slnb the ruh experience a 2014 audit dr m stoddart, dr s cole, mr j horsnell and mr r sutton royal...

SLNB The RUH experience

A 2014 Audit

Dr M Stoddart, Dr S Cole, Mr J Horsnell and Mr R Sutton

Royal United Hospital, Bath

Overview• Report the data from the RUH SLNB audit

2014• Present work looking at the effectiveness of

pre-operative lymphoscintigraphy• Report the role of pre-operative ultrasound

in identification of axillary metastases

Methods• Patients identified based on

• Prospectively recorded data sheet• Interrogation of the online operating

diaries• Electronic patients records

Process• Clinical examination• USS +/- Core Biopsy• If negative SLNB, if positive ALND• If the SLNB is positive (+/- FS) then for

ALND

Patients275 SLNB procedures

8 patients incomplete data

267 patientscomplete data

203 - completed forms

Surgical procedure

WLE60%

Mx38%

SLNB alone2%

Tumour Features• Pathology

• IDC 188 (70%), DCIS 29 (11%), ILC 26 (10%), other 24 (9%)

• Tumour Size• T1 160, T2 86, T3 21

• Grade • Grade 1 60, Grade 2 131, Grade 3 49, DCIS

27

Localisation• Radioactive Colloid

• 201/203• No nodal count in 10/201 ( 95% success)

• Blue dye• 202/203• No blue dye in node on inspection = 31 (85% success)

• Combined• Only 1 patient had neither a blue or radioactive node

(>99%)

Lymphoscintigraphy• 2013 Audit• 167/172 SLNB (with datasheets) localised• 60 patients had more nodes removed• 12 of these had metastatic disease • 1/12 had staging changed based on the

extra nodes

Number of SNs

1 node 2 nodes 3 nodes 4 nodes >40

30

60

90

120Number of nodes excised

2014

Mean number of nodes = 1.93

SLNB Results267 procedures

214 Negative

Macro 34 Micro 14

• 82% Negative (inc 5 ITCs)

• 13% positive for Macro-metastases

• 5% positive for Micrometastases

Further Management• Micrometastases

• 1/14 had an axillary clearance • Macrometastses

• 19/34 had an axillary clearance

• 9/34 radiotherapy

• 3/34 refused surgery

ALND for Macrometastases

• n=19

• Only 6 of these patients had further metastatic disease in the axilla

• Number of non sentinel positive nodes ranged from 2 to 9.

Pre-operative USS

• Patients immediately proceed to ALND (n=46)

• Sensitivity = 57%, Specificity = 99.6% • 2010 : Sensitivity = 62%, Specificity

=100%

Axillary Clearance post USS

• 46 patients avoided SLNB• Mean number of positive nodes =4.06 (range 0-

22)• USS neg = 2.5 (p=0.06)• 12 patients underwent ALND post NAC

• 3 only fibrosis, 3 “disease regression”, 1 no disease

• Mean 2.6 (range 0-16), p=0.07 v other immediate ALND

Conclusions• Only 6/267 who were USS negative had

significant nodal burden• Lymphoscintigraphy remains an important

part of the process• Excellent localisation is achieved with dual

technique• Should we consider SLNB post NAC even if

positive pre NAC

Questions