So I'm going to talk about the threshold and new trends in sentinel node biopsy.
Um Actually, exactly 20 years ago, the first randomised trial on sentinel lymph node biopsy
was published in the New England Journal by Veroni.
And with the MRO trial, at 11 trial, the IBCSG 2301 trial,
we have seen clinical practise changing trials.
However, with all these trials with this new body of evidence that we see,
but also with new emerging concepts in treatment, especially with the much
broader use of neoadjuvant chemotherapy.
And you question arise and we have a lot of controversies and we see that there is
again gaps in evidence, so I'm looking forward to discuss some of the burning questions and I
just want to shortly briefly introduce the panel.
We have Michael Kauer from Galen in Switzerland. He's a breast surgeon.
We have Floreen Fitzel. He's also a breast surgeon from Vienna,
and Nasana, he is an oncoplastic breast surgeon from, and my co-chair is Ash
Khotari, oncoplastic breast surgeon from London, and I myself,
I'm a breast surgeon and breast oncologist from Baden in Switzerland.
Thank you. Could you kindly scan the QR code,
please, because it's very important to the way we're going to run this session.
We're going to put a poll question on your phone.
You can vote, and then we get the experts to discuss the question and then you guys can vote
again to see whether they've convinced you otherwise.
So it's very important.
Oh, It's not working with biking.
We can just, is it?
It's working for them.
There's something wrong with this side of the room.
So I think if it doesn't work for you guys it's not working for you please put your hands up.
So we start with the first question.
Please, oh sir, do we, do we move it? yes.
Can you give us the first question, please?
When Computer says no in the projection room. Oh, thank you.
Nope. We see it already.
Well, yeah, I just wrote it already.
You've got the questions on your phone.
Can we see them because we don't remember them.
Sorry, we made them up about 2 weeks ago and now, oh God,
this is embarrassing.
OK. It'll be in. Mr.
Can you guys project the question or not?
OK, sorry. So is it necessary to perform sentin node
biopsies in all clinically node negative patients with invasive cancer,
of course, but are we saying, is it necessary for everyone to have a sentin node biopsy?
So can you please vote yes or no?
The OK. OK. Yeah.
Has everyone got the town's world?
There you go. 59% think yes.
60% now think yes, and 40% think no.
So we'll start with Yazan and then we'll move down.
What does the panel think very quickly.
So if you know if it's an invasive disease and you know it's a size of invasive disease,
you always will do a biopsy. But in certain ladies,
especially the older ladies, that you think it was a DCIS,
you do the excision, you find a more invasive disease, then you balance the risk.
The risk of having a positive sentin node is quite low.
There are some nomograms that will give you that risk estimation of how much,
what's the risk of having positive sentin node, and will that really change in their management.
So some of the older ladies will not go back and do any sentin node biopsy on them.
Also, some people will argue about a small tubular grade ones and the older ladies not to
touch the axilla. You're not going to add anything much as long
as the pathologist is comfortable with the initial diagnosis on the on the biopsy.
But people value on that.
I think from the sound trial we could probably obey these patients which are included in this
trial showing that the sentinel node biopsy is probably not necessary,
but we have to wait for a little bit longer follow up.
This is an option for all the patients who do a low grade.
Is everything an option, but I still would do sentin node biopsy in all patients.
I would not do it in the second case, as you told DCIS,
and then you find a micro invasion.
I would probably not go for for sentinel.
We have reduced that a little bit, so the recommendation by the Choosing Wising campaign
has been out there for a couple of years.
So we reduced it in patients over 70 with luminal tumours and low risk of
recurrence and It doesn't influence the systemic treatment anyway because we're not
giving chemotherapy to those patients.
We have to await the full publication of the sound trial.
I haven't seen it yet. It has been presented in St.
Gallen in Vienna this year, but this will reduce the amount of patients that undergo
sentinel biopsy by a lot, I would say.
I just would like to say it's it's careful with a patient above 70 years because they have 35%
of positive lymph nodes and of them 10% have more than 4 positive lymph nodes,
and those are, for example, extremely often the luminal A patients.
Luminal A, if they have positive lymph nodes, they have much more positive lymph nodes.
So please take account that you need a good ultrasound from the axilla.
is key for that. The other thing to mention is there's a comment
on the, on the app that sentinel biopsy is minimally invasive.
It is minimally invasive, but everything will have complications.
If you look at the all the studies and all the trials from the almanack,
they had a small percentage of lymphedema.
Yes, it's not significant in lymphedema, sometimes to affect the quality of life of the
patient, but it's lymphedema.
And if you look at meta analysis that was published only last year.
The lymphoedema rate can go up to 10% plus.
So yes, it's small, yes, it's invasive, it will have its own its own problems.
So if there is any point to remember axillary surgery is a staging operation.
You're not treating the problem, you're staging the problem,
and if you're not going to act on it, why to do it in certain ladies.
OK, can we vote again?
And a question come up again, please?
Any burning questions in the meantime? Yeah.
OK. I
I think so that's a very, very good point.
When you have guidelines, guidelines are guidelines.
They're not laws or bylaws, but I think what you need to do is individualise patient
treatment. We are in an area of precision medicine as long
as the patient is involved in the decision making, where you think,
OK, let's say if you can actually tell a patient that Yazan said in pool analysis,
it's about 8% central lymph node biopsy, so your risk of having a positive sentral node is
2%. Your treatment is not going to change greatly.
I'm still going to stick you on endocrine treatment, give you radiotherapy.
Do you want to have a 2% chance of me finding a central node,
or you talk to the radiation oncologist and say, look, when you're giving radiation,
just cheat a bit like Z11 did radiate the lower tangents, we'll give you endocrine treatment
and that will cover it. So that's a shared decision making that you
need to have with your patients.
And if the patients are well.
Informed enough to make that decision, or if they're just lovely old ladies who can't make
up their mind, then you go probably follow protocol, but it has to be an MDT decision.
It has to be shared with the patient.
And So can we vote again and have we changed anybody's mind or are we still the same?
I think they went to the second question, next question right next question.
So you will see the sentinel node biopsy, a viable upfront surgical option
in Z11 Amoros eligible patients that are that have non palpable lymph nodes but have an
ultrasound detected single abnormal lymph node.
go back to the previous question. This is the one,
yeah. OK, so.
Boing But there is a clear yes from the audience to 64%.
I hope you got this question right. It's upfront,
not post new adjuvant chemotherapy.
So you know that there is.
A lymph node in a low burden axilla, so the ultrasound of the axilla says one abnormal,
possibly abnormal lymph node that's come back as positive.
Would you then do an upfront sentin node biopsy or would you clear the axilla?
That's the question. OK,
we can. So where I work we still treat the axilla if
it's a positive axilla. There's very few places that will do a target
dissection in this situation where you pick the abnormal node and take another 2 or 3 nodes.
I don't, I'm not sure that there is any need to.
I think only has published, so there's only small data from centres,
but in certain small sub cohort of patients that you don't want to.
Clear the axilla because of comorbidities. You want to do minimal surgery,
you just want to stage more.
We will do it but very rarely. So we usually we treat as a positive axilla and
clear it. What are you doing?
If I understand this question correctly, you have a suspicious lymph node in the ultrasound
and the patient is possible patient for Amro trial.
I would always biopsy these lymph nodes before I do anything else.
And if the biopsy is not possible, I try to mark the lymph nodes and take it out and the
lymph node because the suspicious lymph node is not always the lymph node,
so I would take out both in case it's positive.
You would go for axillary clearance or no, it would be eligible for you like why should I go
for a for one lymph node.
So the question, OK, let's say you do the central lymph node,
the, the ultrasound and it comes back as positive.
What's your plan then?
Would you clear that is positive? Yes, once and the patient had a mastectomy.
Uh, no, let's say breast conserving breast conservation, just regular radio therapy
afterwards. No, no acceler section, just regular radio
therapy. So I think I'm a little bit more cautious
because there might be that there are more positive notes.
If you see one by ultrasound, you'll probably have more in many cases,
and we have a trial open for that, the Taxis trial that goes across Europe now,
where we put on those patients as well, not only the palpably positive lymph nodes,
but also the ones by ultrasound.
We mark those and then we randomise those patients between axillary dissection or not,
or more or less radiotherapy.
Any, any questions? Yes.
Mhm If you can So you
split second. Mhm.
So an upfront targeted executive section. OK.
No, the targeted executive section, we know what we're saying,
yeah. Sorry, we can't, you're too soft.
We need a mic. Hello, I'm from Bahrain.
If we have a patient with a T1 or a tumour and we did a lymph node biopsy
preoperatively and it was negative one lymph node, is there any role for sentinel lymph
nodes in this patient?
So it could be like we do a sentinel and if only one or two will not proceed with the
you get the gist of what we are asking, there are lots of Things that make common sense.
But there is no evidence to substantiate it like the upfront targeted executive section
which we've been doing as well.
But the sound trial, all these things are coming, but we don't don't want science to
overtake evidence, so we want to see how many there is a place for science,
there's a place for common sense, and then there's evidence.
But if you're talking about game changers, then you need to change to game change.
You said 1 or 2 micrometastasis and you don't do any accelerated dissections,
correct? I think this is a critical issue.
It depends on how many lymph nodes you took out.
If you took out only 2 lymph nodes and both are positive and your patient has luminal beat
cancer, I would eager make an axillary sampling again and try to find maybe some more lymph
nodes to get a better ratio with 2 out of 2, I'm not very happy.
sentinel lymph nodes you make an axillary sampling.
Yes, yes, and that's the way we do. We do more and more axillary samplings in this
world right now, exactly.
We don't have evidence, but we do it.
The question can be why 5? Why not 6?
Why not 7? Why not?
Why not? Why not 3.
So that's which side of the bed you wake up in the morning.
But again, evidence has to be there and like Cornelia said,
there's no evidence at the moment. But it is important for having the indication
for systemic therapy after this. It was sorry,
but Florian was pointing out, if you have two positive lymph nodes and you have the third one,
you have the indication and it is an in label use for the CK46 inhibitors.
So to have only 2 of 2 or 43 in bigger tumours, so there is a grey
zone, but we need the information of the axillary and I'm not in line with you that the
axillary dissection in highly nodal positive patient is not therapeutic.
We have data. We have all data that axillary screening in
patients. 56789, and more lymph nodes, it is therapeutic
and we miss the information if we don't have enough lymph nodes and to be honest.
To do that carefully, that we are avoiding big lymphoedema.
That is the story of 20 years past, so we are able to do that in a very careful way so that
the risk of lymphedema and the complications is low.
But again, we need, if you have a patient with two positive lymph nodes,
we need the information if there is more.
So this is what I said at the start, if you remember, as long as it doesn't change
treatment decision, would you be happy.
This is a very important point, right, if you need this to inform further therapies with the
CDK46 or PARP inhibitors or so, um, I think, um, we need to go there's one more question.
We can just discuss now. We've got more questions but we won't finish
them.
got some evidence from the veterans.
It actually they have.
This is chemotherapy naive patients.
the And you don't look like have
This is why the question is asked.
Breakfast Like you Mhm.
You was
s With a
micrometastasis we're not going further anyway and we're not going to radiotherapy because a
micrometastasis in many cases is because especially in luminal breast cancer,
we're not sending every patient with one single node to the radiation of all the lymph nodes.
So it depends on the risk normally.
Then Mhm.
OK, let me ask you this question. You're sitting in MDM.
You've taken out 3 lymph nodes. All three show micrometastasis.
Then what do you do? Micrometastasis is about like if they have this
is an MDM question. 3 nodes you've taken out all 3 show
micrometastasis. What would you recommend?
I don't want a discussion. I just want to know what would you recommend.
I think it's just overall first thing is a multidiscipline.
What would you recommend as a surgeon?
I think that it was a 3 out of 3 nodes with micrometastasis, there's a risk that nodes will
be positive. That's exactly what he's saying 20%.
That's exactly what he said. I'm saying like are we going to go with the
dissection or sampling? That's my.
If you want to be conservative, you can take out a few more lymph nodes if those are clear
you don't do anything
or you decide that 3 nodes I'm going to give radiation therapy and not do anything if you
getting additional lymph nodes is going to change your plan,
then by all means go back. But if you're not going to change your plan
with micrometastasis, then you're not going to change.
Yeah. Right, this question is now we've got 30
seconds to go, right? Sently for a biopsy after you had chemotherapy.
So let's hear from the people who voted no.
Is it sufficient to state, so you're saying a targeted axillary dissection after the N1
becoming clinically uh pathological complete response in lymph node.
Is that sufficient?
Sorry? Yes, anything that you can do that.
But, no, that's something not biopsy. That's not that.
Yes, it's so with that, sorry. So, so the question is to clip or not to clip
really. is sentinel node biopsy sufficient instead of
targeted? That's different.
No, no, no. So some people will do only dual techniques
sentin node biopsy and take 3 at least nodes. Some people put a clip and do a targeted
dissection. I take the nodes biopsy.
Is a tad always necessary or a sent node biopsy OK?
Mhm. It's Phillip.
Central node with an adequate sample.
I think there's only one.
you Yes they And came up with the idea that
biopsy is sufficient, but that's not published yet.
So you have to keep in mind that the evidence we have does not support that.
And this is why you either remove and we know that if you only remove the tad,
just the one node that was positive beforehand, you reduce,
you know, in 75% of cases that's the only node that you need.
You don't need anything else in that situation.
plus you couple it with sent node you've got adequate staging.
So it's see and not and you've removed the tad.
That's superior to sentin node biopsy from the data that we have so far.
Once we have the data published from the paper that's been presented at San Antonio,
then we may have parity.
Right now we don't have that parity.
Still, we might be careful because this is a series from Milan and maybe they are better
experts than many others, but the multi-enter published data,
they showed negative trials it's not trials, it's studies because the false negative rates
were 12% and 14%.
So this is where at the moment we have to be.
So if you look at the concordance between the targeted node that was biopsied,
that was positive, and finding it on a sentinel node biopsy and all the trials,
it was nearly 2/3. So if you do a sentin node biopsy alone,
without the target dissection, without the clip, then you're missing that positive node in 2 1/3
of the patients. But that has not shown any recurrence,
high recurrence rate or survival benefit.
So is it enough to stage the axilla? I don't think so.
I would always take the targeted node, the node that has a clip in it,
but is it a good enough treatment? Yes, mainly because we are irradiating most of
the axillas. So are you going to take only the targeted node
or are you going to do a targeted node and the central nodes that come with it node and a node
so far and the nodes. So that's the message targeted node and central
nodes, but sent node biopsy with 4 nodes is also enough if if you don't have the clips
available in the part of the world that you are.
But ultrasound is usually available and you can put a little radio the ones that they put for
markers and use an intraoperative ultrasound scan.
So that 711071 was a feasibility study.
It was not based on evidence. It was not supposed to give you supposed to
give you a false negative rate.
It didn't fail. It gave you a horrendously high false negative
rate, yeah. There was no targeted lymph node in 17.
There was no, yes, that was a subset analysis in a minuscule of patients.
And now if you look at the pool data like Gazan said, if you do TAD plus sentral lymph node
biopsy, your false negative rate comes down to between 2.4 and 2.6% as compared to higher if
you do a sentinlo biopsy alone.
That we have to wrap up at some point. I know it's interesting.
OK, well the lymph nodes,
so you do radiotherapy in case of not a complete response,
you do the dissection and then radiotherapy.
I think we're not looking at the important point because we change our behaviour.
observing the response on the tumour, but the radiotherapy is still doing radiotherapy on the
axilla. Yes, surgeons de-escalate and oncologists
escalate. That's fine.
That's the. Any final comments from anybody before we wrap
up? I think what will answer that is the ethnic
trials, so their studies randomising and before then, you will not get no answer.
The ASA did not randomise, they're just looking at prac practises.
So we will not have an answer for that. Yeah.
I'm I'm afraid that this takes a lot of time because radio oncologists usually wait until 30
years or so until they believe something.
Yeah, yeah, that's a point of criticism and especially in,
in HER2 positive cancer where we have so good results, we have 60% PCR rates with long term
disease-free survival. I'm not sure if irradiating all these nodes is
necessary, but yeah.
Yeah, surgeons are sure of what they do, oncologists.
Not so. Right, thank you very much to everyone for a
good session. I hope you found it interactive was better
instead of giving you talks or talking at you.
You all got a chance to voice your opinion. Thank you for the panel,
Michael, Florian, and.