slnb the ruh experience a 2014 audit dr m stoddart, dr s cole, mr j horsnell and mr r sutton royal...
DESCRIPTION
Methods Patients identified based on Prospectively recorded data sheet Interrogation of the online operating diaries Electronic patients recordsTRANSCRIPT
SLNB The RUH experience
A 2014 Audit
Dr M Stoddart, Dr S Cole, Mr J Horsnell and Mr R Sutton
Royal United Hospital, Bath
Overview• Report the data from the RUH SLNB audit
2014• Present work looking at the effectiveness of
pre-operative lymphoscintigraphy• Report the role of pre-operative ultrasound
in identification of axillary metastases
Methods• Patients identified based on
• Prospectively recorded data sheet• Interrogation of the online operating
diaries• Electronic patients records
Process• Clinical examination• USS +/- Core Biopsy• If negative SLNB, if positive ALND• If the SLNB is positive (+/- FS) then for
ALND
Patients275 SLNB procedures
8 patients incomplete data
267 patientscomplete data
203 - completed forms
Surgical procedure
WLE60%
Mx38%
SLNB alone2%
Tumour Features• Pathology
• IDC 188 (70%), DCIS 29 (11%), ILC 26 (10%), other 24 (9%)
• Tumour Size• T1 160, T2 86, T3 21
• Grade • Grade 1 60, Grade 2 131, Grade 3 49, DCIS
27
Localisation• Radioactive Colloid
• 201/203• No nodal count in 10/201 ( 95% success)
• Blue dye• 202/203• No blue dye in node on inspection = 31 (85% success)
• Combined• Only 1 patient had neither a blue or radioactive node
(>99%)
Lymphoscintigraphy• 2013 Audit• 167/172 SLNB (with datasheets) localised• 60 patients had more nodes removed• 12 of these had metastatic disease • 1/12 had staging changed based on the
extra nodes
Number of SNs
1 node 2 nodes 3 nodes 4 nodes >40
30
60
90
120Number of nodes excised
2014
Mean number of nodes = 1.93
SLNB Results267 procedures
214 Negative
Macro 34 Micro 14
• 82% Negative (inc 5 ITCs)
• 13% positive for Macro-metastases
• 5% positive for Micrometastases
Further Management• Micrometastases
• 1/14 had an axillary clearance • Macrometastses
• 19/34 had an axillary clearance
• 9/34 radiotherapy
• 3/34 refused surgery
ALND for Macrometastases
• n=19
• Only 6 of these patients had further metastatic disease in the axilla
• Number of non sentinel positive nodes ranged from 2 to 9.
Pre-operative USS
• Patients immediately proceed to ALND (n=46)
• Sensitivity = 57%, Specificity = 99.6% • 2010 : Sensitivity = 62%, Specificity
=100%
Axillary Clearance post USS
• 46 patients avoided SLNB• Mean number of positive nodes =4.06 (range 0-
22)• USS neg = 2.5 (p=0.06)• 12 patients underwent ALND post NAC
• 3 only fibrosis, 3 “disease regression”, 1 no disease
• Mean 2.6 (range 0-16), p=0.07 v other immediate ALND
Conclusions• Only 6/267 who were USS negative had
significant nodal burden• Lymphoscintigraphy remains an important
part of the process• Excellent localisation is achieved with dual
technique• Should we consider SLNB post NAC even if
positive pre NAC
Questions