Locoregional Recurrence After Sentinel Lymph Node Dissection With or Without Axillary Dissection in Patients With Sentinel Lymph Node Metastases

Abstract

Background and Objective The early results of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated no difference in locoregional recurrence for patients with positive sentinel lymph nodes (SLN) randomized either to axillary lymph node dissection (ALND) or SLN dissection (SLND) alone. We now report long-term locoregional recurrence results. Methods ACOSOG Z0011 prospectively examined overall survival of patients with SLN metastases undergoing breast-conserving therapy randomized to undergo ALND after SLND or no further axillary specific treatment. Locoregional recurrence was prospectively evaluated and compared between the groups. Results Four hundred forty-six patients were randomized to SLND alone and 445 to SLND plus ALND. Both groups were similar with respect to age, Bloom-Richardson score, ER status, adjuvant systemic therapy, histology, and tumor size. Patients randomized to ALND had a median of 17 axillary nodes removed compared to a median of only 2 SLNs removed with SLND alone (P < 0.001). ALND, as expected, also removed more positive lymph nodes (P < 0.001). At a median follow-up of 9.25 years, there was no statistically significant difference in local recurrence-free survival (P=0.13). The cumulative incidence of nodal recurrences at 10 years was 0.5% in the ALND arm and 1.5% in the SLND alone arm (P=0.28). Ten-year cumulative locoregional recurrence was 6.2% with ALND and 5.3% with SLND alone (P=0.36). Conclusion Despite the potential for residual axillary disease after SLND, SLND without ALND offers excellent regional control for selected patients with early metastatic breast cancer treated with breast-conserving therapy and adjuvant systemic therapy.

Fatores preditivos de metástases axilares em pacientes com câncer de mama e biópsia de linfonodo sentinela positivo

“…Z0011 study showed that patients with T1/T2 lesion and negative axillary lymph nodes and with up to two positive SL, referred to adjuvant systemic therapy, did no benefit from axillary surgery, even with 27% of residual disease in the SL arm. These patients had the same survival free of the disease, same mortality and lower morbidity (edema, numbness of arm and quality of life) when compared to patients submitted to axillary surgery 9 . In our study, reinforcing the results of Z0011, T staging, T1/T2 versus T3/T4 could help decide which women should be submitted to further axillary surgery.…”

“…ACOSOG Z0011 work evaluated, in a randomized manner, 891 patients submitted to AL or only follow up after positive SLB. There was no statistical difference between loco-regional and distant relapse rates in both groups 9 . The objective of this study was to verify the existence of association among several studied variables and the axillary lymph node involvement in patients with breast cancer with positive SLB.…”

Paradigm Shift From Halstedian Radical Mastectomy to Personalized Medicine

“…And, most breast surgeons do not perform axillary lymph node dissection even in the presence of 1 or two positive sentinel lymph node(s) due to the results of ACOSOG Z0011 trial (19). New consensus conferences on surgical margins in patients with invasive and ductal carcinoma in situ (DCIS) recommend no-ink on tumour for invasive, and 2 mm for DCIS as clear surgical margin (20)(21).…”

Axillary lymph node management in breast cancer with positive sentinel lymph node biopsy

“…The population studied with mainly ER positive disease (more than 80% of whom would be expected to be Her2 negative) has, often, even in the metastatic setting, a more indolent course (not unusually with bone only disease) and thus OS at 6 years may be too short for definite conclusions when studying localized disease. Moreover, and at closer scrutiny, local recurrence rates display some discernible differences between the two groups in Z0011 [22] . The ALND group had numerically more (3.6% vs 1.9% in the SLN group) in-breast recurrences.…”