Breast Cancer Management for Surgeons

Sentinel lymph node biopsy after neo-adjuvant chemotherapy in patients with breast cancer: Are the current false negative rates acceptable?

Background/aims:This study aimed to (1) develop a decision aid for women considering participation in the Sentinel Node Biopsy versus Axillary Clearance 2 (SNAC-2) breast cancer surgical trial and (2) obtain evidence on its acceptability, feasibility, and potential efficacy in routine trial clinical practice via a two-stage pilot.Methods:The decision aid was developed according to International Patient Decision Aid Standards. Study 1: an initial pilot involved 25 members of the consumer advocacy group, Breast Cancer Network Australia. Study 2: the main pilot involved 20 women eligible to participate in the SNAC-2 trial in New Zealand. In both pilots, a questionnaire assessed: information and involvement preferences, decisional conflict, SNAC-2 trial-related understanding and attitudes, psychological distress, and general decision aid feedback. A follow-up telephone interview elicited more detailed feedback on the decision aid design and content.Results:In both pilots, participants indicated good subjectiv...

Development and piloting of a decision aid for women considering participation in the Sentinel Node Biopsy versus Axillary Clearance 2 breast cancer trial

Sentinel lymph node biopsy (SLNB) is the standard of care for staging N0 primary early breast cancers (EBC) Patients in developing countries mostly present with large (LOBC) or locally advanced cancers (LABC) and are treated with neo-adjuvant chemotherapy (NACT) Accuracy of SLNB in staging stage III N0 and post-NACT N0 patients is uncertain This prospective validation study on LOBC/LABC patients compared the accuracy of SLNB between primary versus post-NACT surgery Fifty T3/T4, N0 patients undergoing primary surgery (Group I) and 70 LOBC/LABC (index stage) treated with NACT and N0 at the time of surgery (Group II) were inducted Validation SLNB was performed using low-cost methylene-blue and 99mTc-Antimony colloid SLN identification (IR) and false-negative (FNR) rates were compared between the groups Sub-group analysis was done in Group II per index tumor and nodal stage to identify factors predicting SLN IR and FNR in post-NACT patients SLN IR and FNR in both groups were compared with those in previously published SLN validation study and meta-analysis in EBC Using combination of blue-dye and radio-colloid, post-NACT SLN IR and FNR (829, 135 %) were far inferior to T3/T4 primary surgery group (94, 77 %; p values 0034, 0041) and in EBC SLN IR using blue-dye alone was dismally low in post-NACT LABCs Factors predicting unidentified post-NACT SLN and false-negative SLNB included young age, LVI, skin infiltration, extra-nodal spread or N2a stage, and UOQ tumors Accuracy of SLNB in T3, N0 tumors undergoing primary surgery is comparable to that of SLNB for N0 EBC In post-NACT patients, SLNB IR are lower and FNR are higher Factors predictive of non-identification and false-negative SLNB include pre-NACT skin involvement (T4b), N2a stage or extra-nodal invasion and LVI, and to a lesser extent, young age and UOQ location of the tumor

A Comparative Validation of Primary Surgical Versus Post-neo-adjuvant Chemotherapy Sentinel Lymph Node Biopsy for Stage III Breast Cancers

Methods for accurately staging the axilla continue to evolve but remain dominated by sentinel lymph node biopsy (SLNB) which is now widely practiced and accepted as standard of care worldwide. Dual localization methods with blue dye and radioisotope are associated with optimal performance parameters such as shorter learning curve, higher identification rates and low false-negative rates. Several issues relating to surgical technique and choice of tracer agent remain unresolved, and the role of intra-operative nodal assessment remains unclear. Indications for SLN biopsy have broadened and now include some tumours larger than 5-cm, multifocal tumours and higher grades of ductal carcinoma undergoing mastectomy. The complexity of axillary management has been compounded with realization that completion axillary lymph node dissection may not be essential for all SLNB-positive cases containing macro- or micrometastases; adjuvant therapies may adequately deal with modest degrees of tumour burden in non-sentinel lymph nodes without compromise of regional control nor overall survival. Patient selection and timing of SLNB in the context of primary chemotherapy is shifting towards SLNB post-chemotherapy. Downstaging of biopsy-proven nodal disease may allow SLNB to be safely performed after chemotherapy with acceptable false-negative rates. Outstanding questions relate to management of SLNB-positive patients post-chemotherapy and whether recommendations for radiotherapy should be based on nodal stage at presentation or following induction chemotherapy.

Management of the Axilla

Background

Sentinel node biopsy is an accurate method for staging the axilla in early (small) breast cancers. However, data for the role of this technique for large breast cancers remain limited.



Method

From the Royal Adelaide Hospital Sentinel Node database and the SNAC trial database, 100 subjects were identified with clinically node negative, large (≥3 cm) primary breast cancer who had undergone sentinel node biopsy and immediate axillary clearance. The pathology results from the sentinel node and axillary specimens were analysed.



Results

Average tumour size was 3.91 cm (range 3–10 cm) and 65 of 100 cases had metastatic disease in the axillary nodes. A sentinel node was successfully identified in 93 out of 100 cases with an average of 1.75 sentinel nodes sampled. Sixty-two per cent (58 out of 93) were sentinel node positive and 43% (43 out of 100) had a positive non-sentinel node. The false negative rate following successful sentinel node identification was 4.9% (3 out of 61).



Conclusion

Sentinel node biopsy was an accurate tool for staging the axilla with a false negative rate comparable to that seen in small tumours. However, given the increased incidence of metastases with larger cancers, further prospective investigation is warranted.

Sentinel node biopsy and large (≥3 cm) breast cancer

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Sentinel node biopsy and large (≥3 cm) breast cancer