NAC FOR cN1 BREAST CANCER PATIENTS - NO Stephen R. Grobmyer, MD, - - PowerPoint PPT Presentation

TARGETED AXILLARY DISSECTION FOLLOWING NAC FOR cN1 BREAST CANCER PATIENTS - NO

Stephen R. Grobmyer, MD, FACS Professor of Surgery Zapis Endowed Chair for Breast Cancer Research Co-Leader, Breast Cancer Program Cleveland Clinic Cleveland, Ohio

Disclosures

• Travel support - Zeiss Meditech
• Medical Advisory Board - Seno Medical
• Research Support - Mitaka USA
• Research Support - GRAIL
• Research Support - Lumicell

Early Trial Results Suggest There May Be Role of SLN Biopsy/Targeted Dissection

We Should Not Be Doing Targeted Dissection or SLN After NAC

• We should be doing axillary dissection
• Axillary lymph node dissection (ALND)

has been a standard for years

• ALND is associated with excellent long

term control

• SLN mapping fails in 7-13% of patients

following NAC

• Does not require use of potentially toxic

blue dyes

Patients Determined to Be ycN0 Following ALND Derive Little Benefit from Radiation Therapy

• 30 patients from MDACC with stage II breast

cancer treated with ALND following NAC

• 10 year LRR recurrence rate
• With adjuvant radiation (n=10) = 0%
• Without adjuvant radiation (n=20) = 0%
• With complete axillary nodal staging we can

truly declare a patient ypN0!

McGuire et al. Int J Radiation Biol Phys 68(4): 1004, 2007.

Complete ALND Provides Accurate Nodal Staging Information with is Prognostic

Residual metastatic LN 3 Year DFS p Value

78% 0.05

• 1-3

80%

• 4-10

50%

• >10

44%

Accurate nodal staging is not possible without ALND as sentinel node biopsy or targeted axillary dissection is associated with false negative rate 7-31%. This type of powerful staging information could be useful for stratifying patients into extended adjuvant therapy trials.

Kuerer et al. Am J. Surg. 176: 502, 1998.

We Don’t Need to Abandon ALND; We Need to Do the Operation Better

• Axillary Reverse

Mapping has been shown to be associated with very low rates of lymphedema

• LV bypass can also be

utilized to minimize lymphedema rates

Axillary Reverse Mapping LV Bypass Tummel, Klimberg et al. Ann Surg 265(5): 987, 2017. Shilad, Cakmakoglu, Schwarz, Valente, Djohan, Grobmyer. ASO 25(1): 3106, 2018.

If One Chooses to Perform SLN Biopsy After NAC for cN1 Patients:

• Addition of targeted node removal adds

little oncologic value

• Addition of targeted node adds cost,

complications, and patient discomfort unnecessarily

TARGETED AXILLARY DISSECTION

• Place clip or

seed in node biopsied before NAC

• Remove

targeted node + SLN biopsy

Newer Studies Suggest that SLN Biopsy Following NAC is Feasible

With use of dual tracer SLN mapping, FNR of SLN biopsy and clipped node is very similar; clinically insignificantly different.

SLN Biopsy Without Node Targeting is Safe and Effective

• 71 SLN (-) patients following NAC
• 87% had > 3 SLNs
• 13% had < 3 SLNs
• SLN mapping with dual tracer and

retrieving 3 nodes results in similar FNR to targeted node dissection

• Performance of targeting procedures

becomes superfluous.

Mamtani et al. Ann Surg Onc 23: 3467, 2016.

Long Term Results with Targeted Axillary Dissection are Sparse

• Little long term recurrence

data from prospective trials

• f SLN biopsy in cN1

patients is available

• Possible that residual

chemo resistant cells left behind have negative impact on recurrence

Most Patients cN1 Patients Having NAC Receive Adjuvant Radiation Therapy

• NCCN guidelines: “Strongly consider” RT

for cN1, ypN0 patients

• Practice pattern studies suggest most cN1,

yPN0 patients receive post-mastectomy RT

• Uncertainty of residual disease in non-

sentinel nodes likely contributes to this decision in patients having

NCCN guidelines V4.2018 De B. Lima, et al. Rep Pract Oncol and Radio 24: 115, 2019.

Many Technical Challenges with Targeted Axillary Dissection

Things Not Discussed in Papers

• Additional invasive axillary procedures
• Risk of hematoma
• Patient discomfort
• Increased cost (seeds, procedures,

localizing devices)

• What do with lost clip at time of

surgery?

• What do if clip migrates from node

which has been treated?

• Multiple positive nodes-which one

should be clipped?

If You Considering Targeted Axillary Dissection

• Axillary dissection +/- ARM

and LVB can give best staging and local control with minimal side effects

• SLN with dual dyes and

removal of > 2 nodes yields good results without limitations of targeted axillary dissection