Breast MRI and tumour biology predict axillary lymph node response to neoadjuvant chemotherapy for breast cancer

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Abstract

Background

In patients who have had axillary nodal metastasis diagnosed prior to neoadjuvant chemotherapy for breast cancer, there is little consensus on how to manage the axilla subsequently. The aim of this study was to explore whether a combination of breast magnetic resonance imaging (MRI) assessed response and primary tumour pathology factors could identify a subset of patients that might be spared axillary node clearance.

Methods

A retrospective data analysis was performed of patients with core biopsy-proven axillary nodal metastasis prior to commencement of neoadjuvant chemotherapy (NAC) who had subsequent axillary node clearance (ANC) at definitive breast surgery. Breast tumour and axillary response at MRI before, during and on completion of NAC, core biopsy tumour grade, tumour type and immunophenotype were correlated with pathological response in the breast and the number of metastatic nodes in the ANC specimens.

Results

Of 87 consecutive patients with MRI at baseline, interim and after neoadjuvant chemotherapy who underwent ANC at time of breast surgery, 33 (38%) had no residual macrometastatic axillary disease, 28 (32%) had 1–2 metastatic nodes and 26 (30%) had more than 2 metastatic nodes. Factors that predicted axillary nodal complete response were MRI complete response in the breast ( p < 0.0001), HER2 positivity ( p = 0.02) and non-lobular tumour type ( p = 0.015).

Conclusion

MRI assessment of breast tumour response to NAC and core biopsy factors are predictive of response in axillary nodes, and can be used to guide decision making regarding appropriate axillary surgery.

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Most cited references 24

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Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18.

B. Fisher, A. Brown, E Mamounas … (1997)

To determine whether preoperative doxorubicin and cyclophosphamide (AC) permits more lumpectomies to be performed and decreases the incidence of positive nodes in women with primary breast cancer. Women (n = 1,523) were randomized to National Surgical Adjuvant Breast and Bowel Project (NSABP) B-18; 759 eligible patients received postoperative AC and 747, preoperative AC. The clinical size of breast and axillary tumors was determined before each of four cycles of AC and before surgery. Tumor response to preoperative therapy was clinically complete (cCR), partial (cPR), stable (cSD), or progressive disease (cPD). Tissue from patients with a cCR was evaluated for a pathologic complete response (pCR). Breast tumor size was reduced in 80% of patients after preoperative therapy; 36% had a cCR. Tumor size and clinical nodal status were independent predictors of cCR. Twenty-six percent of women with a cCR had a pCR. Clinical nodal response occurred in 89% of node-positive patients: 73% had a cCR and 44% of those had a pCR. There was a 37% increase in the incidence of pathologically negative nodes. Before randomization, lumpectomy was proposed for 86% of women with tumors or = 5.1 cm. Clinical tumor size and nodal status influenced the physician's decision. Overall, 12% more lumpectomies were performed in the preoperative group; in women with tumors > or = 5.1 cm, there was a 175% increase. Preoperative therapy reduced the size of most breast tumors and decreased the incidence of positive nodes. The greatest increase in lumpectomy after preoperative therapy occurred in women with tumors > or = 5 cm, since women with tumors less than 5 cm were already lumpectomy candidates. Preoperative therapy should be considered for the initial management of breast tumors judged too large for lumpectomy.

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Significantly higher pathologic complete remission rate after neoadjuvant therapy with trastuzumab, paclitaxel, and epirubicin chemotherapy: results of a randomized trial in human epidermal growth factor receptor 2-positive operable breast cancer.

Aman Buzdar, Nuhad K Ibrahim, Deborah Francis … (2005)

The objective of this study was to determine whether the addition of trastuzumab to chemotherapy in the neoadjuvant setting could increase pathologic complete response (pCR) rate in patients with human epidermal growth factor receptor 2 (HER2) -positive disease. Forty-two patients with HER2-positive disease with operable breast cancer were randomly assigned to either four cycles of paclitaxel followed by four cycles of fluorouracil, epirubicin, and cyclophosphamide or to the same chemotherapy with simultaneous weekly trastuzumab for 24 weeks. The primary objective was to demonstrate a 20% improvement in pCR (assumed 21% to 41%) with the addition of trastuzumab to chemotherapy. The planned sample size was 164 patients. Prognostic factors were similar in the two groups. After 34 patients had completed therapy, the trial's Data Monitoring Committee stopped the trial because of superiority of trastuzumab plus chemotherapy. pCR rates were 25% and 66.7% for chemotherapy (n = 16) and trastuzumab plus chemotherapy (n = 18), respectively (P = .02). The decision was based on the calculation that, if study continued to 164 patients, there was a 95% probability that trastuzumab plus chemotherapy would be superior. Of the 42 randomized patients, 26% in the chemotherapy arm achieved pCR compared with 65.2% in the trastuzumab plus chemotherapy arm (P = .016). The safety of this approach is not established, although no clinical congestive heart failure was observed. A more than 10% decrease in the cardiac ejection fraction was observed in five and seven patients in the chemotherapy and trastuzumab plus chemotherapy arms, respectively. Despite the small sample size, these data indicate that adding trastuzumab to chemotherapy, as used in this trial, significantly increased pCR without clinical congestive heart failure.

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Identification and Resection of Clipped Node Decreases the False-negative Rate of Sentinel Lymph Node Surgery in Patients Presenting With Node-positive Breast Cancer (T0–T4, N1–N2) Who Receive Neoadjuvant Chemotherapy

Elizabeth Mittendorf, Huong T Le-Petross, Karla V. Ballman … (2016)

The American College of Surgeons Oncology Group Z1071 trial reported a false-negative rate (FNR) of 12.6% with sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy in women presenting with node-positive breast cancer. One proposed method to decrease the FNR is clip placement in the positive node at initial diagnosis with confirmation of clipped node resection at surgery.

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Author and article information

Contributors

E. Jane Macaskill:

ORCID: http://orcid.org/0000-0003-3447-3108

ejanemacaskill@nhs.net

Journal

Journal ID (nlm-ta): Cancer Imaging

Journal ID (iso-abbrev): Cancer Imaging

Title: Cancer Imaging

Publisher: BioMed Central (London )

ISSN (Print): 1740-5025

ISSN (Electronic): 1470-7330

Publication date (Electronic): 26 December 2019

Publication date PMC-release: 26 December 2019

Publication date Collection: 2019

Volume: 19

Electronic Location Identifier: 91

Affiliations

[1 ]ISNI 0000 0000 9009 9462, GRID grid.416266.1, Department of Breast Surgery, , Ninewells Hospital and Medical School, ; Dundee, DD1 9SY UK

[2 ]Thirlestaine Breast Centre, Cheltenham, UK

[3 ]ISNI 0000 0000 9009 9462, GRID grid.416266.1, Ninewells Hospital and Medical School, ; Dundee, UK

[4 ]ISNI 0000 0000 9009 9462, GRID grid.416266.1, Department of Breast Radiology, , Ninewells Hospital and Medical School, ; Dundee, UK

[5 ]ISNI 0000 0000 9009 9462, GRID grid.416266.1, Department of Clinical Oncology, , Ninewells Hospital and Medical School, ; Dundee, UK

[6 ]ISNI 0000 0000 9009 9462, GRID grid.416266.1, Department of Breast Pathology, , Ninewells Hospital and Medical School, ; Dundee, UK

Author information

E. Jane Macaskill http://orcid.org/0000-0003-3447-3108

Article

Publisher ID: 279

DOI: 10.1186/s40644-019-0279-4

PMC ID: 6933687

PubMed ID: 31878958

SO-VID: 78003da9-c643-4367-a345-10c8b9de2448

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 6 September 2019

Date accepted : 12 December 2019

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Keywords: neoadjuvant chemotherapy,axilla lymph node,breast cancer,magnetic resonance imaging,sentinel node biopsy

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Keywords: neoadjuvant chemotherapy, axilla lymph node, breast cancer, magnetic resonance imaging, sentinel node biopsy

Breast MRI and tumour biology predict axillary lymph node response to neoadjuvant chemotherapy for breast cancer

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Most cited references 24

Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18.

Significantly higher pathologic complete remission rate after neoadjuvant therapy with trastuzumab, paclitaxel, and epirubicin chemotherapy: results of a randomized trial in human epidermal growth factor receptor 2-positive operable breast cancer.

Identification and Resection of Clipped Node Decreases the False-negative Rate of Sentinel Lymph Node Surgery in Patients Presenting With Node-positive Breast Cancer (T0–T4, N1–N2) Who Receive Neoadjuvant Chemotherapy

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