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ANZ Journal of Surgery, 2002
Background : The trend in breast cancer surgery is toward more conservative operative procedures. The new staging technique of sentinel node biopsy facilitates the identification of pathological node-negative patients in whom axillary dissection may be avoided. However, patients with a positive sentinel node biopsy would require a thorough examination of their nodal status. An axillary dissection provides good local control, and accurate staging and prognostic information to inform decisions about adjuvant therapy. In addition, the survival benefit of axillary treatment is still debated. The objectives of the present study were to examine the pattern of lymph node metastases in the axilla, and evaluate the merits of a level III axillary dissection. Methods : Between June 1997 and May 2000, 308 patients underwent a total of 320 level III dissections as part of their treatment for operable invasive breast cancer. The three axillary levels were marked intraoperatively, and the contents in each level were submitted and examined separately. The patterns of axillary lymph node (ALN) metastases were examined, and factors associated with ≥ 4 positive nodes, and level III ALN metastases were evaluated by univariate and multivariate analyses. Results : An average of 25 lymph nodes were examined per case (range: 8-54), and using strict anatomical criteria, the mean numbers of ALN found in levels I, II and III were 18 (range: 2-43), 4 (range: 0-19), and 3 (range: 0-11), respectively. Axillary lymph node involvement was found in 45% of the cases (143/320). Of the 143 cases, 78% (n = 111) had involvement of level I nodes only, and 21% (n = 30) had positive ALN in levels II and, or, III, in addition to level I. Involvement of lymph nodes in level II or III without a level I metastasis was found in two cases only (0.6%). By including level II, in addition to level I, in the dissection, four cases (1%) were converted from one to three positive nodes to ≥ 4 positive nodes (P = 0.64). By the inclusion of level III to a level I and II dissection, three cases (1%) were converted from one to three positive nodes to ≥ 4 positive nodes (P = 0.74). Involvement of lymph nodes in level III was found in 22 cases (7%), and 51 cases (16%) had ≥ 4 positive nodes. Palpability of ALN, pathological tumour size, and lymphovascular invasion (LVI), were significantly associated with level III involvement and ≥ 4 positive nodes by univariate and multivariate analyses. The frequencies of level III involvement and ≥ 4 positive nodes in patients with palpable ALN were 22% and 42%, respectively. The corresponding frequencies in patients with a clinically negative axilla, and a primary tumour which was >20 mm and LVI positive, were over 14% and 31%, respectively. Conclusion : Level III axillary dissection is appropriate for patients with palpable ALN, and in those with a tumour which is >20 mm and LVI positive, principally to reduce the risk of axillary recurrence. Staging accuracy is achieved with a level II dissection, or even a level I dissection alone based on strict anatomical criteria. Sentinel node biopsy is a promising technique in identifying pathological node-positive patients in whom an axillary clearance provides optimal local control and staging information.
Is Completion Axillary Dissection Necessary For This Patient?
The Journal of Breast Health, 2014
A 70-year-old female patient presents to the breast clinic for annual screening. She has no family history of breast cancer. Her physical examination is normal, however an area of 0.5cm in size located in the lower inner quadrant of the right breast has microcalcifications and the adjacent area of approximately 2cm shows structural distortion on mammography (BIRADS 5). The core biopsy reveales high grade, solid ductal carcinoma in situ that contains areas of comedo necrosis and invasive ductal carcinoma in one border. The estrogen receptor (ER) (+), progesterone receptor (PR) (-), Her 2 (-) and Ki-67 is reported as 12%. The patient undergoes segmental mastectomy with wire guide and sentinel lymph node biopsy (SLNB). A 1% isosulfane blue and gamma probe is used for the detection of SLN. One SLN that was not macroscopically suspicious is sent to the pathology department peroperatively, without a request for frozen section evaluation. The paraffin section examination shows a grade 3, ER (+), PR (-) and HER-neu2n (-) invazive tumor with a 2 cm integrity diameter. Lymphovascular invasion (LVI) is positive, and comedo necrosis that surrounds the invasive tumor and forms 15% of the tumor volume are determined, as well as a nuclear grade 3 ductal carcinoma in situ containing microcalcifications. The nearest margins to DCIS are 0.3cm at the medial and 0.2cm at the lateral borders, with negative surgical margins. The pathologic evaluation of the aferomentioned single lymph node shows an 8mm metastasis with 0.2 X 0.2 cm extracapsular extension by hematoxylin and eosin (H&E).
Position Statement on Management of the Axilla in Patients With Invasive Breast Cancer
Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) for the staging of clinically node-negative breast cancer patients, demonstrating equivalent survival to ALND for lymph node–negative patients 1 while resulting in reduced morbidity. 2 For the majority of patients with pathologically positive SLNs, completion ALND is recommended by the American Society of Clinical Oncology Guidelines and the National Comprehensive Cancer Network (NCCN). 3,4 However, recent data from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial suggest that ALND may be omitted in selected patients with 1 or 2 positive SLNs. 5,6 In the ACOSOG Z0011 trial, 813 patients with clinical T1-2 node-negative tumors who were found to have hematoxylin and eosin (H&E)-positive SLNs were randomized to ALND vs no further axillary surgery. Patients with palpable lymph nodes or clinical T3 tumors were not eligible for this study. The protocol mandated the use of standard whole-breast radiation without an axillary field. Patients with >3 positive SLNs were excluded from the study. The trial was closed early due to poor accrual with an enrollment of only 47% of the targeted 1900 patients. It still showed equivalent results between the 2 treatment arms for loco-regional failure and survival. At 6.3 years' follow-up, no differences were found between the 2 groups in the rates of axillary recurrence (0.5% vs 0.9%), in-breast recurrence (3.6% vs 1.9%), or overall locoregional recurrence (4.1% vs 2.8%, P = 0.53). 5 Disease-free and overall survival were similar (82.2% vs 83.8% and 91.9% vs 92.5%) between the groups. 6 The majority of women in this trial were older than 50 years (64%), had clinical T1 tumors (68%), had ER-positive tumors (77%), had only 1 positive SLN (60%), received whole-breast radiation (89%), and received systemic therapy (96%: 58% adjuvant chemotherapy and 46% adjuvant hormonal therapy). Forty percent of patients had micrometastases or isolated tumor cells and 60% had macrometastases in the sentinel nodes. Additional positive axillary nodes were found in 27.3% of the ALND patients. This study excluded patients undergoing mastectomy and patients receiving neoadjuvant chemotherapy.
Geburtshilfe und Frauenheilkunde, 2012
The prognosis of breast cancer is most heavily influenced by the status of the axillary nodes. Until a few years ago, this knowledge was gained through radical axillary lymph node clearance. In the meantime, sentinel lymph node clearance has become an established part of the surgical treatment of breast cancer. With the development of this procedure, the morbidity caused by axillary dissection has been reduced significantly. Although comprehensive prospective, randomised data regarding the safe use of the sentinel concept are only now available, the focus currently, however, is on the question of whether in the case of positive sentinel lymph nodes, an axillary dissection can be done away with altogether without having any negative impact on the risk of loco-regional recurrence or on progression-free survival and overall survival. The results of the American ACOSOG-Z001 study have changed the fundamental perspective of this. In this study on the advantages of axillary dissection following the confirmation of tumour tissue in the sentinel lymph nodes, there were no statistically significant advantages from axillary dissection for women with a favourable overall risk profile who had received radiotherapy and systemic therapy. If this concept takes hold, the surgical treatment of node-positive breast cancer, at least in the axilla, would be reduced to a minimum, and the focus of treatment would in future lie more on the systemic treatment of this condition. As part of an interdisciplinary consensus meeting, a standardised approach for Austria with regard to this question was decided upon. Zusammenfassung ! Die Prognose des Mammakarzinoms wird durch den axillären Lymphknotenstatus am stärksten beeinflusst. Dieses Wissen wurde noch bis vor wenigen Jahren durch die radikale axilläre Lymphonodektomie erlangt. Inzwischen ist die Sentinel-Lymphonodektomie etablierter Bestandteil in der operativen Behandlung des Mammakarzinoms geworden. Durch die Entwicklung dieses Verfahrens konnte die Morbidität, die durch eine axilläre Dissektion verursacht wird, wesentlich reduziert werden. Wenngleich erst jetzt umfassende prospektiv randomisierte Daten zur sicheren Anwendung des Sentinel-Konzepts vorliegen, geht es aktuell jedoch bereits um die Frage, ob bei positivem Sentinel-Lymphknoten auf eine Axilladissektion (AD) gänzlich verzichtet werden kann, ohne das Risiko für ein lokoregionäres Rezidiv oder das progressionsfreie Überleben und Gesamtüberleben negativ zu beeinflussen. Die Ergebnisse der amerikanischen ACOSOG-Z0011-Studie haben die grundlegende Betrachtungsweise verändert. In dieser Studie zum Vorteil der Axilladissektion nach Tumornachweis im Sentinel-Lymphknoten ergaben sich für die Patientinnen mit günstigem Gesamtrisikoprofil und applizierter Strahlentherapie und systemischer Therapie keine statistisch signifikanten Vorteile durch die Axilladissektion. Setzt sich dieses Konzept durch, wäre die operative Versorgung des nodalpositiven Mammakarzinoms zumindest in der Axilla auf ein Minimum reduziert und der Fokus der Behandlung läge zukünftig mehr in der systemischen Behandlung dieser Erkrankung. Im Rahmen eines interdisziplinären Konsensus-Meetings wurde eine einheitliche Vorgehensweise für Österreich diese Fragestellung betreffend beschlossen.
Breast Cancer Patients Treated Without Axillary Surgery
Annals of Surgery, 2000
Background: It has recently been reported that, using axillary reverse mapping (ARM), the lymphatics from the arm can be spared to reduce the incidence of breast-cancer-related lymphoedema (BCRL). The aim of this study was to assess the feasibility of selective axillary dissection (SAD) after using ARM and partially preserving arm drainage, and to assess the occurrence of BCRL. Methods: Using a radioisotope and lymphoscintigraphy, ARM was performed in 60 patients scheduled for SAD, who were subsequently divided for the purpose of comparing the BCRL rates into: group A, comprising 45 patients who successfully underwent SAD with a residual lymphatic hot spot; and group B with 15 whose hot nodes were removed as is normally the case during complete axillary lymph node dissection (ALND). Results: SAD was feasible in 75% of the 60 patients. SAD was completed successfully in 19 of the first 30 patients, and in 26 of the second 30 patients ( p ¼ 0.072). The median follow-up was 16 months (6e36), during which 9 patients developed a BCRL, 4 in group A (9%) and 5 in group B (33%); p ¼ 0.035. None of the patients had nodal relapses during the follow-up. Conclusions: Using a radioisotope enables an effective and safe SAD in a large proportion of patients. There was evidence of a trend to suggest a learning curve. The rate of BCRL after SAD was less than one third of the rate recorded after ALND, a result that should encourage the development of the former technique.