>>>Dr. Jay Harness: On almost, but not quite a weekly basis, I have patients coming back
who had Neoadjuvant therapy, and the majority of times its Neoadjuvant chemotherapy, but
now we also have patients Neoadjuvant antihormonal therapy.
So, the question then logically arises, “what do we do about the lymph nodes in that set
of circumstances, namely Neoadjuvant therapies?”
I will give you my view of this.
On the national level, I must tell you we are debating this really pretty vigorously
among those of us who specialize in the field, and as a matter of fact there are even different
approaches, sort of upfront on this very subject.
At my location, I think many locations of the country, Breast MRI is very important
prior to beginning Neoadjuvant therapy.
Often based on that examination, ultrasound or the physical exam, if we find that somebody's
lymph nodes are abnormally enlarged, we will core needle biopsy those as a way of proving
that they are positive.
In my location and again many others in the country, following the completion of the Neoadjuvant
therapy we repeat the MRI examination, and so you know the debate goes on and on, and
those who are known to be lymph node positive, upfront by positive needle biopsy, there are
two camps basically.
There is a camp that I'm in that believes you should do an axillary lymph node dissection
to document what the degree of response has actually been in the lymph nodes, and if there
is a complete pathologic response, that is a tremendous important piece of good news.
Now with that, unfortunately, especially if you combine it with radiation therapy, is
the increased risk of lymphedema which every patient I know really deeply fears.
Now, there is another camp out there that says alright, do your follow-up approach and
if the nodes are shrunk down then at that point do a sentinel lymph node biopsy.
Now, remember this is in those who are known to be lymph node positive originally prior
to the Neoadjuvant therapy.
A lot of debate about how reliable the sentinel lymph node is in that set of circumstances
that I have just explained, and clearly when you are operating on these patients, you have
to feel around and palpate to make sure there aren't any lymph nodes that are completely
replaced by cancer because the sentinel lymph node technique won't work in that set of circumstances.
Now, let me give you the other side of the coin.
Let's somebody had a large tumor in their breast, the lymph nodes were negative clinically
by ultrasound and MRI upfront, they then get Neoadjuvant therapy, have a great response
to that.
Follow-up studies: the lymph nodes still look to be negative.
Now, I would recommend doing the sentinel lymph node technique in that set of circumstances,
and there are papers out with that set of circumstances that suggest that after Neoadjuvant
therapy that the sentinel lymph node biopsy is an accurate way to go.
So, that's a very long answer to a very complicated question.
My advice always is please, please, please, please be working with your multidisciplinary
team to help sort through what's appropriate and right for you.
*****
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