The Treatment of the Axilla in the North of England Cancer Network - - PowerPoint PPT Presentation

The Treatment of the Axilla in the North of England Cancer Network – Prospective Audit Complete Data

Andrew Pieri Henry Cain Sebastian Aspinall On behalf of the Breast NSSG

Audit Aims

• Summarise and audit compliance with local and national

guidelines

• Investigate the role of ALNC for micro‐metastases
• Investigate the role of SLNB in T3 tumours
• Analyse predictive factors of nodal disease

Audit Standards

• National Guidelines – ABS 2009
• Local Guidelines – NECN 2013

Standards Consistent in Local & National Guidelines

• All patients with invasive cancer should have pre‐op axillary

staging

• Patients with pre‐op diagnosis of axillary mets should have

ALNC

• If SLNB positive for macro‐mets then ALNC or RTx

Standards Inconsistent in Local & National Guidelines

• If SLNB positive for micro‐mets then ALNC or RTx (ABS)
• NECN states, “With just micro‐mets, the value of further

axillary surgery may not outweigh the morbidity in all except the highest risk cases”

• ALNC is preferred (over RTx) as offers additional staging info

(NECN)

• Combined blue dye/radioisotope should be used (ABS)
• ALNC should retrieve ≥ 10 nodes (ABS)

Region‐wide Data Collected

Number of cases per Trust

50 100 150 200 250 300 N e w c a s t l e C u m b r i a S

• u

t h T e e s N

• r

t h u m b r i a G a t e s h e a d N

• r

t h T e e s D u r h a m S

• u

t h T y n e S u n d e r l a n d Number of Cases

Audit Data – Demographics

• 1142 patients

– 866 SLNB, 120 SLNB + ALNC and 156 ALNC

• Age range 20‐94, mean 60.3, median 61

Tumour Characteristics

Tumour Characteristics Interim Analysis Final Analysis Tumour Type DCIS 38 (8%) 84 (8%) Invasive Ductal 350 (76%) 846 (76%) Invasive Other 73 (16%) 175 (16%) Benign 0 (0%) 1 (0.1%) Tumour Size 0‐19 mm 221 (47%) 556 (50%) 20‐50mm 205 (44%) 479 (43%) >50mm 43 (9%) 83 (7%) Tumour Grade 1 62 (14%) 164 (15%) 2 216 (49%) 525 (49%) 3 165 (37%) 382 (36%)

Pre‐op Axillary Staging

Every patient with suspected breast cancer should have US axilla

1st Cycle 2nd Cycle Combined Results Not recorded 90 Total Recorded 450 602 1052 USS staging performed 445 (99%) 599 (99.5%) 1044 (99.2%) USS staging not performed 5 (1%) 3 (0.5%) 8 (0.8%)

Sentinel Node Biopsy Technique

Method 1st Cycle 2nd Cycle Combined Total Dual 277 (69%) 365 (65%) 642 (66%) Blue dye only 33 (8%) 64 (11%) 97 (10%) Radio‐isotope only 90 (22%) 137 (24%) 227 (24%) Total SLNBs 400 566 966

Combined blue dye/radioisotope technique is recommended

Sentinel Node – Number Excised

• 986 SLNB cases performed
• Range of nodes retrieved = 0 – 16
• Mean = 2.4
• Median = 2

Results of SLNB

Results Available 1st Cycle 2nd Cycle Combined Total SLNB Negative 307 (77%) 473 (80%) 780 (79%) Positive 91 (23%) 115 (20%) 206 (21%) Pathology of positive nodes ITC 4 (4%) 4 (3%) 8 (4%) Micro 26 (29%) 27 (24%) 53 (26%) Macro 61 (67%) 84 (73%) 145 (70%)

Treatment of positive SLNB

Micro‐mets Macro‐mets SLNB result (n) 1st Cycle 2nd Cycle 1st Cycle 2nd Cycle No Treatment 5 (19%) 7 (26%) 4 (7%) 7 (8%) ALNC 16 (61%)* 5 (22%)* 40 (66%) 52 (62%) RTx 4 (15%)* 14 (52%)* 17 (28%) 20 (24%) ALNC & RTx 1 (4%)* 0* 5 (6%)

With micro‐mets, the benefit of ALNC may not outweigh the morbidity (NECN Guidelines) If SLNB positive for macro‐mets then ALNC or RTx (ABS & NECN)

*p = 0.001 (Fisher’s exact)

Axillary Clearance – Number Excised

• 272 ALNC performed
• Range of nodes retrieved = 0 – 46
• Mean = 13
• Median = 13
• 95% confidence interval = 12.9 – 14.6

Indications for ALNC

Indication 1st Cycle (n=125) 2nd Cycle (n=147) Combined Totals Pre‐op +ive 58 (46%) 80 (54%) 138 (51%) SLNB +ive 50 (40%) 60 (40%) 109 (40%) Intra Op Assess +ive 4 (3%) 1 (0.7%) 5 (2%) Other 13 ( 11%) 6 (5%) 20 (7%)

Adequacy of ALNC – should retrieve ≥ 10 nodes

1st Cycle (n=125) 2nd Cycle (n=147) Combined Total (n=272) < 10 nodes retrieved 26 (20%) 45 (31%) 71 (26%)

Summary of Audit Standards

• Rate of pre‐op staging > 99%
• Dual method of SLN localisation used in only

66%

• 21% of micro‐mets do not receive ALNC or RTx
• Significant shift away from ALNC and towards

RTx for micro‐mets in 2nd cycle

• 8% of macro‐mets did not receive ANC or RTx
• 26% of ALNC yielded < 10 nodes

What Pre‐operative factors predict a positive SLNB?

SLNB (%)+ve SLNB ‐ve P value Overall 195 752 Mean age (yrs) 57.3 61.1 <0.0001 T1 84 (16%) 433 0.0001 T2 93 (25%) 279 T3 15 (38%) 24 Symptomatic 126 (25%) 388 0.0002 Screened 57 (15%) 335 G1 19 (12%) 140 0.0035 G2 111 (25%) 339 G3 62 (22%) 222 NST 154 (22%) 554 ns ST 33 (22%) 120

What factors predict non‐SLN metastases at ALND following positive SLNB?

ALND +ve ALND ‐ve P value Overall 34 68 LVI +ve 23 (48%) 25 0.006 LVI ‐ve 12 (21%) 44 ECS +ve 16 (53%) 14 0.01 ECS ‐ve 18 (25%) 55 T1 9 (23%) 31 0.04 T2 19 (38%) 31 T3 6 (50%) 6

Significant increase in risk of non‐ SLN mets on ALNC

ALND (%) +ve ALND ‐ve P value Overall 34 68 NST 25 (30) 58 0.15 ST 8 (50) 8 Screened 10 (45) 12 0.21 Symptomatic 22 (31) 50 G1 1 (12.5) 7 0.31 G2 19 (39) 30 G3 14 (31) 31 Mean age (yrs) 55.3 55.6 0.92

No significant increase in risk of non‐SLN mets on ALNC

Does the number or type of SLN mets affect the risk of non‐SLNB mets at ALND?

Number of SLN mets

SLNB status ANC +ve ANC ‐ve Total 1 of 2+ SLNB +ve 7 (20%) 27 34 1 of 1 SLNB +ve 9 (39%) 14 23 2 of 2+ SLNB +ve 14 (54%) 12 26

Memorial Sloane‐Kettering (MSK) Nomogram

Should we treat the axilla in T3 tumours differently to T1‐2 tumours?

Differences between axillary LN status of T1‐2 and T3 tumours

T1 & T2 T3 P value Overall 954 64 Number of patients with LN mets 280 (29%) 39 (61%) <0.0001 Number of LN mets present on ALND: ‐ Range ‐ Median ‐ Mean (95% CI) 1‐21 2 3.6 (3.0‐4.2) 2‐18 3.5 5.5(3.9‐7.0) 0.008 Number having SLNB 850 44 SLNB +ve 176 (21%) 19 (43%) 0.0011

Summary of Analysis

• Factors that affect risk of SLN mets:

– Age – Tumour size and grade – Mode of presentation

• Factors that affect risk of non‐SLN mets on ALNC:

– Tumour LVI – Nodal ECS – Tumour size – Number of SLN mets

• Factors which don’t affect risk of non‐SLN mets on ALNC:

– Type of SLN

• The majority of T3 tumours have LN mets
• LN mets are twice as prevalent in T3 vs T1/2 tumours

Thank you