for those newly diagnosed--STANDARD of care about to change-old dogma being discarded

[Lani]

Perhaps you will not have to undergo an extensive axillary lymph node dissection if your sentinel lymph node is found to be positive, this decreasing your risk of developing chronic pain, lymphedema and restriction of shoulder motion:


Limited lymph node removal for certain breast cancer does not appear to result in poorer survival

CHICAGO – Among patients with early-stage breast cancer that had spread to a nearby lymph node and who received treatment that included lumpectomy and radiation therapy, women who just had the sentinel lymph node removed (the first lymph node to which cancer is likely to spread from the primary tumor) did not have worse survival than women who had more extensive axillary lymph node dissection (surgery to remove lymph nodes found in the armpit), according to a study in the February 9 issue of JAMA.

Axillary lymph node dissection (ALND) has been part of breast cancer surgery since the use of radical mastectomy and reliably identifies nodal metastases. "Sentinel lymph node dissection (SLND) accurately identifies nodal metastasis of early breast cancer, but it is not clear whether further nodal dissection [removal] affects survival," the authors write. "ALND, as a means for achieving local disease control, carries an indisputable and often unacceptable risk of complications such as seroma [a mass or swelling caused by the localized accumulation of serum within a tissue or organ], infection, and lymphedema [condition in which excess fluid called lymph collects in tissues and causes swelling]."

Armando E. Giuliano, M.D., of the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, Calif., and colleagues conducted a study to determine the effects of ALND on overall survival in patients with SLN metastases treated with lumpectomy (surgical removal of a tumor without removing much of the surrounding tissue or lymph nodes) and radiation therapy. The trial was conducted at 115 sites and enrolled patients from May 1999 to December 2004. Patients were women with T1-T2 (stage of tumor) invasive breast cancer, no palpable adenopathy (enlarged lymph nodes), and 1 to 2 SLNs containing metastases.

Patients with SLN metastases identified by SLND were randomized to undergo ALND or no further axillary treatment. Those randomized to ALND underwent dissection of 10 or more nodes. Of 891 patients, 445 were randomly assigned to the ALND group and 446 to the SLND-alone group.

As expected, there was a difference between ALND and SLND-alone treatment groups in total number of removed lymph nodes and total number of tumor-involved nodes; the median (midpoint) total number of nodes removed was 17 in the ALND group and 2 in the SLND-alone group. At a median follow-up of 6.3 years, there were 94 deaths (SLND-alone group, 42; ALND group, 52). The use of SLND alone compared with ALND did not appear to result in statistically inferior survival, with the 5-year over all survival rates being 92.5 percent in the SLND-alone group and 91.8 percent in the ALND group. Disease-free survival did not differ significantly between treatment groups, with 5-year disease-free survival being 83.9 percent for the SLND-alone group and 82.2 percent for the ALND group.

The rate of wound infections, axillary seromas, and paresthesias (prickly, tingling sensations) among patients in the trial was higher for the ALND group than for the SLND-alone group (70 percent vs. 25 percent).

The authors note that these results suggest that breast cancer patients, such as those in this study, do not benefit from the addition of ALND in terms of local control, disease-free survival, or overall survival, and that ALND may no longer be justified for certain patients. "Implementation of this practice change would improve clinical outcomes in thousands of women each year by reducing the complications associated with ALND and improving quality of life with no diminution in survival."

###
(JAMA. 2011;305[6]:569-575. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Management of Axillary Lymph Node Metastasis in Breast Cancer - Making Progress

Grant Walter Carlson, M.D., and William C. Wood, M.D., of Emory University, Atlanta, write in an accompanying editorial that the adage that less is more may be applicable regarding surgery for breast cancer.

"Giuliano and colleagues have made an important contribution to the surgical management of SLN metastasis in breast cancer," they write. Following the lead of other clinical investigators, "these randomized clinical trials have shown that less surgery combined with more radiation and chemotherapy have improved survival for women with breast cancer. Taken together, findings from these investigators provide strong evidence that patients undergoing partial mastectomy, whole-breast irradiation, and systemic therapy for early breast cancer with microscopic SLN metastasis can be treated effectively and safely without ALND."

(JAMA. 2011;305[6]:606-607. Available pre-embargo to the media at www.jamamedia.org)

the article is open access so I hope someone can post the link if I can't

Here I go trying: http://jama.ama-assn.org/content/305....full.pdf+html

[Colleens_Husband]

Thanks Lani:

I read in the news release that this method is only going to effect about 20% of all breast cancer cases. I didn't see a breakdown in the types of cancers and I am not sure if the fact that you are HER2 positive would make a difference in the lymph node dissections.

[Lani]

study does not seem to have looked at her2+ patients vs nonher2+ patients

(that is why I supplied the link)

The 20% of patients this study applied to/used as its subject were limited :
Patients were women with T1-T2 (stage of tumor) invasive breast cancer, no palpable adenopathy (enlarged lymph nodes), and 1 to 2 SLNs containing metastases. They did not include those with larger tumor(less and less these days with regular mammographic screenings) or those whose SLNs were negative(many, thank goodness). It concentrated on a large group of patients to see if they were unnecessarily being subject to risks of chronic pain, lymphedema and shoulder movement restrction without impacting their prognosis

here is more:

Limited Lymph Node Removal for Certain Breast Cancer Does Not Appear to Result in Poorer Survival
— Among patients with early-stage breast cancer that had spread to a nearby lymph node and who received treatment that included lumpectomy and radiation therapy, women who just had the sentinel lymph node removed (the first lymph node to which cancer is likely to spread from the primary tumor) did not have worse survival than women who had more extensive axillary lymph node dissection (surgery to remove lymph nodes found in the armpit), according to a study in the February 9 issue of JAMA.

Axillary lymph node dissection (ALND) has been part of breast cancer surgery since the use of radical mastectomy and reliably identifies nodal metastases. "Sentinel lymph node dissection (SLND) accurately identifies nodal metastasis of early breast cancer, but it is not clear whether further nodal dissection [removal] affects survival," the authors write. "ALND, as a means for achieving local disease control, carries an indisputable and often unacceptable risk of complications such as seroma [a mass or swelling caused by the localized accumulation of serum within a tissue or organ], infection, and lymphedema [condition in which excess fluid called lymph collects in tissues and causes swelling]."
Armando E. Giuliano, M.D., of the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, Calif., and colleagues conducted a study to determine the effects of ALND on overall survival in patients with SLN metastases treated with lumpectomy (surgical removal of a tumor without removing much of the surrounding tissue or lymph nodes) and radiation therapy. The trial was conducted at 115 sites and enrolled patients from May 1999 to December 2004. Patients were women with T1-T2 (stage of tumor) invasive breast cancer, no palpable adenopathy (enlarged lymph nodes), and 1 to 2 SLNs containing metastases.
Patients with SLN metastases identified by SLND were randomized to undergo ALND or no further axillary treatment. Those randomized to ALND underwent dissection of 10 or more nodes. Of 891 patients, 445 were randomly assigned to the ALND group and 446 to the SLND-alone group.
As expected, there was a difference between ALND and SLND-alone treatment groups in total number of removed lymph nodes and total number of tumor-involved nodes; the median (midpoint) total number of nodes removed was 17 in the ALND group and 2 in the SLND-alone group. At a median follow-up of 6.3 years, there were 94 deaths (SLND-alone group, 42; ALND group, 52). The use of SLND alone compared with ALND did not appear to result in statistically inferior survival, with the 5-year over all survival rates being 92.5 percent in the SLND-alone group and 91.8 percent in the ALND group. Disease-free survival did not differ significantly between treatment groups, with 5-year disease-free survival being 83.9 percent for the SLND-alone group and 82.2 percent for the ALND group.
The rate of wound infections, axillary seromas, and paresthesias (prickly, tingling sensations) among patients in the trial was higher for the ALND group than for the SLND-alone group (70 percent vs. 25 percent).
The authors note that these results suggest that breast cancer patients, such as those in this study, do not benefit from the addition of ALND in terms of local control, disease-free survival, or overall survival, and that ALND may no longer be justified for certain patients. "Implementation of this practice change would improve clinical outcomes in thousands of women each year by reducing the complications associated with ALND and improving quality of life with no diminution in survival."
Editorial: Management of Axillary Lymph Node Metastasis in Breast Cancer -- Making Progress
Grant Walter Carlson, M.D., and William C. Wood, M.D., of Emory University, Atlanta, write in an accompanying editorial that the adage that less is more may be applicable regarding surgery for breast cancer.
"Giuliano and colleagues have made an important contribution to the surgical management of SLN metastasis in breast cancer," they write. Following the lead of other clinical investigators, "these randomized clinical trials have shown that less surgery combined with more radiation and chemotherapy have improved survival for women with breast cancer. Taken together, findings from these investigators provide strong evidence that patients undergoing partial mastectomy, whole-breast irradiation, and systemic therapy for early breast cancer with microscopic SLN metastasis can be treated effectively and safely without ALND."

Journal References:
Grant Walter Carlson, William C. Wood. Management of Axillary Lymph Node Metastasis in Breast Cancer: Making Progress. JAMA, 2011; 305 (6): 606-607 DOI: 10.1001/jama.2011.131
Armando E. Giuliano, Kelly K. Hunt, Karla V. Ballman, Peter D. Beitsch, Pat W. Whitworth, Peter W. Blumencranz, A. Marilyn Leitch, Sukamal Saha, Linda M. Mccall, Monica Morrow. Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastasis: A Randomized Clinical Trial. JAMA, 2011; 305 (6): 569-575 DOI: 10.1001/jama.2011.90
Need to cite this story in your essay, paper, or report? Use one of the following formats:
APA

MLA
JAMA and Archives Journals (2011, February 9). Limited lymph node removal for certain breast cancer does not appear to result in poorer survival. ScienceDaily. Retrieved February 10, 2011, from http://www.sciencedaily.com /releases/2011/02/110208163953.htm
Note: If no author is given, the source is cited instead.

[imatthew]

FWIW, my wife only had 4 lymph nodes removed when the SNB came back positive on the first one, the other three were clear. I didn't, but should have, asked the surgeon why she only took out 4 when I've seen other women who've had many more taken out, from what I had read it was solely a matter of preference.

[rondo]

I was so encouraged by this study as I agonized over my decision not to have ALND after they found micromets in the sentinel node. My surgeon has been very supportive throughout the whole thing. My reasoning was as follows: no guarantee there won't be a locoregional recurrence even if they take the nodes out. What is guaranteed is permanent disability with ALND if you follow all the precautions they recommend! Also, what the @#** is the chemo for anyway if it won't take care of small amounts of cancer left in the nodes? Anyway, so far so good. I'll let you knoe how it turns out. Anyone else buck the trend that had positive sentinal node(s)?

[MCS]

Asimilar article was in the LA Times a couple of days ago in the Health section. When I went through surgery, I wanted to be as aggressive as I could be. I only had 4 nodes removed. I felt that anything close to the bad node was a potential for the bad cell to move out and find a new home. I actually was upset that more were not taken out!
Although I feel good for the women that don't have to more removed I still would feel safer taking out more than necessary-that is just my own paranoia.
mcs