Complete Axillary Lymph Node Dissection Versus Clinical Follow-up in Breast Cancer Patients with Sentinel Node Micrometastasis: Final Results from the Multicenter Clinical Trial AATRM 048/13/2000

Abstract

Our results strongly suggest that in early breast cancer patients with SN micrometastasis, selective SN lymphadenectomy suffices to control locoregional and distant disease, with no significant effects on survival.

Current issues in breast surgery

“…The involvement of NSLNs is influenced by several factors among which the size / degree of the SLN involvement is one of the most important. Low-volume SLN metastases of the micrometastatic category are associated with NSLN positivity in 10-15% of the cases [120], a proportion which is confirmed by the data of recent clinical trials [27][28][29], but as highlighted in the introduction, depending on the combination of several factors, this may double or triple in a minority of patients [35][36][37][38]. In this respect, ITCs do not seem much better, as on average, they are suggested to be associated with NSLN involvement in about 12% of the cases according to a meta-analysis [121].…”

“…It is even evident that further lymph node involvement does not manifest itself in recurrent disease in the majority of patients, provided adjuvant therapies are used according to current standards [26][27][28][29]. Therefore, omission of ALND has been a trend in at least a subset of SLNpositive patients for several years, even before the publication of the results of the American College of Surgeons Oncology Group (ACOSOG) trial Z-0011 [30][31][32].…”

“…The axilla was clinically positive in two cases. Preoperative AXUS 28 was used in 5 patients (55 %) and it showed pathologic lymph nodes in 2 cases. There was no axillary metastasis in 3 cases (33 %).…”

Management of the positive axilla in 2017

“…This difference was statistically significant, but clinically not significant. The IBCSG 23-01 and the Spanish AATRM studies prospectively compared completion of AD with SLNB alone in the treatment of patients with micrometastasis and found equivalent results (five-year DFS 87.8% in the "No AD" group vs. 84.4% in the AD group, p = 0.16 in the IBCSG 23-01 trial; one percent recurrence rate in the AD group vs. 2.5% in the "No AD" group, p = 0.325 after five-year follow-up in the AATRM trial) [15][16]. It was recommended by the authors not to implement multiple sectioning and IHC staining methods in the routine examination of sentinel lymph nodes (SLN), since detection of micrometastasis and ITC did not impact the treatment outcomes.…”

Prognostic impact of macrometastasis linear size in sentinel node biopsy for breast carcinoma

“…The results of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial published by Giuliano et al, 15 even if subject to criticisms, 16 have significantly changed the practice of axillary treatment in breast cancer, and have initiated a large scale validation study, the POSNOC (POsitive Sentinel NOdeadjuvant therapy alone versus adjuvant therapy plus Clearance or axillary radiotherapy) trial which aims to overcome the criticized aspects of the ACOSOG Z0011 trial. 17 Two other randomized trials also support the omission of ALND in cases of SN Mic-m. 18,19 Therefore, recently published guidelines, accept that ALND can be avoided in patients with early stage breast cancer and Mic-m, when matching the selection criteria of the Z0011 trial. 1,2 Avoiding ALND in appropriately selected patients is expected to harbour no or very limited tumour burden in the axilla and greatly reduces the risk of local complications, leading to a better quality of life for patients without increasing the risk of disease recurrence.…”