Omission of Axillary Dissection after a Positive Sentinel Node Dissection may Influence Adjuvant Chemotherapy Indications in Operable Breast Cancer Patients
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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).
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.
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.
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 receptor-positive/HER2-negative tumors. All implications should be taken into account before abandoning AD, including a possible biologically tailored surgical approach.
KeywordsAxillary Dissection Axillary Dissection Ipsilateral Breast Tumor Recurrence Sentinel Lymph Node Dissection Completion Axillary Dissection
- 1.Goldhirsch A, Wood WC, Coates AS, Gelber RD, Thurlimann B, Senn HJ. Strategies for subtypes–dealing with the diversity of breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2011. Ann Oncol. 2011;22:1736–47.Google Scholar
- 4.Fleissig A, Fallowfield LJ, Langridge CI, et al. Postoperative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat. 2006;95:279–93.PubMedCrossRefGoogle Scholar
- 7.Stuart A. A test for homogeneity of the marginal distributions in a two-way classification. Biometrika. 1956;42:412–6.Google Scholar
- 10.Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11:927–33.PubMedCrossRefGoogle Scholar
- 13.van la Parra RF, Peer PG, Ernst MF, Bosscha K. Meta-analysis of predictive factors for non-sentinel lymph node metastases in breast cancer patients with a positive SLN. Eur J Surg Oncol. 2011;37:290–9.Google Scholar
- 15.Galimberti V, Cole BF, Zurrida S, et al. Update of the International Breast Cancer Study Group trial 23-01 to compare axillary dissection versus no axillary dissection in patients with clinically node negative breast cancer and micrometastases in the sentinel node. Cancer Res. 2011;71:34 s (Abstract S3-1).Google Scholar
- 18.Wang Z, Wu LC, Chen JQ. Sentinel lymph node biopsy compared with axillary lymph node dissection in early breast cancer: a meta-analysis. Breast Cancer Res Treat. 2011;129:675–89.Google Scholar
- 26.Albain KS, Barlow WE, Shak S, et al. Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal women with node-positive, oestrogen-receptor-positive breast cancer on chemotherapy: a retrospective analysis of a randomised trial. Lancet Oncol. 2010;11:55–65.PubMedCrossRefGoogle Scholar
- 28.Prat A, Parker JS, Fan C, Cheang MC, Milled LD, Bergh J, Chia SK, Bernard PS, Nielsen TO, Ellis MJ, Carey LA, Perou CM. Concordance among gene expression-based predictors for ER-positive breast cancer treated with adjuvant tamoxifen. Proc Am Soc Clin Oncol. 2011;29(15s), 45s (Abstract 502).Google Scholar