Attualità nella gestione del cavo ascellare
BREAST UNIT
INCONTRI IN CLINICA
OSTETRICA E GINECOLOGICA
“PRATICA CLINICA OTTIMALE”
R O M A 24 giugno 2015
DIPARTIMENTO SCIENZE CHIRURGICHE PROF. MASSIMO MONTI
LINFOADENECTOMIA ASCELLARE
Dolore: 15-30 %
Parestesie: 20-81 %
Linfedema: 2-20%
Haid A, et al: Breast Ca Res and Treat 73:31; 2002
ALND VS SLN
NEGLI ULTIMI 30 ANNI ……….
MASSIMA CHIRURGIA
TOLLERABILE
MINIMA
CHIRURGIA EFFICACE
umberto veronesi
“CHIRURGIA MINIMALISTA”
T N
dall’inizio degli anni 2000
STATO LINFONODALE
principale parametro prognostico
principale parametro decisionale per terapie adiuvanti sistemiche post-chirurgiche
La LA ha prevalentemente un ruolo stadiativo, non migliora la
sopravvivenza
(Fisher B, 2002; NSABP B04)
SENTINEL LYMPHNODE BIOPSY
ARTICLES IN LITERATURE (=7499)
LS + LA ??
Nel 50% circa delle pazienti con linfonodo macrometastatico ed ancora di più nelle pazienti con LS micrometastatico (~85%) tutti gli altri linfonodi non sentinella risultano negativi, all’esame istologico, rendendo la LA
“inopportuna”, anche per le note complicanze.
ACOSOG Z0011
Trial design: Patients with clinically node-negative breast cancer who underwent SN biopsy and had 1 or 2 SN with H&E-detected metastases were randomly assigned to
ALND or no further axillary specific treatment.
Eligibility: Clinical T1-2, N0 breast cancer, H&E detected metastases in SN, lumpectomy with whole breast irradiation, and adjuvant systemic therapy by choice.
Primary endpoints: OS, DFS and locoregional control.
Giuliano AE et al. Proc ASCO 2010;Abstract CRA506.
John Wayne Cancer Institute 2200 Santa Monica Blvd.
Santa Monica, CA 90404
305:569-575;2011
CONCLUSION:
Among patients with limited SLN metastatic breast cancer treated
with breast conservation and systemic therapy, the use of SLND
alone compared with ALND did not result in inferior survival.
Further studies on larger number of patients confirmed that, in case of 2 or 3 positive lymph nodes, ALND gives no advantage to the patients, because residual disease is well controlled by post- operative chemotherapy and radiotherapy
Regarding these particular patients, studies demonstrated that the possible error in preoperative diagnosis reaches the 25-30%, allowing to avoid 70% of useless ALND
However, in this 25-30% of patients with possible presence of metastasis in sentinel lymph node, oncologists consider adequate to remove 4 or 5 lymph nodes for N staging (the question is:
more or less than 3 metastatic lymphnodes).
*e j ban et coll j breast cancer 2011*l t dengel et coll ann surg oncol 2014 *m l pilewskie et coll oncol 2014
Selective Radioguided Axillary Mini Dissection
(SeRAD)
CHIRURGIA CAVO ASCELLARE IN CHIRURGIA PRIMARIA NOSTRE LINEE GUIDA 2015
giuseppe naso
Se T ≤ 3 cm e cavo clinicamente NEG (cN0) L .SENTINELLA*
Se cN0 e pN + fino a 2 linf. (su 4/5 escissi) SOLO RADIOTERAPIA (NO ulteriore chirurgia) Se T >3 cm anche se cavo Clinicamente NEG (cN0) LINFECTOMIA
Qualunque T se cN+ LINFECTOMIA
attenzione se TNBC o cErbB2 pos.
o donna sotto 50 anni !!
* LS = chirurgia radioassistita sui linfonodi con 4/5 linfonodi
Selective Radioguided Axillary Mini Dissection
(SeRAD)
Selective Radioguided Axillary Mini Dissection
(SeRAD)
Selective Radioguided Axillary Mini Dissection (SeRAD)
estensione della dissezione ? LIMITATA
Selective Radioguided Axillary Mini Dissection (SeRAD)
Anno 2014 : 208 pts
# 130 (62,5%)
not subjected to SL
# 78 (37,5%) subjected to
lymphoscintigraphy and SLNB
59 pts (75,64%) SeRAD
12 pts (15,08%) LS only
7 pts (3,37%) ALND
Selective Radioguided Axillary Mini Dissection (SeRAD)
Total 78 pts selected
Selective Radioguided Axillary Mini Dissection (SeRAD)
None of our patients showed lymphedema or arm paresthesias; the only complication detected in 2 cases was lymphorragy, which required
drainage of the fluid mass through needle puncture, and resolved in 7-8 days
43 pts (72%) 2>4 nodes
tot 59 pts
a.
e.
g i u l i a n o
2
0
1
4
m.
m o r r o w
2 0 1 4
Conclusions.:
ALND was avoided in 84 % of a consecutive series of patients having BCT, suggesting that most patients meeting ACOSOG Z0011 eligibility have a low axillary tumor burden.
Age, ER, and HER2 status were not predictive of ALND, and the criteria used for ALND (C3,SNs, ECE) reliably identified patients at high risk for residual axillary disease.
Memorial Sloan-Kettering Cancer Center, New York
Axillary Dissection Can Be Avoided in the Majority of Clinically Node-Negative Patients Undergoing Breast-Conserving Therapy
L S CHTN
PRE POST
cN+
(MANDATORIO core biopsy su T e Citologicosu N + sospetto, cioè se clinicamente NON dirimibile)
CHIRURGIA + LINFECTOMIA + RT
cN+
DOPO Neoadiuvante
cN0 =CHIRURGIA + LS*
Se LS pN0 stop Chirurgia
MANDATORIA RT Se LS pN+ LINFECTOMIA + RT
Se LS pN+ (ma almeno altri 3 N-) cons. solo RT cN+ =CHIRURGIA+ LINFECTOMIA +RT
(nota di attenzione se TNBC o cErbB2 pos.
o donna sotto 50 anni )
NOSTRE LINEE GUIDA
NEOADIUVANTE
giuseppe naso 2015
* LS = chirurgia radioassistita sui linfonodi con 4/5 linfonodi
LS e DCIS
DCIS rappresenta il 20-25% dei carcinomi
DCIS “puro” ha una bassa % di LS +
La presenza di microinvasione nel PO difficilmente può essere diagnosticata io ed incide
in circa il 10% dei casi,e dipende da:
Diametro del tumore
Grado
EO +
Volumi Breast Unit
Policlinico Umberto I
(2010/2014)primi 3 mesi
Anno N. casi
2010 155
2011 236
2012 241
2013 339
2014 345
2015 ( 3 mesi) 140
“ Chi disputa allegando l’autorita’, non adopera lo ingegno,
ma piuttosto la memoria ” Leonardo da Vinci
s bramly 1988
