Contraindications to sentinel lymph node biopsy

1. Contraindications to sentinel lymph node biopsy Martine Berliere GGOLFB Breast Clinic Cancer Center Cliniques Universitaires St Luc

2. Sentinel lymph node biopsy (SLNB)  is an evolving, ongoing process Indications and contraindications can change: Yesterday’s contraindications may not be applicable today

3. SLNB: contraindications Absolute contraindications Relative

4. Absolute contraindications Centers electing to perform SLNB for breast cancer must adopt a multidisciplinary approach, coordinating the efforts of radiology, surgery, gynecology, oncology, nuclear medicine, pathology and radiotherapy.  absence of an experienced surgeon + team is an absolute contraindication to SLNB WHY? • Because the surgeon’s experience is the most important factor in sentinel lymph node identification • Prior to offering SLNB as a stand-alone procedure, attending surgeons should have a false-negative rate of less than or equal to 5 % in their last 20 consecutive cases

6. Absolute contraindications Clinically positive axillary lymph nodes (palpable adenopathy and diagnosis of malignant cells confirmed by fine needle aspiration) Why is this a contraindication to SLNB? The lymphatics leading to these clinically positive nodes may be blocked and prohibit accurate mapping, giving to a false-negative result (up to 30 % false-negative rate)

7. Other advanced breast cancer conditions • Clinically positive supraclavicular lymph node(s) • Locally advanced or inflammatory breast cancer • (T3 / T4 lesions) • Metastatic breast cancer

8. Other conditions • Adverse or allergic reactions to blue dye (isosulfan blue) or 99mTC sulphur colloid radionucleotide • Patients unable to give informed consent for SLNB

9. Relative contraindications Prior axillary surgery • Prior axillary surgery is considered to be a contraindication to SNLB because the lymphatics draining the breast are disrupted and successful axillary mapping is not possible • Pori reported an identification rate of 75 % after prior axillary surgery  More data are required before practice changes are implemented

10. Relative contraindications • Previous breast irradiation • Previous breast surgery  need for more data Small studies on breast implants are encouraging

11. Neoadjuvant chemotherapy (NAC) • Largest report to date: NSABP B27 trial findings updated by Mamounas • 420 patients underwent SLNB for axillary staging after NAC • 340 of them underwent complete axillary dissection • identification rate: 85 % • false-negative rate: 12 % • Most studies are very small, compared to extensive multicentric SLNB trials (NSABP B32, …)

13. NAC: conclusion • Very small studies • SLNB after NAC is feasible, but not yet acceptable outside clinical trials • Timing could be important; for patients with clinically negative axillae, SLNB before NAC seems to be a better alternative (Jones)

14. Question? Alterations in lymphatic drainage in patients with initially clinically positive axillae undergoing NAC

15. Ductal carcinoma in situ (DCIS) • SLNB is not recommended in all cases of DCIS • DCIS, by definition, has little or no metastatic potential in the in situ phase BUT • Patients with DCIS and • high-grade lesions • microinvasion detected by biopsy • large lesions (> 5 cm) identified by mammography are at higher risk of invasive carcinoma Only in these cases is SLNB recommended

16. Prophylactic mastectomy (0.1-5 % of all incidental cancers) King, Goldflam, Cancer 2004

17. Multicentric disease • It has been shown that subareolar injection for SLNB is as accurate as peritumoral injection, indicating that most areas of the breast drain into the subareolar plexus and then into a lymph node in the axilla • Two small studies have shown some degree of success with SLNB in the setting of multicentric disease (Schrenk and Fernandez) • IR: 97 % • FNR: 0 % Although larger studies are required, these preliminary data suggest that SLNB may be an alternative to axillary lymph node dissection (ALND) in patients with clinically negative axillae and multicentric disease

18. Multiple tumors

19. Pregnancy • Lymphoscintigraphy and SLNB can be performed safely during pregnancy, since the very low prenatal doses required for this diagnostic procedure do not significantly increase the risk of prenatal death, malformation or mental impairment (Philadelphia Consensus Conference) • Lymphazurin: not yet tested in pregnant animals or humans

20. The role of SLNB in pregnant women with early breast cancer is unknown • Also unknown is whether lymphatic pathways are altered in pregnancy • 60 % of pregnant women with breast cancer have pathological nodal involvement  pregnant breast cancer patients theoretically eligible for SLNB are infrequently encountered • Not recommended outside clinical trials

21. Axillary assessment is important upon diagnosis of breast cancer for prognosis and adjuvant therapy decisions It offers some benefit in terms of regional control and a possible small survival advantage SLNB has minimal risks compared to ALND It is an evolving and ongoing process

22. Take-home message Contraindications • Absence of experienced surgeon + team • Clinically positive nodes • Locally advanced breast cancer • T3-T4 • inflammatory • Metastatic breast cancer • Allergies • Previous breast / axillary surgery • Previous breast radiotherapy • DCIS / prophylactic surgery • NAC • Multicentric disease • Pregnancy / breastfeeding