Medical interview with Professor Li Yuntao: comprehensively interpret the clinical significance of sentinel lymph node biopsy and formulate the best treatment plan for breast cancer

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In 2020, the incidence of female breast cancer surpassed lung cancer for the first time, becoming the number one cancer
endangering women's life and health.
Sentinel lymph nodes (SLNs) are the first lymph nodes
that must pass through lymph node metastases in the area of primary tumor.
Sentinel lymph node biopsy (SLNB), as an important means of surgical treatment of breast cancer, can effectively avoid unnecessary invasive surgery - axillary lymph node dissection, protect the patient's upper limb function, and improve the patient's quality of life [1].

Physician Daily specially invited Professor Li Yuntao from the Breast Center of the Fourth Hospital of Hebei Medical University to share the treatment options, clinical application and significance
of SLNB.

01

SLNB has become the preferred axillary surgery modality for axillary node-negative early-stage breast cancer

Axillary lymphadenectomy is an important part of breast cancer surgery, but complications such as upper extremity lymphedema seriously affect the quality of life of
patients after surgery.
Therefore, the optimal local (regional) treatment of breast cancer has been a direction
that clinicians continue to explore.
Based on numerous clinical studies [^2,3], there was no significant difference in overall survival, disease-free survival, and regional control between SLNB alone and further axillary lymph node dissection (ALND) in patients with negative clinical axillary lymph nodes
.
SLNB (Figure 1) can accurately evaluate the pathological status of axillary lymph nodes, and can safely and effectively replace ALND in patients with negative axillary lymph nodes, thereby significantly reducing surgical complications and improving the quality of life of patients ^[4].

Figure 1: Sentinel lymph node biopsy

02

Comprehensively interpret the clinical significance of SLNB and formulate the best treatment plan for patients

SLNB is the standard axillary staging method for early-stage invasive breast cancer, and preoperative axillary lymph node clinical staging can provide the necessary conditions for the rational use of SLNB (Table 1).

The guidelines of the Breast Cancer Professional Committee of the Chinese Anti-Cancer Association (CBCS) [5] recommend that SLNB is available for patients with ALN clinically negative, and for patients who are clinically suspected positive, it is recommended to confirm the diagnosis by ultrasound guided puncture, and SLNB
is prohibited in patients who have been confirmed to be metastatic by puncture and who have not received neoadjuvant therapy or are still positive after neoadjuvant therapy.
With the deepening of SLNB research on breast cancer, more and more relative contraindications have gradually been converted into indications, and ALND is now one of
the standard treatments for SLN-positive patients.
Not all SLN-positive patients benefit
from ALND.
In the AMAROS trial, patients with SLN-positive breast cancer can be treated with radiotherapy instead of axillary lymph node dissection ^[6].

Z0011 randomized clinical trials have shown that only about 27.
3% of 1 or 2 SLN-positive patients have non-SLN metastases, and patients with clinical ALN-negative and 1~2 SLN metastases should be classified as low risk and should not undergo ALND ^[7].

The biological mechanism involved in lymph node metastasis of malignant tumor cells is complex, and clinicians need to fully consider the patient's own SLN status, combine clinical and cellular biological mechanisms, and carefully interpret the meaning of SLN from multiple angles, so as to formulate a reasonable treatment and follow-up plan ^[8].

Fig.
1 Results of targeted combination and monotherapy for PFS^[4].

03

Follow guideline recommendations and continuously update clinical practice

The Guidelines and Standards for the Diagnosis and Treatment of Breast Cancer of the Chinese Anti-Cancer Association (2022 Edition) ^[5] suggest that ALND can be exempted from ALND
for breast-conserving patients who have not received neoadjuvant therapy and have negative clinical axillary lymph nodes, but 1~2 SLN macro metastases on pathological examination and will receive subsequent further adjuvant whole breast radiotherapy and systemic therapy.
For patients with 1~2 SLN macro metastases undergoing mastectomy, axillary radiotherapy can be used as a reasonable alternative
to ALND if the prognostic data obtained by ALND does not change the treatment decision and the patient agrees not to ALND.
ALND may not be given to patients with SLN micrometastases while receiving breast-conserving therapy (plus whole breast radiotherapy); However, when only total mastectomy is performed without radiotherapy, the opinion of most Chinese experts is in favor of axillary management of patients
with the same macro transfer.

With the emergence of new evidence-based medical evidence, the relevant concepts of SLNB are constantly updated, and affect specific clinical practice, reducing the occurrence of surgical complications and improving the quality of life of patients under the premise of ensuring the safety of tumor treatment ^[9].

The guidelines of the National Comprehensive Cancer Center (NCCN) ^[10] state that SLNB
can also be used in patients with negative ALN clinical examination, with a small tumor burden, only 1-2 axillary lymph node abnormalities on imaging findings, and positive puncture confirmation.
Therefore, the feasibility of sentinel lymph node biopsy in such patients requires further study
.

04

Professor Li Yuntao concluded:

Axillary SLNB for breast cancer can safely and effectively assess the status of axillary lymph nodes and save patients from axillary lymph node dissection and its complications, but there is still a lot of room
for exploration in the indications, surgical management and subsequent treatment options of SLN.
With the addition of more clinical studies on SLN, the safe development of precision individualized SLNB is the direction of breast surgery, and whether SLNB is feasible for patients with only 1-2 lymph node metastases before surgery needs more exploration and practice
.

Expert profiles

Professor Li Yuntao

The Fourth Hospital of Hebei Medical University

Chief physician, medical doctor, professor, master supervisor

Director of the Breast Center Ward of the Fourth Hospital of Hebei Medical University

Member of the Standing Committee of the Breast Health Professional Committee of the China Maternal and Child Health Care Association

Chairman of the Breast Health Professional Committee of Hebei Maternal and Child Health Care Association

Member of the Standing Committee and Secretary of the Breast Cancer Professional Committee of Hebei Anti-Cancer Association

References: (slide to view)

1.
SHANG Fangjian,CHEN Bo.
Hot issues in sentinel lymph node biopsy in breast cancer[J].
Chinese Journal of Oncology Surgery,2021,13(06):541-545.

2.
Giuliano AE,Ballman K,McCall L,et al.
Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases:long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 randomized trial[J].
Ann Surg,2016,264(3):413-420 .

3.
Galimberti V,Cole BF,Viale G,et al.
Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01):10-year follow-up of a randomised,controlled phase 3 trial[ J].
Lancet Oncol,2018,19(10):1385-1393 .

4.
YANG Qifeng,ZHANG Ning.
Sentinel lymph node biopsy for breast cancer in the era of precision medicine[J].
Journal of Shandong University(Health Sciences),2022,60(08):1-5 .

5.
Breast Cancer Professional Committee of Chinese Anti-Cancer Association.
Guidelines and norms for the diagnosis and treatment of breast cancer of the Chinese Anti-Cancer Association (2022 Edition).
2022.
11.

6.
Donker M, van Tienhoven G, Straver ME, et al.
Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS ) :a randomised, multicentre, open-label, phase 3 non-inferiority trial[J].
Lancet Oncol,2014,15(12):1303-1310 .

7.
 KENNARD J A,STEPHENS A J,AHMAD S,et al.
Sentinel lymph nodes(SLN)in endometrial cancer:the relationship between primary tumor histology,SLN metastasis size,and non-sentinel node metastasis[J].
Gynecol Oncol,2019,154(1):53-59 .

8.
WU Di,FAN Zhimin.
Some problems and treatment protocols of sentinel lymph node biopsy for breast cancer[J].
Chinese Journal of Practical Surgery,2018,38(11):1254-1260.
)

9.
YE Jingming, GUO Baoliang, ZHANG Jianguo, et al.
Clinical practice guidelines for sentinel lymph node biopsy surgery for early breast cancer in China(2022 edition)[J].
Chinese Journal of Practical Surgery,2022,42(02):137-145.
)

10.
 Gradishar WJ, Moran MS, Abraham J, et al.
Breast Cancer, Version 3.
2022, NCCN Clinical Practice Guidelines in Oncology[J].
J Natl Compr Canc Netw, 2022,20(6):691-722.

Typesetting: Hu Haiyan

Editor: Wang Lina

Review: Qin Miao

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