Axillary Surgery for Early-Stage, Node-Positive Mastectomy Patients and the Use of Postmastectomy Chest Wall Radiation Therapy
We examined axillary surgery in mastectomy patients with tumor-positive nodes and how the type of axillary surgery impacted use of postmastectomy chest wall radiation therapy (PMRT).
Using the National Cancer Data Base, we selected patients with AJCC cT1/T2c N0 breast cancer with one to three tumor-positive lymph nodes treated between 2013 and 2014. Type of axillary surgery was analyzed using the FORDS scope of regional lymph node surgery variable. Multivariable logistic regression modeling was used to identify independent predictors associated with SNB alone and the use of PMRT.
Of 8089 patients, 2482 (30.7%) underwent SNB alone, 1339 (16.6%) underwent axillary dissection (ALND) alone, and 4268 (52.7%) underwent SNB followed by ALND. Fifty-seven percent of patients with micrometastases underwent SNB alone compared with 22.6% of patients with macrometastases. Independent predictors of SNB alone for patients with micrometastases were African American race, number of nodes positive, and PMRT. For patients with macrometastases, age, facility type and location, and PMRT were independent predictors for SNB alone. Of 2449 patients who underwent SNB alone, 1538 (62.8%) had no PMRT, 261 (10.7%) had PMRT alone, and 650 (26.5%) had PMRT with regional nodal irradiation. Patients undergoing SNB alone were 1.70 times [96% confidence interval (CI) 1.45–2.00] more likely to undergo PMRT than upfront ALND and 1.51 times (96% CI 1.34–1.71) more likely than SNB followed by ALND.
Surgeons are omitting completion ALND in a third of early-stage, node-positive mastectomy patients. SNB alone patients are more likely to undergo PMRT than patients undergoing ALND.
None to report.
The authors declare no conflicts of interest.
- 1.Gradishar WJ, Anderson BO. NCCN Guidelines Version 2.2017 Invasive Breast Cancer. National Comprehensive Cancer Network.2017. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.
- 3.Galimberti V, Cole BF, Zurrida S, Luini A, Veronesi P, Baratella P, Chifu, C, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013;14(4):297–305.CrossRefPubMedPubMedCentralGoogle Scholar
- 4.Solá M, Alberro JA, Fraile M, Santesteban P, Ramos M, Fabregas R, Moral A, et al. 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. Ann Surg Oncol. 2013;20(1):120–7.CrossRefPubMedGoogle Scholar
- 5.Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJ, Mansel RE, Cataliotti L, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014;15(12):1303–10.CrossRefPubMedPubMedCentralGoogle Scholar
- 6.Sávolt Á, Péley G, Polgár C, Udvarhelyi N, Runovszky G, Kovács E, Gyorffy B, et al. Eight-year follow up result of the OTOASOR trial: The optimal treatment of the axilla-surgery or radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer. A randomized, single centre, phase III, non-inferiority trial. Eur J Surg Oncol. 2017;43(4):672–9.CrossRefPubMedGoogle Scholar
- 7.National Comprehensive Cancer Guidelines Version 3.2017. https://www.nccn.org/professionals/physician_gls/PDF/breast.pdf.
- 13.Facility Oncology Registry Data Standards (FORDS), Commission on Cancer of the American College of Surgeons, Revised 2016.Google Scholar
- 14.U.S. Census. About race. Washington (DC): US Census Bureau; 2010. http://www.census.gov/topics/population/race/about.html.
- 15.National Cancer Data Base—Participate User File. 2015 http://ncdbpuf.facs.org.
- 17.American College of Surgeons. CoC accreditation categories. 2016. https://www.facs.org/quality%20programs/cancer/coc/apply.
- 18.US Census. Statistical Groupings of States and Counties. Washington (DC): US Census Bureau; 2010. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf.
- 19.AJCC Cancer Staging Manual. 7th edn. Chicago, IL: Springer; 2010.Google Scholar
- 22.Stauder MC, Caudle AS, Allen PK, Shaitelman SF, Smith BD, Hoffman KE, Buchholz TA, et al. Outcomes of post mastectomy radiation therapy in patients receiving axillary lymph node dissection after positive sentinel lymph node biopsy. Int J Rad Oncol. 2016;96(3):637–44.Google Scholar
- 26.Barco I, Chabrera C, García-Fernández A, Fraile M, González S, Canales L, Lain JM, et al. Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer. Clin Transl Oncol. 2017;19(6):704–10.CrossRefPubMedGoogle Scholar
- 27.Krag DN, Anderson SJ, Julian TB, Brown Am, Harlow AP, Ashikaga T, Weaver DL, et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 2007;8(10):881–8.CrossRefPubMedGoogle Scholar
- 29.Sturtz LA, Melley J, Mamula K, Shriver CD, Ellsworth RE. Outcome disparities in African American women with triple negative breast cancer: a comparison of epidemiological and molecular factors between African American and Caucasian women with triple-negative breast cancer. BMC Cancer. 2014;14:62.CrossRefPubMedPubMedCentralGoogle Scholar
- 33.de Boniface J, Frisell J, Andersson Y, Bergkvist L, Ahlgren J, Rydén L, Olofsson Bagge R, et al. Survival and axillary recurrence following sentinel node-positive breast cancer without completion axillary lymph node dissection: the randomized controlled SENOMAC trial. BMC Cancer. 2017;17(1):379.CrossRefPubMedPubMedCentralGoogle Scholar
- 36.van Roozendaal LM, Vane MLG, van Dalen T, van der Hage JA, Strobbe LJA, Boersma LJ, Linn SC, et al. Clinically node negative breast cancer patients undergoing breast conserving therapy, sentinel lymph node procedure versus follow-up: a Dutch randomized, controlled multicenter trial (BOOG 2013-08). BMC Cancer. 2017;17(1):459.CrossRefPubMedPubMedCentralGoogle Scholar