To Do or Not to Do: Axillary Nodal Evaluation after ACOSOG Z0011 Trial

Abstract

Methods of axillary evaluation in invasive breast cancer continue to evolve. The recent American College of Surgeons Oncology Group Z0011 Trial is a prospective, randomized, multicenter trial that compared the survival and locoregional recurrence rates after complete axillary lymph node dissection (ALND) versus sentinel node biopsy (SNB) alone in women with a positive sentinel node in an effort to avoid the complications associated with ALND. As the results of this trial are implemented clinically, affecting surgical management of axillary metastatic disease, radiologists may need to redefine their role in the preoperative assessment of the axilla. Before the Z0011 trial, breast imagers worked to identify axillary metastases preoperatively, allowing appropriate patients to proceed directly to ALND and avoiding the need for SNB. However, the Z0011 trial concluded that ALND may not be necessary in women with metastatic axillary disease who meet the trial criteria. In the Z0011 trial, after 6 years of median follow-up there was no difference in either locoregional recurrence or survival among the women who underwent SNB alone compared with those who underwent ALND, suggesting that ALND is unnecessary in a subset of women with a positive node at SNB. These results raise questions about how aggressively radiologists should pursue percutaneous sampling of axillary nodes, as some practitioners conclude that, in an otherwise eligible woman, positive results from imaging-guided percutaneous biopsy preclude a Z0011 trial-directed pathway. Debate about the best way to implement the results of the Z0011 trial into daily clinical practice exists. It is important for breast imagers to work closely with breast surgeons to provide the most appropriate treatment course for each patient.

The Relevance of Ultrasound Imaging of Suspicious Axillary Lymph Nodes and Fine-needle Aspiration Biopsy in the Post-ACOSOG Z11 Era in Early Breast Cancer

“…Seroma, limitation of shoulder movement, nerve injury and lymphedema have been described [30]. A 5–15% false-negative rate for SNB has been reported [20, 31]. Hieken et al [3], Park et al [8] and Baruah et al [16] have noted that following US evaluation and FNA of the suspicious lymph node, 10–30% of potential SNB could have been averted in their respective series.…”

“…It established SNB as the standard-of-care [1, 17–19]. As a consequence, the value of imaging and interventional procedures of axillary lymph nodes has been questioned [3, 19, 20]. In order to remain relevant and continue to contribute meaningfully to patient care it is important for breast imagers to adapt to these changes.…”

“…Some studies estimate that less than 7% of T1 and T2 breast cancers meet the inclusion criteria stated in the Z11 trial [3, 6, 21]. Patients being treated with neoadjuvant chemotherapy (NCT), opting for mastectomy, patients undergoing partial breast radiation, patients with clinically involved nodes, three or more positive sentinel nodes, or nodes with extranodal extension on SNB fall outside the scope of the Z11 eligibility [20]. …”

Retrospective preoperative assessment of the axillary lymph nodes in patients with breast cancer and literature review

“…1 Ultrasound assessment of the axilla is reasonable in all patients with highly suspicious lesions. 2 The Mayo Clinic advised that patients with preoperative biopsy-proved axillary disease undergo complete ANC. 3 Imagers at Royal Perth Hospital, however, continue to evaluate the axilla in patients with a suspicious breast lesion.…”

Paradigm Shifts in Breast Care Delivery: Impact of Imaging in a Multidisciplinary Environment

“…Data reported post Z0011 confirmed a new paradigm whereby surgeons would omit axillary lymph node dissection in patients with 1 to 2 positive sentinel lymph nodes in women with early stage breast cancer scheduled for whole breast irradiation (56–58). Subsequently, surgeons in some institutions also elected to omit preoperative imaging of the axilla for women with early stage breast cancer (59). …”