Outcomes with and without axillary node dissection for node-positive lumpectomy and mastectomy patients

doi:10.1016/j.amjsurg.2015.05.004

The American Journal of Surgery

Volume 210, Issue 4, October 2015, Pages 685-693

Presented in part at the 2014 Annual Cancer Symposium of the Society of Surgical Oncology, March 12–15, 2014, Phoenix, Arizona, and the American Society of Breast Surgeons 15th Annual Meeting, April 30 to May 4, 2014, Las Vegas, Nevada.

https://doi.org/10.1016/j.amjsurg.2015.05.004 Get rights and content

Abstract

Background

American College of Surgeons Oncology Group Z0011 trial of select node-positive breast cancer patients demonstrated no survival or recurrence differences between SLN/axillary lymph node dissection (ALND) vs SLN. Our comparable node-positive lumpectomy and mastectomy populations should have similar outcomes.

Methods

An Institutional Review Board approved, retrospective review of pathologic SLN (N1) cases was performed. Treatment, recurrence, and survival were collected. Statistics was analyzed via exact chi-square test with Monte Carlo estimation, Kaplan–Meier curves, and log-rank tests.

Results

Of 528 node-positive patients, 318 patients met criteria: 28 (21.7%) lumpectomy, 32 (16.9%) mastectomy had SLN; 101 (78.2%) lumpectomy, 157 (83.0%) mastectomy had SLN + ALND. Median age was 57.5 years for SLN and 53 years for SLN + ALND (P = .003). Mean positive nodes were 1.1 for SLN and 1.47 for SLN + ALND (P = .0018). Chemotherapy use differed (SLN = 73.5%, SLN + ALND = 89.7%, P = .0032). Stage and recurrence were higher for SLN + ALND (P = .0001, P = .007). No difference in comorbidities, nodes retrieved, extracapsular extension, radiation, hormone therapy, or overall survival was observed.

Conclusion

In clinically node-negative breast cancer patients, ALND for N1 disease has no impact on short-term recurrence or survival.

Section snippets

Methods

An IRB approved, single institution, retrospective review of women with sentinel lymph node-positive breast cancer from January 1, 1995 to November 1, 2012 was performed. Female patients who underwent sentinel lymph node biopsy with and without completion axillary dissection were identified at our National Comprehensive Center Network-designated comprehensive cancer center. From this population, patients over 18 years of age with a sentinel lymph node biopsy for an invasive cancer with or

Nodal surgery

Of the 528 patients identified as clinically node negative but with positive sentinel lymph node disease, 318 women met eligibility criteria (1 to 3 positive sentinel nodes, absence of neoadjuvant chemotherapy, presence of invasive carcinoma, and not stage IV disease). Sixty (19%) patients had a sentinel lymph node biopsy alone vs 258 (81%) women who had sentinel lymph node biopsy plus ALND (concurrent or delayed). The median age for all 318 patients was 54 years (range 21 to 96). The median

Comments

Trends toward the omission of ALND in sentinel node-positive patients have been increasing, especially in select populations undergoing breast conserving therapy.¹¹ An analysis of the National Cancer Data Base showed an increase in the percentage of sentinel node patients with microscopic metastatic disease omitting ALND from 25% in 1998% to 46% in 2005.¹⁵ These results were similarly reflected in an analysis of the Surveillance, Epidemiology and Survival Registry (SEER) showing the percentage

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Cited by (18)

The Impact of Sentinel Lymph Node Biopsy on Female Patients With T3-4c Breast Cancer and 1-2 Positive Lymph Nodes: A Population-Based Cohort Study
2024, Clinical Breast Cancer
This study aimed to evaluate the efficacy of sentinel lymph node biopsy (SLNB) in patients diagnosed with cT3-4c breast cancer with no more than 2 positive sentinel lymph nodes.
Using data from the Surveillance, Epidemiology, and End Results (SEER) database, this retrospective study identified patients diagnosed with T3-4c breast cancer between 2010 and 2015. These patients were then categorized into 2 groups: the SLNB group, which underwent examination of 1-5 regional lymph nodes and the axillary lymph node dissection (ALND) group, which underwent examination of ≥10 regional lymph nodes. Propensity score matching analysis was used to assess the efficacy of SLNB in cT3-4c patients.
A total of 1139 patients were included in the analysis, with 423 and 716 patients in the SLNB and ALND groups, respectively. The 10-year overall survival (OS) and breast cancer-specific survival (BCSS) rates in the SLNB group were 66.1% and 76.3%, respectively, compared with 66.0% and 73.8%, respectively. Statistical analysis revealed no significant differences between the 2 groups in terms of OS (HR = 1.00, 95% CI = 0.80-1.25, P = .997) and BCSS (HR = 1.08, 95% CI = 0.83-1.41, P = .551). Even after 1:1 propensity score matching, there were no significant differences in OS (HR = 0.87, 95% CI = 0.65-1.16, P = .341) and BCSS (HR = 0.82, 95% CI = 0.59-1.16, P = .266) between the 2 groups.
This study demonstrates that SLNB does not adversely affect the survival of cT3-4c breast cancer patients with 1-2 sentinel lymph node metastases.
Surgeon Bias in the Management of Positive Sentinel Lymph Nodes
2021, Clinical Breast Cancer
Citation Excerpt :
Additionally, the NCCN also supports omission of CALND in patients undergoing lumpectomy or mastectomy whose axillary disease is limited to micrometastatic disease.7-10 Although data is limited to specific patient and tumor characteristics, there are several prospective and retrospective trials showing that CALND does not offer prolonged overall survival, increased disease-free survival, or decreased local-regional recurrence.11-18 These studies, along with patient preference and concern for the morbidity associated with CALND, have shaped current clinical practice.
The standard of care for clinically node-negative (cN0) patients following positive sentinel lymph node biopsy (SLNB) was completion axillary lymph node dissection (CALND). Publication of ACOSOG Z0011 in 2010 changed this standard for patients undergoing lumpectomy. Clinicians have since expanded this practice to mastectomy patients, and ongoing prospective studies are seeking to validate this practice. Here, we evaluate patient and tumor characteristics that led surgeons to forego a second surgery for CALND in cN0 mastectomy patients with positive SLNB.
A single institution, retrospective review of cN0 patients with invasive primary breast cancer and positive SLNB from 2010 to 2016 was performed. Patients with T4 disease, positive preoperative axillary biopsy, prior neoadjuvant therapy or axillary surgery were excluded. Patients with positive SLNB undergoing CALND were compared with patients for whom CALND was omitted. Statistical analysis was performed using Kruskal-Wallis tests for continuous variables and χ² tests or Fischer exact tests for categorical variables.
Of 259 patients with positive SLNB, 180 (69.4%) patients underwent mastectomy. CALND was performed at the time of mastectomy in 54 (30%) patients, at time of second operation in 22 (12.2%) patients, and not performed in 104 (57%) patients. Delayed CALND was significantly associated with younger age, larger tumors, increased number of positive sentinel nodes, invasive lobular carcinoma, extranodal extension, and lymphovascular invasion.
The management of cN0 patients with positive SLNB that do not meet ACOSOG Z0011 criteria is evolving and is influenced by tumor and patient characteristics in an attempt to balance the morbidity of CALND with the low rate of local regional recurrence.
The intraoperative assessment of sentinel nodes – Standards and controversies
2017, Breast
Citation Excerpt :
Patients who were omitted ALND were older, had smaller primary tumors, fewer tumor-positive SLNs and smaller size SLN metastasis without evidence of lymphovascular invasion or extranodal extension. Several earlier studies also suggested ALND (with or without radiotherapy) may be safely omitted in patients who are treated with mastectomy and have a low tumor burden in SLNs [20,21]. The estimated risks of locoregional recurrence should be weighed against the side effects of ALND and/or radiotherapy.
Intraoperative assessment of sentinel lymph nodes (SLNs) has the advantage of allowing breast cancer patients with tumor-positive SLNs to avoid a second surgery by immediately proceeding to axillary lymph node dissection (ALND). However, there are several reasons why the use of intraoperative assessment should be questioned. Whereas ALND was traditionally advised for all breast cancer patients with tumor-positive lymph nodes for axillary staging and locoregional control, more recent studies have demonstrated safety of omitting ALND in a substantial number of patients.
In addition, there are concerns about the accuracy of intraoperative assessment methods including frozen section analysis, touch preparation cytology and one-step nucleic acid amplification. Moreover, intraoperative assessment of SLNs denies patients the opportunity to contribute to their treatment planning. In our opinion, intraoperative assessment of axillary lymph nodes should be reserved for patients who still have a strict indication for ALND. Patients with clinical node negative disease (cN0) and one or two positive SLNs can be safely treated with breast conserving surgery and radiotherapy. There has been more controversy for cN0 patients who are treated with mastectomy since radiotherapy is not routinely administered in these patients. However, there is increasing evidence that ALND may be omitted in patients undergoing mastectomy who have a low tumor-burden in their SLNs. Therefore, we defend the position that in cN0 patients undergoing mastectomy, SLNB should be performed and full pathologic evaluation of the SLN should be awaited. In cN0 patients undergoing neoadjuvant systemic therapy (NST) intraoperative assessment of SLNs can be omitted since ALND will not provide therapeutic benefit. It is being hypothesized that patients with limited axillary disease prior to NST who remain node-positive after NST could be treated safely with axillary radiotherapy instead of ALND. In these patients, omitting intraoperative assessment might be a reasonable option. In patients with extensive nodal disease prior to NST intraoperative assessment of axillary lymph nodes should be performed.
Reevaluating Axillary Lymph Node Dissection in Total Mastectomy for Low Axillary Burden Breast Cancer: Insights from a Meta-Analysis including the SINODAR-ONE Trial
2024, Cancers
Efficacy and safety comparison between axillary lymph node dissection with no axillary surgery in patients with sentinel node-positive breast cancer: a systematic review and meta-analysis
2023, BMC Surgery
Sentinel lymph node biopsy versus axillary lymph node dissection in breast cancer patients undergoing mastectomy with one to two metastatic sentinel lymph nodes: sub-analysis of the SINODAR-ONE multicentre randomized clinical trial and reopening of enrolment
2023, British Journal of Surgery

View all citing articles on Scopus

: Rachael Snow and Chantal Reyna contributed equally to this study.

: Disclosures: Dr. Christine Laronga is on the speaker's bureau for Genomics Health, Inc. None of the other authors have any financial interests to disclose.

¹: Present address: MD Anderson Cancer Center, Department of Breast Surgical Oncology, University of Texas, Woodlands, TX, USA.

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Association of Women SurgeonsOutcomes with and without axillary node dissection for node-positive lumpectomy and mastectomy patients

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Nodal surgery

Comments

Lancet Oncol

Lancet Oncol

Lancet Oncol

J Am Coll Surg

A clinical and histological study of certain adenocarcinoma of the breast: and a brief consideration of the supraclavicular operation and of the results of operations for cancer of the breast from 1889 to 1898 at the Johns Hopkins Hospital

Ann Surg

Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation

N Engl J Med

Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer

N Engl J Med

Lymphatic mapping and sentinel lymphadenectomy for breast cancer

Ann Surg

A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer

N Engl J Med

Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study

Ann Surg

Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection

J Surg Oncol

Association of Women Surgeons
Outcomes with and without axillary node dissection for node-positive lumpectomy and mastectomy patients