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.

 

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.

Evaluation of sentinel lymph node biopsy after previous breast surgery for breast cancer: GATA study

Evaluation of sentinel lymph node biopsy after previous breastsurgery for breast cancer: GATA study

The Breast August 2016 Volume 28, Pages 54–59

Renaudeau, C eta al

Sentinel lymph node (SLN) biopsy was recently recommended after prior breast tumour surgery and lymphadenectomy is not the gold standard anymore for nodal staging after a lesion's removal. The purpose of our study was to evaluate the good practices of use of SLN biopsy in this context.

 

Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy

Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy: A prospective, multicentre cohort study. The lancet oncology, June 2013, Vol. 14(7), p.609-18

Kuehn, T., et al.

http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(13)70166-9/abstract?rss=yes

The optimum timing of sentinel-lymph-node biopsy for breast cancer patients treated with neoadjuvant chemotherapy is uncertain. The SENTINA (SENTinel NeoAdjuvant) study was designed to evaluate a specific algorithm for timing of a standardised sentinel-lymph-node biopsy procedure in patients who undergo neoadjuvant chemotherapy.

A pilot study to examine the experiences and attitudes of women with breast cancer towards one versus two-step axillary surgery

A pilot study to examine the experiences and attitudes of women with breast cancer towards one versus two-step axillary surgery. The Breast, Vol 21(1), Feb 2012, p. 72-76.

Jenkins, V., et al.

http://www.sciencedirect.com/science/article/pii/S096097761100292X

Women generally were unaware about their lymph nodes, what their function is and how they are removed. Preference was indicated for intra-operative sentinel lymph node biopsy (SLNB) analysis provided clear descriptions were given about the risk of experiencing false negative and false positive results.

Breast Journal Vol 17 Iss 1 Jan - Feb 2011

Sentinel lymph node biopsy in breast cancer: an analysis of the maximum number of nodes requiring excision.
Gill J et al.
p3-8
Abstract only

Improvement in dcis detection rates by mri over time in a high-risk breast screening study.
Warner E et al.
p9-17
Abstract only

Breast reconstruction in women under 30: a 10-year experience.
Ellsworth WA et al.
p18-23
Abstract only

Outcome of small invasive breast cancer with no axillary lymph node involvement.
Sánchez-Muñoz A et al.
p32-8
Abstract only

The prognosis of tumors with only microscopic skin involvement without clinical t4b signs is significantly better than t4b tumors in breast carcinoma.
Duraker N et al.
p47-55
Abstract only

Sentinel lymph node biopsy after neo-adjuvant chemotherapy in breast cancer.
Stell VH et al
p71-4
Abstract only

Age <40> is an independent prognostic factor predicting inferior overall survival in patients treated with breast conservative therapy
Kim K et al.
p75-8
Abstract only


N.B. Articles for which there is no abstract are not included here.

NEJM Vol 364 Iss 5 Feb 3 2011

Access the abstract using your Athens username and password

Effect of Occult Metastases on Survival in Node-Negative Breast Cancer
Donald L Weaver et al.
p. 412

British Journal of Surgery Vol 98 Iss 3 March 2011

Access these articles using your Athens username and password under 'Institutional login'

Assessing the clinical effectiveness of breast reconstruction through patient-reported outcome measures
Z. E. Winters and H. J. Thomson
p323-325

Systematic review of the effect of external beam radiation therapy to the breast on axillary recurrence after negative sentinel lymph node biopsy
B. J. van Wely, S. et al.
p326-333

British Journal of Surgery Vol 98 Iss 1 January 2011

Intraoperative assessment of sentinel lymph nodes in breast cancer
D. M. Layfield, A et al.
p4-17
(Access this article using your Athens username/password under 'Institutional login')

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')

The Breast Journal Vol 16 Iss 4 July-Aug 2010

Oncological safety and quality of life associated with mastectomy and immediate breast reconstruction with a latissimus dorsi myocutaneous flap.
Min SY et al.
P356-61
Abstract only

Neoadjuvant chemotherapy of breast cancer: tumor markers as predictors of pathologic response, recurrence, and survival.
Precht LM et al.
P362-8
Abstract only

Role of fusion of prone FDG-PET and magnetic resonance imaging of the breasts in the evaluation of breast cancer.
Moy L et al.
P369-76
Abstract only

Flat epithelial atypia on breast needle core biopsy: a retrospective study with clinical-pathological correlation.
Lee TJ et al.
P377-83
Abstract only

Accuracy of sentinel node biopsy for breast cancer using blue dye alone.
Krikanova M et al.
P384-8
Abstract only

Surgery of cosmetic sequelae after breast-conserving therapy.
Regaño S et al.
P389-93
Abstract only

The utility of breast MRI in the management of breast cancer.
Teller P et al.
P394-403
Abstract only

Matrix-producing carcinoma: a rare variant of metaplastic breast carcinoma with heterologous elements.
Ayar S et al.
P420-3
Abstract only

Annals of Surgery Vol 251 Iss 4 April 2010

Avoiding Radiation After Breast-Conserving Surgery for Ductal Carcinoma In Situ of the Breast: Beyond the Margin
Rourke, Loren L. MD; Hunt, Kelly K. MD, FACS *
pg. 592-594

Sentinel Lymph Node Biopsy in Breast Cancer: Ten-Year Results of a Randomized Controlled Study
Veronesi, Umberto MD et al.
pg. 595-600

Long-Term Follow-Up Confirms the Oncologic Safety of Sentinel Node Biopsy Without Axillary Dissection in Node-Negative Breast Cancer Patients
Giuliano, Armando E. MD; Chung, Alice P. MD
pg. 601-603

Comparison of Skin-Sparing Mastectomy Versus Non–Skin-Sparing Mastectomy for Breast Cancer: A Meta-Analysis of Observational Studies
Lanitis, Sophocles MD et al.
pg. 632-639

MRI-Model to Guide the Surgical Treatment in Breast Cancer Patients After Neoadjuvant Chemotherapy
Straver, Marieke E. MD et al.
pg. 701-707

Annals of Surgery Vol 251 Iss 1 Jan 2010

Letters to the editor
181
Can Sentinel Node Biopsy Be Avoided in Some Elderly Breast Cancer Patients?
W Charles Mylander, PhD; Martin Rosman, MD; Lorraine Tafra, MD

181-182
Can Sentinel Node Biopsy Be Avoided in Some Elderly Breast Cancer Patients?
Anees B. Chagpar, MD; Kelly M. McMasters, MD, PhD; Michael J. Edwards, MD

ANZ Journal of Surgery Vol 79 No 10 2009

p.674-676
Australia's national breast screening program 18 years on: time for a new direction?
Andrew J. Spillane, Meagan E. Brennan
Abstract
Published Online: 28 Oct 2009

p.719-723
Is sentinel lymph node biopsy after neoadjuvant chemotherapy feasible in Chinese patients with invasive breast cancers?
Tanfo T. Cheung, Dacita T. K. Suen, Ava Kwong
AbstractPublished Online: 28 Oct 2009

The Lancet - Oncology Vol 10 Iss 9 Sept 2009

Sentinel-lymph-node biopsy for early breast cancer: PASSION-P, a double-blind, randomised controlled trial assesses the addition of lidocaine to the radiocolloid used for assessing nodal involvement to reduce procedure-related pain.
http://mail.elsevier-alerts.com/go.asp?/bELA001/qQVVPW8/xN9W7W8

Sentinel-lymph-node biopsy for breast cancer: the story is not yet over
Hiram S Cody
http://mail.elsevier-alerts.com/go.asp?/bELA001/qHVM7W8/xN9W7W8

Annals of Surgery March 2009 Vol 249 Iss 3

448-454
Impact of MRI-Evaluated Neoadjuvant Chemotherapy Response on Change of Surgical Recommendation in Breast Cancer
Jeon-Hor Chen, MD; Byron A. Feig, BS; David J-B Hsiang, MD; John A. Butler, MD; Rita S. Mehta, MD; Shadfar Bahri, MD; Orhan Nalcioglu, PhD; Min-Ying Su, PhD

455-460
Can Sentinel Node Biopsy Be Avoided in Some Elderly Breast Cancer Patients?
for the North American Fareston Tamoxifen Adjuvant Trial

461-468
The Oncological Safety of Skin Sparing Mastectomy with Conservation of the Nipple-Areola Complex and Autologous Reconstruction: An Extended Follow-Up Study
Bernd Gerber, MD, PhD; Annette Krause, MD; Max Dieterich, MD; Günther Kundt, PhD,†; Toralf Reimer, MD, PhD

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