Has anyone encountered a patient with breast cancer having lumpectomy and sentinel lymph node biopsy but no lymph node tissue identified on final pathology? Surgeon says lymph node was removed. Would you recommend axillary dissection or no further surgery?
Breast Sentinel Node
- Thread starter jbernar1
- Start date
- Joined
- Apr 16, 2004
- Messages
- 4,660
- Reaction score
- 5,075
Tough call. Pathologist may have missed LN or it may have been accidentally discarded during processing.
Ideally, I'd want a repeat SLNB. If surgeon/patient is not amenable to this then options include:
1. Proceed as if SLNB were negative
2. Full ALND
3. Treat with high tangents to cover axilla
If she is very low risk (> 60, grade I, ER/PR positive, no LVI) then I would personally feel comfortable with #1 after I discussed risks with patient.
Otherwise I would do #3. #2 is probably unwarranted in most scenarios.
Ideally, I'd want a repeat SLNB. If surgeon/patient is not amenable to this then options include:
1. Proceed as if SLNB were negative
2. Full ALND
3. Treat with high tangents to cover axilla
If she is very low risk (> 60, grade I, ER/PR positive, no LVI) then I would personally feel comfortable with #1 after I discussed risks with patient.
Otherwise I would do #3. #2 is probably unwarranted in most scenarios.
- Joined
- Mar 14, 2002
- Messages
- 14,915
- Reaction score
- 8,847
For me it would depend on the details of the primary. If this is a 40 year old with high grade triple negative disease I'd be pushing hard for more management, preferably with dissection. If this is a 70 year old with small, low grade ER/PR+ Her2- disease, I'm just fine with repeat sentinel biopsy or even radiation alone.
I bet the patient is somewhere in the middle of these two extremes, and in most cases I'd agree with Gfunk.
I bet the patient is somewhere in the middle of these two extremes, and in most cases I'd agree with Gfunk.
- Joined
- Apr 16, 2004
- Messages
- 4,660
- Reaction score
- 5,075
Would not recommend ALND. Dealers choice between ignore lack of SLNB and treat standard tangents or treat with high tangents. Personally, I would push for latter.
- Joined
- Dec 17, 2007
- Messages
- 3,384
- Reaction score
- 4,390
I wouldn't do ALND. High tangents are fine.
The MSKCC calculator gives a risk of 20-25% depending on lesion size for positive SLN.
http://nomograms.mskcc.org/Breast/BreastSLNodeMetastasisPage.aspx
The MSKCC calculator gives a risk of 20-25% depending on lesion size for positive SLN.
http://nomograms.mskcc.org/Breast/BreastSLNodeMetastasisPage.aspx
- Joined
- Mar 14, 2002
- Messages
- 14,915
- Reaction score
- 8,847
I don't think I would do APBI in this case. Though that might annoy the surgeon if they were hoping for a brief radiation course after surgery. If time is the issue (considering APBI), would anyone be opposed to high tangents with Canadian fractionation (42.5 Gy / 16 fx)? I can't think of a time when I've seen it with high tangents, but can't think of why not.
As for repeating the SLN biopsy, I was curious what the success rate would be given the concern for "altered lymphatics". I looked up this manuscript: http://link.springer.com/article/10.1245/s10434-006-9237-z. It gives a successful repeat SLN biopsy rate of 74% after prior SLN biopsy. It's not exactly the same scenario (this would be closer to time of initial biopsy). I'm just not sure I would trust a repeat sentinel node biopsy given that and the failure to obtain a node on the first biopsy. So might as well just go with the high tangents.
As for repeating the SLN biopsy, I was curious what the success rate would be given the concern for "altered lymphatics". I looked up this manuscript: http://link.springer.com/article/10.1245/s10434-006-9237-z. It gives a successful repeat SLN biopsy rate of 74% after prior SLN biopsy. It's not exactly the same scenario (this would be closer to time of initial biopsy). I'm just not sure I would trust a repeat sentinel node biopsy given that and the failure to obtain a node on the first biopsy. So might as well just go with the high tangents.
D
deleted4401
I like the idea of high tangents with hypo fx in this case.
Since Canadian has picked up steam, I'm really losing interest in aPBI with HDR. I mean, 16 fractions, no boost is probably comparable to 5 days BID with an additional invasive procedure. And, with mature RCT data, don't have to say it's still being evaluated. So much less labor and resources. Anyone else feeling that way? On the other hand, that HDR source just wastes away otherwise.
Since Canadian has picked up steam, I'm really losing interest in aPBI with HDR. I mean, 16 fractions, no boost is probably comparable to 5 days BID with an additional invasive procedure. And, with mature RCT data, don't have to say it's still being evaluated. So much less labor and resources. Anyone else feeling that way? On the other hand, that HDR source just wastes away otherwise.
- Joined
- Feb 22, 2009
- Messages
- 147
- Reaction score
- 1
Agree completely
- Joined
- Sep 20, 2004
- Messages
- 11,727
- Reaction score
- 11,815
- Joined
- Feb 23, 2005
- Messages
- 32
- Reaction score
- 0
Agree with the high tangents, not APBI, for this case. But in general, I still think APBI using HDR brachy has some advantages over XRT. Less dermatitis issues, as long as patients are properly selected; and one week is still quicker than three weeks. I think APBI will fade out once Intraoperative RT becomes widely available.
