Axillary Dissection Can Be Avoided in the Majority of Clinically Node-Negative Patients Undergoing Breast-Conserving Therapy

Abstract

Background or Purpose The extent to which ACOSOG Z0011 findings are applicable to patients undergoing breast-conserving therapy (BCT) is uncertain. We prospectively assessed how often axillary dissection (ALND) was avoided in an unselected, consecutive patient cohort meeting Z0011 eligibility criteria and whether subgroups requiring ALND could be identified preoperatively. Methods Patients with cT1,2cN0 breast cancer undergoing BCT were managed without ALND for metastases in <3 sentinel nodes (SNs) and no gross extracapsular extension (ECE). Patients with and without indications for ALND were compared using Fisher's exact and Wilcoxon rank sum tests. Results From 8/2010-11/2012, 2157 invasive cancer patients had BCT. 380 had histologic nodal metastasis; 93 did not meet Z0011 criteria. Of 287 with ≥1 H&E-positive SN (209 macrometastases), 242(84%) had indications for SN only. ALND was indicated in 45 for ≥3 positive SNs (n=29) or ECE (n=16). The median number of SNs removed in the SN group was 3 versus 5 in the ALND group (p<.0001). Age, hormone receptor and HER2 status, and grade did not differ between groups; tumors were larger in the ALND group (p<0.0001). 72% of ALND patients had additional positive nodes (median=1;1-19). No axillary recurrences have occurred (median follow-up, 13 months). Conclusions ALND was avoided in 84% of a consecutive series of patients having BCT, suggesting that most patients meeting ACOSOG Z0011 eligibility have a low axillary tumor burden. Age, ER, and HER2 status were not predictive of ALND, and the criteria used for ALND (≥3SNs, ECE) reliably identified patients at high risk for residual axillary disease.

Does Conservative Surgery for Breast Carcinoma Still Require Axillary Lymph Node Evaluation? A Retrospective Analysis of 1156 Consecutive Women With Early Breast Cancer

“…Dengel et al, 17 in a prospective study designed to determine how often ALND can be avoided in patients meeting ACOSOG Z0011 eligibility criteria, reported that 84% of patients, not selected on the basis of age, tumor characteristics, axillary imaging, or nomogram predictions, were found to have metastases in 2 axillary nodes, thus suggesting that these patients had a low axillary tumor burden.…”

Lymph Node Surgery - Stepwise Retirement for the Breast Surgeon?

“…The inclusion of patients with more than 2 positive SLN will add valuable evidence to clinical practice, since these patients were excluded from Z0011. A prospective study of a consecutive cohort of patients who met the Z0011 criteria at the time of initial surgery at the Memorial Sloan-Kettering Cancer Center showed that 29 of 287 patients (10.1%) underwent completion ALND for ≥3 positive SLNs [24.] On the other hand, the randomization of patients with isolated tumor cells or micrometastases into the ALND arm is nowadays considered overtreatment by many, at the latest since the publication of IBCSG 23-01 [9.]…”

General St. Gallen-2015 guidelines for the treatment of early breast cancer (adapted by the experts of the Russian Society of Breast Oncologists)

“…Этот вывод применим независимо от характеристик опухоли, таких как дольковый гистотип рака, обширный внутрипротоковый компонент, молодой возраст или неблагоприятный биологический подтип [6]. Как было показано в ряде крупных исследований, у женщин с опухолями T1-2 и клинически негативны-ми ЛУ (cN0) отказ от подмышечной лимфаденэктомии при наличии макрометастазов в 1 или 2 ЛУ [30,31] оказался безопасным [32]. В большом популяционном исследовании в США, включавшем более 200 тыс.…”