Elsevier

European Journal of Cancer

Volume 45, Issue 18, December 2009, Pages 3124-3130
European Journal of Cancer

Review
Accuracy of sentinel node biopsy after neoadjuvant chemotherapy in breast cancer patients: A systematic review

https://doi.org/10.1016/j.ejca.2009.08.001Get rights and content

Abstract

Background

As neoadjuvant chemotherapy (NAC) is increasingly used to downstage patients with breast cancer, the timing of the sentinel node (SN) biopsy has become an important issue. This review was conducted to determine the accuracy of SN biopsy following NAC.

Methods

We searched Medline, Embase and Cochrane databases from 1993 to February 2009 for studies on patients with invasive breast cancer who underwent SN biopsy after NAC followed by an axillary lymph node dissection (ALND).

Results

Of 574 eligible studies, 27 were included in this review with a total study population of 2148 patients. The pooled SN identification rate was 90.9% (95% confidence interval (CI) = 88.0–93.1%) and the false-negative rate was 10.5% (95% CI = 8.1–13.6%). Negative predictive value and accuracy after NAC were 89.0% (95% CI = 85.1–92.1%) and 94.4% (95% CI = 92.6–95.8%), respectively. The reported SN success rates were heterogeneous and several variables were reported to be associated with decreased SN accuracy, i.e. initially positive clinical nodal status.

Conclusions

There is a potential role for SN biopsy following NAC which could be considered on an individual basis. However, there is insufficient evidence to recommend this as a standard procedure. Further research with subgroup analysis using variables reported to be associated with decreased SN accuracy is required in order to clearly define its value in the subgroups of breast cancer patients.

Introduction

Lymph node status, even after neoadjuvant chemotherapy (NAC), is a strong predictor of disease-free and overall survival in breast cancer patients.1, 2, 3 A sentinel node (SN) biopsy is an accurate method to assess nodal status and has now replaced traditional axillary lymph node dissection (ALND) as an initial staging procedure in early-stage, clinically node-negative breast cancer patients.4, 5 Several studies indicated that SN biopsy is also feasible for patients with large primary breast tumours,6, 7, 8 provided there is no clinical nodal involvement.9

NAC, initially introduced to downstage locally advanced breast cancer to facilitate surgery, results in an improved disease-free and overall survival, which is comparable with the effect of adjuvant chemotherapy.10, 11, 12, 13 More recently, the indication for NAC has been extended to selected patients with an earlier stage disease to allow breast-conserving surgery.14, 15 Another potential advantage of a neoadjuvant approach is the opportunity to observe chemosensitivity in situ, providing prognostic information and the ability to identify effective novel therapies.16

Following NAC, nodal staging was traditionally performed by an ALND at the time of breast surgery, which is associated with substantial morbidity.17, 18 Therefore, a less aggressive approach to the axilla is desirable. In fact, this raises not only the question whether these patients could be staged by SN biopsy, but also the question of what the optimal timing is for this procedure with respect to the NAC.

Performing an SN biopsy before NAC, on the one hand, assures accurate assessment of initial nodal status, avoiding the possible negative effects of lymphatic scarring or uneven nodal tumour response. On the other hand, performing SN biopsy after NAC could be an attractive strategy as NAC may downstage nodal status in a number of patients (20–40%).14, 19 Before such a strategy can be recommended as a routine procedure, validation of the safety and predictive value of SN biopsy following NAC is required.

Numerous, generally retrospective, small and single-institution studies assessed the feasibility of SN biopsy after NAC, with varying conclusions. This systematic review was conducted to give an overview of these studies and provide recommendations regarding the role of SN biopsy following NAC.

Section snippets

Literature search strategy

The electronic databases of Medline, Embase and Cochrane were searched from 1993 to February 2009 using free text and controlled terms for breast cancer, SN and NAC. The year 1993 was selected because this was the year of the first publication on the SN. Articles published in English, German, French or Dutch were considered. Two reviewers (C.H.M. van Deurzen and B.E.P.J. Vriens) independently evaluated titles and abstracts of the identified papers. Potentially relevant articles were retrieved

Results

The initial electronic search identified 574 potentially relevant articles of which we screened the title and abstract. After screening, the full texts of 66 articles were obtained. After full-text review and exclusion of overlapping series, 27 articles that met the inclusion criteria of this review remained for data extraction, including single- (N = 23) and multicentre (N = 4) series. The total study population comprised 2148 patients. The main characteristics and results of these studies are

Discussion

This systematic review was conducted to give an overview of the current literature regarding the accuracy of an SN biopsy in breast cancer patients following NAC. We calculated a pooled SN identification rate and false-negative rate of 90.9% and 10.5%, respectively. These rates do not differ substantially from prior multicentre studies evaluating SN success rates without NAC, reporting an identification rate of 88–97% and a false-negative rate of 5–10%.50, 51, 52, 53, 54, 55 However, these

Conflict of interest statement

None declared.

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