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SLNB After Preoperative Therapy
Anees B. Chagpar, MD, MSc, MPH, MA
Associate Professor of Surgery, Yale University School of Medicine
Director, The Breast Center – Smilow Cancer Hospital at Yale-New Haven
Overview
Pre-NAC SLNB Post-NAC SLNB
Identification rate ~100% > 90%
False negative rate < 5-10% Up to 33% (8-13%)
Second surgery Potentially Not necessarily
Ability to avoid ALND Low Higher
Ability to assess pCR May have removed
only positive node
Better able to assess
response
Influences
management
Maybe Maybe
SLNB after NAC
Study N Identification
rate
False negative
rate
Van Deurzen 2148 90.9% 10.5%
Kelly 1799 89.6% 8.4%
Xing 1273 89.7% 12.0%
Hunt 575 97.4% 5.9%*
Mamounas 428 84.8% 10.7%
Classe 195 90.3% 11.5%
San Antonio Breast Cancer Symposium, December 4-8, 2012
Z1071 schema
T0-4, N1-2, M0 invasive breast cancer (pretreatment axillary ultrasound with FNA or core biopsy
documenting axillary metastases)
↓ REGISTER*
↓
Neoadjuvant chemotherapy
↓ REGISTER*
↓
SLN and ALND
San Antonio Breast Cancer Symposium, December 4-8, 2012
Z1071 Consort Diagram 756 women with T0-4,
N1-2, M0 disease enrolled
701 women underwent axillary
surgery (663 cN1; 38 cN2)
687 women attempted SLN and ALND completed
(649 cN1; 38 cN2)
637 women SLN identified and
ALND completed (603 cN1; 34 cN2)
Exclusions • 34 pts terminated study prior to surgery
• 21 pts ineligible
Axillary surgery • 1 pt ALND was not completed
• 1 pt no nodes found on ALND • 12 pts SLN not performed
SLN surgery • 50 pts SLN not detected
Node positive disease 637 pts
Chemotherapy
Residual nodal disease
382 pts (60%)
SLN positive
326 pts
SLN negative / ALND positive 56 pts
Node negative
255 pts (40%)
ACOSOG Z-1071
• SLN identification rate = 92.5%
• Accuracy = 91.2%
• False negative rate
– Overall: 14.7%
– cN1 disease and 1 SLN: 31.5%
– cN1 disease and 2+ SLNs: 12.8%
• Only 2 SLNs examined: 21.1%
• Dual tracer: 10.8%
Clip
Clip N Residual
disease FNR 95% CI
Placed and
found 96 54 7.4% 2.0 – 17.9%
Placed, but
not found 76 50 14.0% 5.8 – 26.7%
Not placed 353 206 13.6% 9.2 – 19.0%
Role of Ultrasonography
• May provide staging information if done prior
to neoadjuvant chemotherapy without
removing only positive node
• Should we still do SLNB post-NAC in patients
with known axillary disease?
– If so, ultrasound no longer saves patients SLNB
SENTINA Trial 1737 patients
(103 institutions)
cN0 cN1
pN0 pN1
No axillary
surgery
SLNB
Re-SLNB +
ALND
Neoadjuvant Chemotherapy
SLNB +
ALND ALND
Neoadjuvant Chemotherapy
ycN1 ycN0
Arm Identification
Rate FNR
Pre-NAC SLNB 99.1%
Re-SLNB post-NAC 60.8% 51.6%
SLNB post-NAC 80.1% 14.2%
SENTINA Trial
Lobular vs non-lobulal tumor G3 vs G1-2 Unifocal vs multifocal L0 vs L1 V0 vs V1 Extracaps. extension no vs yes
ER/PgR negative vs positive
HER2-negative vs positive
Large center vs small Number of SLN (1 vs >1)
No pCR vs pCR
OR=.132 (.007, 2.51), p=.178 OR=1.20 (.406, 3.55), p=.741 OR=.961 (.322, 2.86), p=.942
OR=1.66 (.553, 4.99), p=.365
OR=2.33 (.069, 78.5), p=.637
OR=.386 (.103, 1.44), p=.157
OR=1.02 (.321, 3.27), p=.967
OR=1.67 (.496, 5.65), p=.406
OR=.416 (.147, 1.18), p=.098
OR=.505 (.306, .833), p=.008
OR=1.34 (.243, 7.37), p=.737
False Negative Rate post-NAC
So….
• Lower identification rate
• Higher false negative rate
• But does it matter?
– NSABP B-04
– ACOSOG Z-0011
Future Studies
• Alliance A11202
– Randomize SLN+ patients post-NAC to ALND vs.
axillary RT
• NSABP B-51
– Node positive patients undergoing NAC
– Node negative post-NAC
– Breast radiation if partial mastectomy
– Randomized to regional LN radiation (+ PMRT) vs.
no regional LN radiation (and no PMRT)
Yale Philosophy
Candidate for
Neoadjuvant Tx Consider clinical trials
Clinically LN- Clinically LN+ If US suspicious,
FNA or core
SLNB +/- ALND
NAC
Try for 3+ SLNs ALND or
SLNB +/- ALND
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