Factors that determine whether a patient receives completion axillary lymph node dissection after a positive sentinel lymph node biopsy in breast cancer in British Columbia

Abstract

Factors that determine whether a patient receives completion axillary lymph node dissection after a positive sentinel lymph node biopsy for breast cancer in British Columbia Background: Completion axillary lymph node dissection (CALND) is recommended in the setting of positive sentinel lymph node biopsy (SLNB) but is associated with a higher rate of postoperative complications. In this study, the characteristics and outcomes of patients who did and did not have CALND are compared. Methods:We identified all patients with breast cancer with positive sentinel lymph nodes (SLNs) who did not have concurrent CALND from 2003 to 2006 using a prospectively collected database (British Columbia Cancer Breast Outcomes database) and retrospective chart review. Patient and tumour characteristics were compared between those who received CALND and those who did not.Results: Among 185 patients with positive SLNs identified by SLNB, 90 had a CALND and 95 had no further surgical therapy. Patients who did not receive CALND had more sentinel nodes removed (p < 0.001), a lower percentage of positive SLNs (p < 0.001) and lower pathologic N stage (p = 0.044) than those who did receive CALND. The size of the breast lesion, size of the largest SLN deposit, estrogen receptor status, grade, lymphovascular invasion, histology and multifocality were not significantly different between groups. Sixty-two percent of women who did not have CALND received radiation to the axilla. Postoperative complication rates (including lymphedema) were higher in the CALND group (21%) compared with the SLNB group (7%). The rates of locoregional recurrence (1% in both groups) and systemic metastases (6% in the CALND group v. 8% in the SLNB group) were similar at 36 months' follow-up. Conclusion:Compared with women who had CALND, women who did not receive CALND had on average a lower N stage with 3 or more SLNs removed and less than 50% node positivity. Most of these women received radiation therapy to the axilla and had comparable recurrence rates to those who had CALND.Contexte : L'ablation des ganglions lymphatiques axillaires (AGLA) est recommandée lorsque la biopsie des ganglions lymphatiques sentinelles donne des résultats positifs, mais cette intervention est associée à un taux plus élevé de complications postopératoires que la seule biopsie. Cette étude a comparé les caractéristiques et les résultats chez les patientes qui ont subi une AGLA et chez celles qui n'ont pas subi cette intervention.

The Relationship Between Positive Sentinel Lymph Node Biopsy and Residual Axillary Lymph Nodes Status in Early Stage Breast Cancer

“…It is also supported by another study by Swanson and Kennecke which shows a higher percentage of positive SLNs to be predictive of higher likelihood of axillary lymph node (ALN) involvement as well as decreased survival [8]. In this study, the presence of extracapsular invasion in the positive SLN the more the number of positive LN that has been found in axillary evacuation as 7 on the status of the axilla itself [8].…”

“…It is also supported by another study by Swanson and Kennecke which shows a higher percentage of positive SLNs to be predictive of higher likelihood of axillary lymph node (ALN) involvement as well as decreased survival [8]. In this study, the presence of extracapsular invasion in the positive SLN the more the number of positive LN that has been found in axillary evacuation as 7 on the status of the axilla itself [8]. Multivariate analysis also showed that primary tumor size also significantly influenced the risk of non-SLN involvement, the risk was 0% in patients with pT1a, b tumors, 17% in those with pT1c tumors, and 67% in those with tumors measuring more than 20 mm.…”

New concepts in axillary management of breast cancer

“…In retrospective studies, older age, severe comorbidities, smaller tumor size, low grade, and hormone receptor positivity were reported as the most frequent reasons for avoiding axillary dissection [15,17] . Besides, higher number of removed sentinel lymph nodes, lower percentage of positive sentinel lymph nodes and pathologic N stage support the decision on only SLNB [18] . In addition, surgeons feel reluctant to perform axillary dissection when metastases in the sentinel lymph nodes were identified postoperatively.…”

“…In addition, surgeons feel reluctant to perform axillary dissection when metastases in the sentinel lymph nodes were identified postoperatively. Low axillary recurrence rates reported in retrospective studies encouraged the surgeons not to perform completion axillary dissection [18][19][20][21] . Presence of metastases in the remaining axilla in only 40%-60% of patients led to the development of nomograms to predict the patients with further metastases in the axilla [12] .…”