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Use of Sentinel Lymph Node Dissection After Neoadjuvant Chemotherapy in Patients with Node-Positive Breast Cancer at Diagnosis: Practice Patterns of American Society of Breast Surgeons Members

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

The accuracy of sentinel lymph node dissection (SLND) in clinically node-positive patients who receive neoadjuvant chemotherapy has been investigated in clinical trials. This survey was designed to assess familiarity and impact of these trial findings into practice.

Methods

American Society of Breast Surgeons members were invited by e-mail to complete an anonymous online survey. A total of 642 members responded (21% of 3090 eligible members). Results were summarized as proportions based on the number of responses to each question.

Results

Respondents indicated knowledge of the Z1071 (86%), SENTINA (57%), and SN-FNAC (39%) trials. The published false negative rates (FNR) of the trials were correctly reported by 53% (336/638) of respondents. Before the trials, 45% (285/636) offered SLND compared with 85% (543/638) after the trials. In the 556 respondents who reported knowledge of at least one trial, 310 (56%) currently offer SLND to >50% of patients, 175 (31%) offer to <50%, and 70 (13%) routinely perform axillary lymph node dissection. Respondents who reported knowledge of the trials but did not change their practice to incorporate SLND (n = 67) cited concerns over lack of outcome data (64%), worries about FNR (42%), lack of resources (34%), or objections from radiation oncologists (25%), medical oncologists (18%), or other surgeons (8%).

Conclusions

The publication of trials evaluating SLND in clinically node-positive patients has resulted in changes in practice. Concerns over the FNR and lack of outcome data limit incorporation of SLND into practice by some surgeons.

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Acknowledgement

Laura Randel and the American Society of Breast Surgeons provided the administrative support for the survey. Grant Support was provided by a Cancer Center Support Grant from the NIH (CA16672).

Disclosure

The authors have no financial disclosures.

Author information

Authors and Affiliations

  1. Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Abigail S. Caudle MD, MS, Isabelle Bedrosian MD, Sarah M. DeSnyder MD, Henry M. Kuerer MD, PhD, Kelly K. Hunt MD & Elizabeth A. Mittendorf MD, PhD

  2. Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Denái R. Milton MS

Authors
  1. Abigail S. Caudle MD, MS
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  2. Isabelle Bedrosian MD
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  3. Denái R. Milton MS
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  4. Sarah M. DeSnyder MD
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  5. Henry M. Kuerer MD, PhD
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  6. Kelly K. Hunt MD
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  7. Elizabeth A. Mittendorf MD, PhD
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Corresponding author

Correspondence to Abigail S. Caudle MD, MS.

Appendix 1: Survey Sent to American Society of Breast Surgeons Membership

Appendix 1: Survey Sent to American Society of Breast Surgeons Membership

1. Which best describes your clinical practice?

  • Private practice general or oncologic surgeon who performs breast surgeries

  • Private practice breast-only surgeon

  • Academic general or oncologic surgeon who performs breast surgeries

  • Academic breast-only surgeon

  • I do not provide clinical care

2. How long have you been in clinical practice?

  • 0–5 years

  • 5–10 years

  • 10–15 years

  • 15–20 years

  • Greater than 20 years

3. Are you familiar with these recent multi-institutional trials evaluating the accuracy of sentinel lymph node biopsy in clinically node positive breast cancer patients who receive neoadjuvant therapy? Please check all trials with which you are familiar:

  • Yes, I am familiar with the ACOSOG Z1071 trial results

  • Yes, I am familiar with the SENTINA trial results

  • Yes, I am familiar with the SN FNAC trial results

  • No, I am not familiar with any of these trial result

4. The ACOSOG Z1071, SENTINA and SN FNAC trials all enrolled patients with clinically node positive breast cancer who received neoadjuvant chemotherapy then went on to SLND with planned completion ALND in order to determine the false negative rate of SLND. For patients who presented with clinical N1 (cN1) disease and had their SLN(s) examined by hematoxylin and eosin staining, the false negative rates in all of these studies was:

  • Less than 5%

  • 5–9%

  • 10–15%

  • >15%

  • I am not familiar with these trial results

5. Before publication of these trial results, did you perform SLND on clinically node positive patients after neoadjuvant chemotherapy with the intent to omit axillary lymph node dissection (ALND) if no residual disease was identified in the SLN(s)?

  • Most of the time

  • In select patients

  • No, my standard practice was to perform ALND

6. What is your current practice in regards to surgical management of clinically node positive patients (cN1) who receive neoadjuvant chemotherapy?

  • In the majority of patients (>50%), I perform SLND with the intent of omitting ALND if no disease is identified in the SLN(s)

  • In a select group of patients (<50%), I perform SLND with the intent of omitting ALND if no residual disease is identified in the SLN(s)

  • My standard practice is to perform ALND in all patients (Skip to question 11)

7. The aim of the following question is to determine which clinicopathologic features impact your pre-operative decision in determining whether a patient is appropriate for SLND and consideration of omission of ALND if no metastases are seen in the SLN(s) after neoadjuvant therapy. Please check all variables that you consider when determining eligibility for SLND in these patients: (Please check all that apply)

  • Primary tumor size

  • Number of abnormal axillary lymph nodes seen on US performed at the time of diagnosis before initiation of neoadjuvant chemotherapy

  • Status of axillary lymph nodes seen on US performed preoperatively after completion of neoadjuvant chemotherapy

  • Tumor subtype (Hormone receptor positive, HER2 positive, triple negative)

  • Patient age

  • Planned postoperative radiation

  • I do not consider any of these variables in my decision

8. The following question is to understand technical aspects that you consider crucial to the accuracy of SLND in clinically node positive patients who receive neoadjuvant chemotherapy. I believe that the following components must be in place for SLND results to be accurate:

Dual tracer technique (i.e. blue dye and radioisotope)

Yes

No

Removal of ≥2 SLNs

Yes

No

Removal of ≥3 SLNs

Yes

No

The biopsied node has a clip placed at the time of diagnosis and removal of the clipped node at surgery is confirmed

Yes

No

Immunohistochemistry is performed to confirm no residual metastasis

Yes

No

Preoperative ultrasonography following neoadjuvant chemotherapy showing normalization of nodes

Yes

No

9. Do you routinely have a clip placed in axillary nodes with biopsy-proven metastases? (If your answer is no, please skip to question #11)

Yes

No

10. If a clip is placed in the biopsied node, how is this clipped node handled intra-operatively?

  • We place clips but do not assess for their removal at surgery

  • I do not selectively remove the clipped node, but I perform an x-ray of the nodes to confirm clip removal

  • I localize clipped nodes with wire/needle localization

  • I localize clipped nodes with I125 seeds

  • I localize clipped nodes with a method other than wire or seed localization

  • We do not place clips in nodes

11. If you do not rely on SLND to stage clinically node positive patients after neoadjuvant chemotherapy, what has limited your use of this technique? (Please check all that apply)

  • I do not feel the reported false negative rates for SLND are low enough to accurately assess axillary nodes after neoadjuvant chemotherapy

  • I do not feel that we have adequate data regarding the long-term, oncologic outcomes when ALND is omitted in these patients

  • I feel that SLND may be appropriate in some patients, but my institution does not have the resources that I feel are essential to accuracy of the technique (such as clip placement in biopsied nodes, or inability to localize clipped nodes)

  • I feel that SLND may be appropriate in some patients, but medical oncologists in my institution do not feel this is appropriate

  • I feel that SLND may be appropriate in some patients, but radiation oncologists in my institution do not feel this is appropriate

  • I feel that SLND may be appropriate in some patients, but other surgeons in my practice do not feel this is appropriate

  • My institution is currently collecting internal data to determine the FNR of SLND in our institution

  • I use SLND in this population with omission of ALND when no metastases are identified

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Caudle, A.S., Bedrosian, I., Milton, D.R. et al. Use of Sentinel Lymph Node Dissection After Neoadjuvant Chemotherapy in Patients with Node-Positive Breast Cancer at Diagnosis: Practice Patterns of American Society of Breast Surgeons Members. Ann Surg Oncol 24, 2925–2934 (2017). https://doi.org/10.1245/s10434-017-5958-4

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