Download BREAST CANCER: SENTINEL LYMPH NODE BIOPSY LIST SERV

BREAST CANCER: SENTINEL LYMPH NODE BIOPSY LIST SERV
SCENARIO 5:
ELDERLY HEALTHY PATIENT
LEARNING OBJECTIVES
CASE PRESENTATION
1. Discuss indications for SLNB
● 77 year old completely healthy woman living on her own,
engaged in an active lifestyle, is found to have a 2 cm lesion in the lateral aspect of her left breast.
● Nodes are clinically negative.
2. Discuss indications for completion
dissection of the axilla
3. Discuss the role of MCCs
INVESTIGATIONS
QUESTIONS FOR DISCUSSION
Technique
● Core biopsy reveals invasive ductal
carcinoma (IDC).
1. Would you perform SLNB?
2. Are there any primary tumour characteristics that would
affect your decision?
FOLLOW-UP
TECHNIQUE
QUESTIONS FOR DISCUSSION
You go ahead and perform a lumpectomy and
SLNB:
● Two SLNs are removed. No introperative
frozen section is available.
● One has a 3 mm metastases seen on H&E
(ie. a macrometasis) in the formalin fixed
paraffin embedded sections.
1. Should the patient have an ALND?
2. What if the metastases were 1 mm in maximal dimension
(ie. a micrometasis)?
3. What if the metastasis was 0.1 mm in maximal dimension
(ie. isolated tumor cells "ITCs")?
4. Should this case be presented at a Multi-disciplinary
Cancer Conference (MCC)?
GUIDELINE INFORMATION
● “Sentinel Lymph Node Biopsy in Early-stage Breast Cancer: Guideline Recommendations”:
http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=45870
● For key evidence, see pages 18, 26-28 of the Evidentiary Base (Section 2) of the guideline.
● Multidisciplinary Cancer Conference Standards”: http://www.cancercare.on.ca/cms/one.aspx?
pageId=10473).
BREAST CANCER: SENTINEL LYMPH NODE BIOPSY LIST SERV
SCENARIO 5:
ELDERLY HEALTHY PATIENT
FOLLOW-UP
KEY LEARNING POINTS
SLNB and ALND
● There was agreement that SLNB is safe in the elderly patient and most surgeons would recommend SLNB
and if positive, then perform ALND. The two issues to consider with regards to the management of the
axilla of this patient are local disease control and guidance of adjuvant therapy. Performing SLNB obviates
the risks of full ALND in patients where the node is negative. However, if there is a positive node, then the
completion ALND is appropriate at least for local control, even if it does not change the decision about
chemotherapy.
● Generally, adjuvant chemotherapy is not given to elderly patients. However, it was suggested that in a
healthy patient over 75 with an ER negative cancer, that chemotherapy might be offered if they are node
positive. In the situation of a low grade, ER positive cancer, nodal status may not affect recommendations
for chemotherapy.
● Patients in this age group may benefit the most from endocrine therapy if they are ER positive.
● Although some of the participants commented that ER status, differentiation and LVI might have an impact
on the decision to perform a SLNB, this information is usually not available before surgical decisionmaking.
● Nodel metastases > 0.2 mm and < 2.0 mm are considered micromestastases and are an indication for
ALND.
● In the case where the metastases were 1 mm in maximal dimension (ie. a micrometasis), it was suggested
that after patient discussion, one could proceed with a completion ALND.
● In the case where the metastasis was 0.1 mm in maximal dimension (ie. isolated tumor cells "ITCs"), after
patient discussion, one would likely not proceed with completion ALND. For micrometastases and ITC's, it
was suggested that other factors such as tumour grade and estrogen receptor status be considered to help
guide the discussion with the patient regarding treatment options.
MCC
● There was disagreement regarding the presentation of this case at an MCC. Some felt that if there was
pressure to present other cases because of volumes, then a patient scenario of this type of scenario would be
low priority for MCC presentation. It was also felt that for surgeons who do a large volume of breast
surgery and SLNB, that this case would be a reasonably common one, and that after discussions with one's
local colleagues at a MCC, the surgeon would have a good sense of the group opinion without presenting
each such case.