Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerNeoadjuvant treatment for patients with clinically positive nodes
2:04 minutes.
TRANSCRIPTION:
DR MAMOUNAS: So for those patients who have clinically positive nodes, we obviously again do the ultrasound, FNA. We make sure we biopsy the nodes and we document the positivity, and we drop a clip. What you do after is debatable. There have been a couple of prospective trials that looked at the efficacy and safety of sentinel node biopsy in that setting — in other words, doing it after you downstage the disease to clinically node-negative. And the false-negative rate in this setting ranges to about 12% to 14%, a little higher than, for example, in the Z1071 had predicted to be the case, which had been 10%. So it may be a little higher. However, what both the studies have shown — and subsequently there was a third study from Canada just published in JCO showing a false-negative rate under 10%, about 8.7%. So all these trials collectively show that the false-negative rate is about, let’s say — I’ll take the average of about 12% — but is a function of how many nodes are being removed. And so if you remove 1 node, the false-negative rate is almost 30%, 2 nodes, close to about 20%. And then after that it drops, actually, to under 10% when you have 3 or more sentinel nodes removed. In addition, if you remove the clipped node and had the clip and if you do dual tracing, the false-negative rate drops. So you can interpret those data 2 ways. If you’re really more supportive of the sentinel node concept, you can say, “As long as I can take 3 or more nodes, have the clipped node taken out, dual mapping, my false-negative rate should be under 10%,” in which case I personally feel comfortable offering the patients sentinel lymph node biopsy alone, provided that they’re clinically node-negative and I take all these caveats and, also, we see the treatment effect on the nodes. Others have looked at the data and said, “That’s not enough to not do a completion axillary dissection.” And it’s okay if you want to do a complete axillary dissection. Or it’s okay to say, “I’m not going to do the sentinel node biopsy in these patients. If there were positive nodes before, I can do an axillary dissection.” I personally would apply sentinel node biopsy in those patients, but if I only take 1 lymph node, there’s no other that you can take, you have to be very careful. In this case, you’ll know that your false-negative rate is high. |