The Need for Axillary Staging in the Context of Prophylactic Mastectomy

• Multiple studies, including a meta-analysis of six studies:
  • Show significant benefit with use of bilateral prophylactic mastectomies (BPM) in BRCA carriers:
    • With up to 90% risk reduction
• The need for axillary staging in the context of prophylactic mastectomy:
  • Pooled results from a meta-analysis and systematic review report similar findings:
    • The risk of occult disease at time of mastectomy:
      • Is low (less than 2%)
    • There is an extremely low risk of nodal involvement:
      • Less than 2%
    • Only 2.8% of cases have a change in management as a result of the SLNB
  • As a result, the routine use of SLNB is not recommended
• Data have evolved that show the benefit of MRI screening in patients at highest risk for breast cancer development
  • McLaughlin and colleagues questioned whether preoperative breast MRI could be used to determine the need for SLNB at time of prophylactic mastectomy:
    • In their series of 178 patients with MRI and SLNB at time of prophylactic mastectomy:
      • Six occult cancers were found
      • All six patients had abnormal findings preoperatively on MRI, with negative predictive value of 100% for invasive disease
        • The researchers concluded that MRI could be utilized to select low-risk patients who may avoid SLNB at time of BPM
  • The study by McLaughlin et al. included BRCA mutation carriers, but only one study specifically evaluated the use of SLNB in BRCA carriers:
    • This trial reported similar results, with occult invasive disease detected in 2.5%
    • No patients in this cohort had node-positive disease, and there were no axillary recurrences at median 34-month followup
• There are case reports of successful SLNB after mastectomy:
  • But currently the routine use is discouraged by the National Comprehensive Cancer Network guidelines
• References
  • Zhou WB, Liu XA, Dai JC, Wang S. Meta-analysis of sentinel lymph node biopsy at the time of prophylactic mastectomy of the breast. Can J Surg 2011;54(5):300-306.
  • Nagaraja V, Edirimanne S, Eslick GD. Is sentinel lymph node biopsy necessary in patients undergoing prophylactic mastectomy? a systematic review and meta-analysis. Breast J. 2016;22(2):158-165.
  • Breast cancer risk reduction. National Comprehensive Cancer Network. Breast Cancer Risk Reduction. Version April 2018. https://www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf. Accessed September 14, 2018
  • McLaughlin SA, Stempel M, Morris EA, Liberman L, King TA. Can magnetic resonance imaging be used to select patients for sentinel lymph node biopsy in prophylactic mastectomy? Cancer. 2008;112(6):1214-1221.
  • Câmara S, Pereira D, André S, et al. The use of sentinel lymph node biopsy in brca1/2 mutation carriers undergoing prophylactic mastectomy: a retrospective consecutive case-series study. Int J Breast Cancer. 2018:1426369
  • Breast cancer. National Comprehensive Cancer Network. 2018. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed September 14, 2018

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