Download BREAST CANCER: SENTINEL LYMPH NODE BIOPSY LIST SERV

BREAST CANCER: SENTINEL LYMPH NODE BIOPSY LIST SERV
SCENARIO 4:
PREGNANT PATIENT
LEARNING OBJECTIVES
CASE PRESENTATION
1. Discuss eligibility of SLNB in pregnancy
2. Discuss the role of MCCs
● A 35 year old pregnant patient, 13 weeks gestation,
presents with a tumor in the upper outer quadrant of her left
breast.
● The tumour is palpable.
INVESTIGATIONS
QUESTIONS FOR DISCUSSION
Ultrasound
● Imaging reveals a 4 cm tumour.
Technique
● Core biopsy reveals poorly differentiated
invasive ductal carcinoma (IDC) and
lymphovascular invasion (LVI) is noted.
1. Would you perform SLNB?
2. If you perform a SLNB, what type of mapping agent
should be used?
3. Should this case be presented at a Multi-disciplinary
Cancer Conference (MCC)?
FOLLOW-UP
TECHNIQUE & PATHOLGY
QUESTIONS FOR DISCUSSION
Technique
● During the SLNB, you palpate a firm node.
It does not appear overtly malignant.
1. What would you do now?
Pathology
● You send the SLN for intraoperative frozen
section analysis and the Pathologist notes a
few atypical cells, but is unable to definitively diagnose metastatic carcinoma in the
frozen section tissue section.
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 19-30 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 4:
PREGNANT PATIENT
FOLLOW-UP
KEY LEARNING POINTS
SLNB and ALND
● There was agreement that SLNB is safe in this patient.
● However, there was agreement that the threshold for proceeding directly with ALND would be low and also
a reasonable alternative to SLNB. The likelihood of nodal mets is high given the large, high grade tumour
and the patient should not be subjected to two operations.
Mapping Technique
○ Discussion supported that the radiation dose from the radioisotope is minor and relatively safe in pregnancy.
○ Some participants indicated that not all of the blue dyes have been tested in pregnancy and therefore may not
be safe with regards to the fetus.
○ Patent blue dye is a Class C drug and potential risk to fetus is unknown. Methylene blue is used for some
amniocentesis procedures, but again increases risk of skin necrosis. Pregnancy was a contraindication to
enrollment in NSABP 32 SLN trial. There are now series and case reports in the literature citing safety of
radiocolloid for SLN surgery in pregnancy.
Chemotherapy
○ There was discussion regarding the use of neoadjuvant chemotherapy to shrink the tumour. Given the size
of the primary and presence of LVI, neoadjuvant chemotherapy could be recommended, with anthracycline
therapy which is safe in pregnancy. Timing of the last dose is important with respect to preventing
neutropenia at delivery. Some thought that giving neoadjuvant chemotherapy would allow for surgery to be
performed later in the pregnancy and possibly allow time for genetic testing.
○ Some felt that the decision to perform a mastectomy vs a lumpectomy should be made prior to neoadjuvant
chemotherapy. If not and a lumpectomy is performed, there are risks associated with this, such as leaving
behind microscopic disease in breast tissue previously occupied by cancer.
○ There was some uncertainty whether SLNB should be performed in patients having neoadjuvant therapy and
if so, when it should be performed. NOTE from the members of the list serv working group:
Performing SLNB following neoaduvant chemotherapy is allowed on NSABP protocols.
○ Recommendation of ALND would be made if the patient underwent neoadjuvant chemotherapy.
MCC
● There was disagreement regarding the presentation of this case at an MCC. Some felt that it was not
necessary, as these types of cases could be dealt with via phone calls and correspondence between treating
physicians. Others felt young women and pregnant women warrant MCC discussion. There would be many
possible management options, and input from radiologists, medical and radiation oncologists, pathologists
and perhaps the obstetricians would be valuable.
FOOTNOTE:
● There was discussion regarding the use of MRI in pregnancy and the need for reporting LVI in core
biopsies. It is the opinion of the experts on the list serv working group that:
1. gadolinium is not approved in pregnancy, and so it is unlikely that an MRI would be done
2. there is no need to report grade and LVI on core biopsy if the patient is going to surgery (small sample may
not be accurate).