Omission of Axillary Dissection after a Positive Sentinel Node Dissection may Influence Adjuvant Chemotherapy Indications in Operable Breast Cancer Patients

Abstract

Background. This study was designed to evaluate how the omission of axillary dissection would have altered the indication for adjuvant chemotherapy (ACT) in patients with early breast cancer submitted to conservative surgery with one or two positive sentinel lymph nodes (SLNs). Methods. We identified 321 women in our institutional database who fulfilled the characteristics. All underwent completion axillary lymph node dissection (AD). Each case was blindly reviewed by our breast team in two rounds, and the total number of positive lymph nodes was disclosed only in the second. At each round, the panel chose between: (1) recommend, (2) discuss, (3) do not recommend ACT. Changes between round 1 and 2 were studied by the marginal homogeneity test. Exploratory logistic regression analyses were performed to study predictors of non-SLN involvement and of changes in the indication for ACT. Results. AD revealed non-SLNs metastases in 96 patients (30 %). Fifty-two patients (16 %) had their initial indication changed at round 2 (p \ 0.001). Most of the changes were toward ACT (83 %), and all except two occurred in patients with immunohistochemically defined luminal A and luminal B/HER2-negative tumors. In these two subgroups, a Ki67 above the median value (21 %) was the only independent predictor of no change in the indication to ACT at round 2.Conclusions. Omission of AD in patients with one or two positive SLNs may change the indication to ACT in a significant proportion of patients with hormone receptorpositive/HER2-negative tumors. All implications should be taken into account before abandoning AD, including a possible biologically tailored surgical approach.Axillary dissection (AD) has long been considered a staging procedure in patients with operable breast cancer. In fact, lymph-nodal spread identifies patients who have increased risk of locoregional and/or distant recurrence and, ultimately, breast cancer-related death after surgery. As a consequence, axillary lymph-nodal involvement has been regarded as one of the pivotal elements in the decision making regarding the indication for subsequent postsurgical treatments, such as radiation therapy, hormonal therapy, and adjuvant chemotherapy (ACT). For example, with a very few exceptions, extensive lymph-nodal involvement (C3 involved nodes) is considered an indication to ACT regardless of the biological breast cancer subset. 1,2 Sentinel lymph node dissection (SLND) with no further axillary surgery if no metastases are identified has allowed a significant reduction in the morbidities that are associated with systematic AD. 3,4 Until recently, this procedure has been indicated for all patients with macro and micro-metastases in the sentinel Electronic supplementary material The online version of this article (

Role of patient and tumor characteristics in sentinel lymph node metastasis in patients with luminal early breast cancer: an observational study

“…The results presented herein may be useful for managing select groups of patients who, due to comorbidities or refusal, have avoided surgical interventions in the axilla. Knowledge of axillary status may influence oncologists in selecting and prescribing adjuvant systemic therapy (Montemurro et al 2012 ).Thus, the information provided by our study may be used to inform treatment decisions; e.g., in discussing with patients the benefits of adjuvant chemotherapy in cases of luminal breast cancer with LVI, irrespective of axillary status.…”

Axillary Sentinel Lymph Nodes in Breast Cancer: Quantitative Evaluation at Dual-Energy CT

“…C, Contrast-enhanced 70-keV monochromatic image and iodine-based pseudo-colorized image (inset) of a metastatic lymph node (L2 area, 52.85 mm 2 ; iodine concentration, 2.95 mg/cm 3 ). D, Contrast-enhanced 70-keV monochromatic image and iodine-based pseudo-colorized image (inset) of a nonmetastatic lymph node (L3 area, 9.15 mm 2 ; iodine concentration, 1.98 mg/cm3 ). E, Graph shows the spectral Hounsfield unit curve of metastatic (L2, red) and nonmetastatic (L3, yellow) lymph nodes.…”

Axillary Lymph Node Biopsy in Newly Diagnosed Invasive Breast Cancer: Comparative Accuracy of Fine-Needle Aspiration Biopsy versus Core-Needle Biopsy

“…xillary lymph node (LN) dissection (ALND) is associated with considerable morbidity that negatively affects patients' quality of life and has no benefit in terms of the overall survival rate. Axillary nodal status remains a major prognostic factor and might influence treatment options (1)(2)(3). The current standard of care for staging the axilla is sentinel LN biopsy (SLNB), and typically, only patients with LNs positive for metastasis require further care, eliminating the need for routine ALND (2,4).…”