Transcript Post Neo-adjuvant Chemo Axillary Node Issues

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• Basic Concepts
Sentinel node biopsy is at least as good for axillary
assessment as ALND and probably superior.
Standard path evaluation for ALND yields ~ 20% false
negative.
SLN eval yields ~ 5% false negative.
Long term follow-up of sentinel node negative patients
with no ALND has recurrence rates of 1.5% or less.
Survival after SLN – with adjuvant Rx is superior to
Historical NSABP standard ALND – with adjuvant rx,
suggesting missed + nodes in old studies and
improved data on modern SLN studies.
Even with + sentinel node and standard BCT Rx
axillary recurrence is rare.
Axillary node dissection probably provides no benefit
to overall survival.
Sentinel node: Next Level
questions
Settings:
• Peri- neoadjuvant chemo
• IBT Recurrence with prior axillary
interventions
Post Neo-adjuvant Chemo
Axillary Node Issues
• Is sentinel node ID possible in this setting?
• Is the sentinel node concept meaningful in
this setting? i.e. =>
• Will it change therapy/ Surgery, Chemo or
Rad Rx?
• Will a positive sentinel node imply additional
positive nodes?
• Can ALND be avoided if SLN Negative?
• Should SLN BX be done pre Neoadj Rx
(instead or in addition)
Questions
• Should a positive sentinel node in the Axillary
Node Dissection Group lead to more detailed
study of additional nodes? Will it change Rx.
• If a sentinel node is positive and add levels to
other nodes, + 20% pickup?
• If ALND “only” may miss mets. Two levels
per node. SLN the Only + node ~50%
• It is the sentinel node “positive” by SLN
protocol, remainder “negative” by standard
protocol, that may be significant. May be
missed if not ID.
Other Issues
• Sentinel node count may be lower post
neoadjuvant Rx
• What is the correlation between in
breast CPR and nodal CPR.
Le Bouedec, Geissler, et al
2006
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74 pts T1T2T3N0N1 POST neo
SLN 68/74 (92%) then ALND
Mets in 30/68 (44%) i.e. Neg 56%
False neg 14% But if clinically neg N0
pre RX then accuracy 100% and FN 0%
• In 32 N1 patients accuracy 83% FN
25%
Reitsamer, Peintinger, et al
(2003)
• 30 Patients Stage II or III, Rx Neoadj Chemo
• Attempted SLN with completion ALND
• SLN 26 of 30 (86.7%) (could not ID SLN in 4
(13.3%)
• SLN accurate 25 of 26 (96.2%)
• 11 pts Neg SLN and Neg ALND
• 6 pts Pos SLN and Pos ALND
• 8 pts SLN pos and the only Pos node (~30%)
• 1 pt false-neg (1/15 = 6.7%)
Cohen, Breslin, et al (2000)
• 38 pts, stage II or III treated with neoadjuvant
chemo
• SLN attempted then ALND
• If SLN neg then all other nodes 3 add’l levels
+ IHC
• SLN ID in 31 (82%) and accurate 28 (90%)
• 3 False neg
• 4 of 20 “neg” SLN with add’l studies + for
occult mets (20%)
Kinoshita, Takasugi, et al,
2006
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Post neo 77 pts Stage II and III
Clinically node neg post Rx
SLN then ALND
SLN ID 72 of 77 (93.5%)
69 of 72 accurate (95.8%)
3 of 27 False Neg (11%)
Mamounas, Brown et al
NSABP B-27
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428 pts
SLN then ALND
SLN ID 89% with isotope
+SLN the only + node in 56% (70 of 125)
Of 218 Neg SLN nonsent + 15 => False neg
11%
POST-NEO PTS
SLN
SLN ID
Le Bouedec
2006
SL/ALND
74 PTs
68
(92%)
Reitsamer
2003
SLN/ALND
30
26
86%
25/26
96%
Cohen
2000
SLN/ALND
38
31
82%
28/30
90%
Kinoshita
2006
SLN/ALND
77
72/77
93%
3/27
11%
B-27
428
89%
11%
False
Neg
14%
If cN0 pre
0%
SLN
Accurate
SLN
only+
83%
100%
8/30
30%
72/77
96%
70/125
56%
Kuerer, Sahin, et al (1999)
• 191 pts “cyto +” ALN => neoadj chemo
• Surgery ALND
• 43 pts ALND “neg” re-eval confirmed Neg
(add’l 1112 sections/half IHC)
• =>43 of 191 “+” converted to neg (23%) by
neoadj chemo
• Of those 43, 11 were N1 and 32 were N2
• If Converted to Neg: 5 yr surv = 87%
• If Residual Positive: 5 yr surv = 51%
• If Occult Positive (10%): 5 yr = 75%
• Proposed: maybe consider SLN
Van Rijk, Nieweg, et al 2006
• 18 studies SLN after neoRX, SLN ID 89%, FN
10%
Then studied:
• SLN in 25 T2 preRX
• if pre SLN + then ALND after neoadj
• 10 pos SLN=>post Rx ALND=> 4 pts addl
nodes pos in compl ALND
• 14 SLN Neg pts=> no completion ALND =>no
recurrence 18 mo
Kahn, Sabel, et al 2005
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91 patients pre neo axillary staging
Pre neo SLN Bx path Neg 58% (53 pts)
Pre neo Pos by US FNA or SLN 42% (38 pts)
These 38 pts then Neo=>then ALND
33 of these SLN attempted, found 32 (97%)
33% of these Node Negative on ALND
Residual disease 22 patients
“False negative” 1 pt (4.5%)
SLN before Neo adjuvant
Cox,Cox, et al., 2006
• 89 pts (42 palp or image+ histo proven; 47
cN0)
• 47 cN0 SLN preRX
• 82 of 89 + nodes
• 7 (8%) of 89 neg SLN=>no completion ALND
(no recurrence in25 mo)
• 24 (27%) pCR axilla; 26% grp 1 and 33% grp
2
• Demonstrated improved prognosis, avoided
ALND 15%, improved staging 53%
Comparison
Jones, Zabicki, et al., 2005
• SLN ID rates better pre than post 100%
vs 80.6%
• Recommend SLN in cN0 pre rx and
question its use post neo
Propose
• If accuracy is important then pre
treatment workup => stage axilla If
clinical + or US+ then Bx; if cN0+US/N0
Then SLN Bx pre treatment
• If post treatment status important then
repeat SLN and complete ALND with
addl levels in non SLNs
Proposed Neoadjuvant
1) Primary Size ?
And/Or
2)“Positive” Nodes ?
3) Inflammatory
Axilla
cN0
Axillary Work-up
Exam and US
SLN
“Biopsy”
Axilla
cN1,2
Tissue Proof
US Biopsy
? Freehand Bx
“Positive”
Positive
Negative
Neoadj
Neoadj
Neoadjuvant
“Surgery”
With SLN
and ALND
“Surgery”
“Surgery”
SLN and ALND
Observe axilla
“Negative”
Next Question
• As BCT has increased the number of
IBTR patients has increased.
• Prior axillary procedures have been
done
• What should we do?
• Does it matter? It should, especially if it
is a “new primary” Late vs. early and/or
separate site IBTR
IBTR ? SLN redo
• Anticipated ~1-2 % per year BCT
patients with IBTR
• Patients with prior SLN no ALND
• Patients with prior ALND
• Need a plan for management
• ? Importance of node eval for planning
Rx
Dinan, Nagle, et al 2005
• 16 pts second IBTR
• Lymphoscintigraphy pos 69%
• Ipsi ax, contra ax, supraclav (ipsi and
contra)
Intra, Trifiro, et al, 2005
• 79 pts recurrent disease prior SLN • 18 pts cN0 ~ 26 mo after initial Dx/Rx
• Pre op ID SLN 100% with lymphoscintigrapy
and SLN removed average 1.3
• SLN pos in 2 patients
• At 12 mo no recurrences in pts SLN Neg w/o
ALND
Re-operative SLN
Taback, Nguyen, et al 2006
• 15 pts prior Rx BCT with IBTR and prior
SLN or ALND
• Preop Lymphoscintig + 11 (73%)
• 3 contralat ax, 5 ipsilat ax, 2 IM, 2 SC, 2
Intra pect
• Intraop ID 11 of 14, Mets in 3; 2
contralat ax and 1 ipsilat ax
• Milardovic 2006 Epigastric node
• Jackson 2006 IBTR prior neg now Pos
SLN single pt
• Agarwal 2005 Two pts prior BCT with
ALND => IBTR => SLN contralateral +.
SLN neg X 2
Newman 2006
• 14 LRR (10 previous ALND, 2 SLN, 2
no ax surg)
• SLN ID 90% no mets, non ipsilat
drainage in 65%
IBTR/ “SLN”
Study
Pts
SLN ID Sites
Dinan
16
70%
Intra
18
100%
Taback
15
73%
3conax 2 con ax
5ipsiax 1 ips ax
2IM,2S
C,2IP
Newman 14
90%
Con ax none
Agarwal
100%
Con ax none
2
Mets
Ip,con, none
ax, scl
2+
Proposed
• With IBTR and prior Ax RX SLN ID is possible
~ 70% of the time.
• The potential sites are many and appearance
of uptake is delayed.
• Imaging needs to be inclusive of “risk” areas
and allow extended time, (24 hours ?).
• Lymphoscintigraphy and planning SLN Bx are
justified if a change in therapy would occur (?
e.g., if postive contralateral Ax then ALND, or
if Increase/change in chemo Rx or Rad Rx.