Sentinel Lymph Node Dissection Non-Inferior to Axillary Node


“Ten-year overall survival for primary breast cancer patients treated with sentinel lymph node dissection (SLND) alone is similar to that seen in those treated with axillary lymph node dissection (ALND), according to a study published in the Sept. 12 issue of the Journal of the American Medical Association.

“Armando E. Giuliano, M.D., from the Cedars-Sinai Medical Center in Los Angeles, and colleagues compared the 10-year overall survival of patients with  metastases treated with breast-conserving therapy and SLND alone without ALND (446 patients) versus women treated with ALND (445 patients). The women, with clinical T1 or T2 invasive , all had planned lumpectomy, tangential whole-breast irradiation, and adjuvant systemic therapy.”

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Targeted Axillary Dissection of Lymph Nodes after Chemotherapy Improves Staging Accuracy of Node-Positive Breast Cancer

“A new procedure developed by surgeons at The University of Texas MD Anderson Cancer Center improves the accuracy of axillary staging and pathologic evaluation in clinically node-positive breast cancer, and reduces the need for a more invasive procedure with debilitating complications.

“The research, published in the Journal of Clinical Oncology, has changed treatment guidelines at the institution for a select group of breast cancer patients with lymph node metastasis, who will now receive Targeted Axillary Dissection (TAD).

“The TAD procedure involves removing sentinel lymph nodes, as well as additional cancerous lymph nodes found during diagnosis. At the time of diagnosis, those select nodes are clipped for identification during later surgery.”

Unnecessary Lymph Node Dissections Are Frequently Performed for DCIS

“In a study reported in JAMA Oncology, Coromilas et al found that axillary lymph node evaluation is frequently performed in women with ductal carcinoma in situ (DCIS), and a number of hospital or surgeon characteristics are associated with likelihood of evaluation. As noted by the authors, benefit of axillary evaluation in this setting has not been demonstrated.

“The study involved cross-sectional analysis of medical records in the Perspective database for women with DCIS who underwent breast-conserving surgery or mastectomy from January 2006 to December 2012. A total of 35,591 women aged 18 to 90 years were included in the analysis.

“Overall, 9,011 women (25.3%) underwent mastectomy and 26,580 (74.7%) underwent breast-conserving surgery. Axillary evaluation was performed in 63.0% of those undergoing mastectomy and 17.7% of those undergoing breast-conserving surgery…

“The investigators concluded: ‘Despite guidelines recommending against axillary lymph node evaluation in women with DCIS undergoing [breast-conserving surgery] and uncertainty regarding its use with mastectomy, [sentinel lymph node biopsy] or [axillary lymph node dissection] is performed frequently. Given the additional morbidity and cost of these procedures, alternative surgical approaches or prospective evaluation of the clinical benefit of axillary evaluation in women with DCIS is needed.’ “

Axillary Lymph Node Evaluation Performed Frequently in Ductal Carcinoma in Situ

“Axillary lymph node evaluation is performed frequently in women with ductal carcinoma in situ breast cancer, despite recommendations generally against such an assessment procedure in women with localized cancer undergoing breast-conserving surgery, according to a study published online by JAMA Oncology.

“While axillary lymph node evaluation is the standard of care in the surgical management of invasive breast cancer, a benefit has not been demonstrated in ductal carcinoma in situ (DCIS). For women with invasive breast cancer, sentinel lymph node biopsy (SLNB) replaced full axillary lymph node dissection (ALND). The sentinel nodes are the first few lymph nodes into which a tumor drains.

“Guidelines published by the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend against axillary evaluation in women undergoing breast-conserving surgery (BCS). If invasive cancer were to be discovered SLNB could be performed at a later date. But because a total mastectomy precludes future SLNB, the guidelines suggest SLNB may be appropriate for some high-risk patients because axillary evaluation would be indicated if invasive cancer was found, according to background in the study.”

Axillary Radiotherapy Reduced Morbidity in Breast Cancer with Positive Sentinel Node

The gist: Some women with breast cancer have some cancer cells in the sentinel lymph node. The standard treatment for a positive sentinel node is a surgery called axillary lymph node dissection. However, that procedure is associated with some harmful side effects. Recent research shows that an alternative treatment called axillary radiotherapy might be just as effective, with fewer side effects.

“Axillary radiotherapy and axillary lymph node dissection achieved similar rates of regional control in patients with breast cancer who have a positive sentinel node, according to results of a randomized phase 3 trial.

“However, radiotherapy was associated with significantly less morbidity.

“Axillary lymph node dissection has been the standard treatment for patients with breast cancer who have a positive sentinel node. Dissection provides excellent control but also is associated with harmful side effects, according to background information provided by researchers.

“In the current multicenter, open-label study, Mila Donker, MD, of the department of surgical oncology at Netherlands Cancer Institute, and colleagues assessed whether axillary radiotherapy provided comparable regional control with fewer side effects.”

Skipping ALND in Some Early Breast Cancers Is Criticized

“The American Society of Clinical Oncology’s (ASCO’s) new recommendation that that some women with early-stage breast cancer and minimal lymph node involvement can forgo extensive lymph node surgery has been questioned separately by two sets of clinicians.

“The guidelines were originally published in May 1 in the Journal of Clinical Oncology (JCO), the flagship journal of ASCO.

“Now, in letters to the journal published on September 22, critics are saying that there is not enough evidence to support the recommendation.

“But the investigators of the trial on which the recommendation is based argue back, saying it is time to skip the surgery in certain patients.”

Counseling Needed to Allay Fear of Lymphedema in Breast Cancer Survivors

“Individualized education and counseling should begin before surgery and continue throughout treatment for breast cancer survivors fearful of developing lymphedema, especially younger patients and those at higher risk after axillary lymph node dissection (ALND), a recent study found.

“More than 300 patients undergoing treatment for unilateral breast cancer were screened for lymphedema before and every 3 to 8 months after surgery and asked to fill out questionnaires assessing their fear. Higher preoperative fear score, age younger than 50 at diagnosis, and ALND were significantly associated with higher mean postoperative fear scores. The findings were published in the September issue of Oncology Nursing Forum.

“ ‘If and when fear of lymphedema is identified, nurses should evaluate whether that fear generates appropriate proactive behavior to prevent lymphedema or whether it negatively affects the survivor’s physical or mental state,’ the authors wrote. ‘In the latter case, such fear should alert nurses to counsel, educate, reassure, support, and reassess the patient on an ongoing basis.’

“The findings indicate that lymphedema—characterized by abnormal accumulation of fluid in the interstitial spaces of the arm, hand, shoulder, breast, or chest wall—is  distressing to many women regardless of whether or not they develop the condition, the authors said. In addition to physical symptoms such as swelling, heaviness and discomfort, and an increased risk of infection, many women experience psychological distress leading to poor body image, lower self-esteem, and increased anxiety.”

Adjuvant Paclitaxel Not Equivalent to Doxorubicin/Cyclophosphamide in Breast Cancer With 0 to 3 Positive Axillary Nodes

“In the phase III Cancer and Leukemia Group B (CALGB) 40101/Alliance trial reported in the Journal of Clinical Oncology, Shulman et al found that noninferiority of adjuvant single-agent paclitaxel was not established vs doxorubicin/cyclophosphamide for relapse-free survival in women with operable breast cancer with 0 to 3 positive nodes. Paclitaxel was less toxic than doxorubicin/cyclophosphamide.”

Editor’s note: A recent study found that treatment with the drug paclitaxel was no better than a combination of doxorubicin and cyclophosphamide for breast cancer patients who had 0-3 positive axillary nodes (i.e. cancer cells were found in 0-3 lymph nodes; cancer cells in lymph nodes can be used to predict the risk of metastatic breast cancer).

ASCO Guidelines Support Sentinel Node Biopsy for Early-Stage Breast Cancer

“New guidelines supporting the broader use of sentinel lymph node biopsy in women with early-stage breast cancer have been issued by the American Society of Clinical Oncology (ASCO). The guidelines were published in the Journal of Clinical Oncology.

“ASCO recommends the use of sentinel node biopsy in most patients, rather than the more invasive axillary lymph node dissection, which is linked to a higher risk of complications.”