Axillary Dissection Is Not Required for All Patients With Breast Cancer and Positive Sentinel Nodes

Guenther, J. Michael; Hansen, Nora M.; DiFronzo, L. Andrew; Giuliano, Armando E.; Collins, J. Craig; Grube, B.; O’Connell, Theodore X.

doi:10.1001/archsurg.138.1.52

Cited by 173 publications

(102 citation statements)

References 21 publications

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“…Some of these patients would receive cytotoxic chemotherapy or radiation therapy (regardless of the NSN status), which might successfully eradicate any residual axillary lymph node disease. Guenther et al 27 reported a low incidence of regional failure in 46 patients with SN metastases who did not undergo ALND (mean follow-up of 32 months). Furthermore, Greco et al 28 documented that axillary lymph node recurrences in untreated axillas are less frequent than would be expected based on the incidence of positive lymph nodes with ALND, implying that only a small proportion of patients with histologically detectable axillary lymph node disease will develop a clinical recurrence.…”

Section: Discussionmentioning

confidence: 99%

Clinicopathologic features of metastasis in nonsentinel lymph nodes of breast carcinoma patients

Degnim

Griffith

Sabel

et al. 2003

Cancer

139

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BACKGROUNDIn breast carcinoma patients with a positive sentinel lymph node (SN), the value of complete axillary lymph node dissection has been questioned. Multiple published reports have attempted to identify clinicopathologic characteristics of the primary tumor and SN that are associated with an increased likelihood of positive nonsentinel lymph nodes (NSN). Because of differences in lymph node evaluation techniques and limited patient numbers in each study, the authors performed a meta‐analysis to assess the regularity and relative strength of association between various characteristics and the risk of NSN metastasis.METHODSA MEDLINE search identified 15 candidate studies, 11 of which met the criteria for analysis. General elements of the studies, the pathologic characteristics evaluated, and the results for selected characteristics were compared. Original data were abstracted from each study and used to calculate odds ratios. The Mantel–Haenszel common odds ratios were calculated to determine the relative strength of the associations.RESULTSDespite methodologic differences, the correlation between positive NSNs and certain pathologic characteristics was found to be remarkably similar among studies. The 5 individual characteristics found to be associated with the highest likelihood of NSN metastasis are SN metastasis > 2 mm in size, extranodal extension in the SN, tumor size > 2 cm, > 1 positive SN, and lymphovascular invasion in the primary tumor.CONCLUSIONSThere is general concordance among studies regarding the association between pathologic characteristics and NSN metastasis in breast carcinoma patients with a positive SN. The pooled analysis identified those factors with the strongest associations that should be evaluated routinely in SN specimens and included in prospective databases for the development of a predictive model. Cancer 2003. © 2003 American Cancer Society.

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Section: Discussionmentioning

confidence: 99%

Clinicopathologic features of metastasis in nonsentinel lymph nodes of breast carcinoma patients

Degnim

Griffith

Sabel

et al. 2003

Cancer

139

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“…Patients are pragmatically categorized as "good" or "poor" should therefore only be informed by established parameters. Indeed, current practice patterns have reduced the necessity for quantifying axillary disease, with decisions informed by patient factors and primary tumour characteristics [48]. Many nodenegative patients receive combination therapy based on young age and primary tumour characteristics.…”

Section: Discussionmentioning

confidence: 99%

“…Guenther et al [48] and distant disease (HR 1.19, CI 1.00-1.41). However, the reduction in OS was marginal (0.6% at 5-years) and insufficient to justify routine analysis of deeper tissue sections or IHC for conventionally negative SLNs.…”

Section: Significance Of Isolated Tumour Cells Evidence Againstmentioning

confidence: 98%

Clinical significance of sentinel lymph node isolated tumour cells in breast cancer

Patani

Mokbel

2011

Breast Cancer Res Treat

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“…Invasive lobular 4 (13) 21 (13) 13 (20) 6 (15) 5 (25) Select studies of patients with positive SLN and who did not undergo ALND have demonstrated low regional recurrence rates in the setting of adjuvant systemic therapy and RT (Table 5). 1,[5][6][7][8][9][10][11][12][13][14]28 Those series differed with respect to the length of median follow-up, the definition of a positive SLN, reasons for omitting ALND, and the receipt of systemic therapy. Although several of those reports 1,5,7,11 described the RT fields used, none reported treatment outcomes stratified by RT field design.…”

Section: Discussionmentioning

confidence: 99%

“…4 The recent publications of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial confirmed the low axillary recurrence rates observed in multiple studies of SLN-positive patients who did not undergo cALND and extended those observations to patients with macrometastases. 1,[5][6][7][8][9][10][11][12][13][14][15] The results suggested that SLNB alone in patients with early stage breast cancer who have low tumor burden in the SLNs, the receipt of adjuvant radiotherapy (RT) and systemic therapy is adequate for locoregional control. 14 Although the ACOSOG Z0011 protocol specified that all patients receive standard tangent field irradiation to the whole breast, details of the RT were not published, raising the question of whether the low regional recurrence rates observed in Z0011 were caused by the treatment of a portion of the axilla with the tangent fields 16 or by radiation oncologists opting to use high tangents to improve axillary coverage.…”

Section: Introductionmentioning

confidence: 99%

Radiation field design and regional control in sentinel lymph node‐positive breast cancer patients with omission of axillary dissection

Setton

Cody

Tan

et al. 2011

Cancer

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BACKGROUND: Randomized data suggest that axillary clearance is not necessary in select, clinically lymph nodenegative women with positive sentinel lymph node (SLN) biopsies (SLNBs) who undergo breast-conserving surgery or receive whole-breast radiotherapy and systemic therapy. The additional value of axillary radiotherapy in these patients is unknown. METHODS: The authors identified 326 patients with positive SLNBs who underwent breast-conserving surgery without axillary lymph node dissection from 1997 to 2009. SLN tumor deposits measured 0.2 mm in 58% of patients, 0.3 to 2.0 mm in 35% of patients, and >2 mm in 7% Patients. Ninety-three percent of patients received adjuvant radiotherapy. Radiation fields were categorized as standard tangents, high tangents, comprehensive (tangents plus supraclavicular), or partial breast to reflect coverage of the axilla. Standard tangents included both prone and supine positions. Regional failure was defined as recurrence in the ipsilateral supraclavicular, axillary, or internal mammary lymph nodes. RESULTS: The median follow-up was 55 months (range, 1-158 months). The 4-year rates of regional control, local control, disease-free survival, and overall survival were 99%, 98%, 95%, and 91%, respectively. Three patients had regional recurrences. Two of those patients received adjuvant radiotherapy with standard supine tangents, and 1 patient did not receive radiotherapy. No regional recurrences occurred among 66 patients who received radiotherapy in the prone position. CONCLUSIONS: Regional control was high (99% at 4 years) in patients who had low-volume SLN disease who did not undergo axillary dissection, regardless of whether the axilla was irradiated. Whole-breast radiation alone, including in the prone position, is sufficient treatment after breast-conserving surgery for select patients with tumor-containing SLNs who omit axillary dissection.

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Axillary Dissection Is Not Required for All Patients With Breast Cancer and Positive Sentinel Nodes

Cited by 173 publications

References 21 publications

Clinicopathologic features of metastasis in nonsentinel lymph nodes of breast carcinoma patients

Clinicopathologic features of metastasis in nonsentinel lymph nodes of breast carcinoma patients

Clinical significance of sentinel lymph node isolated tumour cells in breast cancer

Radiation field design and regional control in sentinel lymph node‐positive breast cancer patients with omission of axillary dissection

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