Routine axillary lymph node dissection (ALND) after selective sentinel lymphadenectomy (SSL) in the treatment of breast cancer remains controversial. We sought to determine the need for routine ALND by exploring the relationship between sentinel lymph node (SLN) and non-SLN (NSLN) status. We also report our experience with disease relapse in the era of SSL and attempt to correlate this with SLN tumor burden.
This was a retrospective study of 390 patients with invasive breast cancer treated at a single institution who underwent successful SSL from November 1997 to November 2002.
Of the 390 patients, 115 received both SSL and ALND. The percentage of additional positive NSLNs in the SLN-positive group (34.2%) was significantly higher than in the SLN-negative group (5.1%; P = .0004). The SLN macrometastasis group had a significantly higher rate of positive NSLNs (39.7%) compared with the SLN-negative group (5.1%; P = .0001). Sixteen patients developed recurrences during follow-up, including 6.1% of SLN-positive and 3.3% of SLN-negative patients. Among the SLN macrometastasis group, 8.7% had recurrence, compared with 2.2% of SLN micrometastases over a median follow-up period of 31.1 months. One regional failure developed out of 38 SLN-positive patients who did not undergo ALND.
ALND is recommended for patients with SLN macrometastasis because of a significantly higher incidence of positive NSLNs. Higher recurrence rates are also seen in these patients. However, the role of routine ALND in patients with a low SLN tumor burden remains to be further determined by prospective randomized trials.
"The latter was observed in a study with only 14 patients. In case of macrometastatic disease in the sentinel node, 6 studies reported that patients had been treated with axillary radiotherapy in 2–63 % of the patients.14,16,19,29,35,40 In the majority of patients who developed an axillary recurrence (n = 24) details regarding the type of surgery of the primary tumor were lacking. "
[Show abstract][Hide abstract] 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.
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.
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.
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.
"Results of studies in which patients with micrometastases in SNB and who were not treated by completion axillary node clearance are summarised in Table 3 [38, 48–54]. Most of the studies had small numbers and relatively short followup and tended to conclude that there was no benefit from completion axillary node clearance. "
[Show abstract][Hide abstract] ABSTRACT: Sentinel lymph node biopsy (SLNB) is a safe and accurate minimally invasive method for detecting axillary lymph node (ALN) involvement in the clinically negative axilla thereby reducing morbidity in patients who avoid unnecessary axillary lymph node dissection (ALND). Although current guidelines recommend completion ALND when macro- and micrometastatic diseases are identified by SLNB, the benefit of this surgical intervention is under debate. Additionally, the management of the axilla in the presence of isolated tumour cells (ITCs) in SLNB is questioned. Particularly controversial is the prognostic significance of minimal SLNB metastasis in relation to local recurrence and overall survival. Preliminary results of the recently published Z0011 trial suggest similar outcomes after SNB or ALND when the SN is positive, but this finding has to be interpreted with caution.
"Thus, we cannot compare these studies with the MIRROR study, which involved a detailed examination of the SN. The few previous studies of SNs were limited by small samples, lack of multivariate analyses, or short followup [26–28]. "
[Show abstract][Hide abstract] ABSTRACT: Most cancer centers now perform sentinel node (SN) biopsies. The limited number of SNs sampled compared with an axillary dissection has allowed more comprehensive lymph node analysis resulting in increased detection of micrometastases. Many node-negative cases are now reclassified as micrometastatic. Recent research on SN biopsy focuses on whether axillary dissection is always necessary when the SN is positive. Some subgroups of patients have a higher risk of more nodal metastases when completion axillary dissections were performed. This paper summarizes the different studies and examines what are the clinically relevant items to report on SN node pathology: volume or size of nodal metastasis, location within the node, extranodal extension, number of involved SN(s) and non-SN(s), total number of SN, and total number of nodes on axillary dissection, if performed.
Pathology Research International 03/2011; 2011:504940. DOI:10.4061/2011/504940
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