Nomogram for predicting axillary upstaging in clinical node-negative breast cancer patients receiving neoadjuvant chemotherapy

Abstract Purpose The prediction of axillary lymph node status after neoadjuvant chemotherapy (NAC) becoming critical because of the advocation of the de-escalation of axillary management. We investigate associated factors of axillary upstaging in clinical node-negative(cN0) breast cancer patients receiving NAC to develop and validate an accurate prediction nomogram; Methods We retrospectively analyzed 2101 breast cancer patients with stage of cT1-3N0 treated by NAC and subsequent surgery between 2010 and 2020 in twenty hospitals across China. Patients randomly divided into a training set and validation set (3:1). Univariate and multivariate logistic regression analysis were performed, after which a nomogram was constructed and validated; Results In total, pathologic node negativity (ypN0) achieved in 1552 (73.9%) patients and another 549(26.1%) patients upstaged to pathologic node positive (ypN+). Breast pathologic complete response (bpCR) was achieved in 499 (23.8%) patients and non-bpCR in 1602 (76.3%) patients. A nomogram was established by ER, tumor histology, NAC regimen, cycle of NAC treatment, and the bpCR, which were confirmed by multivariate logistic analysis as independent predictors of nodal upstaging in the training cohort (n = 1576). The area under the receiver operating characteristic curve (AUC) of the training cohort and validation cohort were 0.74 (95%CI, 0.64–0.71) and 0.76 (95% CI, 0.63–0.75) respectively; Conclusion We present a nomogram with a nationwide large sample data which can effectively predict axillary upstaging after neoadjuvant chemotherapy to give better advice for individualized axillary lymph node management of breast cancer.