Surgical updates:
1. Marker should be placed at tumor and LN prior to NACT
2. Post NAC MRI plus mammogram can predict BCS eligibility in those not previously BCS eligible. MRI alone predicts in 88% versus 92% with bimodality. Mammogram is better at picking up calcifications which can be malignant in upto 40%. All post NACT calcifications should be excised.
3. All multicentric and locally advanced ( skin, muscle infiltration) not eligible for downstaging after NACT
4. Ideal candidate for NACT is unifocal tumor which can be downstaged for BCS.
5. Post NACT MRI eligible for downstaging only to assess accurate surgical planning. If you know she is going to get a post chemo mastectomy, there is no role for MRI.
6. Downstaging for BCS occurred in 75% ( 79% in HER 2 positive). Path CR is not required for downstaging.
7. Safety for downstaging with BCS: no difference in local or OS in those who were downstaged after NACT.
8. Management of axilla:
a. Clinically node positive getting NACT- clinical N1 disease. 4 studies showed false neg rate of > 10%. To bring it down below 10%, the following were done-- use a clip upfront on the node, remove more than or at least 3 SLNB, use dual tracers.
b. Nodal path CR is essential to omit ALND. Nodal recurrence of 1%.
c. Regional nodal radiation is indicated if SLNB is positive. However axillary XRT is not needed if pt undergoes axillary dissection
9. In clinically node negative early BC, if at the time of surgery only 1-2 SLNB are positive, ok to omit ALND and proceed with axillary XRT instead. This reduced lymphedema with XRT.
10. In patients who undergo NACT, we do not have data to safely assume that axillary dissection can be avoided in lieu of axillary XRT as in patients who did not get NACT. Risk of additional LN involvement is not predicted by SLNB findings and can be as high as 62%. Even if isolated tumor cells in the SLNB upto 20% can have additional nodal disease.
11. Regional nodal radiation reduced the risk of local and distant recurrence. Improved OS in 2 trials MA- 20 and EORTC 22922 in high risk patients.
12. RNI Oxford meta-analysis: cardiac sparing techniques--> cardiac toxicity was reduced. BC mortality was reduced. DIBH--> deep inspiratory breath hold--> moves the heart away and inferiorly from the chest wall.
13. Margin of 1 mm is sufficient even after NACT.
14. TDM1 -KATHERINE study adjuvantly for residual disease after NACT--> 7 yr OS 5% difference and 7 yr IDFS benefit by 14%
15 Omitting regional nodal radiation if axillary path CR-- NSABP 51
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