the days of axillary lymph node dissection in her2+ patients may be numbered,at least

[Lani]

for those who get a pCR with neoadjuvant chemo+herceptin.

Hopefully that will avoid a lot of pain and lymphedema and arm limitation

Cancer. 2010 Jun 15;116(12):2884-9.
Cytologically proven axillary lymph node metastases are eradicated in patients receiving preoperative chemotherapy with concurrent trastuzumab for HER2-positive breast cancer.
Dominici LS, Negron Gonzalez VM, Buzdar AU, Lucci A, Mittendorf EA, Le-Petross HT, Babiera GV, Meric-Bernstam F, Hunt KK, Kuerer HM.

Department of Surgical Oncology, Brigham and Women's Hospital, Boston, Massachusetts.
Abstract
BACKGROUND:: The axillary pathologic complete response rate (pCR) and the effect of axillary pCR on disease-free survival (DFS) was determined in patients with HER2-positive breast cancer and biopsy-proven axillary lymph node metastases who were receiving concurrent trastuzumab and neoadjuvant chemotherapy. The use of neoadjuvant chemotherapy is reported to result in pCR in the breast and axilla in up to 25% of patients. Patients achieving a pCR have improved DFS and overall survival. To the authors' knowledge, the rate of eradication of biopsy-proven axillary lymph node metastases with trastuzumab-containing neoadjuvant chemotherapy regimens has not been previously reported. METHODS:: Records were reviewed of 109 consecutive patients with HER2-positive breast cancer and axillary metastases confirmed by ultrasound-guided fine-needle aspiration biopsy who received trastuzumab-containing neoadjuvant chemotherapy followed by breast surgery with complete axillary lymph node dissection. Survival was evaluated by the Kaplan-Meier method. Clinicopathologic factors and DFS were compared between patients with and without axillary pCR. RESULTS:: Eighty-one patients (74%) achieved a pCR in the axilla. Axillary pCR was not associated with age, estrogen receptor status, grade, tumor size, initial N classification, or median number of lymph nodes removed. More patients with an axillary pCR also achieved a pCR in the breast (78% vs 25%; P < .001). At a median follow-up of 29.1 months, DFS was significantly greater in the axillary pCR group (P = .02). CONCLUSIONS:: Trastuzumab-containing neoadjuvant chemotherapy appears to be effective in eradicating axillary lymph node metastases in the majority of patients treated. Patients who achieve an axillary pCR are reported to have improved DFS. The success of pCR with concurrent trastuzumab and chemotherapy in eradicating lymph node metastases has implications for surgical management of the axilla in these patients. Cancer 2010. (c) 2010 American Cancer Society.

PMID: 20564395

[Lani]

unfortunately when I read the whole article, the do not recommend changing treatment protocols until a randomized clinical trial proves that ALND is not necessary in those treated with neoadjuvant chemo+herceptin who achieve a pCR.

They go on to say:

Another alternative to axillary lymph node dissec- tion is intraoperative lymphatic mapping and sentinel lymph node biopsy. The findings presented in the current study suggest that it may be feasible to perform intraoper- ative lymphatic mapping and sentinel lymph node biopsy in patients with clinical complete response to trastuzu- mab-containing neoadjuvant chemotherapy. Patients treated with trastuzumab-containing neoadjuvant chemo- therapy have a 74% chance of achieving an axillary pCR, and therefore complete axillary lymph node dissection represents overtreatment for many of these patients. Lym- phatic mapping and sentinel lymph node biopsy is increasingly being performed by surgeons in patients who receive neoadjuvant chemotherapy and present with an initially clinically negative axilla to guide further therapy of the axilla.16 However, there have been conflicting sin- gle-institution reports regarding the feasibility and accu- racy of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients who present with initial biopsy- proven axillary metastases.17-19 To address this issue, the American College of Surgeons Oncology Group has just opened a clinical trial (ACOSOG Z1071) to investigate the accuracy of lymphatic mapping and sentinel lymph node biopsy in patients who present with biopsy-proven axillary lymph node metastasis and undergo neoadjuvant chemotherapy. As better systemic agents are introduced into the breast cancer armamentarium, it will be critically important to develop minimally invasive and less morbid surgical approaches to the axilla in patients treated with neoadjuvant chemotherapy.