Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉JAMA Surg. Published online November 6, 2019. doi:10.1001/jamasurg.2019.4613

👉Although neoadjuvant chemotherapy (NAC) can decrease the size of a primary tumor to allow for breast conservation, eliminate nodal metastasis in some patients, and provide prognostic information, the optimal timing of SLNB for patients treated with NAC has been controversial.

👉Clinical staging of the axilla with SLNB is feasible both before and after chemotherapy.

👉SLNB prior to NAC may be a more accurate approach than after NAC.

👉Chemotherapy may alter lymphatic drainage through fibrosis of lymphatic channels and decreases the accuracy of SLNB.

👉SLNB before NAC has a lower false negative rate and provides more accurate staging, which could determine radiation fields.

👉Unfortunately, SLNB prior to NAC requires an additional operation, could delay the initiation of chemotherapy, and fails to decrease the rate of ALND.

👉It also eliminates prognostic information given by the effect of chemotherapy on axillary metastasis. Ç

👉These concerns have led to interest in performing SLNB after NAC.

👉Several recent prospective trials have examined the accuracy of SLNB after NAC.

👉The American College of Surgeons Oncology Group (ACOSOG) Z1071 enrolled women with cT0 to cT4, cN1 to cN2 clinical disease who underwent neoadjuvant chemotherapy.

👉 All patients underwent pre-NAC axillary needle biopsy.

👉41% of patients had a pathologic complete response (PCR) in the axilla.

👉After chemotherapy, patients underwent both SLNB and ALND.

👉A sentinel lymph node could not be identified in 7% of patients.

👉The overall false negative rate was 13%, which did not meet the preset target of 10%.

👉The false negative rate was 21% in patients with two or fewer sentinel lymph nodes identified but dropped to 9.1% when greater than three sentinel lymph nodes were sampled.

👉In the Sentinel Lymph Node Biopsy in Patients with Breast Cancer Before and After Neoadjuvant Chemotherapy (SENTINA) trial, 1,022 patients underwent SLNB before NAC, with a detection rate of 99%.

👉For patients who were evaluated after NAC and converted from cN+ to ycN0, the sentinel lymph node detection rate was only 80%, with a false negative rate of 14.2%.

👉As seen in ACOSOG Z1071, the false negative rate was much higher in patients with only one node removed (24%) than in those with three or more sentinel nodes removed (7%).

👉The false negative rate was also improved by the use of radiocolloid and blue dye together compared with blue dye alone (false negative rate of 9% versus 16%).

👉The Sentinel Node Biopsy following NeoAdjuvant Chemotherapy (SN FNAC) study enrolled patients with cT0 to cT3 with cN1 to cN2 biopsy-proven breast cancer treated with NAC.

👉Following chemotherapy, patients underwent clinical and ultrasound examination followed by SLNB and completion ALND.

👉The overall post-NAC SLNB false negative rate was 8% in 153 patients.

👉When only one sentinel lymph node was evaluated, the false negative rate was again unacceptably high at 20%.

👉On the basis of these three trials, resecting only one sentinel node is associated with an unacceptably high false negative rate (between 22% to 24%).

👉The false negative rate after NAC may be lowered with the use of dual tracers (from 16% to 9%) and resecting three or more sentinel nodes.

👉Placing clips in positive lymph nodes before chemotherapy decreases the false negative rate if the clipped node is then resected during SLNB.

👉The sentinel lymph node identification rate after NAC is significantly improved with increased surgeon experience, suggesting that a learning curve is needed to obtain accurate SLNB after NAC.

👉SLNB after NAC has the potential to decrease the number of women who receive ALND.

👉A study of 288 prospectively identified clinically node-positive patients reported that 132 became clinically node negative after NAC.

👉The clinically node-negative patients were then eligible for SLNB, and 48% had negative sentinel lymph nodes and were able to avoid an ALND.

👉Current ASCO recommendations state that SLNB should be offered to patients who have received preoperative neoadjuvant systemic therapy and have clinically negative lymph nodes.

👉However, no large studies have examined local recurrence rates or survival when ALND is omitted in patients who convert from node positive to node negative after NAC.

👉The safety of avoiding ALND in these patients has not been demonstrated.

👉The National Surgical Adjuvant Breast and Bowel Project (NSABP) B51 and Alliance A011202 are two sister studies examining the role of SLNB, ALND, and nodal radiation in patients who receive NAC.

👉The results of these trials will help identify patients who can safely avoid ALND after NAC.

Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉Prophylactic mastectomy rates are rapidly rising in the United States.

👉Prophylactic mastectomy may be associated with a 3.5 to 5% occurrence of occult carcinoma depending on the indication for the operation.

👉 SLNB at the time of prophylactic mastectomy may eliminate the need for axillary lymph node dissection (ALND) if occult disease is identified.

👉A recent meta-analysis reviewed 14 studies where SLNB was routinely performed for prophylactic mastectomy in patients undergoing bilateral mastectomy for unilateral cancer.

👉This study found metastatic disease in the SLNB of the prophylactic mastectomy in 0% to 4% of patients with contralateral cancer.

👉The majority of metastatic disease was associated with contralateral axillary tumor spread from the primary tumor, not an occult primary tumor.

👉In patients who were found to have occult malignancy in the prophylactic mastectomy breast, less than 1% of sentinel lymph nodes were positive for metastatic disease.

👉Given the low rates of occult malignancy and axillary metastasis, SLNB is not indicated for patients undergoing prophylactic mastectomy.

Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉In this issue of JAMA Surgery, Benmiloud et provide evidence that the common and harmful complication of early postoperative hypocalcemia may be reduced with this new technique.

👉The primary aim of the study, was to see post operative hypocalcemia may be reduced by using the fluorescent properties of the parathyroid glands intraoperatively.

👉Although some important data are not reported in the study, particularly concerning how and by whom the patients were followed up, the completeness of follow-up, and biochemical data with blood levels of calcium and parathyroid hormone at 6 months, the results suggest that the concept of parathyroid autofluorescence can be used to reduce early postoperative hypocalcemia.

👉If these results are reproduced by other centers in randomized clinical trials with other devices, and for long-term hypoparathyroidism, this will represent a substantial improvement in the quality of thyroid surgery.

Commentary: New Technique to Reduce the Risk For Hypocalcemia in Thyroid Surgery https://ja.ma/2ClR5CO

👉A new study published by researchers from Fox Chase Cancer Center showed that delaying surgery for a noninvasive breast cancer can have dire consequences.

👉Longer delays in surgery for ductal carcinoma in situ (DCIS) breast cancer lead to a higher risk of invasive ductal carcinoma and a slightly lower survival rate says Dr. Arrangoiz based on the results of the study.

👉For each month of delay, there was well under a 1% difference in survival.

👉But for each month of delay, there was an approximate 1% increase in the finding of invasive cancer.

👉DCIS arises from abnormal cells form the milk duct of the breast and is the earliest stage of breast cancer.

👉When cancerous cells spread beyond the milk duct, it becomes invasive ductal carcinoma.

👉Standard treatment for DCIS is surgery and radiotherapy, along with endocrine therapy.

👉But research suggests that some DCIS may never progress to invasive disease, and clinical trials are being conducted to determine whether DCIS can be observed, rather than surgically removed.

👉This study suggests that delays in operative management of DCIS are associated with invasion and slightly worse short-term outcomes.

👉Since observation represents infinite delay, it suggests that observation should not yet be pursued outside of a clinical trial in patients who will tolerate excision.

👉The study included more than 140,600 U.S. women (123,947 with DCIS, 16,668 with invasive ductal carcinoma).

👉They were diagnosed between 2004 and 2014.

👉Survival was compared with five time intervals in delays to have surgery: less than 30 days, 31-60 days, 61-90 days, 91-120 days, or 121-365 days.

👉Overall survival was 95.8%, with a median time from diagnosis to surgery of 38 days.

👉However, each increase in diagnosis-to-surgery interval was associated with a 7.4% increase in the risk of death.

👉The study was published in the Annals of Surgical Oncology.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉The physical examination alone cannot accurately predict the presence of axillary disease.

👉The accuracy of a physical examination to detect axillary metastasis ranges from 61% to 68% when compared with resection. 👉Ultrasonography, magnetic resonance imaging, and positron emission tomography–computed tomography have all been used to evaluate the axilla, and although these imaging modalities may improve on physical examination, they are not as accurate as lymphadenectomy for small deposits and have a higher rate of false positives.

👉A level I and II axillary lymph node dissection (ALND) has been the gold standard for evaluating the extent of axillary disease.

👉Unfortunately, the incidences of lymphedema, chronic pain, seroma development, future cellulitis, numbness, and limits to mobility are all significant sequelae following ALND.

👉Approximately 70% of patients who are clinically node negative will have no evidence of disease detected with ALND, putting these patients needlessly at risk for complications.

👉In 1991, the technique of sentinel lymph node biopsy (SLNB) was proposed as an alternative to ALND in breast cancer patients.

👉The development of SLNB has now replaced ALND as a highly accurate and less morbid axillary staging procedure for most patients. 

👉Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉HER-2 expression in breast cancer is primarily assessed semiquantitatively by IHC.

👉The 2013 ASCO guidelines outline an IHC scoring method based on four classes:

– 0, 1+, 2+, and 3+.

👉A score of 0 is negative, indicating no observed staining in invasive tumor cells.

👉A score of 1+ is negative and indicates weak, incomplete membrane staining in any proportion of invasive tumor cells or weak, complete membrane staining in less than 10% of invasive tumor cells.

👉A score of 2+ is equivocal, indicating circumferential membrane staining that is incomplete and/or weak/moderate and in more than 10% of invasive tumor cells or complete and circumferential membrane staining that is intense and in 10% or less of invasive tumor cells.

👉All 2+ equivocal cases undergo subsequent testing by FISH.

👉A score of 3+ is positive and indicates circumferential membrane staining that is complete and intense in a homogeneous and contiguous population, present in more than 10% of invasive tumor cells, and readily appreciated using a low-power objective. 

👉FISH is a sensitive and accurate method of scoring invasive breast tumor tissue for HER-2 expression.

👉Initial gene amplification studies by FISH assessment used chromosome 17 centromere (CEP17) or another gene on the same chromosome as an internal control, with a ratio of 2.0 or more considered evidence of HER-2 amplification.

👉These criteria were used as the cutoff for enrollment in trials evaluating HER-2 targeted therapies.

👉In 2007, the ASCO/CAP guidelines were changed to define HER-2 amplified as a ratio of 2.2 or more.

👉More recent guidelines have changed the ratio cutoff back to a ratio of 2.0 or more with the inclusion of criteria to account for HER-2 copy number per tumor cell.

👉Based on the recent guidelines, HER-2 is amplified in cases where the HER-2/CEP17 ratio is 2.0 or more with an average HER-2 copy number of less than 4.0 signals/cell or the HER-2/CEP17 ratio is less than 2.0 with an average HER-2 copy number of 6.0 or more signals/cell using a dual probe or a HER-2 copy number of 6.0 or more copies/cell using a single probe.

👉FISH testing is negative for HER-2 amplification with a HER-2/CEP17 ratio of less than 2.0 with an average HER-2 copy number of less than 4.0 signals/cell or an average HER-2 copy number of less than 4.0 signals/cell using a single probe.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y cirujano de mama miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

REFERENCES

👉Digital breast tomosynthesis (DBT) is increasingly used for routine breast cancer screening. This study evaluates the long-term impact and cost-effectivenss of DBT compared to digital mammography.

• Tumor kinetics matter in active surveillance
• Molecular markers help many patients avoid thyroid surgery for indeterminate thyroid nodules (Bethesda III and IV)
• BRAF V600E interacts with patients age and gender
• ATA 2015 guidelines are cost effective
• High volumen thyroid surgeons clean up the neck
• Surgery improves quality of life in Hashimoto’s patients
• Surgery more attractive for Graves’ disease?

👉Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello y cirugía endocrina de Sociedad Quirúrgica S.C. es experto en el manejo de nódulos tiroides y del cáncer de tiroides.

Articulo publicado por el Dr. Arrangoiz sobre el manejo de nódulos tiroides:

https://file.scirp.org/pdf/IJOHNS_2018072717023407.pdf

Es pionero en México:

• Cirugia tiroidea minimamente invasiva
• La cirugia minimamente invasiva radio-guiada de paratiroides

Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

http://www.sociedadquirurgica.com

http://www.hiperparatiroidismo.info

http://www.cirugiatiroides.com

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology