Nodal Recurrence With Sentinel Node Biopsy Alone Following Neoadjuvant Chemotherapy for Node-Positive Breast Cancer

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In a single-center cohort study reported in JAMA Oncology, Barrio et al evaluated nodal recurrence rates in patients with clinically node-negative breast cancer following neoadjuvant chemotherapy for biopsy-proven node-positive disease. The investigators found an extremely low incidence of nodal recurrence in patients who did not undergo axillary lymph node dissection (ALND) after the finding of three or more negative sentinel lymph nodes (SLNs).

The study included 610 consecutive patients with cT1 to cT3 biopsy-proven N1 breast cancer treated with neoadjuvant chemotherapy at Memorial Sloan Kettering Cancer Center between November 2013 and February 2019. Patients with conversion to cN0 by neoadjuvant chemotherapy underwent SLN biopsy with dual tracer mapping and omission of ALND if three or more SLNs were identified and found to be pathologically negative. Metastatic nodes were not routinely clipped, and localization of clipped nodes was not performed.

Key Findings

Of the 610 patients with cN1 breast cancer treated with neoadjuvant chemotherapy, 555 (91%) converted to cN0 and underwent SLN biopsy and 234 (42%) had three or more negative SLNs and received SLN biopsy alone with omission of ALND.

Among the 234 patients receiving SLN biopsy alone, the median age was 49 years; the median tumor size was 3 cm; 62% had HER2-positive disease and 18% had triple-negative disease. Ninety-one percent received doxorubicin-based neoadjuvant chemotherapy; 205 (88%) received adjuvant radiotherapy and 164 (70%) also received nodal radiotherapy.

At a median follow-up of 40 months, one axillary nodal recurrence concurrent with local recurrence was observed in a patient who refused adjuvant radiotherapy. No nodal recurrences were observed among the 205 patients who received adjuvant radiotherapy.

Isolated local recurrence was observed in one patient at 6 years after surgery. A total of 13 patients developed distant recurrence, all isolated distant failures; 5-year distant recurrence–free survival was 92.7% (95% confidence interval [CI] = 86.7%–96.1%). A total of 10 patients died during follow-up; 5-year overall survival was 94.2% (95% CI = 89.0%–97.0%).

The investigators concluded, “This cohort study found that in patients with cN1 disease rendered cN0 with neoadjuvant chemotherapy, with three or more negative SLNs with SLN [biopsy] alone, nodal recurrence rates were low, without routine nodal clipping. These findings potentially support omitting ALND in such patients.”

Monica Morrow, MD, of the Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, is the corresponding author for the JAMA Oncology article.

Disclosure: The study was supported by a grant from the National Cancer Institute. For full disclosures of the study authors, visit

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