Management of the positive sentinel lymph node following neoadjuvant chemotherapy: results of a survey conducted with breast surgeons

Francisco Pimentel Cavalcante; Felipe Zerwes; Eduardo Camargo Millen; Guilherme Novita; Alessandra Borba Anton de Souza; João Henrique Penna Reis; Helio Rubens de Oliveira Filho; Luciana Naíra de B L Limongi; Barbara Pace Silva de Assis Carvalho; Adriana Magalhães de Oliveira Freitas; Monica Travassos Jourdan; Vilmar Marques de Oliveira; Ruffo Freitas-Junior

doi:10.3332/ecancer.2022.1357

Management of the positive sentinel lymph node following neoadjuvant chemotherapy: results of a survey conducted with breast surgeons

Ecancermedicalscience. 2022 Feb 18:16:1357. doi: 10.3332/ecancer.2022.1357. eCollection 2022.

Authors

Francisco Pimentel Cavalcante^{1

2}, Felipe Zerwes^{3

4}, Eduardo Camargo Millen^{5

6}, Guilherme Novita^{7

8}, Alessandra Borba Anton de Souza^{9

10}, João Henrique Penna Reis^{11

12}, Helio Rubens de Oliveira Filho^{13

14}, Luciana Naíra de B L Limongi^{15

16}, Barbara Pace Silva de Assis Carvalho^{17

18}, Adriana Magalhães de Oliveira Freitas^{19

20}, Monica Travassos Jourdan^{21

22}, Vilmar Marques de Oliveira^{23

24

25}, Ruffo Freitas-Junior^{26

27}

Affiliations

¹ Breast Unit, Fortaleza General Hospital (HGF), Fortaleza, CE 60150160, Brazil.
² https://orcid.org/0000-0002-7156-2890.
³ School of Medicine, Pontificia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS 90450130, Brazil.
⁴ https://orcid.org/0000-0002-1643-727X.
⁵ Instituto Oncoclinicas, Rio de Janeiro, RJ 22440040, Brazil.
⁶ https://orcid.org/0000-0002-2113-6324.
⁷ Breast Unit, Hospital Israelita Albert Einstein, São Paulo, SP 01321001, Brazil.
⁸ https://orcid.org/0000-0003-2983-3199.
⁹ Oncology Research Group-CNPq, PUCRS, Porto Alegre, RS 90610000, Brazil.
¹⁰ https://orcid.org/0000-0002-6215-7076.
¹¹ Breast Center, Instituto Orizonti and Hospital Mater Dei, Belo Horizonte, Minas Gerais, MG 30210080, Brazil.
¹² https://orcid.org/0000-0002-7754-9793.
¹³ School of Medicine, Federal University of Paraná, Curitiba, PR 80060900, Brazil.
¹⁴ https://orcid.org/0000-0003-4136-7047.
¹⁵ Breast Unit, Real Hospital Português, Recife, PE 52010075, Brazil.
¹⁶ https://orcid.org/0000-0001-9014-4793.
¹⁷ Breast Unit, Pace Hospital, Belo Horizonte, MG 30110062, Brazil.
¹⁸ https://orcid.org/0000-0003-1888-4433.
¹⁹ Breast Unit, Larmony Mastologia, Florianópolis, SC 88015300, Brazil.
²⁰ https://orcid.org/0000-0003-1068-4154.
²¹ Breast Unit, Samaritano Botafogo (Américas Serviços Médicos), Rio de Janeiro, RJ 22270010, Brazil.
²² https://orcid.org/0000-0003-0910-0270.
²³ School of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP 01224001, Brazil.
²⁴ Breast Unit, Santa Casa de São Paulo, São Paulo, SP 01221010, Brazil.
²⁵ https://orcid.org/0000-0002-9478-5616.
²⁶ CORA Advanced Centre for Diagnosis of Breast Cancer, Department of Obstetrics and Gynaecology, Federal University of Goiás, Goiânia, GO 74605050, Brazil.
²⁷ https://orcid.org/0000-0003-4145-8598.

Abstract

Introduction: Despite the lack of randomised evidence, there is a current trend towards omitting axillary surgery in cases of positive sentinel lymph node (SLN) following neoadjuvant chemotherapy (NACT). This study evaluated practice patterns of Brazilian breast surgeons when managing positive SLN following NACT.

Methods: This was a nationwide electronic survey of breast surgeons affiliated with the Brazilian Society of Mastology. Management approaches for positive SLN after NACT (axillary dissection (AD), regional nodal irradiation (RNI) or no additional treatment) were evaluated as a function of residual disease volume in the SLN (macro-metastasis, micro-metastasis or isolated tumour cells (ITC)).

Results: Survey response rate was 49%, with 799/1,627 questionnaires returned. Most respondents were <50 years old (61%), lived in south-eastern Brazil (50%), in a major city (67%), worked in an academic institute (80%) and were board-certified (80%). AD recommendation rate decreased according to residual nodal disease volume: 91% of respondents recommended AD for cases of macro-metastasis, 64% for micro-metastasis and 38% for ITC (p < 0.00001). Furthermore, 35% would recommend no additional surgery for micro-metastasis, while 27% would recommend no treatment at all for ITC (p < 0.00001). Not working in an academic institute was associated with RNI for micro-metastasis (p = 0.02), but not for macro-metastasis or ITC. Being board-certified did not affect axillary management.

Conclusion: Most respondents would recommend AD and/or RNI in residual nodal disease following NACT irrespective of disease volume. Nevertheless, a trend towards surgical de-escalation was found with low-volume disease (micro-metastasis and ITC). Ongoing randomised trials will clarify the impact of this trend.

Keywords: axillary dissection; breast cancer; neoadjuvant chemotherapy; regional nodal irradiation; residual nodal disease; sentinel lymph node biopsy.