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Sentinel Lymph Node Disease
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Sentinel Lymph Node Disease

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by Elshami Elamin, Consultant Oncologist, Wichita, KS

by Elshami Elamin, Consultant Oncologist, Wichita, KS

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Sentinel Lymph Node Disease Sentinel Lymph Node Disease Presentation Transcript

  • Elshami M Elamin, MD Medical Oncologist Central Care Cancer Center www.ccancer.com Wichita, KS - USA
  •  LN mets are the most significant prognostic indicator for breast cancer SLN biopsy can be used as an initial evaluation of the axilla in patients with clinically negative axillary nodes.
  • No ALND Negative Stage I-II SLN *SLN mapping Positivecandidate Yes ALND SN not identified*SLN involvement identified by H&E.*IHC for equivocal cases only*SLN +ve by routine IHC is not recommended in clinical decision making
  •  We all agree:  ALND reliably identifies nodal mets  ALND maintains regional control Agree  Disagree Contribution of local therapy to breast ca survival
  •  Diagnostic and/or Therapeutic?  LN –ve:  70-90% 5YS  10% chance of death in 10Y  LN+ve:  50-70% risk of relapse  35% chance of death in 10Y  1-3 LN+ve: 60-80% 5YS  >4 LN+ve: 30-50% 5YS 6
  •  A meta-analysis of breast cancer pts showing that locally controlling breast cancer via ALND improve disease patient survival ALND remain the standard of care for breast cancer pts that have + SLN
  •  In the absence of definitive data showing superior survival from ALND.  ALND should be considered optional in pts:  Favorable tumors  Unlike change of adj therapy  Elderly  Co-morbidities
  •  ALND risks:  Restricted range of motion  Pain discomfort  Lymphedema  Infection  Seroma SLND
  •  Candidates:  Clinically -ve nodes  Solitary T1 or T2  ?? High grade/extensive DCIS  No large hematoma or seroma  No neoadjuvant chemo SLN can’t be identified or +ve:  Formal axillary dissection 10
  •  Lymphatic mapping:  Blue dye = 83% success rate  Lymphoscintigraphy = 94%  Combined = 97%  False –ve: 0-11% 11
  •  Minimally invasive way to determine whether the axilla is involved  Decision to eliminate nodal dissection in face of a negative SLN is being examined by large clinical trial. If SLN +ve proceed with complete nodal dissection 12
  •  Definition: SLN metastases between 0.2mm and 2.0mm in size. It is considered negative by standard H&E, but positive by CK-IHC staining Clinical significance remains unknown  ALND: Yes or No????  Treat as N0 or N1????
  •  Hansen et al JCO 27:4679– 4684:  pts with isolated tumor cells (ITCs) and  de Boer et al. NEJM pN0[i+] and pN1mi do 361:653–663: not have worse 8-year  Pts with ITCs and DFS or OS compared pN1mi have reduced with pN0 pts. 5-year DFS  Pts with SLN mes >2 mm (pN1) have significantly reduced survival.
  • NCCN:*SLN involvement identified by H&E.*IHC for equivocal cases only*SLN +ve by routine IHC is notrecommended in clinical decision making
  • *Prognostic Advantage *? DFSALNDrisks
  • When SLN positive !!!•NO Study conclusively demonstrated: •Survival benefit or •Detriment for omitting ALND
  •  SLND accurately identifies nodal metastasis of early breast cancer But it is not clear whether further nodal dissection affects survival
  • The Current Standard•SLND alone: •If SLN is free of cancer•ALND: •If SLN contains cancer
  • Q: Whether ALND affectsoverall survival in breastcancer with SNLmetastasis or whetherSNLD alone is sufficient? A: --------------------
  •  Originally presented at the 2010 ASCO Annual Meeting Published on February 9, 2011, JAMA
  •  Randomized, multi-center, Phase III non- inferiority trial Conducted at 115 sites (May 1999 to Dec 2004) I or IIA (891 pts) No palpable LN Randomized 1:1  SLND  ALND or SLND alone  Both groups had a lumpectomy and adjuvant systemic treatment
  • Not eligible SLN by IHC > 3 positive SLNs Matted LNs Gross extra nodal disease Neoadjuvant therapy
  •  Age, stage of cancer, and tumor size did not vary significantly between the two groups The median number of LN removed in the ALND group was 17 compared with 2 in the SLND group The adjuvant systemic therapies received by both groups were comparable:  96% and 97% of the ALND and SLND patients The majority of pts received whole-breast RT
  •  To determine the effects of complete ALND on survival of patients with SLN metastasis of breast cancer
  •  OS was the primary end point, with a noninferiority margin of a 1-sided hazard ratio of less than 1.3 indicating that SLND alone is noninferior to ALND. DFS was a secondary end point.
  • 5 year OS 0.7% absolute difference  Favoring SLND
  •  SLND compared to ALND was not statistically inferior in terms of OS (P=0.008) The 5 YOS rates:  92.5% and 91.8% in the SLND-alone compared to the ALND DFS did not vary between the groups Morbidity:  Wound infections significantly more frequent  Axillary seromas in the ALND  Lymphedema group
  • Total Locoregional recurrence rate at 5 years •2.5% in SLND •3.6% in ALND Further F/U unlikely would result enough additional recurrences to generate aclinically meaningful survival difference
  •  The trial results suggest that women may be exposed to morbidity due to ALND with no meaningful improvement in overall survival, including women classified as high- risk (ER/PR -ve)
  •  Failure to achieve a target accrual of 1900 pts Potential randomization imbalance that favored the SLND-only cohort Follow-up was approximately 6 yrs and a longer- term follow-up would be beneficial, as early- stage breast cancer can reoccur at 10 to 15 years after diagnosis
  •  This data will likely change physician practice for early stage disease Caution:  That the study results do not apply to early-stage pts with high risk for reoccurrence:  Three or more positive SLN  Larger tumors  Those who received preoperative chemotherapy
  •  The results currently apply only to early stage breast cancer  Tumors < 5 cm  No clinically evident nodal involvement  Lumpectomy/RT  No MRM pts included in the study  >95% received adj systemic therapy  1-2 positive SLN  No extracapsular extension We have concerns about routinely omitting axillary dissection in younger women (under age 50), and cancers with particularly aggressive features, including those considered high grade In some cases, additional information about possible remaining lymph node involvement will be necessary to make decisions about chemotherapy or radiation, and further surgery may still be warranted
  • According to Z0011 The only additional information gained from ALND is the number of involved LN  Unlikely to change systemic therapy decison Z0011 results indicate that women with a positive SLN and clinical T1-2 undergoing L/RT  systemic therapy do not benefit from ALND in terms of:  Local control  DFS  OS
  • Z0011 vs NSABP B04 Z0011  NSABP B04  6 yrs f/u: No survival  25 yrs f/u No survival difference difference  N+ve: 100%  N+ve: 40%  5YS: > 90%  5YS: only 60%  First axillary failure in  First axillary failure: 19% SLND: Only 0.9% Conclusion: High rate of locoregional control even without ALNDNSABP B04: N-ve pts: rad mastectomy vs total mastectomy + Nodal RT or Delayed Nodal RT for node recurrence
  • Z0011 vs NSABP B04 Changes of breast cancer management during the interval between the 2 studies  Improved imaging  Detailed pathologic evaluation  Improved planning of surgical and radiation approaches  More effective systemic therapy
  • The International Breast Cancer Study Group Trial of ALND vs Observation > 50% of pts did not receive breast or axillary RT Women >60 on adj Tamoxifen and No axillary treatment:  Axillary recurrence was only 3%  OS was 73% (median F/U of 6.6Y)
  • For which pts is the ALND remains the standard of care? Pts with positive SLN and: 1. Mastectomy 2. Lumpectomy without RT 3. Partial breast RT 4. Neoadjuvant therapy 5. Whole breast RT in the prone position (low axilla is not treated)
  •  These findings should encourage new and continuing dialogue between physicians and breast cancer patients and their families regarding the most appropriate treatment options available