Node-Positive Breast Cancer: SLN after Chemotherapy

Kelly K. Hunt, MD F.A.C.S. Professor, Department of Surgical Oncology, Division of Surgery Chief, Breast Surgical Oncology Section, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TXMedicalResearch.com Interview with:
Kelly K. Hunt, MD F.A.C.S.
Professor, Department of Surgical Oncology, Division of Surgery
Chief, Breast Surgical Oncology Section, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX

MedicalResearch.com: What are the main findings of the study?

Dr. Hunt: We found that 40% of women who had node positive disease at initial presentation (confirmed by needle biopsy) had no evidence of residual cancer in the lymph nodes after chemotherapy.

We performed sentinel lymph node (SLN) surgery followed by axillary lymph node dissection in all of the patients and found a false negative rate of 12.6% with the SLN procedure.

The false negative rate was lower when surgeons used two mapping agents (blue dye and radioisotope) to identify the sentinel nodes and when they removed more than 2 sentinel nodes.

MedicalResearch.com: Were any of the findings unexpected?

Dr. Hunt: The false negative rate was higher than our predefined acceptability rate of 10%, however, we did not select patients for SLN surgery after chemotherapy based on clinical and radiographic (ultrasound findings) response.  In clinical practice all of that information would be considered when determining if a patient was a candidate for a less invasive procedure like SLN surgery as compared with the standard axillary lymph node dissection.  Since ALND is associated with significant long-term morbidity such as lymphedema, we would like to reduce the extent of surgery in those patients who have a good response to the chemotherapy.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Hunt: The technical aspects of the SLN procedure are important and attention to these details can significantly reduce the risk of false negative findings.

Patient selection is also important and this should be done with a multidisciplinary team (medical oncology, surgical oncology, radiation oncology, and diagnostic radiology).

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Hunt: We have just opened a clinical trial through the Alliance for Clinical Trials in Oncology that will randomize patients with a positive SLN after chemotherapy to undergo the standard ALND versus radiation to the lymph node basins.  Research suggests that radiation provides equivalent local-regional control and may have fewer long-term side effects than ALND.

We are also using clip placement at the time of initial lymph node biopsy and then confirming that the clipped node is removed at the time of SLN surgery after chemotherapy.  This can also reduce the risk of false negative findings from the SLN surgery.

Citation:

Sentinel Lymph Node Surgery After Neoadjuvant Chemotherapy in Patients With Node-Positive Breast Cancer: The ACOSOG Z1071 (Alliance) Clinical Trial

Boughey JC, Suman VJ, Mittendorf EA, et al. Sentinel Lymph Node Surgery After Neoadjuvant Chemotherapy in Patients With Node-Positive Breast Cancer: The ACOSOG Z1071 (Alliance) Clinical Trial. JAMA. 2013;():-. doi:10.1001/jama.2013.278932.

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