Sentinel Lymph Node Biopsy in Large Size Breast Cancer

1
Sentinel Lymph Node Biopsy in Large Size Breast
Cancer

• The Journal Club Meeting POWH
• 26th February 2007
• Presenter Alexander Koshman
• Mentor Dr. A. Parasyn

2
Value of the Sentinel Lymph Node Procedure in
Patients With Large Size Breast Cancer

• L. Lelievre, G. Houvenaeghel, M. Buttarelli et
  al.
• Annals of Surgical Oncology, Vol. 14, No. 2,
  February, 2007
• Departments of Surgery, Radiation and Medical
  Oncology, Pathology, Oncogenetics, Institute
  Paoli-Calmettes, Marseilles, France

3
Background

• Sentinel node Bx widely accepted in early breast
  Ca (T0/T1) with no evidence of lymph nodes
  involvement (N0)
• Benefits
• better pathological assessment of the lymphatic
  involvement
• decreased morbidity in case of no ALND
• 10 to 20 of invasive breast tumours are gt T1 at
  diagnosis
• Lymphatic spread estimate is 50 (pT2) up to 80
  (pT3)

4
Background

• Widely used in routine for small breast cancers,
  the SN Bx is still discussed in tumours gt 3 cm
• Questions raised
• Could the patients with large breast cancers
  benefit from the SN biopsy?
• Reliability of the SN biopsy in large breast
  tumours gt3 cm

5
Study design

• Non-randomized prospective observational trial
• Inclusion criteria
• 1022 patients with needle biopsy-proven invasive
  or large ductal Ca in situ
• TNM clasification T0, T1, T2lt3 cm, N0, Mx
• SN procedure at the time of surgical treatment
• Study group 152 pts with tumour gt 3 cm with
  additional ALND
• All histologically invasive carcinoma subtypes

6
Study design

• SN Detection
• pre-operative lymphoscintigraphy
• intraoperative blue dye injection
• palpation of the open axilla so as to detect and
  remove enlarged (gt1 cm) and abnormally firm
  tracer and blue dye negative nodes
• ALND
• Complete level I/II ALND in patients whose
  tumours measured gt 3 cm.

7
Statistical Analysis

• Patients age and tumour characteristics
  (location, TNM stage, histology, pT, grade,
  lymphovascular invasion, hormonal receptivity, SN
  status and NSN status) prospectively recorded
• Factors influencing the false negative risk were
  studied by univariate analysis performed by the
  Fishers exact test and the Mann-Whitney test

8
Results

• Intra-operative detection of blue and/or
  radio-labeled SN successful in 97.4 pts
  (148/152)
• Detection is 78.9 with blue dye only, 96.7
  with isotopic method, 97.4 with the combined
  method
• An axillary node involvement observed in 67.1
  (102/152)
• The median number of SN cleared out was 2 (range
  1-9)
• Tumour size ranged from 30 to 200 mm (median 42
  mm)

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Results

• False negative risk of SN procedure was 4 (4/99)
• False negative risk was not related to the tumour
  size and not related to the number of SN removed

10
Conclusions

• SN procedure is feasible in patients with breast
  tumours gt 3 cm with an acceptable false negative
  risk lt5, similar to false negatives reported for
  smaller tumours
• SN procedure would avoid the morbidity of ALND
  like in early breast Ca and allow a better
  evaluation of the nodal involvement
• SN Bx could be part of the pre-treatment
  evaluation before neo-adjuvant therapy
• Can alter therapy decisions ( breast conservation
  in case of ve SN, neo-adjuvant Tx in ve SN)

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Limitations of the Study and Ideas for Future
Research

• Single centre, non-randomized, not blinded
• Sample size limited
• Other studies are needed to confirm the
  reproducibility of these results
• Further studies of factors influencing the risk
  of false negatives would be of interest