Kuehn: Can we omit SLNB in patients who undergo primary surgery and how can we select these patients?

Rubio: Actually, we can omit SLN in those patients >70 y/o in whom the results of the SLN would not change treatment, as far as the axilla is clinically negative (US).

Gentilini: At the moment, SLNS is still the standard of care for axillary staging in early breast cancer. Data from randomized trial will help refining the indications but for the time being SLNB might be omitted in elderly or frail patients in whom the information from SLNB is not affecting the treatment plan. In those patients, we suggest to perform axillary ultrasound as a simple, not expensive, and reproducible technique to rule out lymph node involvement which might be missed by clinical evaluation alone.

Smidt: So, the SLN is still the gold standard in the Netherlands, though the American guideline already suggests to choose wisely: to be restrained in 70+, gr1-2, not too big tumors. Especially, since we know that axillary staging or treatment does not impact overall survival, since comorbidity is leading in impacting that. Preliminary evidence of the BOOG 13-07 study (retrospective study – mastectomy – SN + -add ax treatment or not) shows the same: comorbidity is leading in impacting survival. By the way, this “choosing wisely” is based on studies that somehow never really landed in Europe.

Classe: Considering that trials based on this question are ongoing, I think we must wait for their results.

Kuehn: How should the planned target volume of radiation therapy be defined in patients who undergo primary surgery and fulfill the ACOSOG Z 11 criteria (T1/2, 1–2 SLN positive, breast conserving therapy)?

Rubio: Whole-breast RT using standard tangential fields unless high risk of recurrence, in those cases nodal irradiation will be added.

Gentilini: Would prefer RO to answer.

Smidt: No adaptation of the fields (article Roozendaal) shows that without adaptation enough radiation hits the axilla (in 75% 100% dose, in 85% an 85% dose, thereby: radiotherapists are not sure whether the current 100% dose is not actually too high).

Classe: Only the breast, without lymph node areas.

Kuehn: What is your surgical access to the axilla in patients with more than three suspicious nodes before treatment who convert to ycN0 after primary systemic treatment?

Rubio: If cN2, SLN + clip node + ALND (study). Otherwise, we performed excision of clipped node and SLN with dual tracer.

Gentilini: In our institution, we rely on SLNB alone even in this clinical scenario, whenever preoperative imaging suggests complete remission. In the final decision, biology of the disease and response in both breast and axillary nodes should be considered in order to achieve better results.

Smidt: Sn mari/risas/or tad, however, you want to call it. Biology is most important here (and actually, there is a very nice paper that radiological conversion is a sign for a high FNR. Better rely on biology – Sanaz Samiei has a very nice paper on conversion rates).

Classe: TAD surgery and if positive, lymphadenectomy, discussed in medical meeting. There are ongoing trials based on this issue.

Kuehn: What is your regional treatment concept in patients with micrometastases or isolated tumor cells in the lymph nodes after primary systemic treatment?

Rubio: Axillary lymph node dissection generally. Exceptions would be for ITCs if there is a pCR in the breast.

Gentilini: This situation rarely occurs but, as of today, ALND is the standard of care. Participation to clinical trials such as the NEONOD2 is highly encouraged.

Smidt: In case radiation is indicated Rt of level 1–2.

If not, we discuss per pt taking into account: primary breast tumor, response, subtype, grade, age and comorb, add syst treatment, and of course the wishes of the patient.

Classe: We consider it as metastasis.

Kuehn: Is there an impact of tumor biology on regional management of lymph nodes?

Rubio: The impact comes in the neoadjuvant setting where biology dictates axillary complete response and de-escalation of axillary surgery. In the upfront surgery no differences.

Gentilini: Yes, in my opinion. Biology affects both response to therapies and also timing of different treatments. Therefore, choices usually highly vary according to the diagnosis of luminal versus TNBC or HER2+ disease.

Smidt: I fully agree with Gentilini: there are very nice papers on the fact that biology overrules number of suspicious nodes. This is interesting especially in the light that this is included in various treatment strategies.

Classe: For sure, for example, HER2 over expressed, TN, patients with a breast PCR… are at low risk of lymph node involvement after NAC.

Conflict of Interest Statement

Thorsten Kühn, Jean-Marc Classe, and Isabel T. Rubio: no conflict of interest; Oreste D. Gentilini: consultation fees and honoraria: MSD, Astra-Zeneca, BD, Bayer; Marjolein Smidt: grant from Servier Pharma and Nutricia Danone.

Chair

Prof. Dr. Thorsten Kühn

Städtische Kliniken Esslingen a.N. Frauenklinik

Hirschlandstr. 97

73730 Esslingen, Germany

Kuehn.thorsten@t-online.de

Participants

Prof. Isabel T. Rubio

Breast Surgical Unit

Clinica Universidad de Navarra

28027 Madrid, Spain

irubior@unav.es

Dr. Oreste D. Gentilini

Primario Ch. Mammella

Responsabile Breast Unit

IRCCS Ospedale San Raffaele

20132 Milano, Italy

gentilini.oreste@hsr.it

Prof. Marjolein Smidt

Department of Surgery, Maastricht University Medical Center

Universiteitssingel50, UNS50

6229 ER Maastricht, The Netherlands

marjoleinsmidt@yahoo.com

Prof. Jean-Marc CLASSE

Department of Surgery

Institut de Cancerologie de l’Ouest

Boulevard Professor Monod

44805 Saint Herblain, France

jean-marc.classe@ico.unicancer.fr

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