Journal Article

Clipping the Positive Lymph Node in Patients with Clinically Node Positive Breast Cancer Treated with Neoadjuvant Chemotherapy: Impact on Axillary Surgery in the ISPY-2 Clinical Trial

Tseng, Jennifer, Mukhtar, Rita A., Lancaster, Rachael, Esserman, Laura J., Piltin, Mara, Lee, Marie Catherine, Switalla, Kayla M., Matsen, Cindy B., Norwood, Peter, Howard-McNatt, Marissa, Golshan, Mehra, Rao, Roshni, Tchou, Julia, Boughey, Judy C., Son, Jennifer, Tuttle, Todd M., Dimitroff, Katrina, Yu, Hongmei, Reyna, Chantal R., Wallace, Anne M., Arciero, Cletus A., Yau, Christina, Sauder, Candice, Naik, Arpana, Ladores, Velle, Ahrendt, Gretchen, Postlewait, Lauren M.

2024

Overview

Background For patients with clinically node-positive (cN+) breast cancer undergoing neoadjuvant chemotherapy (NAC), retrieving previously clipped, biopsy-proven positive lymph nodes during sentinel lymph node biopsy [i.e., targeted axillary dissection (TAD)] may reduce false negative rates. However, the overall utilization and impact of clipping positive nodes remains uncertain. Patients and Methods We retrospectively analyzed cN+ ISPY-2 patients (2011–2022) undergoing axillary surgery after NAC. We evaluated trends in node clipping and associations with type of axillary surgery [sentinel lymph node (SLN) only, SLN and axillary lymph node dissection (ALND), or ALND only] and event-free survival (EFS) in patients that were cN+ on a NAC trial. Results Among 801 cN+ patients, 161 (20.1%) had pre-NAC clip placement in the positive node. The proportion of patients that were cN+ undergoing clip placement increased from 2.4 to 36.2% between 2011 and 2021. Multivariable logistic regression showed nodal clipping was independently associated with higher odds of SLN-only surgery [odds ratio (OR) 4.3, 95% confidence interval (CI) 2.8–6.8, p < 0.001]. This was also true among patients with residual pathologically node-positive (pN+) disease. Completion ALND rate did not differ based on clip retrieval success. No significant differences in EFS were observed in those with or without clip placement, both with or without successful clip retrieval [hazard ratio (HR) 0.85, 95% CI 0.4–1.7, p = 0.7; HR 1.8, 95% CI 0.5–6.0, p = 0.3, respectively]. Conclusion Clip placement in the positive lymph node before NAC is increasingly common. The significant association between clip placement and omission of axillary dissection, even among patients with pN+ disease, suggests a paradigm shift toward TAD as a definitive surgical management strategy in patients with pN+ disease after NAC.

• Publisher: Springer International Publishing,Springer Nature B.V
• Subject: Adult / Aged / Antineoplastic Combined Chemotherapy Protocols - therapeutic use / Axilla / Biopsy / Breast cancer / Breast Neoplasms - drug therapy / Breast Neoplasms - pathology / Breast Neoplasms - surgery / Breast Neoplasms - therapy / Breast Oncology / Chemotherapy / Chemotherapy, Adjuvant / Dissection / Female / Follow-Up Studies / Humans / Lymph Node Excision / Lymph nodes / Lymph Nodes - pathology / Lymph Nodes - surgery / Lymphatic Metastasis / Lymphatic system / Medicine / Medicine & Public Health / Middle Aged / Neoadjuvant Therapy / Oncology / Patients / Prognosis / Retrospective Studies / Sentinel Lymph Node - pathology / Sentinel Lymph Node - surgery / Sentinel Lymph Node Biopsy / Surgery / Surgical Instruments / Surgical Oncology / Survival Rate