Neoadjuvant Chemotherapy And Axillary Lymph Nodes: Factors Affecting Lymph Node Yield In Patients Undergoing Axillary Node Dissection

Öz

İntroduction: This study aims to investigate the impact of neoadjuvant chemotherapy (NAC) on the number of lymph nodes dissected during axillary lymph node dissection (ALND) in breast cancer patients, a topic of significant debate among surgeons and pathologists. Material and Methods: We conducted a retrospective analysis of 440 breast cancer patients who underwent surgery between January 1, 2018, and December 31, 2020. Patients were categorized into two groups based on NAC administration. We collected demographic, clinical, and pathological data, focusing on the total and malignant lymph node counts. Results: Among the 440 patients, 124 received NAC, while 316 did not. The mean number of lymph nodes removed was 18.1 in total, with 17.2 in the NAC group and 18.5 in the non-NAC group (P = 0.17). No significant differences were observed in the number of malignant lymph nodes between the two groups (P = 0.73). However, multivariate analysis indicated that NAC significantly influenced the total number of lymph nodes dissected (P = 0.05). Additionally, lymphovascular invasion (LVI) was found to significantly impact the number of malignant lymph nodes. Conclusion: Our findings suggest that NAC is associated with a reduced number of lymph nodes dissected during ALND in breast cancer patients. These results indicate that the standard guideline of removing at least 10 lymph nodes may require reconsideration for patients undergoing NAC. Further studies are needed to clarify the implications of these findings for staging and treatment protocols.

Anahtar Kelimeler

• Neoadjuvant chemotherapy
• Axillary dissection
• Lymph node retrieval

Neoadjuvan Kemoterapi ve Aksiller Diseksiyon İlişkisi: Çıkartılan Lenf Nodu Sayısını Etkileyen Faktörler

Öz

Giriş: Bu çalışma, cerrahlar ve patologlar arasında önemli bir tartışma konusu olan, meme kanseri hastalarında aksiller lenf nodu diseksiyonu (ALND) sırasında diseke edilen lenf nodu sayısına neoadjuvan kemoterapinin (NAC) etkisini araştırmayı amaçlamaktadır. Gereç ve Yöntemler: 1 Ocak 2018 ile 31 Aralık 2020 tarihleri arasında ameliyat geçiren 440 meme kanseri hastası üzerinde retrospektif bir analiz gerçekleştirdik. Hastalar, NAC uygulamasına göre iki gruba ayrıldı. Çıkartılan toplam ve malign lenf nodu sayılarına odaklanarak demografik, klinik ve patolojik verileri topladık. Sonuç: 440 hastanın 124'üne NAC uygulanırken, 316'sına uygulanmadı. Çıkarılan lenf nodlarının ortalama sayısı toplamda 18,1 idi; NAC grubunda 17,2, NAC uygulanmayan grupta ise 18,5 idi (P = 0,17). İki grup arasında malign lenf nodu sayısında anlamlı bir fark gözlenmedi (P = 0,73). Ancak, çok değişkenli analiz, NAC'nin çıkarılan toplam lenf nodu sayısını önemli ölçüde etkilediğini gösterdi (P = 0,05). Ayrıca, lenfovasküler invazyonun (LVI) malign lenf nodu sayısını önemli ölçüde etkilediği bulundu. Tartışma: Bulgularımız, NAC'nin meme kanseri hastalarında ALND sırasında diseke edilen lenf nodu sayısının azalmasıyla ilişkili olduğunu göstermektedir. Bu sonuçlar, en az 10 lenf nodunun çıkarılmasına ilişkin standart kılavuzun, NAC uygulanan hastalar için yeniden gözden geçirilmesi gerektiğini düşündürmektedir. Bu bulguların evreleme ve tedavi protokolleri üzerindeki etkilerini açıklığa kavuşturmak için daha fazla çalışma yapılması gerekmektedir.

Anahtar Kelimeler

• Neoadjuvan kemoterapi
• Aksiller diseksiyon
• Lenf nodu alınması
• Meme kanseri cerrahisi

Kaynakça

1. Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer. 1989;63(1):181-187. Crossref
2. Bélanger J, Soucy G, Sidéris L, et al. Neoadjuvant chemotherapy in invasive breast cancer results in a lower axillary lymph node count. J Am Coll Surg. 2008;206(4):704-708. Crossref
3. Neuman H, Carey LA, Ollila DW, et al. Axillary lymph node count is lower after neoadjuvant chemotherapy. Am J Surg. 2006;191(6):827-829. Crossref
4. Boughey JC, Donohue JH, Jakub JW, Lohse CM, Degnim AC. Number of lymph nodes identified at axillary dissection: effect of neoadjuvant chemotherapy and other factors. Cancer. 2010;116(14):3322-3329. Crossref
5. Erbes T, Orlowska-Volk M, zur Hausen A, et al. Neoadjuvant chemotherapy in breast cancer significantly reduces number of yielded lymph nodes by axillary dissection. BMC Cancer. 2014;14:4. Crossref
6. Baslaim MM, Al Malik OA, Al-Sobhi SS, et al. Decreased axillary lymph node retrieval in patients after neoadjuvant chemotherapy. Am J Surg. 2002;184(4):299-301. Crossref
7. Rosai J. Rosai and Ackerman's Surgical Pathology. 10th ed. Elsevier Health Sciences; 2011.
8. The American Society of Breast Surgeons. Performance and practice guidelines for axillary lymph node dissection in breast cancer patients. https://www.breastsurgeons.org/new_layout/about/statements/PDF_Statements/PerformancePracticeGuidelines_ALND.pdf. Published November 2014.

9. Uyan M, Koca B, Yuruker S, Ozen N. Effect of neoadjuvant chemotherapy on axillary lymph node positivity and numbers in breast cancer cases. Asian Pac J Cancer Prev. 2016;17(3):1181-1185. Crossref
10. Rahusen FD, Torrenga H, van Diest PJ, et al. Predictive factors for metastatic involvement of nonsentinel nodes in patients with breast cancer. Arch Surg. 2001;136(9):1059-1063. Crossref
11. Brotherick I, Shenton BK, Cowan WK, et al. The relationship between flow-cytometric and immunohistochemically detected c-erbB-2 expression, grade and DNA ploidy in breast cancer. Cancer Immunol Immunother. 1995;41(3):137-145. Crossref
12. Clark GM, McGuire WL. Steroid receptors and other prognostic factors in primary breast cancer. Semin Oncol. 1988;15(4 Suppl 1):20-27.
13. Giani C, Campani D, De Negri F, et al. Relationship between progesterone receptor, axillary node status and productive fibrosis in ductal infiltrating carcinoma of the breast. Appl Pathol. 1989;7(4):225-232.
14. Ozao-Choy J, Moazzez A, Dauphine C. Lower lymph node yield in axillary lymph node dissection specimens in breast cancer patients receiving neoadjuvant chemotherapy: Quality concern or treatment effect? Breast J. 2021;27(12):851-856. Crossref
15. Duraker N, Caynak ZC, Türköz K. Perineural invasion has no prognostic value in patients with invasive breast carcinoma. Breast. 2006;15(5):629-634. Crossref
16. Ansari B, Ogston SA, Purdie CA, Adamson DJ, Brown DC, Thompson AM. Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast. Br J Surg. 2008;95(5):547-554. Crossref
17. Moore KH, Sweeney KJ, Wilson ME, et al. Outcomes for women with ductal carcinoma-in-situ and a positive sentinel node: a multi-institutional audit. Ann Surg Oncol. 2007;14(10):2911-2917. Crossref
18. Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer. 1989;63(1):181-187.
19. Min SK, Lee SK, Woo J, et al. Relation between tumor size and lymph node metastasis according to subtypes of breast cancer. J Breast Cancer. 2021;24(1):75-84. Crossref
20. Seidman JD, Schnaper LA, Aisner SC. Relationship of the size of the invasive component of the primary breast carcinoma to axillary lymph node metastasis. Cancer. 1995;75(1):65-71. Crossref
21. Li FY, Wu SG, Zhou J, et al. Prognostic value of Ki-67 in breast cancer patients with positive axillary lymph nodes: a retrospective cohort study. PLoS One. 2014;9(2):e87264. Crossref
22. Yin Y, Zeng K, Wu M, Ding Y, Zhao M, Chen Q. The levels of Ki-67 positive are positively associated with lymph node metastasis in invasive ductal breast cancer. Cell Biochem Biophys. 2014;70(3):1145-1151. Crossref
23. Miglietta L, Vanella P, Canobbio L, et al. Prognostic value of estrogen receptor and Ki-67 index after neoadjuvant chemotherapy in locally advanced breast cancer expressing high levels of proliferation at diagnosis. Oncology. 2011;79(3-4):255-261. Crossref
24. Tanei T, Shimomura A, Shimazu K, et al. Prognostic significance of Ki67 index after neoadjuvant chemotherapy in breast cancer. Eur J Surg Oncol. 2011;37(2):155-161. Crossref
25. Cabioglu N, Ozmen V, Kaya H, et al. Increased lymph node positivity in multifocal and multicentric breast cancer. J Am Coll Surg. 2009;208(1):67-74. Crossref
26. Andea AA, Wallis T, Newman LA, Bouwman D, Dey J, Visscher DW. Pathologic analysis of tumor size and lymph node status in multifocal/multicentric breast carcinoma. Cancer. 2002;94(5):1383-1390. Crossref
27. Boughey JC, McCall LM, Ballman KV, et al. Tumor biology correlates with rates of breast-conserving surgery and pathologic complete response after neoadjuvant chemotherapy for breast cancer: findings from the ACOSOG Z1071 (Alliance) Prospective Multicenter Clinical Trial. Ann Surg. 2014;260(4):608-614. Crossref
28. Hoffmann J. Analysis of surgical and diagnostic quality at a specialist breast unit. Breast. 2006;15(4):490-497. Crossref
29. Rosenberger LH, Ren Y, Thomas SM, et al. Axillary lymph node dissection in node-positive breast cancer: are ten nodes adequate and when is enough, enough? Breast Cancer Res Treat. 2020;179(3):661-670. Crossref
30. Cil T, Hauspy J, Kahn H, et al. Factors affecting axillary lymph node retrieval and assessment in breast cancer patients. Ann Surg Oncol. 2008;15(12):3361-3368. Crossref