版权说明：本文档由用户提供并上传，收益归属内容提供方，若内容存在侵权，请进行举报或认领
文档简介
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)
温馨提示
- 1. 本站所有资源如无特殊说明，都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
- 2. 本站的文档不包含任何第三方提供的附件图纸等，如果需要附件，请联系上传者。文件的所有权益归上传用户所有。
- 3. 本站RAR压缩包中若带图纸，网页内容里面会有图纸预览，若没有图纸预览就没有图纸。
- 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
- 5. 人人文库网仅提供信息存储空间，仅对用户上传内容的表现方式做保护处理，对用户上传分享的文档内容本身不做任何修改或编辑，并不能对任何下载内容负责。
- 6. 下载文件中如有侵权或不适当内容，请与我们联系，我们立即纠正。
- 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
评论
0/150
提交评论