Changes in Surgical Management of the Axilla Over 11 Years - Report on More Than 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial

Judy C Boughey; Hongmei Yu; Catherine Lu Dugan; Mara A Piltin; Lauren Postlewait; Jennifer D Son; Kirsten K Edmiston; Constantine V Godellas; Marie C Lee; Michael J Carr; Jennifer E Tonneson; Angelena Crown; Rachel B Lancaster; Hannah E Woriax; Cheryl A Ewing; Harrison S Chau; Anne K Patterson; Jasmine M Wong; Michael D Alvarado; Rachel L Yang; Theresa W Chan; Jori B Sheade; Gretchen M Ahrendt; Kelsey E Larson; Kayla Switalla; Todd M Tuttle; Julia C Tchou; Roshni Rao; Nina Tamirisa; Puneet Singh; Rebekah E Gould; Alicia Terando; Candice Sauder; Kelly Hewitt; Akiko Chiba; Laura J Esserman; Rita A Mukhtar

doi:10.1245/s10434-023-13759-y

Changes in Surgical Management of the Axilla Over 11 Years - Report on More Than 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial

Ann Surg Oncol. 2023 Oct;30(11):6401-6410. doi: 10.1245/s10434-023-13759-y. Epub 2023 Jun 28.

Authors

Judy C Boughey¹, Hongmei Yu², Catherine Lu Dugan³, Mara A Piltin⁴, Lauren Postlewait⁵, Jennifer D Son⁶, Kirsten K Edmiston⁷, Constantine V Godellas⁸, Marie C Lee⁹, Michael J Carr¹⁰, Jennifer E Tonneson¹¹, Angelena Crown¹², Rachel B Lancaster¹³, Hannah E Woriax¹⁴, Cheryl A Ewing¹⁵, Harrison S Chau¹⁶, Anne K Patterson¹⁷, Jasmine M Wong¹⁷, Michael D Alvarado¹⁷, Rachel L Yang¹⁸, Theresa W Chan¹⁹, Jori B Sheade²⁰, Gretchen M Ahrendt²¹, Kelsey E Larson²², Kayla Switalla²³, Todd M Tuttle²³, Julia C Tchou²⁴, Roshni Rao²⁵, Nina Tamirisa²⁶, Puneet Singh²⁷, Rebekah E Gould²⁸, Alicia Terando²⁹, Candice Sauder³⁰, Kelly Hewitt³¹, Akiko Chiba³², Laura J Esserman³³, Rita A Mukhtar³⁴

Affiliations

¹ Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA. boughey.judy@mayo.edu.
² Quantum Leap Healthcare Collaborative, San Francisco, CA, USA.
³ Breast Care Center, UCSF Health, San Francisco, CA, USA.
⁴ Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
⁵ Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
⁶ Ourisman Breast Center, MedStar Georgetown University, Washington, DC, USA.
⁷ Department of Surgery, University of Virginia, Inova Campus, Fairfax, VA, USA.
⁸ Department of Surgery, Loyola University Medical Center, Maywood, IL, USA.
⁹ Division of Breast Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
¹⁰ Department of Breast Surgery, Moffitt Cancer Center, Tampa, FL, USA.
¹¹ Division of Surgical Oncology, Oregon Health and Science University, Portland, OR, USA.
¹² True Family Women's Cancer Center, Swedish Cancer Institute, Seattle, WA, USA.
¹³ Division of Surgical Oncology, The University of Alabama at Birmingham Medical Center, Birmingham, AL, USA.
¹⁴ Division of Surgical Oncology, Duke University of School of Medicine, Durham, NC, USA.
¹⁵ Division of Surgical Oncology, University of California, San Francisco, CA, USA.
¹⁶ Department of Surgery, UC San Diego, La Jolla, CA, USA.
¹⁷ Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA.
¹⁸ Department of Surgery, Stanford Hospital and Clinics, Stanford, CA, USA.
¹⁹ Department of Breast Surgical Oncology, Ironwood Cancer and Research Centers, Scottsdale, AZ, USA.
²⁰ Division of Hematology and Oncology, University of Chicago, Chicago, IL, USA.
²¹ Division of Surgical Oncology, University of Colorado Denver - Anschutz Medical Campus, Boulder, CO, USA.
²² Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA.
²³ Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
²⁴ Department of Breast Surgery Research, Penn Medicine at University of Pennsylvania, Philadelphia, PA, USA.
²⁵ Division of Breast Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
²⁶ Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
²⁷ Department of Breast Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
²⁸ Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
²⁹ Division of Surgical Oncology, Department of Surgery, Huntington Cancer Center/Cedars Sinai Cancer, Pasadena, CA, USA.
³⁰ Department of Surgery, UC Davis Health Comprehensive Cancer Center, Sacramento, CA, USA.
³¹ Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
³² Department of Surgery, Duke University Medical Center, Durham, NC, USA.
³³ Departments of Surgery and Radiology, UCSF, San Francisco, CA, USA.
³⁴ Department of Surgery, UCSF, San Francisco, CA, USA.

PMID: 37380911
DOI: 10.1245/s10434-023-13759-y

Abstract

Background: Axillary surgery after neoadjuvant chemotherapy (NAC) is becoming less extensive. We evaluated the evolution of axillary surgery after NAC on the multi-institutional I-SPY2 prospective trial.

Methods: We examined annual rates of sentinel lymph node (SLN) surgery with resection of clipped node, if present), axillary lymph node dissection (ALND), and SLN and ALND in patients enrolled in I-SPY2 from January 1, 2011 to December 31, 2021 by clinical N status at diagnosis and pathologic N status at surgery. Cochran-Armitage trend tests were calculated to evaluate patterns over time.

Results: Of 1578 patients, 973 patients (61.7%) had SLN-only, 136 (8.6%) had SLN and ALND, and 469 (29.7%) had ALND-only. In the cN0 group, ALND-only decreased from 20% in 2011 to 6.25% in 2021 (p = 0.0078) and SLN-only increased from 70.0% to 87.5% (p = 0.0020). This was even more striking in patients with clinically node-positive (cN+) disease at diagnosis, where ALND-only decreased from 70.7% to 29.4% (p < 0.0001) and SLN-only significantly increased from 14.6% to 56.5% (p < 0.0001). This change was significant across subtypes (HR-/HER2-, HR+/HER2-, and HER2+). Among pathologically node-positive (pN+) patients after NAC (n = 525) ALND-only decreased from 69.0% to 39.2% (p < 0.0001) and SLN-only increased from 6.9% to 39.2% (p < 0.0001).

Conclusions: Use of ALND after NAC has significantly decreased over the past decade. This is most pronounced in cN+ disease at diagnosis with an increase in the use of SLN surgery after NAC. Additionally, in pN+ disease after NAC, there has been a decrease in use of completion ALND, a practice pattern change that precedes results from clinical trials.

Keywords: Axillary dissection; Neoadjuvant chemotherapy; Sentinel lymph node surgery.

MeSH terms

Axilla / pathology
Breast Neoplasms* / drug therapy
Breast Neoplasms* / pathology
Breast Neoplasms* / surgery
Female
Humans
Lymph Node Excision
Lymphatic Metastasis / pathology
Neoadjuvant Therapy / methods
Prospective Studies
Sentinel Lymph Node Biopsy / methods
Sentinel Lymph Node* / pathology
Sentinel Lymph Node* / surgery

Abstract

MeSH terms

Grants and funding