A Randomized Trial Comparing Axillary Dissection to No Axillary Dissection in Older Patients With T1N0 Breast Cancer

Abstract

Older patients with T1N0 breast cancer can be treated by conservative breast surgery and no axillary dissection without adversely affecting breast cancer mortality or overall survival. The very low cumulative incidence of axillary events suggests that even sentinel node biopsy is unnecessary in these patients. Axillary dissection should be reserved for the small proportion of patients who later develop overt axillary disease.

Is Axillary Dissection Necessary for Breast Cancer in Old Women? A Meta-analysis of Randomized Clinical Trials

“…We identified 2133 potentially relevant articles in the primary literature search (Figure 1), three RCTs (Martelli et al, 2005;IBCSG et al, 2006;Krag et al, 2010) that met the inclusion criteria and included a total of 5,337 old woman with breast cancer and were published in English. The basic characteristic of the studies included cases, tumor size, ER status, follow-up period, interventions and outcomes (Table 1).…”

Early Breast Cancer in the Older Woman

“…Whether sentinel node-positive disease is then treated with full surgical dissection or primary radiotherapy appears to be center specific, and no clear guidelines exist for this in the elderly population [4]. Finally, one study illustrated that older women aged 65-80 with clinically small, lymph node negative (T1N0) tumors may not require even sentinel lymph node biopsy; patients in that trial were randomized to breast surgery with or without axillary dissection and there was no difference in survival between the two groups at 60 months, and Ͻ2% of patients in the no axillary dissection arm developed axillary disease [15]. It is important to note, however, that most patients in that study had other favorable tumor characteristics (low grade, strongly hormone sensitive).…”

Axillary lymph node management in breast cancer with positive sentinel lymph node biopsy

“…These patients are spared the adverse effects of ALND without adverse oncologic outcome in the short term. Nevertheless even these studies suggest that axillary recurrences are much more frequent (up to three times) if no axillary intervention is undertaken, although low in absolute numbers [15,16] . In addition another study with the same design that included younger patients (mean age 62 years old) showed a statistically significant worse overall and disease-free survival in patients with no axillary intervention as compared with the group that underwent ALND [17] .…”

“…For example in a small study of 47 patients with positive SLN (33 with micrometastases only) and a low risk of 11.5% of additional LN positivity by the MSKCC model two patients (4.2%) had an axillary recurrence [14] . On the other hand, as studies performed before the routine introduction of SLN biopsy that compare ALND with no dissection in older patients (mean age over 70 years old) with small primaries (mostly T1a and T1b), ER positive and clinically negative axilla have shown, most patients with a predicted low burden axillary disease will not have a clinically apparent axillary recurrence even if left untreated [15,16] . These patients are spared the adverse effects of ALND without adverse oncologic outcome in the short term.…”

“…In this study patients were mostly ER positive and had a low incidence of 21% of positive nodes in the ALND and similar axillary disease positivity could be expected to have been present in the radiation arm. [7] The main randomized trial informing the clinical question IBCSG 23-01 [8] Randomized trial in patients with micrometastatic only axillary disease Yegiyants et al [14] Small study of patients followed after micrometastases found in SLN biopsy Martelli et al [15] Randomized trial comparing ALND vs no surgery in older patients IBCSG Trial 10-93 [16] Similar to reference 15 Avril et al [17] Similar to references 15 and 16 but in a younger patient population Louis-Sylvestre et al [19] Randomized trial comparing ALND with axillary radiation treatment Wang et al [21] Retrospective SEER-based study in patients with lobular carcinomas SLN: Sentinel lymph node; ALND: Axillary lymph node dissection; SEER: Surveillance, Epidemiology and End Results.…”