Axillary Management in Patients with Isolated Tumor Cells (ITCs) and Micrometastatic Disease

  • It is clear that patients with pathologically negative sentinel lymph nodes:
    • Do not require completion ALND:
      • But the management of patients with ITCs and micrometastatic disease in sentinel lymph nodes:
        • Has extensively been debated
  • Micrometastatic disease is defined as:
    • Tumor deposits spanning:
      • 0.2 mm to 2.0 mm:
        • Within lymph nodes
  • ITCs are:
    • Groupings of cells not greater than 0.2 mm or 200 cells:
      • In a single lymph node cross section
  • According to the American Joint Committee on Cancer (AJCC) staging guidelines:
    • Patients with ITCs are N0(i+)
    • Patients with micrometastases in one to three axillary lymph nodes are N1mi
  • ACOSOG Z0010:
    • Is one of the largest trials to prospectively evaluate the significance of small metastases in sentinel nodes
    • Hematoxylin and eosin (H&E) tumor-free sentinel nodes:
      • From patients with early breast cancer were evaluated in a central laboratory with:
        • Immunohistochemistry (IHC)
    • Micrometastatic or ITC disease:
      • Was found in 11% of 3,326 sentinel lymph nodes
    • With a median follow-up of 6.3 years:
      • Occult sentinel lymph node metastases:
        • Were not associated with differences in overall survival, disease-free survival, or recurrence:
          • When compared with patients with IHC-negative lymph nodes
  • A subset analysis of NSABP-32:
    • Looked retrospectively at patients with occult metastatic disease:
      • Including patients with micrometastatic or isolated tumor cells
    • In patients who were sentinel node negative:
      • 16% had occult metastases detected on further evaluation:
        • 11% of occult metastases were isolated tumor-cell clusters, 4% were micrometastases, and less than 1% of patients had macrometastatic deposits seen on additional sectioning of the lymph node
    • Log-rank tests indicated that patients with occult metastasis:
      • Had worse overall survival (95% versus 96%), disease-free survival (87% versus 89%), and distant disease-free interval (90% versus 93%):
        • When compared with patients without occult metastases
      • Although statistically significant:
        • These differences were not felt to be clinically relevant
    • There was no improvement in overall or disease-free survival:
      • When patients with occult metastasis underwent completion ALND

#Arrangoiz #CancerSurgeon #BreastSurgeon #SurgicalOncologist #BreastExpert #BreastCancer #SLNM #SLNB #SentinelLymphNodeBiopsy #Surgeon #Teacher #MSMC #MountSinaiMedicalCenter #Miami #Mexico

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