title: Comprehensive axillary evaluation in neoadjuvant chemotherapy patients with ultrasonography and sentinel lymph node biopsy.
abstract: BACKGROUND
  There is ongoing debate regarding the optimal sequence of sentinel lymph node (SLN) biopsy and neoadjuvant chemotherapy (CTX) for breast cancer. We report the accuracy of comprehensive pre-neoadjuvant CTX and post-neoadjuvant CTX axillary staging via ultrasound imaging, fine-needle aspiration (FNA) biopsy, and SLN biopsy.
  
  
  METHODS
  From 2001 to 2004, 91 neoadjuvant CTX patients at the University of Michigan Comprehensive Cancer Center underwent axillary staging by ultrasonography, ultrasound-guided FNA biopsy, SLN biopsy, or a combination of these.
  
  
  RESULTS
  Axillary staging was pathologically negative by pre-neoadjuvant CTX SLN biopsy in 53 cases (58%); these patients had no further axillary surgery. In 38 cases (42%), axillary metastases were confirmed at presentation by either ultrasound-guided FNA or SLN biopsy. These 38 patients underwent completion axillary lymph node dissection (ALND) after delivery of neoadjuvant CTX. Follow-up lymphatic mapping was attempted in 33 of these cases, and the SLN was identified in 32 (identification rate, 97%). One third of these cases were completely node negative on ALND. Residual metastatic disease was identified in 22 cases, and the SLN was falsely negative in 1 (4.5%).
  
  
  CONCLUSIONS
  Patients receiving neoadjuvant CTX can have accurate axillary nodal staging by ultrasound-guided FNA or SLN biopsy. In cases of documented axillary metastasis at presentation, repeat axillary staging with SLN biopsy can document the post-neoadjuvant CTX nodal status. This strategy optimizes pre-neoadjuvant CTX and post-neoadjuvant CTX staging information by distinguishing the patients who are node negative at presentation from those who have been downstaged to node negativity and offers the potential for avoiding unnecessary ALNDs in both of these patient subsets.
authors.affiliation: Department of Surgery, Comprehensive Cancer Center, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, Michigan, 48109, USA.
authors.forename: Amina
authors.initials: A
authors.lastname: Khan
authors.forename: Michael S
authors.initials: MS
authors.lastname: Sabel
authors.forename: Alexis
authors.initials: A
authors.lastname: Nees
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Diehl
authors.forename: Vincent M
authors.initials: VM
authors.lastname: Cimmino
authors.forename: Celina G
authors.initials: CG
authors.lastname: Kleer
authors.forename: Anne F
authors.initials: AF
authors.lastname: Schott
authors.forename: Dan F
authors.initials: DF
authors.lastname: Hayes
authors.forename: Alfred E
authors.initials: AE
authors.lastname: Chang
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Newman
mesh_terms: D000328:Adult; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D001365:Axilla; D044963:Biopsy, Fine-Needle; D001943:Breast Neoplasms / Q000188:drug therapy / Q000473:pathology*; D018270:Carcinoma, Ductal, Breast / Q000188:drug therapy / Q000473:pathology*; D018275:Carcinoma, Lobular / Q000188:drug therapy / Q000473:pathology*; D005260:Female; D006801:Humans; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D015203:Reproducibility of Results; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D013997:Time Factors; D016217:Ultrasonography, Mammary
chemical_list: D000970:Antineoplastic Agents