Surgical considerations in patients receiving neoadjuvant systemic therapy

Neoadjuvant chemotherapy is being increasingly used in the treatment of patients presenting with early-stage, operable breast cancer. Neoadjuvant chemotherapy downsizes most tumors, allowing appropriately selected patients to undergo breast-conserving therapy. Management of the axilla in patients receiving neoadjuvant chemotherapy is dictated by whether patients present with clinically node-negative or node-positive disease. Patients with clinically node-negative disease can undergo sentinel lymph node dissection after neoadjuvant chemotherapy, with axillary lymph node dissection reserved for patients with a positive sentinel lymph node. For patients with clinically node-positive disease at presentation, the current standard of care is axillary lymph node dissection. An ongoing cooperative group trial is investigating the utility of sentinel lymph node surgery in the clinically node-positive population.