Evaluating Neoadjuvant Chemotherapy in Breast Cancer
Authors: Gilbert Lawrence, John Crawford, Faina Sherman, Jos A. van der Hage, Cornelis J.H. van de Velde
Journal: Journal of Clinical Oncology (2002)

Article Tools SPECIAL DEPARTMENTS Article Tools OPTIONS & TOOLS Export Citation Track Citation Add To Favorites Rights & Permissions COMPANION ARTICLES No companion articles ARTICLE CITATION DOI: 10.1200/JCO.2002.20.12.2905 Journal of Clinical Oncology - published online before print September 21, 2016 PMID: 12065569 Evaluating Neoadjuvant Chemotherapy in Breast Cancer Gilbert LawrencexGilbert LawrenceSearch for articles by this author , John CrawfordxJohn CrawfordSearch for articles by this author , Faina ShermanxFaina ShermanSearch for articles by this author Jos A. van der HagexJos A. van der HageSearch for articles by this author , Cornelis J.H. van de VeldexCornelis J.H. van de VeldeSearch for articles by this author Show More Faxton-St Luke’s Healthcare, The Regional Cancer Center Radiation Oncology, Utica, NYLeiden University Medical Center, Leiden, the Netherlands https://doi.org/10.1200/JCO.2002.20.12.2905 First Page Full Text PDF Figures and Tables © 2002 by American Society of Clinical OncologyjcoJ Clin OncolJournal of Clinical OncologyJCO0732-183X1527-7755American Society of Clinical OncologyResponse15062002In Reply:We appreciate the comments of Lawrence, Crawford, and Sherman to our manuscript on preoperative versus postoperative chemotherapy in primary operable breast cancer (European Organization for Research and Treatment of Cancer [EORTC] trial 10902).1 As pointed out in their letter, the management of the axilla after preoperative chemotherapy as well as in the primary surgery situation evokes discussion and is, therefore, not surprisingly the subject of clinical trials.Since the introduction of the sentinel lymph node biopsy, the question has been raised whether, in the case of a positive sentinel node, axillary lymph node dissection (ALND) is still required or adjuvant radiotherapy alone to the axilla may be sufficient in terms of locoregional control. The EORTC Breast Cancer Group has recently started a randomized trial (After Mapping of the Axilla; Radiotherapy or Surgery [AMAROS]) that is addressing this particular question in patients with nonpalpable nodes. The results of this trial have to be awaited to give a definite answer to this problem.As Lawrence et al state themselves, there is no doubt that ALND is indicated in patients with palpable nodal disease with or without preoperative chemotherapy. In clinically node-negative patients, especially with smaller tumor (T1a,b), ALND is debatable, and these patients should first undergo sentinel lymph node biopsy.The possibility of nonsurgical management of the axilla after preoperative chemotherapy has been suggested before.2 However, the conversion of axillary nodal status is poorly evaluated by palpation or, for instance, ultrasonography (negative predictive values of 39% to 44% and 44% to 58%, respectively).3,4 In addition, other investigators,4 as well as us, found that axillary nodal status after preoperative chemotherapy remains an independent prognostic factor and thus may be crucial in determining subsequent treatment strategies.Finally, approximately 30% of patients with axillary relapse will have uncontrollable disease.5-7 The chance of axillary recurrence in initially untreated clinical node-negative patients (T1c/T2) is approximately 15%.5-8 Therefore, approximately 5% of T1c/T2 cN0 patients who do not receive ALND will end up with uncontrollable disease. Therefore, we conclude that ALND cannot be routinely dismissed after preoperative chemotherapy because this will lead to understaging and may hamper locoregional control.1. van der Hage JA, van De Velde CJ, Julien JP, et al: Preoperative chemotherapy in primary operable breast cancer: Results from the European Organization for Research and Treatment of Cancer Trial 10902. J Clin Oncol 19:: 4224,2001-4237, Link, Google Scholar2. Kuerer HM, Sahin AA, Hunt KK, et al: Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy. Ann Surg 230:: 72,1999-78, Crossref, Medline, Google Scholar3. Herrada J, Iyer RB, Atkinson EN, et al: Relative value of physical examination, mammography, and breast sonography in evaluating the size of the primary tumor and regional lymph node metastases in women receiving neoadjuvant chemotherapy for locally advanced breast carcinoma. Clin Cancer Res 3:: 1565,1997-1569, Medline, Google Scholar4. Rouzier R, Extra JM, Klijanienko J, et al: Incidence and prognostic significance of complete axillary downstaging after primary chemotherapy in breast cancer patients with t1 to t3 tumors and cytologically proven axillary metastatic lymph nodes. J Clin Oncol 20:: 1304,2002-1310, Link, Google Scholar5. Chua B, Ung O, Boyages J: Competing considerations in regional nodal treatment for early breast cancer. Breast J 8:: 15,2002-22, Crossref, Medline, Google Scholar6. Recht A, Pierce SM, Abner A, et al: Regional nodal failure after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol 9:: 988,1991-996, Link, Google Scholar7. McKinna F, Gothard L, Ashley S, et al: Lymphatic relapse in women with early breast cancer: A difficult management problem. Eur J Cancer 35:: 1065,1999-1069, Crossref, Medline, Google Scholar8. Greco M, Agresti R, Cascinelli N, et al: Breast cancer patients treated without axillary surgery: Clinical implications and biologic analysis. Ann Surg 232:: 1,2000-7, Crossref, Medline, Google Scholar