Axillary Lymph Node Dissection Can Be Omitted in Breast Cancer Patients With Mastectomy and False-Negative Frozen Section in Sentinel Lymph Node Biopsy

Abstract

BackgroundThe IBCSG 23-01 and AMAROS trials both reported that axillary lymph node dissection (ALND) did not change survival rates in breast cancer patients with positive nodes detected by sentinel lymph node biopsy (SLNB). The aim of this study was to determine whether breast cancer patients with mastectomy and false-negative frozen section (FS) in SLNB could forgo ALND.Materials and MethodsThis was a retrospective study of cN0 patients diagnosed with primary invasive breast cancer treated by mastectomy and SLNB at our institute between January 2010 and December 2014. Patients with false-negative FS in SLNB were separated by the following management of axillary lymph node dissection in the non-ALND group (nonprocess or axillary radiation only) and ALND group (with or without radiation).ResultsA total of 212 patients were included, 86 and 126 patients in the non-ALND and ALND groups, respectively. The positive rate of non-sentinel lymph nodes (SLNs) was 15.87% (20/126) in the ALND group. In multivariate analysis, we found that patients with larger tumor size (>2 cm) (OR, 1.989; p = 0.030) and multifocal lesions (OR, 3.542; p = 0.029) tended to receive ALND. The positivity of non-SLNs in the ALND group was associated with SLN macrometastasis (OR, 3.551; p = 0.043) and lymphovascular invasion (OR, 6.158; p = 0.003). Also, removing more SLNs (≥3) was related to negativity in non-SLNs (OR, 0.255; p = 0.016). After a median follow-up of 59.43 months, RFS and OS of the two groups were similar (p = 0.994 and 0.441). In subgroup analysis, we found that 97 patients who met the inclusive criteria of the IBCSG 23-01 trial had similar RFS and OS between the non-ALND and ALND groups (p = 0.856 and 0.298). The positive rate of non-SLNs was 9.62% (5/52). Also, in 174 patients who met the criteria of the AMAROS trial, RFS and OS in the non-ALND and ALND groups were similar (p = 0.930 and 0.616). The positive rate of non-SLNs was 18.27% (19/104).ConclusionALND can be carefully omitted in selected breast cancer patients with mastectomy and false-negative FS in SLNB. SLNB is relatively sufficient in the IBCSG 23-01-eligible patients, and axillary radiation was an effective option in the AMAROS-eligible patients.

Indo-cyanine green administration to identify loss of lymph after axillary lymph node dissection

“…The visualization of lymph nodes and lymphatic vessels using indocyanine green (ICG) and laser-assisted near-infrared (NIR) imaging systems is now considered an established method for the detection of sentinel lymph nodes and evaluation of lymphedema ( 12 – 14 ).…”

Can Axillary Lymph Node Dissection be Omitted in Breast Cancer Patients with Metastatic Sentinel Lymph Nodes Undergoing Mastectomy? A Systematic Review and Meta‐Analysis of Real‐World Evidence

“…The question is whether those cases with FN results reoperation with further ALND. Acceptable FN rates of SLND ranged from 4 to 15% in most reports [38][39][40][41]. Regarding survival outcomes, Qiao et al showed that patients with FN SLNs experienced significantly poorer DFS and OS compared to those with true-negative SLNs [40].…”

“…However, Takei et al demonstrated that although a significantly higher proportion of patients with FN SLNs received adjuvant radiation therapy and systemic therapies than those with true‐negative SLNs, none of the patients with FN SLNs who underwent SLND only without ALND experienced recurrence in the axillary nodes [38]. Recently, Si et al showed no significantly different survival outcomes when performing ALND among patients with FN SLNs treated with mastectomy [41]. The findings from our meta‐analysis further implied that subsequent ALND may be omitted in mastectomy patients with a limited number of FN SLNs, as no significantly superior OS or DFS was observed with the application of ALND in patients who had a limited number of positive SLNs and underwent mastectomy.…”