Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerTiming of sentinel node biopsy
3:11 minutes.
TRANSCRIPTION:
DR MAMOUNAS: The argument for doing it before is that it’s obviously in a setting that there is no potential effect of neoadjuvant chemotherapy changing the lymphatics or changing the patterns of involving the node. And if you do it up front and it’s negative, then you can say, “Okay. This patient has negative nodes.” The radiation oncologists are fine with not giving radiotherapy, as long as the primary tumor doesn’t require it and therefore everybody is happy. My argument against that, though, is that if it’s not negative, then you get stuck. But if it’s negative, it’s great. I agree. If I had my rather and I knew it was negative, I would do it before, too. But the point is, you don’t know. DR BLACKWELL: Yes. DR MAMOUNAS: And you get very close to similar information by doing the axillary ultrasound and biopsy of suspicious nodes. So in other words, somebody who has normal nodes in the axilla, looking by ultrasound, it’s very unlikely that they will be substantially involved with disease. But they could be microscopically involved. And that’s the whole point. Now, what gets a little tricky is that if you have like an ER-positive, HER2-negative patient with negative axilla, let’s say, and you do the sentinel node up front for whatever reason and you find a little bit of disease and the patient potentially will have a lumpectomy, that falls into the Z11 category where you can spare an axillary dissection anyways. But that’s a minority of patients in general. I think the majority of patients, particularly if you have HER2-positive or triple-negative disease, may not fall into that category, because they may have positive nodes. And then you may commit to an axillary dissection after neoadjuvant chemotherapy. That’s why I don’t like to do it up front. But for ER-positive, HER2-negative patients and you’re not sure if you’re going to give chemotherapy, it makes sense to do it. DR LOVE: I guess there’s the issue of is it worth knowing that you’ve initially had a positive axilla that became negative? Would you treat that patient differently than a patient who started out with a negative axilla? DR BLACKWELL: From a radiotherapy — and I’m not a card-carrying radiotherapist — but from a radiation therapy, we know that postmastectomy radiation in patients who have positive lymph nodes has been shown to improve outcome. So I guess it wouldn’t affect what I’m doing from a medical oncology standpoint. I don’t think it would necessarily affect what our surgeon — though Terry can speak to that. But I think from a radiotherapy standpoint, it might inform some decisions to know that the nodes were positive up front, because in certain institutions, for whatever reason, there is a reluctance to give immediate reconstruction at the time of mastectomy, because radiation is required. And that’s a discussion that the plastic surgeon has to have with the patient. But I still believe that for patients — the question is unanswered and is being examined as to whether or not you really need to give negative lymph nodes after neoadjuvant therapy, radiation therapy. But right now the standard of care in my mind remains that if you have positive lymph nodes up front, there is some potential benefit for radiation therapy postsurgically. DR MAMOUNAS: Right. I agree. And the onus is for us to show that potentially you don’t need it. |