Changing practice patterns in axillary management for patients with node-positive breast cancer towards increased use of sentinel lymph node biopsy-alone after neoadjuvant chemotherapy: results of a survey (MF17-01) among Turkish surgeons.

Abstract

Background: This study aimed to determine the knowledge of major benchmark trials among Turkish general surgeons to investigate if they have adopted the results in their practice.

Methods: A total of 101 general surgeons from the Turkish Federation of Breast Diseases Society (TFBDS) were asked to complete a survey that included 24 multiple-choice questions regarding the surgical practice in axillary surgery for early and locally advanced breast cancer.

Results: Most surgeons were familiar with prospective axillary surgery studies including ACOSOG Z0011 (n = 77, 76.2%), AMAROS (n = 76, 75.2%), IBCSG 23 - 01 (n = 58, 57.4%), ACOSOG Z1071 (n = 63, 62.4%), and SENTINA (n = 67, 66.3%). Among the surgeons participating in the present survey, breast surgeons (38.6%) were less likely to perform axillary lymph node dissection (ALND) in early stage patients with a 1-2 positive sentinel lymph node biopsy (SLNB) with micro- or macrometastases, as opposed to those who defined themselves as general surgeons (ALND; 36.8% vs. 63.9%, p = 0.015). Almost all surgeons suggested neoadjuvant chemotherapy (NAC) for patients presenting with T4 (94.8%) or N2-3 disease (92.0%), whereas almost half of the surgeons (40.5%) always proceeded with NAC in patients with clinically node-positive cN1 breast cancer. Overall, 86.1% of surgeons performed SLNB in patients whose axilla became clinically negative after NAC. More than half of the surgeons (55.2%) preferred blue dye as the SLNB technique and 37 (42.5%) used the combined method. Among 87 surgeons, 24.1% (n = 21) always, 39.1% (n = 34) sometimes, and 36.8% (n = 32) never preferred clip marking of axillary metastatic lymph nodes before NAC, whereas 56.4% performed targeted axillary dissection (TAD) after NAC. In cN+ patients before NAC, the majority of surgeons (74.3%) did not perform ALND in patients with at least three lymph nodes removed and SLNB negative. Of note, more than half of the surgeons (51.5%) did not perform ALND in the presence of isolated tumor cells or micrometastases among the three SLNs as long as regional nodal irradiation was received. However, 54.5% of the patients routinely underwent ALND in the presence of macrometastatic residual nodal disease after NAC.

Conclusion: Deescalating strategies in axillary surgery have been increasing in both initially clinically node-negative and-positive breast cancers as long as nodal radiation is provided.