This slideshow discusses new points for sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patients

1. Sadaf Alipour
Oncologic Surgeon
Tehran University of Medical Sciences 1

2. Case 1
F 44 yr
Small breast, T= 4.5 cm, N1 in US
ILC, ER+, PR+, Her2+
LN involvement confirmed in CNB
Does not accept mastectomy, wants BCS
Undergoes Neoadjuvant Chemotherapy
(NAC)
T=1 cm, LN- in exam
Plan for axillary surgery? 2

3. Case 2
F 30 yr
T= 23 mm, LN felt in exam (N1)
IDC, triple negative
LN involvement confirmed in CNB
Undergoes NAC
No breast mass, no LAP in exam
Plan for axillary surgery? 3

4. Case 3
F 61 yr
T= 7.3 cm, skin involved, clinically LN+
IDC, ER+, PR+, Her2-
N1 confirmed in CNB
Undergoes NAC
No breast mass, no LAP in exam
Plan for axillary surgery?
4

5. Case 4
F 46 yr
Red and edematous breast skin in UOQ,
multiple architectural distortion in
mammography, no breast mass, no LAP
Stereotactic biopsy: IDC, ER+, PR-,
Her2-
Undergoes NAC
Normal breast, no LAP in exam
Plan for axillary surgery?
5

6. Case 5
F 52 yr
T= 32 mm, LAP +, N2
IDC, triple negative
CNB of LN: involved
Undergoes NAC
No breast mass, LN- in exam
Plan for axillary surgery?
6

7. F 52 yr
T= 52 mm, LAP in US, N1
IDC, Er+, PR+, Her2-
LN biopsy not performed
Undergoes NAC
Breast mass T=13 mm, 2 LAP in exam
Plan for axillary surgery?
Case 6
7

8. Sentinel lymph nodes (SLN)
Those 1st receiving drainage from tumor
can be variably located
usually found in lower axilla (level I)
8

9. SLN Biopsy (SLNB)
Injection of tracers into breast skin or
parenchyma
in vicinity of tumor or periareolar
enter lymphatics
–flow to draining LNs
»SLNs identified and removed.
9

10. Blue dye
The surgeon injects 3 to 5 mL
of blue dye
1% isosulfan blue
severe anaphylaxis: 0.7-1.1 %
diluted methylene blue:
Intradermal inj: may skin necrosis;
intraparenchymal inj: may
induration, erythema, pain
10

11. SLN with Blue dye
Then via axillary incision:
Removal of all blue LNs and any LNs
at the end of a blue lymphatic channel
= SLN
Removal of suspicious palpable LNs
11

12. Radioactive colloid
 Injection of technetium sulfur colloid
0.5 mCi if same day as surgery
2.5 mCi if the day before surgery
12

13. Radioactive colloid
handheld gamma probe used for the
axilla
to identify the “hot spot” (maximum
radioactivity)
Then axillary incision over "hot spot"
13

14. SLN with radioactive colloid
1st SLN: the most active (10% of inj site)
Removal of other SLNs by "10% rule"
All LNs with counts >10% of the 1st
–Usually up to 2 to 3 SLNs
»After 4-5 SLNs, some surgeons do
not remove more non-suspicious LNs
But controversial
Suspicious palpable LNs also removed
14

15. SLN with Blue + Colloid
Removal of all blue LNs
and all hot LNs
These may be 1, 2, 3,….
15

16. Single versus dual technique
In an early report of NSABP B-32
65% of SLNs: hot and blue
24% hot only
5% blue only
4 % not SLN, but palpably abnormal
16
Hot & Blue Hot only
Blue only Non-SLN

17. CONTROVERSIAL ISSUES
17

18. Single versus dual technique
SLN can be performed with blue dye,
radioactive colloid, or both
determined by surgeon preference
excellent results for each
–but combined use minimizes false
negative
18

19. Dual technique recommended
If low rate of finding SLN is expected
neoadjuvant ChT prior to SLN
prior breast or axillary surgery
obese patient
19

20. Optimum number of SLNs
In study of over 144,000 patients
disease-specific survival better for
patients with 2 or 3 SLNs than one SLN
20

21. Intraoperative evaluation of SLN
One-quarter of patients with SLN+
Residual disease in axilla
may completion ALND be required
–Intraop. evaluation immediate
ALND
–Obviates need for 2nd operation 21

22. Decreasing the false(-) rate of SLN
false (-) rate= 7.3%
range 0- 29%
Decreased by
CNB/ FNA rather than surgical Bx of
primary breast lesion
use of dual tracer
removal of any firm suspicious LN
removal of > 1 SLN if present
increased experience of surgeon
22

23. Management after SLN biopsy
SLNB has replaced ALND as initial LN
assessment in early BC
no further ALND in
Negative SLNs
Patient undergoing (BCS)+RT with
Clinical LN- and
T1≤5 cm and
<3 involved SLNs
23
Z-0011
AMOROS

24. SLN Indications
Early breast cancer with clinically LN-
DCIS
with planned mastectomy or
with suspicious features
DCIS larger than 5 cm
with a palpable mass
24

25. SLNB Contraindications
Absolute contraindications
Clinically positive LNs
Inflammatory breast cancer (T4d)
Tumor with skin/chest wall
involvement
25

26. SLNB Contraindications
Relative contraindications
Locally advanced breast cancer
some studies: SLNB accurate in T3, LN-
–T> 5 cm not absolute contraindication
Patients whose axillary status does not
guide adjuvant therapy
eg, women> 70 yr, T1, ER+, clinically
LN-
–decision is better made in MDT
Those who undergo NAC... 26

27. After NAC
27

28. When LN(-) before NAC
SLNB performed after NAC
during breast surgery
28

29. Choice between ALND or SLNB after
NAC
Depends on extent of LN involvement
before NAC
And if LN involvement is limited
–Depends on response to treatment
When LN(+) before NAC
29

30. When LN(+) before NAC
30
If clinical advanced LN involvement
(N2, N3) before NAC
ALND should be done

31. When LN(+) before NAC
If clinical N2 or N3 before NAC
but biopsy not obtained
ALND should be done
31

32. If clinical N1
Treatment based on response to NAC
If clinically LN+ after NAC
–ALND should be done
When LN(+) before NAC
32

33. If clinical N1
If clinically LN- after NAC
Axillary US should be done after NAC
–If LN+ in US
»ALND should be done
–If LN- in US
»SLNB should be done
•If SLN+ or no SLN found
• ALND should be done
When LN(+) before NAC
33

34. If clinical N1 before NAC
With negative SLNB post-NAC,
ALND can usually be avoided,
particularly if at least 2 SLNs are sampled,
and axillary RT will be performed
34

35. POINT 1: For SLNB after NAC
If cN1 converts to cN0 after NAC
False- rate of SLN similar to surgery
without NAC
Esp. if caring for maximizing SLN
identification
–use of dual tracer for SLNB
–clip in + LN
–retrieval of 2-3 SLNs
35

36. In positive FNA or CNB
before NAC
Recommended: clip in the suspicious LN
Removal of clipped node at the time of
SLNB lowers false (-)
1.4 vs 10.1 percent
–However, locating clip challenging
if no radiography in the OR
36

37. POINT 2: For SLNB after NAC
When only one SLN- is identified,
the optimal management is unclear
because of high likelihood of false- SLNB.
In the SENTINA study,
False- rate of 1, 2, or 3 SLN-
were 24, 18, and 5 %
So ALND vs axillary RT
must be discussed with the patient 37

38. POINT 3: For SLNB and NAC
Some specialists do SLNB before NAC
when clinically LN(-)
But most do not
To avoid an additional surgery and
preserve the prognostic information
from status of SLN after NAC
38

39. Summary for SLNB vs. ALND after
NAC for previous LN(+)
Clinical N2/N3
before NAC
ALND
Clinical LN+
after NAC
SLNB
Axillary US
If LN- in US
Clinical LN-
after NAC
If LN+ in US
Clinical N1 and LN+ in
FNA/CNB before NAC
If SLN+ or no
SLN found
39
21
If SLN-
If
2-3(-)
If 1
No
ALND
??
NACNAC

40. Case 1
F 44 yr
Small breast, T= 4.5 cm, N1
ILC, ER+, PR+, Her2+
Wants BCS
T=1 cm, LN- in exam
Plan for axillary surgery?
If US+:ALND
If US-: SLNB 40

41. Case 2
F 30 yr
T= 23 mm, N1 in exam
Triple negative
LN+ in CNB
No breast mass, no LAP in exam
Plan for axillary surgery?
SLNB 41

42. Case 3
42
F 61 yr
T= 7.3 cm, skin involved, clinically LN+
ER+, PR+, Her2-
N1+ in CNB
After NAC: No mass, no LAP in exam
Plan for axillary surgery?
ALND

43. Case 4
F 46 yr
Inflammatory Cancer, no LAP
ER+, PR-, Her2-
After NAC: NL breast, no LAP
Plan for axillary surgery?
ALND
43

44. Case 5
F 52 yr
T= 32 mm, LAP +, N2
Triple negative
LN+ in CNB
After NAC: No mass, LN- in exam
Plan for axillary surgery?
ALND
44

45. Case 6
F 52 yr
T= 52 mm, cN1, biopsy not performed
Er+, PR+, Her2-
After NAC: T=13 mm, 2 LAP in exam
Plan for axillary surgery?
If US+: ALND
If US -: ALND/SLNB 45

46. 46

47. REFERENCES
- UpTodate 2019
- NCCN 2019
- Adrienne G. Waks et al. Breast cancer treatment, a review, JAMA,
2019;321(3):288-300.
- Rastogi P et al. Preoperative chemotherapy: updates of National Surgical
Adjuvant Breast and Bowel Project Protocols B-18 and B-27. J. Clin. Oncol.
2008; 26(5): 778-785.
- Pilewskie M et al. Axillary nodal management following neoadjuvant
chemotherapy: a review. JAMA Oncol. 2017;3
- AND Google scholar images for pictures
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