Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with node-positive breast cancer: guiding a more selective axillary approach

Abstract

We have read with a great interest the article by Damin et al. [1]. In this small study the authors used the sentinel lymph node biopsy (SLNB) rather than targeted axillary dissection (TAD). We have recently demonstrated in a metaanalysis that the former has a false negative rate (FNR) of 13% [2] whereas TAD has a FNR of 5.2% [3]. Therefore TAD should be considered the gold standard for accurate axillary staging following neoadjuvant systemic therapy (NST). Although there are no randomised trials to confirm the oncological safety of SLNB or TAD following NST, we were very surprised that the authors did not make a reference to a very important retrospective study that evaluated the oncological outcome of SLNB in 688 consecutive patients undergoing NST for T1-3, cN0/1/2 breast cancer [4]. After a median follow up of 9.2 year, the authors of the study reported an axillary recurrence rate of 1.8% in patients with cN1/2 who were rendered SLNB negative compared with 1.5% in patients with initially cN0 disease. No differences between cN0 and cN1/2 groups were observed in overall survival and distant disease free survival. Although patients with a negative SLNB did not undergo axillary lymph node dissection (ALND) some patients received axillary radiation therapy. Patients with Her2 + or TNBC who achieve a complete radiological response should be considered for de-escalation of axillary surgery towards TAD in order to reduce the morbidity associated with ALND and enhance their quality of life. The results of ongoing clinical trials to confirm the oncological safety are awaited with interest.