Management of the Axilla in Breast Cancer

Question 1

What is the size of macrometastases in breast lymph nodes?

Answer 1

> 2mm, N1

Question 2

What is the size of micrometastases in breast lymph nodes?

Answer 2

0.2-2 mm, N1mic

Question 3

What is the size of isolated tumor cells when staging breast cancer?

Answer 3

<0.2 mm, NO[i+]

Question 4

Can you do a repeat SLNBx after prior SNBx or dissection?

Answer 4

Yes, with lower rates of success. But the results are reliable if a new SLN is identified.

Question 5

Why is SLNBx contraindicated in patients with inflammatory breast cancer?

Answer 5

SLNBx results are unreliable. Suspect that lymphatic tumor deposits imede dye mapping.

Question 6

When is a completion axillary dissection indicated following a SLNBx?

Answer 6

When a patient has either macro- or micrometastatic disease. Not for isolated tumor cells

Question 7

When is axillary XRT a reasonable alternative to axillary dissection?

Answer 7

In pts whose nodal pathology results will not change treatment plans

Question 8

A standard axillary dissection takes out what levels of LNs?

Answer 8

Levels I and II

Question 9

When is an axillary level III dissection performed?

Answer 9

Only whne palpable nodes are present.

Question 10

Why is a level III axillary dissection typically not done?

Answer 10

Increased risk of lymphadema

Question 11

How does aggressive post-op pain control facilitate a decrease in morbidity following an axillary dissection?

Answer 11

Pain releife facilitates early post-op mobilization of the arm -> hopefully results in reduced shoulder stiffness and lymphedema

Question 12

Following axillary dissection, lymphedema occurs in what % of patients?

Answer 12

10-25%

Question 13

How many Gy are given for axillary XRT following an axillary dissection?

Answer 13

45-50. Given daily in 1.8-2 Gy fractions

Question 14

What is the rate of brachial plexus injury after axillary XRT?

Answer 14

1%

Question 15

What is the rate of lymphadema following an axillary dissection and XRT?

Answer 15

15-30%

Question 16

After a core bx dx of DCIS, what % of pts will have invasive CA after definitive excision?

Answer 16

20%

Question 17

What % of pts w/ DCIS will have tumor deposits in SLNBx on standard H&E?

Answer 17

1-3%

Question 18

What % of pts w/DCIS will have tumor deposits on keratin staining of SLNBx?

Answer 18

9-13%

Question 19

With a + SLNBx, is there an increase in local or distant recurrence in pts with pure DCIS w/ or w/o microinvasion?

Answer 19

No.

Question 20

Should pts undergoing a mastectomy for DCIS receive a SLNBx?

Answer 20

Yes. The mastectomy will affect lymphatic mapping to the sentinel lymph node.

Question 21

When should the elderly undergo an axillary dissection?

Answer 21

Clinically positive LN, in those chemotherapy will be considered, or those who are at high risk for + LN

Question 22

What % of breast CA present as enlarged ax LN without a detectable primary?

Answer 22

0.3-1%

Question 23

What imaging study should be used for pts. with ax LNA, but no detectable primary?

Answer 23

MRI. Will detect 50% of the primaries.

Question 24

If no primary breast lesion is found with a pt with metastatic LN dz, and metastatic dz from other sites is ruled out, what is the next step?

Answer 24

Axillary dissection to remove nodes. Whole breast XRT.