The Need for Axillary Dissection in Patients with Positive Axillary Sentinel Lymph Nodes

Abstract

The need for completion axillary dissection after a positive sentinel node biopsy continues to be challenged. In the 2 years since we last reviewed this subject, a number of authors have shared their experiences about micrometastatic disease and isolated tumor cells, opining both for and against axillary treatment. Data from the ACOSOG Z0011 trial and other small studies do not appear to support the use of completion axillary dissection even for macro-metastatic disease in patients with clinically node-negative (N0) disease. While existing guidelines still recommend axillary dissection for patients with clinically positive nodes, even when conversion to clinically negative disease following neoadjuvant chemotherapy has occurred, this concept is being questioned in ACOSOG Z1071 and in several other recent small trials. The surgical approach to the treatment of breast cancer continues to move away from the traditional Halstedian concept.

Performance characteristics of ultrasound‐guided fine‐needle aspiration of axillary lymph nodes for metastatic breast cancer employing rapid on‐site evaluation of adequacy: Analysis of 136 cases and review of the literature

“…Surgical excision of lymph nodes is associated with multiple sequelae, such as lymphedema, pain, joint dysfunction, and numbness. Although sentinel lymph node biopsy has fewer sequelae, it still has a significant association with lymphedema . In addition, sentinel lymph node biopsy increases the complexity and cost of the surgical procedure and, in some patients, necessitates a second surgery for a completion axillary dissection.…”

Risk of non-sentinel node metastases in patients with symptomatic cancers compared to screen-detected breast cancers

“…Until recently, ALND has been recommended to all sentinel node positive breast cancer patients. However, the results from a randomized trial from American College of Surgeons Oncology Group (ACOSOG) (Z0011) have put the benefit from ALND in sentinel node positive patients under debate [1,2]. In the trial on patients undergoing breast conserving surgery, there were no difference in axillary recurrence rate or survival between patients with up to two positive sentinel nodes with or without ALND.…”

The positive non‐sentinel status is not the main decisional factor for chemotherapy assignment in breast cancer with micrometastatic disease in the sentinel lymph node

“…The improvement in the characterization of LN metastasis currently raises the question of its prognostic significance. Recently, some major studies have shown contrasting results on the prognosis of micrometastasis on overall survival with or without adjuvant chemotherapy 5–7. Adjuvant systemic chemotherapy (CT) may reduce the risk of relapse and may improve survival 8.…”