1. SLNB Scenario Group Discussion Presented at: The Sentinel Lymph Node Biopsy Surgery Refresher Course October 29, 2010

2. SLNB Patient Scenarios The following SLNB cases were presented at the SLNB Surgery Refresher Course as part of the 2010 Update in Surgical Oncology. The surgical management of these cases was discussed by an expert panel. Purpose CCO has made these cases available, including the expert panel discussion, to be used as a discussion or teaching tool in local regions. Audience Surgeons & surgical residents who encounter SLNB in their practice. 2

3. SLNB INJECTION TECHNIQUES Case 1: 3

4. Case 1 A 55 year old patient underwent a right breast wire – localization lumpectomy for a 2cm area of DCIS. Final pathology reveals DCIS and a 8 mm focus of grade II, IDCa. 4

5. You would recommend: 1.SLNB possible ALND (with frozen section intra-operatively) 2.SLNB 3.ALND – the SLNB is not accurate in this situation 5

6. You arrange for a SLNB… Where do you inject the Tc-99? What is the time frame for this injection? Do you use blue dye and if so- what kind? Where do you inject? 6

7. Panel Discussion Points Where do you inject the Tc-99?  Periareolar injection  If incision is in upper outer quadrant, inject around incision What is the time frame for this injection?  Usually the day of (more than 2h) or day before surgery  If injected day before surgery - dose doubled 7

8. Panel Discussion Points Do you use blue dye and if so- what kind?  Patent blue dye used, injected on day of the surgery Where do you inject?  Injection of blue dye depends on incision but generally will inject periareolar  If the incision is in the upper outer quadrant directly in line with the axilla, then would inject a bit into sub-areolar region and a bit lateral to incision line  Inject around the lumpectomy cavity 8

9. NON IDENTIFICATION OF THE SENTINEL NODE - NOW WHAT? Case 2: 9

10. Case 2 A 60 year old obese post-menopausal patient presents with a mammographically detected stellate mass in the left breast at 4 o’clock measuring 1.2cm. No pre-operative evidence of axillary adenopathy. You plan a wire-localization lumpectomy and SLNB. Pre-operative lymphoscintigraphy shows no uptake outside of the breast. You proceed and are unable to find any hot or blue nodes…. 10

11. You are unable to find any sentinel nodes… You would: 1. Proceed with ALND 2. Perform a “low axillary sampling” 11

12. Panel Discussion Points Very rare circumstance in current environment Clinical data:  2 studies: > 400 patients in each study, randomized  Studies showed that sampling of 4LNs is equivalentto completion ALND Therefore, in a favorable setting, low axillary sampling could be performed (but this is not standardmanagement). 12

13. You succeed in finding only ONE sentinel node…. Is this enough? When should you stop? 13

14. Panel Discussion Points Quality issue → if consistently finding only 1 SLNthat is problematicPanel removes 4 or 5 SLNs to reduce falsenegative rate (FNR) B-32 study: FNR <1% by 5 th SLN  Almanac study: little benefit after the 4 th SLN Injection technique is important  Current subdermal periareolar injections identify fewerSLNs than peritumoral injections 14

15. DECISION MAKING AROUND ALND AND THE ROLE OF RADIATION THERAPY Case 3: 15

16. Case 3 A 58 year old patient presents with a palpable right breast mass. Mammogram reveals extensive microcalcifications surrounding the 2cm lesion. Core biopsy confirms IDCa with high grade DCIS. You proceed to a right mastectomy and SLNB. Final pathology reveals a 3 cm grade II, IDCa, 4cm of DCIS, no LVI, ER/PR+ve and Her2-ve SLNB: 1 out of 4 nodes has a 1.8 mm metastasis 16

17. You would : 1.Recommend ALND 2.Recommend no further surgery 3.Run the MSK nomogram & discuss this at a MCC 17

18. Panel Discussion Points Panel Split:Nomogram and MCC Nomogram is 9% therefore a 91% chance of no residualdisease If there is residual disease, difficult to determine thepotential harm to patient therefore should present attumor board Morbidity associated with ALND Nomogram can provide a good starting point fordiscussion with patient 18

19. Panel Discussion Points ALND There is debate since it is a micrometastasis but 2/4 would recommend ALND to patient Agree that tumor boards are helpful but concern about delays If going outside of current guidelines, then would present at tumor board but in this case, the patient has positive nodal disease therefore ALND is recommended 19

20. SENTINEL NODE WITH MASTECTOMY AND IN DCIS: WHEN AND HOW? Case 4: 20

21. Case 4 A 40 year old female with a family history (mother and aunt) presents with extensive microcalcifications (approximately 4cm) in the left breast on first screening mammogram. Sterotactic core biopsy shows high grade DCIS. The patient elects to have a mastectomy for treatment. 21

22. I would perform a SLNB at the time of mastectomy for DCIS: 1. Yes 2. No 22

23. Panel Discussion Points Yes, SLNB should be done at the same time as mastectomy for DCIS There is no date to indicate you can accurately perform SLNB after mastectomy. 23

24. I would perform a SLNB at the time of lumpectomy for DCIS: 1. Yes 2. No 24

25. Panel Discussion Points No – SLNB would require a separate incision and would increase morbidity SLNB can be performed after lumpectomy as a separate procedure  Data available to support that SLNB post- lumpectomy is acceptable; while the FN rate may be slightly higher than if SLNB was performed at the same time as lumpectomy (B-32) 25

26. Final pathology: 5mm, grade III, IDCa, +LVI, ER/PR +ve, Her 2-ve with 4.5cm of high grade DCIS 1 of 2 SLNs shows a 0.1mm metastasis Nomogram score is 10% 26

27. You would : 1.Recommend ALND 2.Recommend no further surgery 3.Run the MSK nomogram & discuss this at a MCC 27

28. Panel Discussion Points Panel Split: A)No Further Surgery  Micromet/ITC → this woman is at increased risk of systemic disease (Medical Oncologist consideration) however, she is not at increased risk of having disease in her axilla B)Nomogram  Very small amount of disease  Young age worrisome but 5mm w/ ITC not enough to perform ALND in the absence of data 28

29. SLNB IN SPECIAL SITUATIONS Case 5: 29

30. Case 5a: SLNB in Pregnancy A 32 year old pregnant patient (32 weeks gestation) presents with a palpable left breast mass at 2 o’clock measuring approximately 2cm. Ultrasound guided core biopsy reveals high grade IDCa; sonographically there is no axillary lymphadenopathy. 30

31. You plan for a lumpectomy and: 1. ALND – SLNB is not safe in pregnancy 2. SLNB with radioisotope alone 3. SLNB with blue dye alone 4. SLNB with both 31

32. Panel Discussion Points SLNB can be offered to pregnant women with radioisotope alone Blue dyes are Class C drugs for pregnant women → safety has not been proven Radioisotope studies show that exposure is well below limit for teratogenic effects so safe for pregnant women Important to discuss with the patient 32

33. Case 5b: SLNB after neoadjuvant chemotherapy A 53 year old patient with significant family history presents with a right central breast mass. Work-up reveals a 5cm invasive lobular carcinoma; MRI and U/S show no suspicious lymphadenopathy. The patient undergoes neoadjuvant chemotherapy with excellent response clinically. Repeat MRI shows <1cm lesion and no lymphadenopathy. 33

34. Your surgical plan: 1. Modified radical mastectomy 2. Mastectomy and SLNB 3. Lumpectomy and ALND 4. Lumpectomy and SLNB 34

35. Panel Discussion Points Comments Dramatic response to neoadjuvant chemotherapy surprising/unusual since most invasive lobular tumors are ER+/PR+ and tend not to respond as well MRI is highly variable at detecting response rates post- neoadjuvant therapy Studies (e.g. B-18) show no survival difference between administration of chemotherapy prior to or after surgery  Does allow for down staging 35

36. Panel Discussion Points Surgical Plan Mastectomy or lumpectomy with SLNB given that the patient was node negative pre-operatively SLNB mapping post-neoadjuvant chemotherapy is reliable Central lumpectomies on central lesion can allow for a good breast mound in this situation 36

37. Case 5c: SLNB after previous SLNB or ALND Part 1 A 62 year old female patient has a history of left breast cancer 3 years prior treated with lumpectomy, SLNB (0 of 4 nodes positive), adjuvant radiation and is currently on endocrine therapy. She now presents with a mammographically detected distortion in the area of the scar – biopsy confirms recurrence of IDCa. 37

38. You recommend: 1.Simple mastectomy 2.Mastectomy and ALND 3.Mastectomy and SLNB 4.Lumpectomy and ALND 5.Lumpectomy and SLNB 38

39. Panel Discussion Points Panel would try to find the SLN  Some recent studies have shown that the SLN can still be located post previous SLNB and ALND Lymphoscintigram very important in “redos”  Guides you where to look One panel member indicated that if the SLN did not map, they would not do the dissection In some cases, SLN mapping may be more accurate in directing you to involved nodes  ALND – may miss LNs if not normally removed (e.g. nodes above the clavicle) 39

40. Case 5c: SLNB after previous SLNB or ALND Part 2 A 62 year old female patient has a history of left breast cancer 10 years prior treated with lumpectomy, ALND (0 of 11 nodes positive), adjuvant radiation and endocrine therapy for 5 years. She now presents with a mammographically detected distortion in the area of the scar – biopsy confirms recurrence of IDCa. 40

41. You recommend: 1.Simple mastectomy 2.Mastectomy and ALND 3.Mastectomy and SLNB 4.Lumpectomy and ALND 5.Lumpectomy and SLNB 41

42. Panel Discussion Points MSK data:  Previous dissection where >10 nodes were removed: chance of finding SLN ~47%  Previous dissection, where <10 nodes were removed: chance of finding SLN ~85%  Panel would try to find SLN Mastectomy & SLNB recommended But – still hard to argue against mastectomy alone; that is also a reasonable option 42

43. CCO would like to thank: Dr. Tulin Cil Dr. Ralph George Dr. Julia Jones Dr. David McCready Dr. May Lynn Quan for their contributions to the SLNB Surgery Refresher Course 43