Lidia Schapira, MD; Judy C. Boughey, MD


February 13, 2013

In This Article

Editor's Note:
Because high pathologic complete response rates can now be attained by neoadjuvant therapy, the question arises as to whether less invasive surgery is advisable in some breast cancer patients. Dr. Lidia Schapira, of Harvard Medical School and Massachusetts General Hospital, spoke to the Mayo Clinic's Judy C. Boughey, MD, about the ACOSOG Z1071 trial, which looked at whether patients who had axillary lymph node involvement before neoadjuvant chemotherapy and who had a good response to systemic therapy could avoid axillary lymph node dissection. The provocative study was presented by Dr. Boughey at the 2012 San Antonio Breast Cancer Symposium (SABCS).

Can Neoadjuvant Response Mean Less Surgery?

Dr. Schapira: Given current interest in treating more patients with neoadjuvant chemotherapy, can you tell us about the study and what your findings mean for patients who have a good response to treatment?

Dr. Boughey: The hypothesis for the ACOSOG Z1071 study[1] was to see whether sentinel lymph node surgery -- a technique that removes only the first few draining lymph nodes in the axilla -- can reliably identify patients who have had a complete response to neoadjuvant therapy and therefore have no residual disease in their lymph nodes. These patients may not need further axillary surgery to remove the remaining lymph nodes. We also wanted to know whether we can reliably identify patients who have residual disease and in whom axillary dissection may be beneficial.

Dr. Judy Boughey

Dr. Schapira: What prompted this study?

Dr. Boughey Over the past 5-10 years we have seen a significant increase in the rates of pathologic complete response to neoadjuvant chemotherapy. As we improve our targeted and systemic therapies and are able to eradicate disease more effectively from the breast and lymph nodes, it becomes important to assess whether we can tailor surgical therapy on the basis of response to neoadjuvant chemotherapy.

If node-positive patients receive neoadjuvant chemotherapy, the current standard of care is removal of all of the lymph nodes with axillary lymph node dissection after chemotherapy. The aim of the study was to determine whether we can be less invasive in the extent of axillary surgery in patients who present with node-positive breast cancer and who are treated with neoadjuvant chemotherapy. The hypothesis was that sentinel lymph node surgery could be a successful way to stage the axilla in patients with node-positive breast cancer who receive neoadjuvant chemotherapy and then undergo definitive breast surgery. The primary endpoint was the false-negative rate of the sentinel lymph node procedure in patients with clinical N1 disease at presentation who had at least 2 sentinel lymph nodes evaluated pathologically.

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Video: Sentinel lymph node surgery used in the ACOSOG Z1071 trial

Dr. Schapira: What did you find?

Dr. Boughey: We enrolled 756 women from 136 institutions over a 2-year period. We closed the study 2 years early because we had superb enrollment from our investigators, which was very exciting. When we looked at the overall cohort of 639 women who had a sentinel node identified and underwent axillary lymph node dissection, sentinel node surgery was a reliable procedure identifying the correct nodal status in 91.2% of women. Out of that cohort, disease was completely eradicated from the lymph nodes in about 40% of patients (255 patients). This is the group that potentially could be spared axillary lymph node dissection. The remaining 60% had residual disease in the lymph nodes.

Dr. Schapira: How many of the patients in your study had a sentinel node biopsy prior to neoadjuvant chemotherapy?

Dr. Boughey: Sentinel node surgery prior to neoadjuvant chemotherapy was not permitted in this study. All patients enrolled in this study were cytologically or histologically proven node-positive with a percutaneous fine-needle aspiration biopsy or core needle biopsy.