Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerAxillary ultrasound in a patient with clinically negative axilla
3:39 minutes.
TRANSCRIPTION:
DR MAMOUNAS: We typically will do an axillary ultrasound, look at the nodes. If the nodes are either thickened cortex or one abnormally looking, then we’ll do a fine needle aspiration or a core biopsy. And in addition to biopsying the node, we’ll usually drop a clip on the nodes, just to know the node that was positive with the image. So that’s my approach. I like to know what the axilla is, but on the other hand, I don’t like to take the sentinel node out up front, because by doing that, you potentially can deprive the patient of the chance of downstaging and doing a lesser procedure afterwards. So that’s how I approach, in general, the clinically node-negative patients. DR LOVE: And then how do you approach the issue of sentinel node biopsy in those patients? DR MAMOUNAS: So for these patients we’ll do the axillary ultrasound, possible biopsy up front. If they’re negative by ultrasound, we give them all the neoadjuvant chemotherapy up front, and then we go ahead and do a sentinel node biopsy after neoadjuvant chemotherapy at the time of definitive surgery. If the sentinel node is negative, then there is really no reason for an axillary dissection in these patients. Obviously, if the sentinel node is positive, then you can make the decision to take additional nodes, which is probably the standard at this point. DR LOVE: Can you talk a little bit about the data and the trials that have been done, that justify what you just said? DR MAMOUNAS: Most of the data that are in the setting of clinically negative axilla before neoadjuvant chemotherapy with sentinel node afterwards are essentially retrospective studies from large cohorts of patients. There are actually some prospective multicenter studies. The French “GANEA study did that and essentially showed that the false-negative rate of sentinel node biopsy after neoadjuvant chemotherapy with clinically negative axilla before is very similar to the false-negative rate of sentinel node biopsy up front. So based on these data — and the rate is about 9% to 10%, and the meta analysis of sentinel node biopsy after neoadjuvant chemotherapy is about 8.7%, the last meta-analysis. And when you look at the up-front setting, whether we like it or not, it’s about the same, because in the multicenter randomized trials, including the NSABP-B-32, we had a 9.7% false-negative rate. DR LOVE: From a medical oncology point of view, what are your thoughts about this? DR BLACKWELL: Yes. I think that sometimes it is helpful, almost all the time, to know the axillary status prior to starting adjuvant therapy. And we don’t have anyone sitting around the table today, but I know, in particular, radiation therapists would like to have that information. So we take a great amount of time. Our role as a medical oncologist is to make certain that all the clips are in place. And you don’t want to start neoadjuvant therapy and then get to the end of it and find out, “Oh, it really was important to know which lymph node.” I don't know why, but there’s a clip in place. We tend to clip our axillary biopsies as well, or, more importantly, the radiation therapist thinks it’s important to have had that information up front, and you didn’t necessarily — maybe there was a questionable lymph node and a decision was made not to do a biopsy. That doesn’t happen in our practice, but we do see patients out back who didn’t have an axillary examination. I don’t mean a sentinel lymph node. I mean ultrasound and biopsy. And probably one of the more important points in this component is, many of the trials looking at how to manage the axilla and the role of radiation therapy after neoadjuvant do require an up-front biopsy of axillary lymph node, documentation that they’re positive. You can’t just say, “We think it’s positive.” You really have to biopsy it in order for patients to be eligible for these studies. |