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Sentinel Lymph Node Biopsy in Breast Cancer

Axillary Dissection. Breast cancer is a common disease.Level I

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Sentinel Lymph Node Biopsy in Breast Cancer

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    1. Sentinel Lymph Node Biopsy in Breast Cancer Dr Peter Lovrics St Joseph’s Healthcare, Department of Surgery, McMaster University Hamilton, Ontario

    2. Axillary Dissection Breast cancer is a common disease. Level I & II axillary dissection has been the standard of care .

    3. Why not do ALND? Inaccurate predictor of prognosis. Primary tumour & patient characteristics guide adjuvant therapies. Radiation therapy & delayed ALND provide effective local control. No impact on survival. Morbidity

    5. Why perform ALND? Staging ? prognosis Staging ? guide chemo & radiation therapy Longterm regional control Minimal morbidity Positive impact on survival?

    6. Is there a better way? Acceptance of BCS & minimizing surgical morbidity. Increased awareness & widespread adoption of screening ? decreased size of primary & earlier stage. Enhanced, more accurate pathological examination of nodal tissue. Noninvasive modalities

    7. Lymphatic Mapping Drainage primarily to the axilla. Isolated internal mammary or supraclavicular drainage rare. Morton ? melanoma Cabanas ? penile carcinoma

    9. Sentinel lymph node The lymphatic effluent of a tumour drains preferentially to one (or more) “sentinel” lymph node(s). The sentinel node accurately reflects the disease status of the entire nodal basin. Offers opportunity for enhanced pathological evaluation.

    10. SLN localization Radiopharmaceutical injection ? uptake into lymphatics ? phagocytosis & retention by lymph node. Minimal diffusion/absorption. Depends on particle size. Detectable by gamma camera (lymphoscintogram) & by handheld gamma probe.

    11. SLN localization Vital blue dye injection ? uptake into lymphatics ? retention by lymph nodes. Significant diffusion, absorption & passage. Rapid Visible Complementary to radiopharmaceutical

    12. Identification of the Sentinel Node

    13. Intraop Identification of Sentinel Node (s)

    15. Blue Dye Allergic reactions Inform anaesthesia – drop in saturation monitor Patient may appear “ashen”, cadaveric ? inform recovery room nurses Counsel patient re blue-green urine/BM Skin Tatooing

    16. Validation of SLN hypothesis Does SLN reflect disease status of the nodal basin? Can SLN be consistently identified? What is the risk of a false negative SLNB? Can SLNB technique be widely disseminated with acceptable success & accuracy?

    17. Validation of SLN hypothesis Giuliano et al, Ann Surg 1999 Negative SLN ? positive ALN: 1/1087 Veronesi et al, Lancet 1997: Negative SLN ? positive ALN: 3% Krag et al, NEJM 1998: Negative SLN ? positive ALN: 3% Risk of false negative ALND: 3-10%

    18. Validation of SLN concept Cox et al, J Am Coll Surg 1997: 96% successful identification of SLN Giuliano et al, J Clin Onc 1997: 99% successful identification of SLN Veronesi et al Lancet 1997: 98% successful identification of SLN

    19. Implementation & dissemination Krag & Giuliano: identified “learning curve” in both identification rate & false negative rate. However, validation series, multicentered trials & meta-analyses have demonstrated that technique can be implemented with acceptable accuracy rates.

    20. Learning Curves Data suggest increased volume lead to decreased failure rates COX learning curve- logistic regression on mapping failures <3 SLN biopsies/month – 86% success rate 3-6 SLN biopsies/month- 89 % success rate >6 SLN/biopsies/month- 97% success rate

    21. Learning Curve & FN Rate Four multicenter trials: Decrease in False Negative rate to =or < 5% after 20-30 procedures A minimum of 25 cases with completion ALND is recommended

    22. Is SLNB better than ALND? Enhanced staging: single/small number of nodes enables serial sectioning with H & E, and also immunohistochemical staining (IHC). Most series: nodal positivity rates 10-25% higher than ALND. Reflects historical rates of serial sectioning entire ALND.

    23. Pathology

    24. Micrometastasis

    25. Revised AJCC Staging pN0 pN0 (i-)-negative IHC pN0 (i+) positive IHC but no cluster > 0.2 mm (Isolated Tumour Cells) pN1mi: micrometastases (greater than 0.2 and none greater than 2.0 mm) pN1: 1-3 positive nodes

    26. Is SLNB better than ALND? Morbidity: ALND is the leading cause of decreased cancer-specific quality of life. Postoperative complications Lymphedema: 3-10% Numbness: 30-60% Chronic pain/neuritis: 20-30%

    27. Is SLNB better than ALND? Burak et al Am J Surg 2002 & Temple et al Ann Surg Onc 2002: Significantly less lymphedema, numbness & pain. Veronesi et al NEJM 2004: significantly fewer patients with edema, pain, numbness, & improved mobility & cosmesis

    28. ACOSOG Z010 5237 patients Surgical outcomes at 30 days and 6 months Anaphylaxis 0.1% Wound infection 1.0% Seroma 7.1% Hematoma 1.4% Axillary parasthesias 8.6% Lymphedema 6.9%

    29. Unresolved issues Patient selection Implementation & accreditation. Importance of micrometastatic disease. Technical controversies & variations. Intraoperative SLN evaluation. Internal mammary nodes What to do with a positive SLN?

    30. Clinical trials NSABP B-32: studies node negatives Survival, regional control & toxicity of SLNB versus ALND. Prognostic value of IHC. Technical success rate. Target accrual: 5400 patients

    31. NSABP- B-32

    32. Clinical trials: ACOSOG Z0010: all patients SLNB ? risk of negative SLNB & no further surgery with or without positive micrometastatic disease. Target accrual: 5300 Z0011: all patients SLNB ? risk of positive SLNB and full ALND versus no ALND (with breast XRT & adjuvant therapy). Target accrual: 1900

    33. Integration of Sentinel Node Canadian Survey Results Canadian Survey 61% response rate 1413 surgeons- 490 treated breast cancer Doubling of # of surgeons performing SLN over five year period

    34. 2006 Survey Results 76% learned SLN procedure from mentor or Formal course 56% cited inadequate resources as a deterrent Specifically lack of gamma probe or nuclear medicine resources

    35. Is Sentinel Node Biopsy the Standard of Care? Veronesi- RCT N Engl J Med. 2003 Aug 7;349(6):546-53. Underpowered ( n=516) Short follow-up Definitive trial-----NSABP 32 Trial 23-01----European IO, Italy ALMANAC Trial- Quality

    36. National Surgeons Survey

    37. Canadian Survey 2006

    38. What to do with a positive SLN? In patients with a SLN routine H&E: 30-40% disease on completion ALND ? ALND If micrometastatic disease: 10-35% ? If ITC: <10% risk of additional +ve nodes ? Literature difficult to interpret. NSABP/ACOSOG studies

    39. Nomogram for Predicting additional Axillary Metasases Memorial Sloan Kettering Cancer Center Primary characteristics: size, grade, LVI, ER, multifocality SLN: number positive & negative, detection method. Calculates risk of further positive nodes in completion axillary dissection. Van Zee et al. Ann Surg Oncol:1140-1151, 2003

    40. Sentinel lymph node biopsy It’s here. More accurate & less morbid. Accepted as standard of care. Unresolved issues: variances in techniques, implementation/standards, positive SLN & patient selection.

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