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.

 

Omission of axillary sentinel lymph node biopsy in early invasive breast cancer

 

by Toralf Reimer 

 

The Breast: Published: January 09, 2023

 

Abstract

 Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated after publication of ACOSOG Z0011 data in 2010. Currently, prospective randomized surgical trials investigating the omission of SLNB in upfront breast-conserving surgery (BCS) and in the neoadjuvant setting, respectively. Several prospective randomized trials (SOUND, INSEMA, BOOG 2013–08, and NAUTILUS) with axillary observation alone versus SLNB in cN0 patients and primary BCS have primary objectives to evaluate oncologic safety when omitting SLNB. The Italian SOUND trial was the earliest to open in 2012 and has completed accrual in 2017. First oncologic outcome data are expected soon for SOUND and at the end of 2024 for INSEMA. Improvements in systemic treatments for breast cancer have increased the rates of pathologic complete response (pCR) in patients receiving neoadjuvant systemic therapy (NAST), offering the opportunity to de-escalate surgery in patients who have a pCR. Two prospective single-arm trials (EUBREAST-01, ASICS) include only patients with the highest likelihood of having a pCR after NAST (triple-negative or HER2-positive breast cancer) and type of surgery will be defined according to the response to NAST rather than on the classical T and N status. The ongoing trials will hopefully help us to understand whether we might take the best therapeutic decisions without the pathologic evaluation of nodal status.

 

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.

 

Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer: A multicentre study on 1,950 patients

 

by Fabio Corsi, Sara Albasini, Luca Sorrentino, Giulia Armatura, Claudia Carolla, Corrado Chiappa, Francesca Combi, Annalisa Curcio, Angelica Della Valle, Guglielmo Ferrari, Maria Luisa Gasparri, Oreste Gentilini, Matteo Ghilli, Chiara Listorti, Stefano Mancini, Peter Marinello, Francesco Meani, Simone Mele, Anna Pertusati, Manuela Roncella, Francesca Rovera, Adele Sgarella, Giovanni Tazzioli, Daniela Tognali, Secondo Folli 

 

The Breast:  VOLUME 60, P131-137, DECEMBER 01, 2021

 

Background

Type of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized.

Patients and methods

1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR).

Results

Independent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75–0.80). After external validation the accuracy of the nomogram was confirmed.

Conclusion

The accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients.

AJR Vol 195 Iss 5 November 2010

N.B. Please contact the Health Sciences Library if you require full text access to any of the following articles.

Contrast-Enhanced MR Angiography of the Breast: Evaluation of Ipsilateral Increased Vascularity and Adjacent Vessel Sign in the Characterization of Breast Lesions
Sibel Kul et al.

Stereotactic Vacuum-Assisted Breast Biopsy Is Not a Therapeutic Procedure Even When All Mammographically Found Calcifications Are Removed: Analysis of 4,086 Procedures
Silvia Penco et al.

Axillary Ultrasound and Fine-Needle Aspiration in the Preoperative Evaluation of the Breast Cancer Patient: An Algorithm Based on Tumor Size and Lymph Node Appearance
Martha B. Mainiero et al.

Features of Prospectively Overlooked Computer-Aided Detection Marks on Prior Screening Digital Mammograms in Women With Breast Cancer
Nariya Cho et al.

Breast Journal Vol 16 Iss 5 Sept - Oct 2010

Axillary Ultrasound Assessment in Primary Breast Cancer: An Audit of 653 Cases.
P Mills et al.
p460-3
Abstract only


Breast Reduction in the Irradiated Breast: Evidence for the Role of Breast Reduction at the Time of Lumpectomy.
B M Parrett et al.
p498-502
Abstract only


Survival in Breast Cancer Patients Undergoing Immediate Breast Reconstruction.
S Agarwal et al.
p503-9
Abstract only


Lobular Neoplasia of the Breast.
R Venkitaraman
p519-28
Abstract only


Trastuzumab in Primary Inflammatory Breast Cancer (IBC): High Pathological Response Rates and Improved Outcome.
S Dawood et al
p529-32
Abstract only


The Extent of Axillary Lymph Node Clearance Required Following Detection of Sentinel Node Micrometastases.
M F Dillon et al.
p533-6
Abstract only


Pleomorphic Liposarcoma of the Breast Mimicking Breast Abscess in a 19-Year-Old Postpartum Female: a Case Report and Review of the Literature.
K C Nadipati et al
p537-40
Abstract only


Imaging of Dermatofibrosarcoma Protuberans of Breast.
S Liu et al.
p541-3
Abstract only

British Journal of Surgery Vol 97 Iss 11 November 2010

New anatomical classification of the axilla with implications for sentinel node biopsy
K. B. Clough et al.
p1659 - 1665
(Access this using your Athens username/password under 'Institutional login')

BMJ 12 Jan 2010

Prevention of lymphoedema after axillary surgery for breast cancer
Andrea Cheville
BMJ 2010;340 b5235

Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial
María Torres Lacomba, María José Yuste Sánchez, Álvaro Zapico Goñi, David Prieto Merino, Orlando Mayoral del Moral, Ester Cerezo Téllez, and Elena Minayo Mogollón
BMJ 2010;340 b5396

Articles from Annals of Surgery

August 2009, Volume 250, Issue 2
p.288-292
Subcutaneous Mastectomy With Conservation of the Nipple-Areola Skin: Broadening the Indications
Stefan Paepke, MD; Rainer Schmid, MD; Stefanie Fleckner; Daniela Paepke et al

October 2009, Volume 250, Issue 4
p.558-566
Sentinel Lymph Node Surgery After Neoadjuvant Chemotherapy is Accurate and Reduces the Need for Axillary Dissection in Breast Cancer Patients
Kelly K. Hunt, MD; Min Yi, MS; Elizabeth A. Mittendorf, MD; Cynthia Guerrero, et al

Letters
p. 657-658
Breast Cancer: Is Nipple Sparing Mastectomy Safe?
J Arthur Jensen
p. 658-659
Breast Cancer: Is Nipple Sparing Mastectomy Safe?
Bernd Gerber, MD, PhD; Annette Krause, MD; Max Dieterich, MD; Toralf Reimer, MD, PhD; Günther Kundt

British Journal of Surgery Vol 96 Iss 8 2009

p. 859-864
Circumferential suction-assisted lipectomy for lymphoedema after surgery for breast cancer
R. J. Damstra, H. G. J. M. Voesten, P. Klinkert, H. Brorson
Abstract
Published Online: 9 Jul 2009
865-869
Sympathetic nerve damage as a potential cause of lymphoedema after axillary dissection for breast cancer
T. M. Bennett Britton, S. M. L. Wallace, I. B. Wilkinson, P. S. Mortimer, A. M. Peters, A. D. Purushotham
Abstract
Published Online: 9 Jul 2009

Acta oncologica 2008, vol. 47, no. 4

Organized nation-wide implementation of sentinel lymph node biopsy in Denmark.
p. 556-60
Friis-Esbern, Galatius-Hanne, Garne-Jens-Peter
Abstract
Prior to the initiation of a nationwide study of the sentinel node staging technique the Danish Breast Cancer Cooperative Group (DBCG) defined a set of minimum requirements to be met by surgical departments before they could include patients in the study. The requirements specified a minimum patient load in the individual surgical unit, a minimum surgical training in the sentinel node biopsy technique and a minimum quality outcome in a validating learning series of SNLB procedures. A working group assisted departments in meeting these terms and later audited and certified departments before they could include patients into the study. As a result of this strategy the sentinel lymph node staging was fully implemented in all Danish surgical breast cancer centres within three years and all sentinel node biopsies in the period were recorded in the DBCG data centre. Furthermore, the strategy accelerated the ongoing process of centralizing breast surgery in specialized departments.

Shoulder disability and late symptoms following surgery for early breast cancer.
p. 569-75
Lauridsen-Mette-Cathrine, Overgaard-Marie, Overgaard-Jens, Hessov-I- B, Cristiansen-Peer.
Abstract
INTRODUCTION: Axillary dissection in combination with radiation therapy is thought to be the main reason why patients surgically treated for breast cancer may develop decreased shoulder mobility on the operated side. The surgery performed on the breast has not been ascribed any considerable importance. In order to evaluate the influence of the surgical technique and the adjuvant oncological therapy on the development of shoulder morbidity, we assessed the physical disability in 132 breast cancer patients with a median follow-up time of 3 years after surgery. METHODS AND METHODS: Eighty nine (67%) patients had been subjected to modified radical mastectomy and 43 (33%) to breast conserving therapy (BCT). All patients had axillary dissection of level I and II. The shoulder function was assessed by the Constant Shoulder Score including both subjective parameters on pain and ability to perform the normal tasks of daily living, and objective parameters assessing active range of motion and muscle strength. RESULTS: Shoulder disability seems to be a frequent late complication to the treatment of early breast cancer (35%). When equal axillary dissection and radiation therapy had been applied, BCT patients were found to suffer less frequent from this complication than patients treated with mastectomy.