Routine Use of Axillary Dissection in Treatment of Breast Cancer Questioned

Routine use of completion axillary lymph node dissection (ALND) is not needed in women with breast cancer who have only 1 or 2 positive sentinel lymph nodes, since it does not improve survival, claims a new study.

Researchers at the John Wayne Cancer Institute Breast Center (JWCI; Santa Monica, CA, USA) conducted a trial that involved 856 women with clinical stage I disease and one or two positive sentinel lymph nodes. All patients were treated with lumpectomy and opposing tangential field irradiation, with adjuvant systemic therapy administered at the discretion of their physicians. All women received a sentinel lymph node dissection (SLND) and they were found to have at least one positive node. They were then randomized to either no further treatment (436 patients) or ALND (420 patients). Overall survival (OS), disease-free survival (DFS), and locoregional control were then evaluated.

The results showed that at eight years, there was no significant difference in overall survival between patients treated with SLND alone (92.5%) and those treated with completion ALND (91.8%). There was also no significant difference in disease-free survival between patients treated with SLND (83.9%) and those treated with ALND (82.2%). Only older age, estrogen-receptor-negative disease, and lack of adjuvant systemic therapy (not the type of surgery) were found to be statistically significantly associated with worse overall survival on multivariable analysis. The study was presented at the American Society of Clinical Oncology (ASCO) annual meeting, held during June 2010 in Chicago (IL, USA).

"Since we have always done axillary dissection, it's hard to abandon it,” said lead author and study presenter Armando Giuliano, M.D., director of the JWCI. "The fact that axillary dissection is not needed in women who have positive sentinel nodes is counterintuitive and hard to accept, because it means not removing all the cancer.”

"The role of this operation needs to be reconsidered,” stressed Dr. Giuliano. "We have to selectively avoid doing completion axillary lymph node dissections.”

Sentinel node biopsy (SNB) eliminates the need for ALND in patients whose sentinel node is tumor-free. However, completion ALND remains the gold standard for patients with a tumor-involved sentinel node, since ALND achieves regional control. Its effect on survival, however, remains controversial.

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John Wayne Cancer Institute Breast Center