Is Sentinel Lymph Node Biopsy Necessary in Patients Undergoing Prophylactic Mastectomy? A Systematic Review and Meta-Analysis

Is Sentinel Lymph Node Biopsy Necessary in Patients Undergoing Prophylactic Mastectomy? A Systematic Review and Meta-Analysis

undergoing axillary staging after NAC. J. C. Boughey, MD T. Nguyen, MD References 1. Boughey JC, Suman VJ, Mittendorf EA, et al. Alliance for Clinica...

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undergoing axillary staging after NAC. J. C. Boughey, MD T. Nguyen, MD

References 1. Boughey JC, Suman VJ, Mittendorf EA, et al. Alliance for Clinical Trials in Oncology. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with nodepositive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455-1461. 2. Kuehn T, Bauerfeind I, Fehm T, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective,

Is Sentinel Lymph Node Biopsy Necessary in Patients Undergoing Prophylactic Mastectomy? A Systematic Review and Meta-Analysis Nagaraja V, Edirimanne S, Eslick GD (The Sydney Med School Nepean, Penrith, New South Wales, Australia) Breast J 22:158-165, 2016

The gain by performing sentinel lymph node biopsy (SLNB) during prophylactic mastectomy (PM) is debatable, and we performed a metaanalysis of existing literature to evaluate that the role of SLNB in subjects undergoing PM. A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 11 relevant articles reporting on patients who

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multicentre cohort study. Lancet Oncol. 2013;14:609-618. 3. Boileau JF, Poirier B, Basik M, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsyproven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015;33:258-264. 4. Boughey JC, Ballman KV, Le-Petross HT, et al. Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with nodepositive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 2016;263:802-807. 5. Donker M, Straver ME, Wesseling J, et al. Marking axillary lymph nodes

underwent SLNB at the time of PM. Data were abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). We included 14 studies comprising of 2,708 prophylactic mastectomies. Among 2,708 prophylactic mastectomies, the frequency of occult invasive cancer (51 cases) was 1.8% and the rate of positive SLNs (33 cases) was 1.2%. In 25 invasive cancers at the time of PM were found to have negative SLNs which avoided axillary lymph node dissection (ALND). In seven cases with positive SLNBs were found not to have invasive cancer at the time of PM and needed a subsequent ALND. Most of the patients with positive SLNs had locally advanced disease in the contralateral breast. SLNB may be suitable for patients with ipsilateral, locally advanced breast cancer and is not recommend for all patients undergoing PM.

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with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients: the MARI procedure. Ann Surg. 2015;261:378-382. 6. Caudle AS, Yang WT, Mittendorf EA, et al. Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg. 2015;150:137-143. 7. Caudle AS, Yang WT, Krishnamurthy S, et al. Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 2016;34: 1072-1078.

The issue of whether to perform an SLNB at the time of PM has troubled surgeons for decades. This study by Nagaraja and colleagues highlights what we already know: the rate of patients having cancer in what was thought to be a prophylactic mastectomy is less than 2%. Of interest, however, was the finding that over half of these patients had a positive SLNB. Why patients with occult disease should have such a preponderance of lymph node positivity remains unclear, and elucidating which patients may harbor occult disease may be beneficial. Some have touted the benefits of preoperative MRI in this regard, but it important to remember that this test is not completely sensitive or specific and is not without the risk of both physical and financial toxicity.1 SLNB, on the other hand, has been widely accepted as an accurate means of staging the axilla. While the rate of sentinel lymph node

positivity in patients undergoing PM is certainly low, and the procedure of SLNB is not without risk (albeit minimal), avoidance of this procedure must be counterbalanced against the potential need for an ALND, with its considerable concomitant morbidity, if an occult cancer is found in the PM specimen. It is difficult, therefore, to come up with the “right” strategy in these circumstances. Ideally, we would like to avoid SLNB when it is not necessarydwhich is in 98% of PM

casesdbut we would also like to ensure that we perform an SLNB to avoid an ALND in those cases with potentially occult disease. What may be missing here is the patient’s viewpoint: would the patient prefer to have the potentially unnecessary procedure of an SLNB in the setting of PM, with its risk, albeit minimal, of complications, or take the 2% risk of requiring an ALND if a cancer should be found? In an era of patient-centered care and shared decision-making, it may be the

voices of our patients that guide our way. A. B. Chagpar, MD, MSc, MPH, MA, MBA, FRCS(C), FACS

Reference 1. Solin LJ. Counterview: pre-operative breast MRI (magnetic resonance imaging) is not recommended for all patients with newly diagnosed breast cancer. Breast. 2010;19:7-9.

SURGICAL TREATMENT Contralateral Prophylactic Mastectomy: Factors Predictive of Occult Malignancy or HighRisk Lesion and the Impact of MRI and Genetic Testing Erdahl LM, Boughey JC, Hoskin TL, et al (Mayo Clinic, Rochester, MN) Ann Surg Oncol 23:72-77, 2016

Background.dDespite decreasing rates of subsequent contralateral breast cancer after diagnosis of unilateral primary breast cancer, the proportion of patients electing contralateral prophylactic mastectomy (CPM) is increasing. Our aim was to identify risk factors associated with the identification of occult malignancy (OM) or high-risk lesion (HRL) in CPM to facilitate patient counseling and operative planning. Methods.dWe identified patients undergoing CPM in addition to mastectomy for index breast cancer between October 2008 and June 2013. Patient

and tumor factors were analyzed to identify associations with OM or HRL in CPM. Results.dAmong 740 CPM patients, an OM was identified in 4.1% and an HRL was identified in 10.5%. On multivariable analysis, factors associated with either occult finding included older age [odds ratio (OR) 1.37, per 10-year increase], invasive lobular index tumor histology (OR 2.60), progesterone receptor (PR)-positive index tumor (OR 1.79), and neoadjuvant therapy (OR 0.55). Overall, 244 patients (33%) underwent BRCA testing, and 38 (16%) had a deleterious mutation; 494 patients (67%) had a preoperative breast MRI. Neither absence of a deleterious BRCA mutation nor a negative preoperative MRI decreased the likelihood of an occult finding in CPM. Conclusions.dAlthough invasive cancer was identified infrequently in CPM specimens, the rate of HRL or OM in our study was 14.6%. Older age and infiltrating lobular and

PR-positive index breast cancers were associated with a higher risk of OM in CPM, while neoadjuvant therapy diminished the risk. BRCA testing and preoperative MRI were not associated with HRL or OM. This information is valuable for patient counseling and surgical planning. In the United States, rates of CPM continue to climb for women with invasive and in situ unilateral breast carcinoma.1,2 In theory, CPM should be considered for women at highest risk of developing a contralateral breast cancer, although clinical and epidemiologic studies have identified a multitude of both patient and surgeon factors that influence a woman’s decision to undergo CPM that often do not mirror contralateral breast cancer risk.3,4 When a woman elects to undergo CPM, the surgeon must estimate the patient’s potential risk of harboring a synchronous occult cancer, as this information affects the decision to perform a sentinel lymph

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