Partial axillary lymph node dissection inferior to the intercostobrachial nerves complements sentinel node biopsy in patients with clinically node-negative breast cancer

Abstract

BackgroundThe practice of breast cancer diagnosis and treatment in China varies to that in western developed countries. With the unavailability of radioactive tracer technique for sentinel lymph nodes biopsy (SLNB), using blue dye alone has been the only option in China. Also, the diagnosis of breast malignant tumor in most Chinese centres heavily relies on intraoperative instant frozen histology which is normally followed by sentinel lymph nodes mapping, SLNB and the potential breast and axillary operations in one consecutive session. This practice appears to cause a high false negative rate (FNR) for SLNB. The present study aimed to investigate the impact of the current practice in China on the accuracy of SLNB, and whether partial axillary lymph node dissection (PALND), dissection of lymph nodes inferior to the intercostobrachial nerve (ICBN), was a good complementary procedure following SLNB using blue dye.Methods289 patients with clinically node-negative breast cancer were identified and recruited. Tumorectomy, intraoperative instant frozen histological diagnosis, SLNB using methylene blue dye, and PALND or complete axillary node dissection (ALND) were performed in one consecutive operative session. The choice of SLNB only, SLNB followed by PALND or by ALND was based on the pre-determined protocol and preoperative choice by the patient. Clinical parameters were analyzed and survival analysis was performed.Results37 % patients with clinically negative nodes were found nodes positive. 59 patients with positive SLN underwent ALND, including 47 patients with up to two positive nodes which were all located inferior to the ICBN. 9 patients had failed SLNB and underwent PALND. Among them, 3 (33.3 %) patients were found to have one metastatic node. 149 patients showed negative SLNB but chose PALND. Among them, 30 (20.1 %), 14 (9.4) and 1 (0.7 %) patients were found to have one, two and three metastatic node(s), respectively. PALND detected 48 (30.4 %) patients who had either failed SLNB or negative SLNB to have additional positive nodes. All the patients with up to two positive nodes had their nodes located inferior to the ICBN. The FNR of SLNB was 43 %. The accuracy rate was 58 %. The follow-up ranged 12–33 months. The incidence of lymphedema for SLNB, PALND, and ALND was 0 %, 0 %, and 25.4 %, respectively (P < 0.005). The disease-free survivals for SLNB, PALND, and ALND groups were 95.8 %, 96.8 %, and 94.9 %, respectively (p > 0.05).ConclusionsUnder the circumstances of current practice in China, PALND is a good complementary procedure following SLNB in clinically node-negative breast cancer.

Axillary Staging of Early‐Stage Invasive Breast Cancer by Ultrasound‐Guided Fine‐Needle Aspiration Cytology

“…However, the practice of axillary evaluation used in our center, including preoperative US assessment of axillary nodes, a higher proportion of US-guided FNAC on axilla (60.4%), and frozen section analysis of sentinel lymph nodes, may have partly reduced the sentinel lymph node identification failure and false-negative rates. 28 In addition, Li et al 29 reported that 97.8% of patients (44 of 45) with false-negative sentinel lymph node biopsy results by using methylene blue dye alone were found to have only 1 or 2 metastatic nodes on final pathology analysis. Therefore, the sentinel lymph node mapping technique used in this study might had have little effect on the extent of axillary nodal involvement, which was categorized into limited positive nodes (without or with <3 metastatic lymph nodes) and several positive lymph nodes (≥3 metastatic nodes) for analysis.…”

Role of number of sentinel nodes in predicting non-sentinel node metastasis in breast cancer

“… 12 In the present study, the FNR was 5.48% in patients who underwent ALND. Other researchers have reported that peripheral lymph node sampling 13 or atrial ALND 14 may further reduce the FNR of SLNB. However, more extensive surgery may lead to more unnecessary injury.…”

Axillary Sampling as an Alternative Option for Complete Nodal Response in Triple Negative and HER2 Type Breast Cancer Patients after Neoadjuvant Chemotherapy

“…However, ALND is associated with lymphedema, arm pain, sensory defects, decreased range of motion, and other morbidities that could impair quality of life. Sentinel lymph node biopsy can decrease the risk of these morbidities and has become a standard method for the evaluation of axillary lymph nodes [19][20][21][22]27]. However, ALND remains standard care for patients with a clinically positive lymph node before neoadjuvant chemotherapy.…”

“…[18,23,28,29]. Since then, many surgeons have considered less invasive techniques than ALND, including AS, sentinel lymph node dissection, or partial ALND [19][20][21][22].…”

“…AS includes limited or partial ALND; however, the concept and technique of AS are not yet clearly defined. Therefore, the clinical usefulness of AS is limited [19][20][21][22]. Nodal irradiation after sentinel lymph node biopsy has been proven as a safe alternative to ALND among patients with one or two metastatic lymph nodes undergoing surgery [23].…”