Evaluation of the Axilla Post Z-0011 Trial New Paradigm

Transcription

1 Evaluation of the Axilla Post Z-0011 Trial New Paradigm Belinda Curpen, MD, FRCPC; Tetyana Dushenkovska; Mia Skarpathiotakis MD, FRCPC; Carrie Betel, MD, FRCPC; Kalesha Hack, MD, FRCPC; Lara Richmond, MD, FCPSC

2 NO DISCLOSURES

3 Learning objectives Review the role of axillary (AX) imaging for breast cancer (BC) management before Z-0011 trial Provide an update on relevant approach to preoperative ultrasound (US) of AX before Z-0011 trial Discuss the impact of Z-0011 trial on management of AX in patient with invasive carcinoma (IC)

4 Evolution of Breast Cancer Treatment Radical mastectomy Modified radical mastectomy and breast conservation procedures with axillary lymph node dissection Sentinel node biopsy +/- axillary lymph node dissection in patients with early-stage breast cancer

5 Axillary dissection (ALND) Played key role in BC management More accurate staging Treatment planning Choice of adjuvant therapy Prognosis Complications Lymphedema Seroma Infection Chronic pain Axillary web

6 Sentinel Lymph Node Biopsy (SLND) Provides accurate staging Less lymphedema Less numbness Less morbidity

7 What is ACOSOG Z-0011 TRIAL? Axillary dissection vs No Axillary Dissection with Invasive Breast Cancer and Sentinel Node Metastasis: A Randomized Clinical Trial

8 ACOSOG Z-0011 TRIAL women with a positive SLN and clinical T1-T2 tumors undergoing lumpectomy with radiation therapy followed by systemic therapy DO NOT BENEFIT from the addition of ALND in terms of local control, disease-free survival, or overall survival A.E.Giuliano et al. Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastasis. A Randomized Clinical Trial. JAMA, Feb 9, 2011-Vol 305, No

9 ACOSOG Z-0011 TRIAL Not applicable T3-T4 tumors Multicentric or multifocal disease Locally advanced breast cancer (LABC) More than 2 positive sentinel nodes Palpable nodes Extranodal extension Partial breast radiation

10 Evaluating Axilla Pre-op before Z-0011 US main method of identifying abnormal lymph nodes when IC Cortical thickening Cortical lobulation Loss of fatty hilum Round shape Abnormal blood flow Rosso et al. The Role of Ultrasonography in the management of Axillary Node Metastasis In Breast Cancer. Austin J Clin Res 2015;2(7): 1058

11 Pre-op evaluation AX pre Z-0011 Imaging-guided sampling of suspicious lymph nodes with US-guided fine-needle aspiration or core-needle biopsy

12 Evaluation AX pre Z-0011 IC US of axilla Abnormal FNA+ FNA- ALND SLNB

13 Evaluation AX post Z-0011* T1, T2 cancer >T2 cancer No US of axilla Neoadjuvant chemo SLNB US of axilla Negative Positive Negative Positive 2 nodes 3 nodes No ALND ALND Radiation ALND Radiation * based on ASCO clinical practice guidelines updated JCO March 24, 2014

14 Evaluation AX post Z-0011 Post Z-0011 trial, evaluation AX has became less invasive and role of US AX and US guided lymph node biopsy is redefined The National Comprehensive Cancer Network guidelines do not advocate for routine AX US in patients with clinically negative AX Rosso KJ et al. The role of ultrasonography in the management of axillary node metastasis in breast cancer. Austin J Cancer Clin Res Vol 2 Issue-2015

15 Is There Still A Place for AX US in 2016?

16 Evaluation AX post Z-0011 some centers do not perform pre-op US AX in clinically negative AX and go directly to sentinel node bx (SNB) some prefer to limit AX US and biopsy to the patients with obvious abnormal AX lymph nodes at imaging and bypass SNB others do AX US to gather as much information as possible to guide management

17 AX US correlation with histological AX node disease burden 1 FNA positive node on AX US correlates with a mean of 5.2 nodes on final histology - therefore patients not eligible for SLNB Patients with AX US and negative FNA had a mean nodal burden of 2.2 and median of 1 node. Negative axillary AX US therefore eligible for SLNB T.P.J Farrell at al.the Z0011 Trial: Is this the end of axillary ultrasound in the preoperative assessment of breast cancer patients? Eur Radiol (2015) 25

18 TO DO OR NOT TO DO?

19 To FNA or not Do not FNA FNA

20 Conclusions AX US provides accurate information for selecting patients eligible for Z0011 trial-directed pathway AX US with sampling selects patients who require axillary node dissection AX US when lymph node is completely hypoechoic has a high predictive value of metastatic lymph node Pre-op AX imaging and sampling when lymph node completely hypoechoic avoids unnecessary SLNB

21 Acknowledgement Dr. Claire Holloway MD, FRCPC, Breast Surgeon, Associate Professor University of Toronto, Sunnybrook Health Sciences Center

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