Axillary Staging in Pregnant Women with Breast Cancer

  • Sentinel lymph node biopsy (SLNB):
    • Is the standard of care in patients with early stage, clinically node negative breast cancer
  • Compared to axillary lymph node dissection (ALND),:
    • SLNB has lower morbidity, including a:
      • Lower risk of musculoskeletal limitations and lymphedema
  • In general, SLNB can be performed with the use of:
    • Blue dye
    • Technetium-99 (99mTc), or
    • Dual agents
  • The role of SLNB in pregnancy is not clearly defined:
    • Recently updated American Society of Clinical Oncology (ASCO) Guidelines:
      • Upholds its prior recommendation that SLNB should not be performed in pregnancy:
        • The strength of the recommendation, however;
          • Is described by the ASCO expert panel to be “weak,” as it is based on ”informal consensus” rather than quality evidence.
  • Several retrospective studies have described the safety of SLNB during pregnancy
    • The majority of patients in these studies underwent SLNB with 99mTc alone:
      • However, methylene blue dye was used in some patients
    • One recent retrospective review reported on 145 women with clinical node-negative disease who underwent SLNB during pregnancy:
      • The mapping agents utilized were:
        • 99mTc alone (66%), methylene blue dye alone (9.7%), dual agents (10.3%), and the remainder was unknown
      • Sentinel lymph nodes were identified in 99.3% of patients, with excellent gestational outcomes
    • No neonatal adverse events related to the SLNB procedure were reported
  • Models of fetal radiation exposure have demonstrated that the use of 99mTc for SLNB:
    • Leads to a negligible dose to the fetus of 0.014 mGy or less:
      • Whereas risk of fetal malformation is associated with levels > 100 mGy
    • Lower doses of exposure can be achieved using a 1-day protocol rather than a 2-day protocol
  • The use of lymphazurin dye is not recommended:
    • Due to the 1% to 2% risk of anaphylaxis
  • Historically, the use of direct intra-amniotic injection of methylene blue dye for identification of ruptured membranes led to significant neonatal complications:
    • Recent pharmacokinetic data indicate that the absorption of methylene blue dye used during SLNB is minimal
    • Although the use of methylene blue dye for SLNB has been described, the data are limited in comparison to that of 99mTc
  • Thus, with respect to axillary staging, the risks and benefits of ALND vs. SLNB must be discussed with the patient prior to surgery
  • References
    • Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220(3):391-398.
    • Lyman GH, Somerfield MR, Bosserman LD, Perkins CL, Weaver DL, Giuliano AE. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology Clinical Practice Guideline Update.J Clin Oncol. 2017;35(5):561-564.
    • Han SN, Amant F, Cardonick EH, et al. Axillary staging for breast cancer during pregnancy: feasibility and safety of sentinel lymph node biopsy. Breast Cancer Res Treat. 2018;168(2):551-557.
    • Gropper AB, Calvillo KZ, Dominici L, et al. Sentinel lymph node biopsy in pregnant women with breast cancer. Ann Surg Oncol. 2014;21(8):2506-2511.
    • Gentilini O, Cremonesi M, Toesca A et al. Sentinel lymph node biopsy in pregnant patients with breast cancer. Eur J Nucl Med Mol Imaging. 2010;37(1):78-83.
    • Pandit-Taskar N, Dauer LT, Montgomery L et al. Organ and fetal absorbed dose estimates from 99mTc-sulfur colloid lymphoscintigraphy and sentinel node localization in breast cancer patients. J Nucl Med. 2006;47(7):1202-1208.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #CASO #CenterforAdvancedSurgicalOncologist #BreastCancer #BreastCancerandPregnancy

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