Predictors of completion axillary lymph node dissection in patients with immunohistochemical metastases to the sentinel lymph node in breast cancer

Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
Annals of Surgical Oncology (Impact Factor: 3.93). 04/2010; 17(4):1063-8. DOI: 10.1245/s10434-009-0834-5
Source: PubMed

ABSTRACT Axillary lymph node dissection (ALND) in patients with immunohistochemistry (IHC)-determined metastases to the sentinel lymph node (SLN) is controversial. The goal of this study was to examine factors associated with ALND in IHC-only patients.
Retrospective review of an institutional SLN database from July 1997 to July 2003 was performed. We compared sociodemographic, pathologic, and therapeutic variables between IHC-only patients who had SLN biopsy alone and those that had ALND.
Our study group consisted of 171 patients with IHC-only metastases to the SLN. Young age, estrogen receptor negative status, high Memorial Sloan-Kettering Cancer Center nomogram score, and chemotherapy were associated with ALND. Among patients who had ALND (n = 95), 18% had a positive non-SLN. Rates of systemic therapy were similar between those with and without positive non-SLNs at ALND. No axillary recurrences were observed in this series with a median follow-up of 6.4 years. The percentage of patients who were recurrence-free after 5 years was 97% (95% confidence interval, 92.1-98.6).
On the basis of our findings and the lack of prospective randomized data, the practice of selectively limiting ALND to IHC-only patients thought to be at high risk and to patients for whom the identification of additional positive nodes may change systemic therapy recommendations seems to be a safe and reasonable approach.

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    • "The median age was 58 years (range 53–67 years), most patients had undergone BCT (44–100 %) and had received some form of adjuvant systemic therapy (36–100 %). Nine studies reported on radiotherapy of the axilla in 2–63 % of patients.14,16,19,25–27,29,35,39 "
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    ABSTRACT: Background Sentinel lymph node biopsy (SLNB) has become standard of care as a staging procedure in patients with invasive breast cancer. A positive SLNB allows completion axillary lymph node dissection (cALND) to be performed. The axillary recurrence rate (ARR) after cALND in patients with positive SLNB is low. Recently, several studies have reported a similar low ARR when cALND is not performed. This review aims to determine the ARR when cALND is omitted in SLNB-positive patients. Methods A literature search was performed in the PubMed database with the search terms “breast cancer,” “sentinel lymph node biopsy,” “axillary” and “recurrence.” Articles with data regarding follow-up of patients with SLNB-positive breast cancer were identified. To be eligible, patients should not have received cALND and ARR should be reported. Results Thirty articles were analyzed. This resulted in 7,151 patients with SLNB-positive breast cancer in whom a cALND was omitted (median follow-up of 45 months, range 1–142 months). Overall, 41 patients developed an axillary recurrence. 27 studies described 3,468 patients with micrometastases in the SLNB, of whom 10 (0.3 %) developed an axillary recurrence. ARR varied between 0 and 3.7 %. Sixteen studies described 3,268 patients with macrometastases, 24 (0.7 %) axillary recurrences were seen. ARR varied between 0 and 7.1 %. Details regarding type of surgery and adjuvant treatment were lacking in the majority of studies. Conclusions ARR appears to be low in SLNB-positive patients even when a cALND is not performed. Withholding cALND may be safe in breast cancer selected patients such as those with isolated tumor cells or micrometastatic disease.
    Annals of Surgical Oncology 08/2012; 19(13). DOI:10.1245/s10434-012-2490-4 · 3.93 Impact Factor
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    • "No axillary recurrences were observed in this series with a median followup of 6.4 years. The percentage of patients who were recurrence-free after 5 years was 97 [54]. "
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    ABSTRACT: Sentinel node biopsy has been established for several years now as a standard procedure of breast cancer surgery, but there are several variations of the indications and the technique used. This paper provides information regarding several issues of debate for its application as are the selection criteria, the application to patients with multifocal/multicentric breast cancer or DCIS, postneoadjuvant chemotherapy, the necessary number of nodes to be biopsied, the need for lymphoscintigraphy, the technique for frozen section, the factors that may predict nonsentinel nodes (NSNs) involvement, the value of micrometastasis and isolated tumour cells, the internal mammary chain sentinel nodes, and finally the axillary recurrence after SLNB. Our view for these issues is included together with our experience of 430 SLNBs.
    Pathology Research International 12/2010; 2011:109712. DOI:10.4061/2011/109712
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    ABSTRACT: Although the current American Joint Commission on Cancer (AJCC) staging system is the most widely used classification scheme for the prognostication of breast cancer, recent work has offered the potential for refinement of this system. Incorporation of grade, lymphovascular invasion, and various biomarkers have all been proposed as options for improvement of primary tumor staging. In addition, there remains controversy regarding optimal staging of lymph node metastases, as the value isolated tumor cells and micrometastases, lymph node ratio, and the value of internal mammary nodes remain at issue. Finally, nuances about the location and number of distant metastases, and the amount of circulating tumor cells may differentiate patients within Stage IV disease. This review highlights recent advances in breast cancer research that may offer insight into potential ways that the AJCC staging system can be improved.
    Current Breast Cancer Reports 06/2011; 3(2). DOI:10.1007/s12609-011-0041-9
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