Breast
Judy C. Boughey, MD (she/her/hers)
Chair, Division of Breast and Melanoma Surgical Oncology
Mayo Clinic
Rochester, Minnesota, United States
Judy C. Boughey, MD (she/her/hers)
Chair, Division of Breast and Melanoma Surgical Oncology
Mayo Clinic
Rochester, Minnesota, United States
Judy C. Boughey, MD (she/her/hers)
Chair, Division of Breast and Melanoma Surgical Oncology
Mayo Clinic
Rochester, Minnesota, United States
Hongmei Yu, Ph.D.
n/a
Quantum Leap Healthcare Collaborative
San Francisco, California, United States
Kayla Switalla, B.S.
Clinical Fellow
University of California, San Francisco
San Francisco, California, United States
Ladores Velle, B.S.
Research Assistant, Department of Surgery
University of California, San Francisco
San Francisco, California, United States
Anne M. Wallace, M.D.
Professor of Surgery
UC San Diego Health
San Diego, California, United States
Rachel B. Lancaster, M.D.
Associate Professor of Surgery
The University of Alabama at Birmingham Medical Center
Birmingham, Alabama, United States
Chantal R. Reyna, M.D.
Associate Professor; Primary Department: Surgical Oncology
Loyola University Medical Center
Maywood, Illinois, United States
Todd M. Tuttle, MD MS
Professor
Division of Surgical Oncology, Department of Surgery, University of Minnesota
Minneapolis, Minnesota, United States
Nora Jaskowiak, M.D.
Professor of Surgery
The University of Chicago Medicine
Chicago, Illinois, United States
Julia Tchou, MD PhD
Professor of Clinical Surgery
University of Pennsylvania
Wayne, Pennsylvania, United States
Roshni Rao, MD
Associate Professor of Surgery
Columbia University Medical Center
New York, NY, United States
Marie Catherine Lee, MD, FACS
Senior Member Breast Surgical Oncology
Moffitt Cancer Center
Tampa, Florida, United States
Arpana M. Naik, M.D.
Associate Professor of Surgery, Division of Surgical Oncology, School of Medicine
Oregon Health & Science University
Portland, Oregon, United States
Mehra Golshan, MD, MBA, FACS
Professor of Surgery (Oncology, Breast); Executive Vice Chair, Surgery; Deputy Chief Medical Officer
Yale School of Medicine Department of Surgery
New Haven, Connecticut, United States
Cletus A. Arciero, M.D.
Professor, Division of Surgical Oncology, Department of Surgery
Emory University School of Medicine
Atlanta, Georgia, United States
Candice A. Sauder, M.D.
Assistant Professor, Department of Surgery
UC Davis Comprehensive Cancer Center
Sacramento, California, United States
Cindy B. Matsen, M.D.
Associate Professor of Surgery
University of Utah Health
Salt Lake City, Utah, United States
Laura Essermann, M.D., M.B.A
Professor of Surgery
University of California, San Francisco
San Francisco, California, United States
Rita A. Mukhtar, MD
Associate Professor
University of California, San Francisco
San Francisco, California, United States
ISPY2 Locoregional Working Group, .
Working Group
UCSF, United States
De-escalation of axillary surgery after neoadjuvant chemotherapy (NAC) for breast cancer has unknown oncologic outcomes. We sought to evaluate impact of axillary surgery on outcomes in patients with nodal response and with residual nodal disease.
Methods:
We retrospectively evaluated axillary surgery and outcomes for patients in the ISPY-2 trial from 2011-2022 who completed surgery after NAC. Axillary surgery was classified as sentinel lymph node (SLN) surgery only, or axillary dissection (ALND +/- SLN surgery). Rates of axillary recurrence (AxR), locoregional recurrence (LRR), distant recurrence (DR) and event free survival (EFS) were compared by axillary surgery type in univariate and multivariate analyses.
Results:
Of 1,515 patients, 714 (47.1%) were cN0 at diagnosis, of whom 104 (14.6%) were pN+, and 801 (52.9%) were cN+, of whom 396 (49.4%) were pN+. SLN surgery only was performed in 805 (79.3%) of 1,015 pN0 patients and 126 (25.2%) of 500 pN+ patients. Median follow up time was 3.5 years. Most patients received adjuvant radiation (74.6% of pN0 and 93.6% of pN+). Radiation use was lower in pN0 patients with SLN vs ALND (71.9% vs 85.3%, p< 0.001) and did not differ in pN+ patients (94.4% vs 93.4%).
In pN0 disease, SLN was more frequent in white patients, lower cT category, cN0 cases and lower pT category (ypT0-2). In pN+ disease, SLN was more common with cN0 disease and lower pT category (ypT0-2). (each p< 0.05)
Among pN0 cases, there were no significant differences between SLN and ALND in 5-year estimated rate of AxR (2.0% vs 0.78%, p=0.26), LRR (4.6% vs 4.4%, p=0.86), DR (7.8% vs 10%, p=0.15) and EFS (12.0% vs 14.0%, p=0.19). These findings were consistent on multivariate analysis adjusting for tumor receptor subtype, age, cN status, and pT category.
Among pN+ cases, there was no difference between SLN and ALND in 5-year estimated AxR (5.2% vs 3.6%, p=0.80) or LRR (7.7% vs 14%, p=0.11). DR was significantly lower in SLN than ALND (20% vs 29%, p=0.01) and EFS was better in SLN than ALND (30% vs 37%, p=0.03). On multivariable analysis SLN only was associated with better distant disease-free survival (hazard ratio 0.52, 95% CI 0.30-0.92, p=0.02).
Conclusions:
With short-term follow up in this cohort with selective use of SLN surgery alone after NAC, ALND did not improve AxR, LR, DR or EFS, even in patients with pN+. While data from prospective trials are pending, in appropriately selected patients SLN surgery with adjuvant radiation may provide appropriate oncologic control without routine use of ALND.