[Lani]

Some Breast Cancer Patients with Node-Positive Disease Derive No Significant Benefit from Axillary Lymph Node Dissection
[American College of Surgeons]
CHICAGO: A recent observational study of 97,000 women with breast cancer and nodal metastases indicates that there is no appreciable difference in axillary recurrence and survival between those who undergo sentinel lymph node (SLN) biopsy alone versus SLN biopsy with the more invasive completion axillary lymph node dissection (ALND). This new analysis from the National Cancer Data Base (NCDB) of the American College of Surgeons (ACS) was recently published online in the Journal of Clinical Oncologyand will appear in a print version of the journal within the next few weeks. The study's authors analyzed data from approximately 1,400 hospitals. These women with breast cancer underwent SLN biopsy for clinically node-negative breast cancer from 1998 to 2005 and were found to have nodal metastases. The authors found that some patients with lymph node metastases identified on sentinel node biopsy may not need to have the rest of their lymph nodes removed.
"In certain patients, particularly those with microscopic nodal metastases, one may not need to perform a completion axillary lymph node dissection. However in patients with more tumor burden in their lymph nodes—with macroscopic disease—completion ALND may provide a small benefit and potentially result in better outcomes," according to lead author Karl Bilimoria, MD, MS, who was an American College of Surgeons (ACS) Research Fellow at the time the analysis was performed, and is a surgical resident at the Feinberg School of Medicine, Northwestern University, Chicago, IL.
Despite these findings, many women with axillary nodal involvement confirmed via SLN biopsy still undergo completion ALND, cautioned coauthor David J. Winchester, MD, FACS, of Northwestern University Medical School. "The average physician out there may be overusing axillary lymph node dissection in many patients," Dr. Winchester explained. "We have relied upon that operation too much, and this paper points out we may not need to do it in terms of a survival difference or a regional recurrence difference. This is an operation associated with significant morbidity." Among the morbidities linked to ALND are a lifetime risk of lymphedema, problematic cosmetic outcomes, longer recovery times and more postoperative pain than SLN biopsy alone. The researchers detected a shift in practice patterns that made sense in light of their findings. "For microscopic nodal disease from 1998 to 2005, the proportion of patients undergoing SLN biopsy alone without a completion nodal dissection increased considerably, from about 25 percent to 45 percent, whereas for patients with more substantial nodal metastases, the macroscopic group, the proportion stayed fairly constant over the time course of the study," Dr. Bilimoria said. "This shift in practice patterns makes sense as physicians may have anecdotally found that completion nodal dissection is not necessary in all patients." The study findings along with conclusions from small institutional series and previous clinical trials can be interpreted together and potentially change how physicians counsel their patients. "These data allow clinicians to have a discussion with their patients, especially those with microscopic nodal metastases, whether a completion axillary lymph node dissection would be beneficial," Dr. Bilimoria concluded.
In addition to Drs. Bilimoria and Winchester, contributing authors were David J. Bentrem, MD, FACS,(Northwestern University); Nora M. Hansen, MD, FACS, (Northwestern University); Kevin P. Bethke, MD, FACS,(Northwestern University); Alfred W. Rademaker, PhD, (Northwestern University); Clifford Y. Ko, MD, FACS, (University of California at Los Angeles and VA Greater Los Angeles Healthcare System); David P. Winchester, MD, FACS, (North Shore University Health System).
EARLY VIEW: ABSTRACT: Comparison of Sentinel Lymph Node Biopsy Alone and Completion Axillary Lymph Node Dissection for Node-Positive Breast Cancer
[Journal of Clinical Oncology]
Purpose: For women with breast cancer, the role of completion axillary lymph node dissection (ALND) after identification of nodal metastases by sentinel lymph node biopsy (SLNB) has been questioned. Our objectives were to assess national nodal evaluation practice patterns and to examine differences in recurrence and survival for SLNB alone versus SLNB with completion ALND.
Patients and Methods: From the National Cancer Data Base (1998 to 2005), women with clinically node-negative breast cancer who underwent SLNB and who had nodal metastases were identified. Practice patterns and outcomes were examined for patients who underwent SLNB alone versus SLNB with completion ALND (median follow-up, 63 months).
Results: Of 97,314 patients, 20.8% underwent SLNB alone, and 79.2% underwent SLNB with completion ALND. In 2004 to 2005, patients were significantly more likely to undergo SLNB alone if they were older, had smaller tumors, or were treated at non-National Cancer Institute-designated cancer centers. In patients with macroscopic nodal metastases (n = 20,075 during 1998 to 2000), there was a nonsignificant trend toward better outcomes for completion ALND (v SLNB alone) after analysis was adjusted for differences between the two groups: axillary recurrence (hazard ratio [HR], 0.58; 95% CI, 0.32 to 1.06) and overall survival (HR, 0.89; 95% CI, 0.76 to 1.04). In patients with microscopic nodal metastases (n = 2,203 during 1998 to 2000), there were no significant differences in axillary recurrence or survival for patients who underwent SLNB alone versus completion ALND.
Conclusion: Compared with SLNB alone, completion ALND does not appear to improve outcomes for breast cancer patients with microscopic nodal metastases; however, there was a nonsignificant trend toward better outcomes with completion ALND for those with macroscopic disease.