Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Second opinion: Role of SLNB in the setting of recurrent BC
7:07 minutes.
TRANSCRIPTION:
DR LOVE: We’ve got another case here that I think is very interesting — 59-year-old woman. In 2011, she has a 2-cm breast cancer, sentinel node biopsy-negative. She gets a lumpectomy, adjuvant chemo, followed by radiation therapy and then adjuvant letrozole. So she was ER-positive, HER2-negative. And after 4 years on the letrozole, she develops a local recurrence in the breast. So this doc wants to know what’s the role of sentinel node biopsy in the setting of local recurrence? But I also want to know how you would be thinking about in terms of so-called pseudoadjuvant therapy, systemic therapy, after local recurrence? But first, what about the axilla? DR KHAN: Right. So for the axilla, the reflex I find in my group as well as when I hear this discussed in other places, the reflex is to say we should do a sentinel node biopsy. The likelihood of success of a repeat sentinel node biopsy is probably in the 70%, 80% range, not as high as with primary surgery. But still, it can be done. It is often successful. If you do the sentinel node biopsy a second time, you should do lymphoscintigraphy because the mapping can be erratic. It can go to the internal mammaries, to the supraclavicular or even to the other axilla. So I have to say that I really try in my own practice when I talk to patients, I try to separate out what I consider a true recurrence from a new primary. And it’s actually hard sometimes to figure that out. But if you use a combination of distance in space and distance in time, I think you can do it most of the time. So if the recurrence is 20 years later, even if it’s sitting on the same spot as the original tumor, I think it’s fair to think of it as a new primary. But if it’s 3 or 4 years later in the same region, it’s very reasonable to think of it as a true recurrence. If it’s a true recurrence, I really don’t see the value of nodal staging. And I have actually made this argument when this has come up at SSO meetings and other places, because the very fact that the woman developed a local recurrence is an adverse feature and we don’t have any data that the additional knowledge of the nodal status is going to change her outcomes. So I think one needs to make the decision about what you call pseudoadjuvant therapy based on the characteristics of the tumor and the recurrence. And I’m not sure that nodal information will add a lot. So I don’t see the value of doing an internal mammary node biopsy, which can be quite morbid, or going to the other axilla or going to the supraclavicular region, which a second sentinel node might do, if I’m not convinced that, in fact, this nodal information really should change our treatment. So this is, again, a multidisciplinary discussion. I usually present this before doing the surgery. I usually present it at our conference to get input from medical oncology, whether they feel that the lymph node information is going to impact the medical oncology management. If it is, I attempt it. And sometimes we sort of come to a consensus agreement that it’s not going to make a difference, then I don’t think it’s worthwhile to subject the patient to the injection, the lymphoscintigraphy, and maybe searching in other areas for a sentinel node. On the other hand, if I determine or if it seems clear that this is a second primary, not a true recurrence, then I think the sentinel node biopsy should be attempted, that that information should be sought and it probably should be included in the medical oncology discussion. So again, I think there’s some room for interpretation there. But as I said at the beginning, the reflex, generally, that I hear from people is to try to identify that sentinel node. DR LOVE: And in terms of using chemotherapy or hormonal therapy, et cetera, we did see a trial a couple of years ago, the so-called CALOR study. It wasn’t very big. But it seemed like it showed a benefit, kind of this pseudoadjuvant chemotherapy. And a lot of investigators have started to utilize that approach. So first of all, in this situation, she’s ER-positive, HER2-negative, so she could have a change in hormonal therapy from the letrozole. DR KHAN: So her recurrence is also ER-positive, is it? DR LOVE: Right. Yes. Yes. So if she were HER2-positive, theoretically she could get anti-HER therapy with or without chemotherapy. But in terms of triple-negative, she could get chemotherapy. So in general, what’s been the approach of your team to these local recurrences? And another issue that nobody really talks about except when I was interviewing Norm Wolmark, he said he does genomic assays. He does a Recurrence Score on the local recurrence. Which is — I don’t think we have too much data on it, but it kind of makes sense. But how do you think through this question, particularly of chemotherapy after a local recurrence? DR KHAN: So the CALOR trial, as you remember, showed clearly a benefit for women who had ER-negative disease. And for ER-positive disease, it was — I don’t remember if it reached statistical significance or not. I think it may have been borderline or maybe not significant in the ER-positive group. But it was a small study. They didn’t reach their accrual goals. And when we discuss it at our conferences, I think the medical oncology read often is that it was not sufficiently powered for some of these questions. So they always, since — before the CALOR study was published, there was a lot of discussion about whether women should get repeat systemic therapy. Since the CALOR study, for hormone receptor-negative disease, no one has any hesitation. For hormone receptor-positive disease, we discuss it. The best scenario, the easiest scenario is where the woman was on tamoxifen previously and had a little interval of tamoxifen. Or even if she hasn’t, then it’s easy to go to an aromatase inhibitor. If she’s on an aromatase inhibitor, and this lady has been on one for 4 years, then one could argue that this tumor is resistant to AI therapy and maybe tamoxifen would be the right thing to use. |