Predicting Axillary Response to Neoadjuvant Chemotherapy: Breast MRI and US in Patients with Node-Positive Breast Cancer

Background In patients who are expected to achieve axillary pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC), omission of axillary lymph node (LN) dissection could prevent morbidity and complications. Purpose To develop a clinical model to predict residual axillary LN metastasis in patients with clinically node-positive breast cancer after NAC by using MRI and US. Materials and Methods In this retrospective study, women with clinically node-positive breast cancer who were treated with NAC following surgery between January 2015 and September 2017 were included. The patients were randomly assigned to a test and validation set (7:3 ratio). Univariable and multivariable logistic regression analyses were performed to evaluate the independent predictors of residual axillary LN metastasis in the test set. A prediction risk score was developed based on the odds ratios from the multivariable analysis and validated in both sets. Results A total of 408 women were included (mean age ± standard deviation, 47.9 years ± 9.6). The axillary pCR rate was 56.6% (231 of 408). Independent predictors of residual axillary LN metastasis were clinical stage N2 or N3, presence of axillary lymphadenopathy at US after NAC, tumor size reduction less than 50% at MRI, Ki-67 negativity, hormone receptor positivity, and human epidermal growth factor receptor 2 negativity (all, P < .05). In a model using these predictors, the area under the receiver operating characteristic curve in the test and validation sets was 0.84 (95% confidence interval: 0.79, 0.88) and 0.78 (95% confidence interval: 0.70, 0.87), respectively. When the patients had a simplified risk score of 1, the false-negative rates ranged between 5%-10%. Conclusion A prediction model incorporating nodal status stage, US finding, MRI response, and molecular receptor status shows good diagnostic performance for residual axillary lymph node metastasis after neoadjuvant chemotherapy in patients with clinically node-positive breast cancer. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Whitman in this issue.