Top Line: Neoadjuvant systemic therapy, especially when it is successful, can leave us unsure of how best to surgically manage the axilla.
The Study: The NCCN guidelines currently continue to recommend an axillary dissection regardless of response to neoadjuvant therapy whenever nodes are initially clinically involved. However, a complete dissection clearly confers the bulk of risk for future lymphedema, prompting a category 2B recommendation for sentinel node biopsy alone if the patient is counseled on an increased risk of a false negative result. The prospective observational SenTa study evaluated a compromise, a procedure referred to as a “targeted axillary dissection.” This involved placing a marker at the most suspicious clinically involved node prior to neoadjuvant therapy followed by surgical removal of this targeted node in addition to sentinel nodes—ideally at least three sentinel nodes identified by a dual tracer. The study enrolled 199 women across 50 centers in Germany undergoing targeted axillary dissection post-neoadjuvant therapy with (40%) or without (60%) a follow-on completion dissection at surgeon discretion. The majority had cN1 disease. Axillary recurrence rates were 1.8% with versus and 1.4% without completion dissection, and receipt of targeted axillary dissection alone was not associated with increased risk of any disease recurrence on multivariate analysis. Of course in a nonrandomized trial, one has to ask what factors prompted 40% of patients to have a completion dissection. Among 34 patients with no pathologic nodal involvement who had a targeted axillary dissection followed by completion dissection (42.5%), 2 had pathologic nodes discovered at further dissected nodes, producing a false negative rate of 4%. Not unexpected, the minority of women with cN2-3 disease at initial presentation (9%) had significantly higher risk of disease recurrence.
TBL: In this observational study, de-escalated targeted axillary dissection in lieu of standard axillary dissection following a clinical axillary response to neoadjuvant therapy for cN1 breast cancer resulted in a relatively low risk of recurrence and false negative rate. | Kuemmel, JAMA Surg 2023
The Study: The NCCN guidelines currently continue to recommend an axillary dissection regardless of response to neoadjuvant therapy whenever nodes are initially clinically involved. However, a complete dissection clearly confers the bulk of risk for future lymphedema, prompting a category 2B recommendation for sentinel node biopsy alone if the patient is counseled on an increased risk of a false negative result. The prospective observational SenTa study evaluated a compromise, a procedure referred to as a “targeted axillary dissection.” This involved placing a marker at the most suspicious clinically involved node prior to neoadjuvant therapy followed by surgical removal of this targeted node in addition to sentinel nodes—ideally at least three sentinel nodes identified by a dual tracer. The study enrolled 199 women across 50 centers in Germany undergoing targeted axillary dissection post-neoadjuvant therapy with (40%) or without (60%) a follow-on completion dissection at surgeon discretion. The majority had cN1 disease. Axillary recurrence rates were 1.8% with versus and 1.4% without completion dissection, and receipt of targeted axillary dissection alone was not associated with increased risk of any disease recurrence on multivariate analysis. Of course in a nonrandomized trial, one has to ask what factors prompted 40% of patients to have a completion dissection. Among 34 patients with no pathologic nodal involvement who had a targeted axillary dissection followed by completion dissection (42.5%), 2 had pathologic nodes discovered at further dissected nodes, producing a false negative rate of 4%. Not unexpected, the minority of women with cN2-3 disease at initial presentation (9%) had significantly higher risk of disease recurrence.
TBL: In this observational study, de-escalated targeted axillary dissection in lieu of standard axillary dissection following a clinical axillary response to neoadjuvant therapy for cN1 breast cancer resulted in a relatively low risk of recurrence and false negative rate. | Kuemmel, JAMA Surg 2023