Managing the axilla

Published Date: 19th July 2016

Publication Authors: Pennick M

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Background:  Data suggest neoadjuvant chemotherapy (NAC) can downstage the axilla in up to 40% of breast cancers, yet there is no consensus regarding timing and extent of axillary surgery post NAC. Sentinel lymph node biopsy (SLNB) after NAC is also debated. We performed a literature review and suggest an algorithm for the management of the axilla post NAC.

Methods:  Available literature & trial data relating to the topic were re viewed. We then designed a suggested treatment algorithm for these pa tients, based on the available evidence.

Results:  Level one evidence supports of SLNBpost chemotherapy. No con sensus exists regarding the management of the 'downstaged' axilla. National Trial data show low chest wall and regional node failure rates in these patients, especially when complete pathological response in the breast is achieved.

Conclusions:  SLNB post NAC is possible, false negative rates are comparable to SLNB pre systemic treatment. We suggest an NAC Axillary algorithm: Any patient with clinically involved nodes pre NAC undergoes ALND post NAC. All patients have pre NAC axillary ultrasound (USS). If node negative pre NAC, perform SLNB post NAC. If SLNB

positive, for axillary lymph node dissection (ALND). If USS shows positive node but there is complete clinical response (CCR) and complete radiological response (CRR) post-NAC, for SLNB. If SLNB positive then ALND, if SLNB negative consider radiotherapy without ALND.

Pennick M. (2013).  Managing the axilla after neoadjuvant chemotherapy - An alorithm approach . European Journal of Surgical Oncology. 39 (5), 497-8.

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