Axillary lymph node dissection: Dead or still alive?

 

by Anna C. Beck, Monica Morrow 

 

The Breast: Published: January 23, 2023

 

Highlights

·         Axillary surgery in BC has been de-escalated for a significant group of patients, but an ALND is still necessary for some

·         ALND remains necessary for staging in patients where SLNB has not been demonstrated to be accurate

·         This includes patients with clinically palpable lymph nodes and patients with cT4 or cN2-3 disease

·         ALND is required for local control in patients with a heavy axillary tumor burden and recurrent axillary disease

·         Use of newer systemic therapy may require complete axillary staging with ALND to determine eligibility for use.

Abstract

Although sentinel lymph node biopsy is now the primary method of axillary staging and is therapeutic for patients with limited nodal disease, axillary lymph node dissection (ALND) is still necessary for staging in groups where sentinel lymph node biopsy has not been proven to be accurate and to maintain local control in those with a heavy axillary tumor burden. Additionally, newer approaches to systemic therapy tailored to risk level sometimes necessitate knowledge of the number of involved axillary nodes which can only be obtained with ALND. Ongoing trials will address whether there are additional circumstances where radiotherapy can replace ALND.

 

Patient-reported outcomes one year after positive sentinel lymph node biopsy with or without axillary lymph node dissection in the randomized SENOMAC trial

by Matilda Appelgren, Helena Sackey, Yvonne Wengström, Karin Johansson, Johan Ahlgren, Yvette Andersson, Leif Bergkvist, Jan Frisell, Dan Lundstedt, Lisa Rydén, Malin Sund, Sara Alkner, Birgitte Vrou Offersen, Tove Filtenborg Tvedskov, Peer Christiansen, Jana de Boniface, the SENOMAC Trialists' Group 

The Breast: VOLUME 63, P16-23, JUNE 01, 2022

Introduction

This report evaluates whether health related quality of life (HRQoL) and patient-reported arm morbidity one year after axillary surgery are affected by the omission of axillary lymph node dissection (ALND).

Methods

The ongoing international non-inferiority SENOMAC trial randomizes clinically node-negative breast cancer patients (T1-T3) with 1–2 sentinel lymph node (SLN) macrometastases to completion ALND or no further axillary surgery. For this analysis, the first 1181 patients enrolled in Sweden and Denmark between March 2015, and June 2019, were eligible. Data extraction from the trial database was on November 2020. This report covers the secondary outcomes of the SENOMAC trial: HRQoL and patient-reported arm morbidity. The EORTC QLQ-C30, EORTC QLQ-BR23 and Lymph-ICF questionnaires were completed in the early postoperative phase and at one-year follow-up. Adjusted one-year mean scores and mean differences between the groups are presented corrected for multiple testing.

Results

Overall, 976 questionnaires (501 in the SLN biopsy only group and 475 in the completion ALND group) were analysed, corresponding to a response rate of 82.6%. No significant group differences in overall HRQoL were identified. Participants receiving SLN biopsy only, reported significantly lower symptom scores on the EORTC subscales of pain, arm symptoms and breast symptoms. The Lymph-ICF domain scores of physical function, mental function and mobility activities were significantly in favour of the SLN biopsy only group.

Conclusion

One year after surgery, arm morbidity is significantly worse affected by ALND than by SLN biopsy only. The results underline the importance of ongoing attempts to safely de-escalate axillary surgery.

 

Trends in axillary surgery and clinical outcomes among breast cancer patients with sentinel node metastasis

 

by Zongchao Gou, Xunxi Lu, Mengting He, Luoting Yu 

 

The Breast: VOLUME 63, P9-15, JUNE 01, 2022

 

Background

There is a lack of studies examining the long-term trend and survival of axillary surgery for breast cancer patients with sentinel node metastasis, especially for the patients with 3–5 node metastases.

Methods

Breast cancer patients with 1–5 sentinel node metastases from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2016. Our study presented the trend of axillary surgery and assessed the long-term survival of sentinel lymph node biopsy (SLNB) alone vs axillary lymph node dissection (ALND) for those patients.

Results

Of the 41,996 patients diagnosed with T1-2 breast cancer after lumpectomy and radiation included, 34,940 had 1-2 sentinel node metastases and 7056 had 3-5 sentinel node metastases. The percentage of patients undergoing SLNB alone increased from 22.4% in 2000 to 81.0% in 2016 for patients with 1–2 sentinel node metastases, and quadrupled from 5.2% in 2009 to 20.6% in 2016 for those with 3–5 sentinel node metastases. Completion of ALND did not benefit the long-term survival of 1–2 sentinel node metastasis patients (hazard ratio [HR] = 1.02, P = 0.539), but improved the long-term survival of 3–5 node metastasis patients (HR = 0.73, P < 0.001). Subgroup analysis demonstrated the inferiority of SLNB to ALND in all subgroups of 3–5 sentinel node metastases.

Conclusion

For patients with T1-2 breast cancer after lumpectomy and radiation, SLNB alone was an efficient and safe surgical choice for 1–2 sentinel node metastases but not for 3–5 sentinel node metastases. It is worth noting that for patients with 3–5 node metastasis, the proportion of omitted ALND quadrupled after 2009.

 

De-escalating axillary surgery in early stage breast cancer

 

by Eliza H. Hersh, Tari A. King 

The Breast: Published: December 15, 2021

The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013–08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.

The applicability of Magseed® for Targeted Axillary Dissection in breast cancer patients treated with neoadjuvant chemotherapy

 

The applicability of Magseed® for Targeted Axillary Dissection in breast cancer patients treated with neoadjuvant chemotherapy

by Reitsamer R, Peintinger F, Forsthuber E, Sir A 

The Breast VOLUME 57, P113-117, JUNE 01, 2021 (Published: March 25, 2021)

Background

Targeted axillary dissection (TAD), the combination of sentinel lymph node biopsy (SLNB) and targeted lymph node biopsy (TLNB), can reduce the false negative rates of sentinel node biopsy alone dramatically in breast cancer patients, who received neoadjuvant chemotherapy (NAC). However methods for TAD are still under investigation.

Methods

Magseed®, a non-radioactive magnetic marker was used to mark the biopsied positive TLN after NAC. The SLNB with the standard technetium-based method and the selective TLNB with Magseed® localization were performed in 40 patients. The TLNs were identified with the Sentimag® probe and excised in all patients. Specimen x-ray was performed to confirm the Magseed® within the prior to NAC biopsied and clipped lymph node.

Results

The TLN identification rate was 100% (40/40), the SLN identification rate was 82.5% (33/40), the concordance rate between the TLN and the SLN was 65% (26/40). Complications according Magseed® deployment or identification could not be observed.

Conclusion

Magseed® is a reliable and feasible marker for the identification of TLNs after NAC.

Trends in axillary lymph node dissection for early-stage breast cancer in Europe: Impact of evidence on practice

Trends in axillary lymph node dissection for early-stage breast cancer in Europe: Impact of evidence on practice

by Carlos A. Garcia-Etienne, Robert E. Mansel, Mariano Tomatis, Joerg Heil, Laura Biganzoli, Alberta Ferrari, Lorenza Marotti, Adele Sgarella, Antonio Ponti, EUSOMA Working Group  

The Breast: June 2019, Volume 45, Pages 89-96

Data from recently published trials have provided practice-changing recommendations for the surgical approach to the axilla in breast cancer. Patients with T1-2 lesions, treated with breast conservation, who have not received neoadjuvant chemotherapy and have 1–2 positive sentinel nodes (Z0011-criteria) may avoid axillary lymph node dissection (ALND). We aim to describe the dissemination of this practice in Europe over an extended period of time.

Chemotherapy port related lymphedema after axillary lymph node dissection

Chemotherapy port related lymphedema after axillary lymph node dissection
The Breast August 2016 Volume 28, Pages 145–147

Turfe Z et al

The Mascagni lymphatic pathway comprises superficial channels along the clavicle that drain upper extremity lymph. A 65 year-old woman with recurrent left breast cancer presented with a non-functioning chemotherapy port in the right deltopectoral groove. She had undergone right mastectomy with axillary lymph node dissection (ALND). After port removal and wound closure she developed right upper extremity lymphedema. Patients who have undergone ALND may depend solely on this pathway for upper extremity lymphatic drainage.

Re-evaluating the role of axillary lymph node dissection in screen-detected breast cancer patients

Re-evaluating the role of axillary lymph node dissection in screen-detected breast cancer patients. The Breast, Vol. 21(1), Feb 2012, p. 58-60.

Barry, M. & Kell, M.R.

http://www.sciencedirect.com/science/article/pii/S0960977611001640

The American College of Surgeons Oncology Group (ACOSOG), Z0011 trial, demonstrated that there was no therapeutic benefit from completion lymphadenectomy in early stage breast cancer patients with positive sentinel node (SLN) biopsy. Patients with asymptomatic screen-detected tumors may represent a subgroup where completion axillary dissection with its attendant morbidities is unacceptable. Therefore, the aim of this study was to evaluate the role of ALND in an asymptomatic screen-detected breast cancer cohort.

Annals of Surgery Vol 252 Iss 3 September 2010

Locoregional Recurrence After Sentinel Lymph Node Dissection With or Without Axillary Dissection in Patients With Sentinel Lymph Node Metastases: The American College of Surgeons Oncology Group Z0011 Randomized Trial.
Giuliano, Armando E. MD et al.
pg. 426-433

Annals of Surgery November 2008 Volume 248 Issue 5

Letters to the Editor
895
A Randomized Controlled Clinical Trial on Sentinel Node Lymph Node Dissection Versus Axillary Lymph Node Dissection: A Matter of Technique or Patient Selection?
Amtul R. Carmichael, MD, FRCS

895-896
A Randomized Controlled Clinical Trial on Sentinel Node Lymph Node Dissection Versus Axillary Lymph Node Dissection: A Matter of Technique or Patient Selection?
Giorgio Zavagno, MD