: 2.29). 11/2005; 190(4):517-20. DOI: 10.1016/j.amjsurg.2005.06.004
Source: PubMed

ABSTRACT Because neoadjuvant chemotherapy is being used more frequently, the optimal timing of sentinel node biopsy (SNB) remains controversial. We previously evaluated the predictive value of SNB before neoadjuvant chemotherapy in clinically node-negative breast cancer. Our identification rate of the sentinel node among 52 patients before chemotherapy with a mean tumor size of 4 cm was 100%. In this study, we compared the identification rates of SNB before and after neoadjuvant chemotherapy and evaluated the false-negative rate of SNB after chemotherapy.
A retrospective institutional database review identified 36 women who underwent SNB after neoadjuvant chemotherapy for breast cancer from 1999 to 2004. The initial clinical tumor size and lymph node status, SNB pathology, axillary lymph node dissection pathology, and residual pathologic tumor size were reviewed.
Sixteen of 36 patients had a clinically negative axilla before neoadjuvant therapy. SNB after neoadjuvant therapy was successful in 29 patients (80.6%), although 7 patients did not map (19.4%). Six of the 7 patients who failed to map had a clinically positive axilla initially. Axillary disease was found in 6 of 7 of these patients at dissection (85.7%). Of the 29 patients who mapped successfully, 13 (45%) were SNB negative, and 16 (55%) were SNB positive. Of the 13 SNB-negative patients, 2 had a positive axillary lymph node dissection, yielding a false-negative rate of 11%. Thirteen patients who mapped had a clinically positive axilla before therapy (45%). Of the 11 patients with true-negative SNBs, 7 (64%) were clinically node negative at presentation. The initial tumor sizes on examination ranged from 2 to 9 cm (mean, 5.0 cm), and residual pathologic tumor sizes ranged from 0 to 6 cm (mean, 1.8 cm). Failure to map correlated with a clinically positive axilla at presentation (100% vs 45%) but did not correlate with initial tumor size.
Sentinel node identification rates are significantly better when mapping is performed before neoadjuvant chemotherapy (100% vs 80.6%), with failure to map correlated with clinically positive nodal disease at presentation and residual disease at axillary lymph node dissection. Among patients who map successfully after chemotherapy, the false-negative rate is high (11%). Given these findings, we currently recommend SNB before neoadjuvant chemotherapy for clinically node-negative patients, and raise concerns about the use of SNB after neoadjuvant therapy in patients with an initially clinically positive axilla.

Download full-text


Available from: Kevin S Hughes, Mar 05, 2015
24 Reads
  • Source
    • "Despite these concerns, SLN biopsy has been shown to be both accurate and feasible in women who receive neoadjuvant chemotherapy. These studies are detailed in Table 2 [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] [64]. Early studies evaluating the use of SLN biopsy among women receiving neoadjuvant chemotherapy were limited by small sample size and single-center setting. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Neoadjuvant chemotherapy is standard management for women who have locally advanced or inflammatory breast cancer, but can be applied to all women who may require postoperative chemotherapy for early-stage breast cancer. Disease-free survival and overall survival are equivalent between patients treated with neoadjuvant chemotherapy and patients treated with the same regimen postoperatively. Preoperative chemotherapy can offer women less morbid surgical treatment by down-staging both the primary breast tumor and axillary metastases. Finally, response to chemotherapy can inform clinicians of the chemosensitivity of the tumor, and can predict long-term outcome for women who have breast cancer.
    Surgical Clinics of North America 05/2007; 87(2):399-415, ix. DOI:10.1016/j.suc.2007.02.004 · 1.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Sentinel lymph node biopsy has become an ordinary method for breast cancer staging. Neoadjuvant chemotherapy has been considered one of the contraindications for sentinel lymph node biopsy due to potential secondary fibrosis and lymphatic distortion. Timing and influence on sentinel lymph node biopsy result by primary systemic therapy are current and controversial topics. The experience in the medical literature is reviewed. A search was performed in the following databases: Medline (through Pubmed), EMBASE, Tripdatabase and Cochrane Library, between January 1998 and December 2008. After analyzing the conclusions from 42 series and waiting for the end of related prospective trials, it could be concluded that sentinel lymph node biopsy is a useful diagnostic tool that should be integrated in the algorithm for the management of breast cancer patients when primary systemic therapy is needed.
    Tumori 01/2010; 96(1):17-23. DOI:10.1700/479.5645 · 1.27 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: BackgroundThe value of axillary staging prior to delivery of neoadjuvant chemotherapy (NEO) for breast cancer is controversial. Our goal was to analyze the prognostic and therapeutic impact of axillary staging on recurrence. MethodsThe study cohort included 161 patients undergoing comprehensive evaluation by a multidisciplinary approach during the period 1996–2006. Clinicopathologic features were assessed before and after delivery of NEO. Patients with node-positive disease before NEO underwent a post-NEO axillary lymph node dissection at time of definitive breast surgery. ResultsAt presentation, median age was 49 years; mean tumor size was 45 mm. The axilla was negative in 45 (28.6%) patients. Of the 114 pre-NEO node-positive patients, 65 (57%) were staged histologically. At completion of NEO, partial or complete clinical response was observed in 90.6%; complete pathologic response occurred in 23.6%. Mean residual tumor size was 10.5 mm. Of the 112 initially node-positive patients, 36 (31.6%) had no residual axillary disease post NEO. At median follow-up of 38.1 months, 21.7% patients relapsed. The pre-NEO nodal status was the strongest predictor of treatment failure. A significant risk of distant relapse was based on nodal response to NEO: 8.1% in node-negative patients, 13.9% in the downstaged group, and 22.1% in the persistently positive group (P=0.047). Delivery of nodal irradiation decreased local recurrence in the downstaged group (12.5% versus 3.7%, P=NS). ConclusionOur experience suggests that comprehensive axillary staging with ultrasound and fine-needle aspiration (FNA) and sentinel lymph node biopsy prior to NEO is both prognostically and therapeutically important in predicting those patients at higher risk of recurrence.
    Annals of Surgical Oncology 11/2008; 15(11):3252-3258. DOI:10.1245/s10434-008-0136-3 · 3.93 Impact Factor
Show more