LA CHIRURGIA DELL’ ASCELLA
BREAST UNIT
DIPARTIMENTO SCIENZE CHIRURGICHE
PROF. MASSIMO MONTI
MASTECTOMIA RADICALE
Haid A, et al: Breast Ca Res and Treat 73:31; 2002
ALND VS SLNB
LINFOADENECTOMIA ASCELLARE
l Dolore: 15-30 %
l Parestesie: 20-81 %
l Linfedema: 2-20%
“QUADRANTECTOMIA”
NEGLI ULTIMI 30 ANNI ……….
MASSIMA CHIRURGIA
TOLLERABILE
MINIMA CHIRURGIA
EFFICACE
umberto veronesi
“CHIRURGIA MINIMALISTA”
T N
fino all’inizio degli anni 2000
STATO LINFONODALE
l
principale parametro prognostico,
l
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)
SNB + ALND
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, all’esame istologico, negativi, rendendo la LA
“inopportuna”, con possibili sequele irreversibili.
ACOSOG Z0011
l
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.
l
Eligibility: Clinical T1-2, N0 breast cancer, H&E detected metastases in SN, lumpectomy with whole breast irradiation, and adjuvant systemic therapy by choice.
l
Primary endpoints: OS, DFS and locoregional control.
Giuliano AE et al. Proc ASCO 2010;Abstract CRA506.
lumpectomy + radiation not inferior to ALND
for OS e DFS
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.
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 Further studies on larger number of patients confirmed that, in case of 2 or 3 positive lymphnodes, ALND gives no advantage to the patients, because residual disease is well controlled by post- operative chemotherapy and radiotherapy
l Regarding these particular patients, studies demonstrated that the possible error in preoperative diagnosis reaches the 25-30%, allowing to avoid 70% of useless ALND
l However, in this 25-30% of patients with possible presence of metastasis in sentinel lymph node, oncologists consider adequate to remove 4 or 5 lymphnodes 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
HOW MANY LYMPHONODES ?
Selective Radioguided Axillary Mini Dissection
(SeRAD)
Selective Radioguided Axillary Mini Dissection
(SeRAD)
Selective Radioguided Axillary Mini Dissection (SeRAD)
limited extension of surgical dissection
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
35 pts (60%) 2>4 nodes
Totale pz operate con tecnica del linfonodo sentinella (SLNB classica + SeRAD) 184 Pz sottoposte a biopsia del solo linfonodo sentinella (SLNB) 71
Pz sottoposte a minilinfectomia radioguidata (SeRAD) 111
CASISTICA
(2013-6/2015)Pazienti operate (totale) Linfonodi positivi Pazienti rioperate
SLNB 71 14 14
SeRAD 111 21 2
CASISTICA
(2013-6/2015)Tecnica SLNB Tecnica SeRAD
REINTERVENTI
CASISTICA
(2014-6/2015)REINTERVENTI
l
Nel caso della tecnica SeRAD, in 19 (su 111) casi è stato possibile evitare lo svuotamento ascellare (ALND)
–
In 10 casi abbiamo documentato il cd “salto del sentinella”, in cui è stato trovato negativo il linfonodo sentinella e positivo uno dei linfonodi parasentinella
–
In 9 casi è stato trovato positivo solo il linfonodo sentinella e l’asportazione dei linfonodi parasentinella è stata considerata oncologicamente sicura
l
Nei 2 casi rimanenti è stato necessario procedere ad ALND in un secondo tempo a causa del coinvolgimento di più del 50% dei linfonodi asportati
CONCLUSIONI
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 >0 =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
cN0
cT1
(cT1a-b) AgoaspiratoSuff. NON Suff.
Pos. Neg.
Chirurgia Follow-up Biopsia
Core Biopsy Open Biopsy
-anyT
Core BiopsyPos. Neg. Non Dirimente
Neoad. Chirur.
Follow-up Open Biopsy
cN+ o N dubbio
Core Biopsy su T
Se T Pos. N dubbio Agoasp.
cN+ (vedi II parte) Se T NEG ma ancora dubbi su N
Core Biopsy su N
Se Neoad.
(C def. = E.O +/- Ecografia )
cT1c
NOSTRE LINEE GUIDA
giuseppe naso 2015
NeoAdjuvant Chemotherapy NAC
NAC SLNB-ALND
PRE POST
NeoAdjuvant Chemotherapy NAC
can downstage
tumors in the breast node positive in axilla
Mastectomy Breast Conservative Surgery
Node Positive Node Negative 10%-30% pts
40% pts
*g hortobagyi et coll j clin oncol 2005*h m kuerer et coll ann surg 1999*j a van hage et coll j clin oncol 2001
NeoAdjuvant Chemotherapy NAC
Node Positive Node Negative
ALND SLNB
* l gianni et coll lancet oncol 2014
40 % pts
?
NeoAdjuvant Chemotherapy NAC
Node Negative Preop SLNB Node Positive (clinical/microscopic)
Variability to identify the SLN after NAC in positive axilla false negative
*kk hunt et coll ann surg 2009
?
l
# increase axillary fibrosis
l
# alter lymphatic drainage
l
# decrease SLN identification rate
l
# increase FNR
* a maguire et coll MSKCC histopathology 2016
NeoAdjuvant Chemotherapy NAC
effects in the axilla
NeoAdjuvant Chemotherapy NAC
number of sentinel nodes after NAC><FNR
higher false negative 35%
1 SLN only
2 SLN 3 > SLN 18,5% 10%
* t kuehn et coll lancet oncol 2013*ACOSOG Z1071 (alliance) 2013
NCT - Selective Radioguided Axillary Mini Dissection (SeRAD)
SLN
adipose tissue PSN
cN+
(MANDATORIO core biopsy su T e Citologicosu N + sospetto, cioè se clinicamente NON dirimibile)
CHIRURGIA + LINFECTOMIA + RT 00
cN+
POST NCT
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
giuseppe naso 2015
* LS = chirurgia radioassistita sui linfonodi con 4/5 linfonodi
NeoAdjuvant Chemotherapy NAC
jc boughey et coll alliance A11202 JAMA 2013
Prospective randomized study
patients with T1-3 N1 M0 breast cancer with SLN + , after NAC, Radiotherapy (breast + chest wall) + ALND
is compared with Radiotherapy only
Further studies are necessary to determine
optimal axillary management in NCT patients
NAC >< SNB
l
# luminal-HER2
l
# HER2-enriched
l
# TNBC subtypes
147 pts
* e katsutoshi et coll clin breast canc 2016
Volumi Breast Unit
Policlinico Umberto I
(2010/2015)Anno N. casi
2010 155
2011 236
2012 241
2013 339
2014 345
2015 365
“ Chi disputa allegando l’autorita’, non adopera lo ingegno,
ma piuttosto la memoria ” Leonardo da Vinci
s bramly 1988