1. SLNB The RUH experience A 2014 Audit Dr M Stoddart, Dr S Cole, Mr J Horsnell and Mr R Sutton Royal United Hospital, Bath

2. 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

3. Methods Patients identified based on Prospectively recorded data sheet Interrogation of the online operating diaries Electronic patients records

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

5. Patients 275 SLNB procedures 8 patients incomplete data 267 patients complete data 203 - completed forms

6. Surgical procedure

7. 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

8. 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%)

9. 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

10. Number of SNs Mean number of nodes = 1.93

11. SLNB Results 267 procedures 214 Negative Macro 34Micro 14 82% Negative (inc 5 ITCs) 13% positive for Macro-metastases 5% positive for Micrometastases

12. Further Management Micrometastases 1/14 had an axillary clearance Macrometastses 19/34 had an axillary clearance 9/34 radiotherapy 3/34 refused surgery

13. 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.

14. Pre-operative USS Patients immediately proceed to ALND (n=46) Sensitivity = 57%, Specificity = 99.6% 2010 : Sensitivity = 62%, Specificity =100%

15. 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

16. 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

17. Questions