黃俊升：我們能避免腋窩淋巴結(jié)解剖嗎

CanWeAvoid

AxillaryLymphNodeDissection?

Chiun-ShengHuang,MD,PhD,MPHProfessorofSurgeryDirectorofBreastCareCenterNationalTaiwanUniversityHospitalNationalTaiwanUniversityCollegeofMedicine1AsALNDimpactspatients’lifequalityalot,canweavoidALNDeventuallyinpatientswithpalpablenode?InclinicallynegativepatientswithpositiveSLNs?

morethan2positivenodesinBCSpatients

oneormorepositivenodesinmastectomy2SLNBhasreplacedALNDforaxillarystagingforpatientwithoutclinicallypalpablenode

Let’stryourbesttoavoidALNDinpatientswithpalpablenode?

giveneoadjuvanttherapy,esp.Her2+orTNBC,todownstageinclinicallynegativepatientswithpositiveSLNs?1or2positivenodesinBCSpatientsmorethan2positivenodesinBCSpatientsoneormorepositivenodesinmastectomygiveadjuvantchemotherapy,thendo2ndSLNB?shouldhavecheckedultrasoundbeforesurgery,thengiveneoadjuvantif

axillaryultrasoundispositive

IsSLNBaloneaccurateafterneoadjuvanttherapyinpatientswithpositivenodeatdiagnosis?Is2ndSLNBfeasible?ShouldwefollowZ0011?

32014ASCOGuidelineofSLNBRecommendation2.1:ForwomenwithearlybreastcancerwhohaveoneortwosentinellymphnodemetastasesandwillreceiveBCSwithconventionallyfractionatedwhole-breastradiotherapy

and

systemic

therapy,cliniciansshouldnotrecommendALND42016ASCO

ACOSOGZ0011:10-yearsurvivalresults

ALNDvs.SLNDalonefor1or2SLN+NodifferenceinlocalorregionalrecurrenceNodifferencein10-yearDFS(OS80.3%forSLNBalonevs78.3%forSLNB+ALND)andOS(86.3%forSLNBalonevs83.6%forSLNB+ALND)11%ofpatientsdidnotreceiveradiation.Variationsinradiationdeliverywereequallydistributedamongarms.Althoughdidnotmeetinitialaccuralnumbers-resultsstatisticallysignificant-veryloweventrate:resultsprobably

wouldnotbechangedbyadditionalaccuralZ0011

findings27.4%of

patientsreceivingSLNBandALNDshowedpositivenon-sentinelnodes0.9%axillaryrelapseinSLNDalonearmSignificantcontributionofradiationandsystemictherapytolocalcontrolIt

should

be

safe

to

leave

behind

metastatic

nonSLNs6

IBCSG23-01

SNBalonevs.ALND

forSLN

micrometastasis

Nodifferencein5yrDFS

SLNB-88.4%ALND–87.3%OmittingALNDinMastectomy

patients?(9%ofpatientsineacharm)GalimbertiSABCS2011Recommendation2.2:CliniciansmayofferALNDforwomenwithearly-stagebreastcancerwithnodalmetastasesfoundonSNBwhowillreceivemastectomy.Evidencequality:low.Strengthofrecommendation:weak.

ThisrecommendationisbasedonasubgroupofparticipantsinIBCSG23-01.Ninepercentoftheparticipantsineacharmunderwentmastectomy(ALND,n=

44;noALND,n=

42).2014ASCOGuidelineofSLNBcN01334SLNBpN0684pN1

455cN1797NEOADJUVANTCHEMOTHERPY(NACT)NoaxillarytreatmentRe-SLNB+ALNDycN0

642ycN1123

SLNB

+ALND

248

N(-)ALNDArmBArmAArmCArmDSENTINATrialDesignSanAntonioBreastCancerSymposium–Dec4-8,2012T.Kuehn,sabcs2012UltrasoundUltrasound9T.Kuehn,sabcs2012ArmB2ndSLNBafterSLNB+NACTArmCSLNBafterNACTforcN1ycN0SENTINATrialFalse-NegativeRateSanAntonioBreastCancerSymposium–Dec4-8,201210IDRFalseNegativeRateTracerTracerSLNnumberPostCTAUS≥2SLNs

removedIHCSingleDualSingleDual1

≥2NoYesNoYesSENTINA77.4%87.8%16.0%8.6%24.3%9.6%(18%

if

2

SLNs)ACOSOGZ107120.3%10.8%31.5%9.1%

if

≥3SLNs,

21.1%if

2

SLNs

12.6%

(N1)9.8%US(-)SNFNAC16.0%5.2%18.2%4.9%

(with

IHC)13.3%8.4%SLNB

after

Neoadjuvant

Chemotherapy

in

Node-Positive

PatientsIDR:IdentificationRateSENTINALancetoncology14(7):609-618SNFNACJCO.

2015Jan20;33(3):258-64ACOSOG

Z1071

(Alliance)

JAMA.

2013Oct9;310(14):1455-61,

JCO

2015doi:10.1200

/JCO.2014.55.782711From:SelectiveSurgicalLocalizationofAxillaryLymphNodesContainingMetastasesinPatientsWithBreastCancer:

AProspectiveFeasibilityTrialJAMASurg.2015;150(2):137-143.doi:10.1001/jamasurg.2014.1086UltrasonographicImageoftheClipinaLymphNodeAfterNeoadjuvantChemotherapyTheclipmarkerwasplacedwithinthesampledlymphnodeunderultrasonographicguidance.Mammogram:Aniodine-125seedisplacedintheclipped1-5dbeforesurgeryunderUSguidance.Oncethelocalizednodeisremoved,aspecimenradiographisperformedtoensurethattheclipandseedhavebeenremoved.JCO2016;34:1072-AssessmentnodalresponseafterneoadjuvanttherapyFalse-negativerateClippedNodes4.2%SLND10.1%TAD(clippednodes+SLND)2.0%CortexFatty

hilumThickenedCortexUSbenignCorrelationsbetweenUltrasoundandCNB

Findingsin144PatientsCNBFinding*USFindingMalignantBenignSensitivity?Specificity?PPV?NPV?Corticalthickening632379

(63/80)64(41/64)73(63/86)71(41/58)Absenceoffattyhilum26233(26/80)97

(62/64)93(26/28)53(62/116)NHBF521565(52/80)77(49/64)78(52/67)64(49/77)CorticalthickeningandNHBFcombined521265(52/80)81(52/64)81(52/64)65(52/80)NHBF:Non-hilarbloodflow*Dataarenumbersoflymphnodes(sameasnumbersofpatients).?Dataarepercentages,withthenumbersofpatientsusedtocalculatethepercentagesinparentheses.NPV=negativepredictivevalue,PPV=positivepredictivevalue.P<0.001forallcorrelationsbetweenUSandhistopathologicfindingsatX2testing.Abeetal.Radiology2009:41UltrasoundFeaturesofAxillaryNodesandResultsof

Ultrasound-GuidedNeedleLocalizationChoet.al.AJR2009:1731SurgicalResults,No.(%)ofCasesNeedle-LocalizedNodetoNodeBasedSLND/ALNDAnalysisPositive(n=41)Negative(n=150)Positive(n=54)Negative(n=137)Corticalthicknessof≤1.5mm1(2)42(98)3(7)40(93)1.5<corticalthickness≤2.5mm5(6)75(94)11(14)69(86)2.5<corticalthickness≤3.5mm19(40)29(60)23(48)25(52)Corticalthicknessof>3.5mmandintactfattyhilum7(70)3(30)7(70)3(30)Corticalthicknessof>3.5mmandlossoffattyhilum9(90)1(10)10(100)0(0)UltrasoundNumberofTotalPositiveLymphNodesTotal01-3>3Positive/Suspicious1281337433538.2%39.7%22.1%21.3%Negative/Slightlysuspicious95825624123877.4%20.7%1.9%78.7%Total1086389981573Fisher'sExactTest:p<0.0001CanAxillaryUltrasoundpredictLymphNodeStatussothatwecanavoidpositivesentinelnodes?

1573NTUHPatients20Whenaxillaryultrasoundisnegative….

thechanceofhavingnegativesentinelnodeisabout77%,andthechanceofhavingmore

than

two

orthreepositive

nodesislowItissafetofollowZ0011toomitALNDafter

breast-preserving

surgery

whenaxillary

US

is

negative

and

onlytwoSLNsarepositiveItisnotnecessarytodointraoperativeexaminationofsentinelnodeforbreastconservingsurgeryThechanceofneedingradiationtherapyaftermastectomyislow.Immediatereconstructionaftermastectomycanbeplanned.210.00.20.40.60.81.0Recurrence-freesurvival06121824303642485460Timetorecurrence/death(months)319304286274262243190140107551362585452514432211291

PathnegativePathpositivep=0.793path=NEGpath=POSThereisnodifferenceinadjuvanttreatmentdecision-makingandrecurrence-freesurvivalforpatientswithtrue-negativeandfalse-negativeAUS

TuckerAnnSurg2016TheConcordanceBetweenActualTreatmentandTwo

BlindReviewers’TreatmentRecommendationsGroup1(FalseNegativeAxillaryUltrasound)

vsGroup2(TrueNegativeAxillaryUltrasound)

Group1Group2POverallActualand#165%(40/62)