The Need for Axillary Dissection in Patients with Positive Axillary Sentinel Lymph Nodes
Department of Human Oncology, Drexel University College of Medicine, Philadelphia, PA, USA.Current Oncology Reports (Impact Factor: 2.89). 10/2010; 13(1):5-10. DOI: 10.1007/s11912-010-0133-0
The need for completion axillary dissection after a positive sentinel node biopsy continues to be challenged. In the 2 years since we last reviewed this subject, a number of authors have shared their experiences about micrometastatic disease and isolated tumor cells, opining both for and against axillary treatment. Data from the ACOSOG Z0011 trial and other small studies do not appear to support the use of completion axillary dissection even for macro-metastatic disease in patients with clinically node-negative (N0) disease. While existing guidelines still recommend axillary dissection for patients with clinically positive nodes, even when conversion to clinically negative disease following neoadjuvant chemotherapy has occurred, this concept is being questioned in ACOSOG Z1071 and in several other recent small trials. The surgical approach to the treatment of breast cancer continues to move away from the traditional Halstedian concept.
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ABSTRACT: Today, sentinel lymph node dissection (SLND) has replaced axillary lymph node dissection (ALND) as standard procedure for staging of the axilla in the treatment of breast cancer. SLND can accurately stage the axilla by removing on average only two lymph nodes. Only in case of metastatic spread to sentinel nodes an ALND is offered. Removing fewer nodes has made more extensive histopathological examinations of the lymph nodes possible and as a consequence more metastases are found. This has resulted in stage migration. Based on data from the nationwide Danish Breast Cancer Cooperative Group (DBCG) database we have estimated the magnitude and therapeutic consequences of this stage migration in Denmark by comparing the distribution of lymph node metastases in breast cancer patients operated in 1993-1996 and 2005-2008; before and after introducing SLND. The proportion of patients having macrometastases was not significantly different in the two periods, whereas the proportion of patients with micrometastases increased significantly from 5.1% to 9.0%. However, the proportion of patients offered adjuvant systemic treatment due to positive nodal status as the only high-risk criterion did only increase from 7.8% to 8.8%, when estimated using today´s criteria for risk-allocation, because nodal status is now less important in risk-allocation. In general, only 15-20% of patients with micrometastases and 10-15% of patients with isolated tumor cells (ITC) in sentinel node have further metastatic spread to non-sentinel nodes (NSN). Thus, the majority of these patients does not benefit from additional ALND but still run the risk of arm morbidity. Based on data from the DBCG database, we have developed two models to predict NSN metastases in breast cancer patients with micrometastases or ITC in the sentinel node. A total number of 304 breast cancer patients with ITC and 1577 patients with micrometastases in sentinel node operated in 2001-2008 with SLND and subsequent ALND were identified in the database. In patients with ITC in sentinel node the risk of NSN metastases was significantly associated with younger age at diagnosis, increasing tumor size and increasing proportion of positive sentinel nodes in a multivariate analysis. If patients were ≥ 40 years at diagnosis with tumor size ≤ 2 cm as well as one or more negative sentinel nodes, NSN metastases were found in only 2%. Omission of ALND in this group would spare 1/3 of patients with ITC in sentinel node for an ALND. In patients with micrometastases in sentinel node the risk of NSN metastases was significantly associated with increasing tumor size, lymphovascular invasion, negative hormone receptor status, location of tumor in the upper lateral quadrant of the breast and increasing proportion of positive sentinel nodes in a multivariate analysis. However, a model based on these traditional prognostic markers could not identify a subgroup of patients with a risk of NSN metastases less than 10%. We then investigated whether the biochemical prognostic markers TIMP-1, Ki67 and HER2 could support the model. In a matched case-control study 25 cases with micrometastases in sentinel node and additional metastatic spread to NSN were compared to 50 matched controls with micrometastases in sentinel node but without NSN metastases. Despite being prognostic markers in breast cancer, we found no significant differences in the expression of these three biochemical markers between patients with and without NSN metastases. Not all NSN metastases will become clinically relevant, making ALND redundant in many breast cancer patients. Accordingly, there is a trend towards omission of ALND in breast cancer patients with minimal metastatic disease in sentinel node. As a result, a tool is needed to identify a group of patients with high risk of recurrence, where ALND should still be offered. In our model a small group of patients with micrometastases had a high risk of NSN metastases on nearly 40%, comparable to patients with macrometastases, indicating that ALND may still be recommended in this subgroup in the future.Danish Medical Journal 07/2012; 59(7):B4475. · 1.07 Impact Factor
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ABSTRACT: Sentinel lymph node (SLN) dissection has been investigated after neoadjuvant chemotherapy and has shown mixed results. Our objective was to evaluate SLN dissection in node-positive patients and to determine whether postchemotherapy ultrasound could select patients for this technique. Between 1994 and 2010, 150 patients with biopsy proven axillary metastasis underwent SLN dissection after chemotherapy and 121 underwent axillary lymph node dissection (ALND). Clinicopathologic characteristics were analyzed before and after chemotherapy. Statistical analyses included Fisher's exact test for nodal response and multivariate logistic regression for factors associated with false-negative events. Median age was 52 years. Median tumor size at presentation was 2 cm. The SLN was identified in 93 % (139/150). In 111 patients in whom a SLN was identified and ALND performed, 15 patients had a false-negative SLN (20.8 %). In the 52 patients with normalized nodes on ultrasound, the false-negative rate decreased to 16.1 %. Multivariate analysis revealed smaller initial tumor size and fewer SLNs removed (<2) were associated with a false-negative SLN. There were 63 (42 %) patients with a pathologic complete response (pCR) in the nodes. Of those with normalized nodes on ultrasound, 38 (51 %) of 75 had a pCR. Only 25 (33 %) of 75 with persistent suspicious/malignant-appearing nodes had a pCR (p = 0.047). Approximately 42 % of patients have a pCR in the nodes after chemotherapy. Normalized morphology on ultrasound correlates with a higher pCR rate. SLN dissection in these patients is associated with a false-negative rate of 20.8 %. Removing fewer than two SLNs is associated with a higher false-negative rate.Annals of Surgical Oncology 07/2012; 19(10):3177-84. DOI:10.1245/s10434-012-2484-2 · 3.93 Impact Factor
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ABSTRACT: Surgical and systemic treatment modalities for breast cancer (BC) patients with micrometastatic disease in the sentinel lymph node biopsy (SNB) are controversial. The aim of this study was to evaluate decisional factors associated with assignment of adjuvant chemotherapy (CT). In a retrospective multicentric European study we evaluated cases of primary BC patients who underwent SNB. Logistic regression (LR) and recursive partitioning analyses (RPA) were performed to determine factors associated with CT. Of the 172 patients with micrometastatic disease, 39.5% received adjuvant CT. In the group treated with CT, patients tended to be younger (P = 0.001), with higher grade (P = 0.001) and HER2 positive tumors (P = 0.006) compared to patients without CT. In multivariate LR, age (P = 0.0027), high grading (P = 0.01) HER2 positivity (P = 0.03), and positive non-SN status (P = 0.03) were significantly associated with CT. RPA demonstrated that tumor grade, and not the non-SN status, was the first split in the partition tree followed by HER2 status, and non-SN status influencing the probability for CT administration. High tumor grade is the main decisional factor followed by HER2 positivity and then by the positive non-SN status for CT in micrometastatic disease in the SN. J. Surg. Oncol. 2012; 106:703-707. © 2012 Wiley Periodicals, Inc.Journal of Surgical Oncology 11/2012; 106(6):703-7. DOI:10.1002/jso.23188 · 3.24 Impact Factor
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