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

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10/10/19 Current Evidence for the I have no relevant financial relationships with any companies Evaluation of Sentinel related to the content of this course. Lymph Nodes and the Management of the Axilla in Breast Cancer Jasmine M. Wong, MD

  1. 10/10/19 Current Evidence for the § I have no relevant financial relationships with any companies Evaluation of Sentinel related to the content of this course. Lymph Nodes and the Management of the Axilla in Breast Cancer Jasmine M. Wong, MD FACS October 10, 2019 1 2 NSABP - B04 Surgical History § Compared women undergoing radical mastectomy, total mastectomy with XRT, and total mastectomy only Axillary management in clinically Challenged node negative breast cancer § In both node negative and node positive patients there was no Halsteadian theory significant difference in distant disease free survival and overall survival between the 3 surgical groups Halstead ACOSOG ACOSOG NSABP B04 NSABP B32 § Conclusions: Radical Z011 Z1071 Mastectomy AMAROS • Axillary lymph node dissection provides no survival benefit • Axillary node status is an important prognostic factor Radical operation Use of sentinel lymph node in for cure • Axillary lymph node status is most helpful to determine node negative breast cancer Axillary management after neoadjuvant chemotherapy adjuvant treatment recommendations 3 4 1

  2. 10/10/19 Sentinel Lymph Node Biopsy ACOSOG Z0011 5 6 AMAROS Trial ACOSOG Z0011 Local Recurrence Free Survival P value = 0.24 7 8 2

  3. 10/10/19 AMAROS Trial Clinically Node Negative Patients New Diagnosis Axillary recurrences Clinically Node (-) 4 ALND arm P=0.18 7 XRT arm Lumpectomy Mastectomy + + SLN SLN Clinical lymphedema at 5 years (-) SLN (+) SLN (-) SLN (+) SLN 23% ALND arm Z011 11% XRT arm P=0.34 p < 0.0001 XRT or ALND (AMAROS) 9 10 Clinically Node Positive Patients ACOSOG Z1071 637 women with node positive breast cancers receiving neoadjuvant § § Neoadjuvant chemotherapy chemotherapy who underwent sentinel lymph node biopsy and completion axillary lymph node dissection • Ability to access response to chemotherapy FNR 12.6% if at least 2 sentinel lymph nodes were removed § • Increase chance of breast conservation Use of dual tracer (Tc99 and blue dye) FNR 10.8% § • Potentially downstage the axilla 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 § Is a sentinel lymph node biopsy still accurate after neoadjuvant § chemotherapy? • FNR 6.8% if clipped node is removed at the time of the sentinel lymph node surgery 11 12 3

  4. 10/10/19 Clinically Node Positive Patients New Tools for Lymph Node Detection § 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 14 New Diagnosis Clinically Node Magseed In A Clipped Axillary Lymph Node (+) Neoadj Surgery Chemo Become Residual ALND Clinically Node disease (-) SLNB* ALND * use dual tracer and excision (+) à of the clipped node (-) ALND 15 16 4

  5. 10/10/19 Thank You! 17 5

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