10/10/19 Current Evidence for the I have no relevant financial - - PDF document

10/10/19 1

Current Evidence for the Evaluation of Sentinel Lymph Nodes and the Management of the Axilla in Breast Cancer

Jasmine M. Wong, MD FACS October 10, 2019

1

§ I have no relevant financial relationships with any companies

related to the content of this course.

2

Halstead Radical Mastectomy NSABP B04 NSABP B32 ACOSOG Z011 AMAROS ACOSOG Z1071 Radical operation for cure Challenged Halsteadian theory Use of sentinel lymph node in node negative breast cancer Axillary management in clinically node negative breast cancer Axillary management after neoadjuvant chemotherapy

Surgical History

3

NSABP - B04

§ Compared women undergoing radical mastectomy, total

mastectomy with XRT, and total mastectomy only

§ In both node negative and node positive patients there was no

significant difference in distant disease free survival and overall survival between the 3 surgical groups

§ Conclusions:

• Axillary lymph node dissection provides no survival benefit
• Axillary node status is an important prognostic factor
• Axillary lymph node status is most helpful to determine

adjuvant treatment recommendations

4

10/10/19 2

Sentinel Lymph Node Biopsy

5

ACOSOG Z0011

6

ACOSOG Z0011 Local Recurrence Free Survival

P value = 0.24

7

AMAROS Trial

8

10/10/19 3

AMAROS Trial

Axillary recurrences

4 ALND arm 7 XRT arm

Clinical lymphedema at 5 years

23% ALND arm 11% XRT arm p < 0.0001

P=0.18 P=0.34

9

New Diagnosis Clinically Node (-) Lumpectomy + SLN (-) SLN (+) SLN Z011 Mastectomy + SLN (-) SLN (+) SLN XRT or ALND (AMAROS)

Clinically Node Negative Patients

10

Clinically Node Positive Patients

§ Neoadjuvant chemotherapy

• Ability to access response to chemotherapy
• Increase chance of breast conservation
• Potentially downstage the axilla

§ Is a sentinel lymph node biopsy still accurate after neoadjuvant

chemotherapy?

11

ACOSOG Z1071

§

637 women with node positive breast cancers receiving neoadjuvant chemotherapy who underwent sentinel lymph node biopsy and completion axillary lymph node dissection

§

FNR 12.6% if at least 2 sentinel lymph nodes were removed

§

Use of dual tracer (Tc99 and blue dye) FNR 10.8%

§

FNR 9.1% if at least 3 sentinel lymph nodes were identified using dual tracer and removed

§

170 patients had their positive lymph node clipped at the time of biopsy

• FNR 6.8% if clipped node is removed at the time of the sentinel lymph

node surgery

12

10/10/19 4

Clinically Node Positive Patients

§ Place a clip in the axillary node at the time of the biopsy § If post chemotherapy exam and imaging suggests good

response with resolution of previously noted lymphadenopathy then consider

• Sentinel lymph node with dual tracer
• Localizing and excising the previously clipped node
• Try to identify and excise at least 2-3 sentinel lymph nodes

along with any palpable lymph nodes

13

New Tools for Lymph Node Detection

14

Magseed In A Clipped Axillary Lymph Node

15

New Diagnosis Clinically Node (+) Surgery ALND Neoadj Chemo Become Clinically Node (-) SLNB* (-) (+) à ALND Residual disease ALND *use dual tracer and excision

• f the clipped node

16

10/10/19 5

Thank You!

17