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TOPLINE:

Targeted axillary dissection (TAD) emerged as the optimal minimally invasive technique, demonstrating superior diagnostic accuracy over other approaches in patients with node-positive breast cancer receiving neoadjuvant chemotherapy. TAD and sentinel lymph node biopsy (SLNB) were viable alternatives to axillary lymph node dissection and did not compromise oncological safety.

METHODOLOGY:

• This meta-analysis assessed the efficacy and safety of minimally invasive axillary dissection techniques such as SLNB, marked lymph node biopsy (MLNB), and TAD after the administration of neoadjuvant chemotherapy in patients with clinical node-positive disease.
• Overall, 28 studies examined diagnostic outcomes (SLNB: n = 3392; MLNB: n = 1130; TAD: n = 946), while nine assessed survival outcomes (n = 5647).
• Primary outcomes focused on diagnostic measures such as the identification rate, the false-negative rate, and the negative predictive value of less invasive strategies relative to axillary lymph node dissection.

TAKEAWAY:

• TAD demonstrated superior diagnostic accuracy relative to SLNB, with an identification rate of 96.8% vs 91.9%, a false-negative rate of 4.7% vs 13.7%, and a negative predictive value of 93.2% vs 84.8% (meta-regression; P < .001).
• The false-negative rate of SLNB was higher than the false-negative rates of TAD and MLNB (P < .001) and remained significantly higher than that of TAD even after the removal of three or more nodes (8.1% vs 4.7%; P = .034).
• The identification rate of SLNB in patients who achieved a complete clinical response to neoadjuvant therapy was statistically lower than that in all patients (85.8% vs 91.9%; P < .001); however, no such difference was observed for TAD.
• The pooled hazard ratios for disease-free survival (DFS) in SLNB/TAD, SLNB, and TAD vs axillary lymph node dissection were 0.90 (95% CI, 0.77-1.04), 0.89 (95% CI, 0.74-1.08; P = .25), and 0.91 (95% CI, 0.64-1.29; P = .58), respectively, indicating no statistical difference.
• Taken together, the findings suggest that de-escalation of axillary surgery did not affect long-term DFS in patients with initially node-positive disease prior to neoadjuvant chemotherapy.

IN PRACTICE:

"In conclusion, the findings support the ongoing de-escalation of axillary sampling and confirms that TAD is the optimal minimally invasive strategy in terms of diagnostic accuracy in node-positive patients undergoing NAC [neoadjuvant chemotherapy]. Despite a high level of nodal concordance, SNLB and MLNB do not provide the same level of diagnostic reliability as TAD. The survival analysis suggests that SLNB and TAD are viable alternatives to ALND [axillary lymph node dissection] and do not compromise oncological safety," the authors wrote.

SOURCE:

The study was led by James Lucocq, MBChB, PhD, Edinburgh Breast Unit, Western General Hospital, Edinburgh, United Kingdom. It was published online on February 19, 2025, in the European Journal of Surgical Oncology.

LIMITATIONS:

The meta-analysis of diagnostic accuracy outcomes utilised prospective studies, whereas the analysis of survival outcomes relied on retrospective studies, highlighting the need for higher-level evidence. There was inherent heterogeneity, which was not addressed by the meta-regression. The authors noted a limited investigation of key cancer types and subgroups defined by clinical and pathological response to neoadjuvant chemotherapy. Additionally, relatively short follow-up durations for oncological outcomes and poor access to radiotherapy data affected the robustness of long-term conclusions.

DISCLOSURES:

The authors did not disclose any funding information. The authors reported no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.