San Stadializare
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Transcript of San Stadializare
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prognosis of breast cancer is strongly associated withthe presence or absence of metastatic disease in theaxillary lymph nodes
Nodal staging
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60-70% of:
1) patients with breast cancers have no
involvement of axillary lymph nodes atdiagnosis2) patients with positive sentinel lymph nodesurvive more than 10 years after breast
cancer diagnosis3) lymph node sentinel procedures undergoaxillary dissection4) patients with breast carcinoma diagnosis
undergo direct axillary dissection
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60-70% breast lesions have no axillarylymph node metastases
70% node free pts at dx have >10 yssurvival
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N1 (mobile path. axillarynodes)
N2 (fixed axillary nodes)
N3 (axilla+internal mammarychain)
M1 (sovraclavear,laterocervical, contralat intmamm)
chemio and/or hormontherapy
chemio + radio therapy
preop neoadjuvant chemio
Pres or abs of nodal involvement influences prognosis and therapy.
EurJSurgOncol 2007
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Ann Surg 1983;198:681-684Ann Surg 1985;202:702-707
Independent prognostic factor 30% 10-yr survival w/both axillary and IM basins + 53-55% w/either axillary or IM nodal basins + 80% when neither involved
Increased risk of IM node + when primary > 2 cm or age < 40
75%
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Clinical sensitivity 34-76%US sensitivity 36-92%US - FNAB sensitivity 36-100%
EurJSurgOncol 2007
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Axillary lymph nodedissection (ALND)
Sentinel lymph nodeprocedure (SLNP)
Sentinel lymph nodeassessement prior tosurgery
lymphedema, pain,seroma, limitedmovements, paresthesia
operating timegamma cameradye-radiotracer $radiation expos.
ClinicalUS
CEUSUS guided biopsy
Ann Surg Oncol. 2007;14:2928-31.
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Injection site (30-60MBq99
Tc nanocolloid): subareolar (nonpalpable or multiple tumors) subdermal in the site of the tumor peritumoral (poorer detection)Identification: via hand-held gamma probe if radiotracer ( 99m Tc) visually if lymphotropic dye (if alone, higher FN)
Sentinel lymph node is thefirst node receivingmetastatic cells from the
primary tumor.
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T1 (2cm),T2 (2-5cm) clinically nodenegative
multicentric breast ca (IEO with no axillarymets after 24 mths fu)*
DCIS (not everybody) * DCISM* Locally advanced tumor prior to neoadjuvant
chemotherapy *
Eur J Surg Oncol. 2006 Jun;32(5):507-1Ann Surg Oncol. 2006 Apr;13(4):483-900
Ann Surg Oncol. 2007 Aug;14(8):2202-8Breast Cancer Res Treat 2006;98:311-4
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DCIS 5% sln+ >1cm ->25% sln+DCIS on presurgical
assessement -> IDC on surgery
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Palpable axillary nodesAnatomical lymphatic system disrupted ->
localisation failure (skip mets) Previous neoadjuvant chemotherapy Previous excisional biopsy Clinically positive limph nodes
M1
Honig et al. State of the art of neoadjuvant chemotherapy in breastcancer. GMS Ger Med Sci. 2005;3:Doc08
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Advanced ageHigh body mass index
Massive metastasis invasion(skip metastasis) Tumor location other thanUOQ>3mm node slicesMICROMETASTASES
WJSO 2005;5:132EJSO 2007;7:198
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Can Assoc Radiol J 2005;56:289-296
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Radiol Med 2005;109:330-344
false positive
QuickTime and adecompressor
are needed to see this picture.
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> 10 mm size
Absence of fatty hilumCortical diffuse thickening >2-3mmCircular shape - L/T diameter >2Longitudinal total axis/hilum >50%Sharply demarcated border compared with surroundingfatty tissueHypoechoic internal echoCortical focal thickeningSmall vessels along cortex
Focal vasculature lossNodal vessels dislocation
Australasian Radiology 2006; 50:122-126
Diagn Cytopathol. 2002 ;26:69-74Radiol Med 2005;109:330-344
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US guided-FNAB
PPV 97-100%NPV 56.6-62%Sensit 84-94.7%Specif 91-100%
Australasian Radiology 2006; 50:122-126Diagn Cytopathol. 2002 ;26:69-74Radiol Med 2005;109:330-344Eur Radiol 2005;15:1044-1050
Am J Surg 2007;193:16-20Radiology 2008;246:81-9-
US
PPV 61.3-79%NPV 50-77.2%Sensit 45.2-92%Specif 86.6-100%
Discrepancies due to operator dependanceand equipment dependance
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US guided-FNAB
sensit tumor size and gradesensit clinically pos nodes > clin negSimilar sensit IDC and ILCFN due to sampling error or lecture error(pathologist absent during sampling)
Australasian Radiology 2006; 50:122-126Diagn Cytopathol. 2002 ;26:69-74Radiol Med 2005;109:330-344Eur Radiol 2005;15:1044-1050
Am J Surg 2007;193:16-20Radiology 2008;246:81-9-
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3. All of them4. Prior to possible SLNP c+d undergo US guided
samplinga) axilla
d) axillac) axilla
b) Internal mamm. chain
Which one undergoes SLNP? 1. Only a+b SLNP2. Only c+d SLNP
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FNAB (21G)
Core biopsy (14-16G)
US FNAB versus BIOPSY
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preoperative US sampling-> 8-24% sparing vs SLNP
World J Surg. 2007;31:1153-4.Am J Surg 2007; 194:524-526
timecostsradiotracer - blue dye morbidity
additional surgery
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in favour of US guided FNABin favour of US guided FNABPositive PV ~ 100% - Negative PV ~ 67%
Krishnamurthy S et al. Cancer ;95, 2002
Oruwari JU et al. Am J Surg; 184, 2002
Bedrosian I et al. Ann Surg Oncol; 10, 2003Deurloo EE et al. Eur J Cancer 39, 2003
Kuenen-Boumeester V et al. Eur J Cancer; 39, 2003
Sapino A et al. Br J Cancer; 88, 2003
Lemos S et al. Eur J Gynaecol Oncol; 26, 2005
Mobbs LM et al. JDMS; 21, 2005
Ciatto S et al.Br Cancer Res Treat; 103, 2007
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in favour of US guided Core Biopsyin favour of US guided Core Biopsy The sensitivity of US-FNAB was 86.9%, the specificity was
78.6%, and the accuracy was 84% The sensitivity of US-Core was 86.2%, the specificity was
95.8%, and the accuracy was 89% Hatada T et al. J Am Coll Surg; 190, 2003
The sensitivity of US-Core was 90%, the specificity was100%, and the accuracy was 92%.
Topal U et al. Eur J Radiol;36, 2005
Damera A et al Br J Cancer; 89, 2003
Nori J et al. Radiol Med; 109, 2005
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US guided FNAB
With FNAB we can use afan-like approach with asingle pass
capillarity - suction technique
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US guided Core
Biopsy With core there is no
proof that multiple passes
do not damagethe lymphatic networkreducing the accuracy of theSLN procedure
Technical difficulties if vessels nearby