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Metastatic Breast Cancer
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Mayer Gorbaty
Aug 20, 2016
I would appreciate hearing from a breast surgeon or surgical oncologist about this case. In my geographic area this 51 year old woman would be considered relatively young; with 3/3 + LNs with one having extracapsular extension she would go on to have a full axillary dissection and then chemotherapy/RT//hormonal therapy.
Would everyone agree not to offer her a completion axillary dissection?
Regarding this pt with a 4.2cm ILC and 3/3 SLN + (+ENE) it would be helpful to know the size of the nodal metastasis. Given the ENE, I suspect there is macrometastatic (>2mm) disease in the sentinel nodes. Per ASCO and NCCN guidelines, ALND cannot be omitted in this pt because she has 3/3 positive lymph nodes, as well as extranodal extension, which suggests her level of axillary disease is significant. To adequately stage her, she requires ALND. While we only know of 3 positive axillary nodes currently, she may be found to have pN2 disease with adequate staging. While it is understandable to want to spare the patient further axillary surgery, extrapolating from the AMAROS trial is not appropriate because in AMAROS 95% pts had <3 positive sentinel nodes and much less tumor burden in the axilla (40% had only ITCs or micrometastatic disease). Similarily, we must be careful not to extrapolate from ACOSOG Z-0011, evaluating the need for completion axillary dissection in patients who will receive radiation, to this patient. ACOSOG enrolled clinically node negative patients with T1-T2 tumors with <3 positive sentinel nodes.
Mayer Gorbaty
Aug 23, 2016
Thank you Dr. O'Donnell. My recommendation is also to go ahead with an axillary dissection. There would have to be an extenuating circumstance such as advanced age, comorbidity, patient refusal, etc. to omit that step.
homam alkaied
Aug 10, 2017
My recommendation is that to proceed with axillary dissection for 2 reasons: 1- 3 S sLN involved. 2- Extra capsular extension ( Gross extra capsular extension excluded from Z11)
Apr 25, 2024
Pending Moderator approval.
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Sameer
Nasir
MD
Mayer Gorbaty
Aug 20, 2016
Maureen O'Donnell MD
Aug 23, 2016
Mayer Gorbaty
Aug 23, 2016
homam alkaied
Aug 10, 2017
Apr 25, 2024
Pending Moderator approval.