Sentinel Lymph Node Resection in Breast Cancer

• Sentinel node vs. axillary clearance (SNAC):
  • One-year outcomes from the SNAC trial:
    • Demonstrated that sentinel lymph node resection (SLNR) alone in the setting of a sentinel node (SN)-negative axilla:
      • Reduced arm morbidity:
        • While preserving oncologic safety
  • In this study (SNAC):
    • 1088 women
    • With clinically node-negative early-stage breast cancer:
      • Were assigned to receive either:
        • SLNR followed by ALND:
          • If the SN was positive or not detected, or
        • Routine ALND:
          • Defined as SLNR followed immediately by ALND
  • The primary endpoint was:
    • Increase in arm volume from baseline
  • Secondary endpoints included:
    • An increase in arm volume by 15%
    • Early axillary morbidity:
      • Defined as arm dysfunction, or disability
  • Arm volume increased:
    • In the SLNR group by 2.8%, and
    • By 4.2% in the ALND group
      • P=0.002
  • Lower rates of:
    • Arm swelling (P<0.001), symptoms (P<0.001), and dysfunction (P=0.02):
      • Were reported in the SLNR group:
        • While disability (P=0.5) was not
  • The study showed that SLNR:
    • Had a sensitivity of 94.5%
    • A false-negative rate of 5.5%, and
    • A negative predictive value of 98%
  • The study concluded:
    • That SLNR followed oncologic principles and
    • Resulted in significantly less morbidity than ALND
• The ALMANAC trial:
  • A randomized multicenter trial:
    • Of sentinel node (SN) biopsy versus standard axillary treatment:
      • In operable breast cancer:
    • It took the benefits of SLNR in the clinically node-negative axilla one step further:
      • By demonstrating improved quality of life:
        • In patients receiving SLNR versus ALND
• In this study (ALMANAC):
  • 1031 patients
  • Were assigned to undergo SLNR or ALND
  • Patients with a SN-positive axilla:
    • Were subsequently treated:
      • With delayed ALND or
      • Axillary radiation
  • Such measures as:
    • Usage of drains
    • Hospital length of stay, and
    • Time to resumption of daily activities postoperatively were monitored
  • All were statistically significant and lower:
    • In the SLNR group:
      • P<0.001
  • Quality of life and arm functioning scores as reported by patients were statistically significantly better:
    • In the SLNR group:
      • P≤0.003
  • From these results:
    • It was concluded that:
      • SLNR should be the treatment of choice for patients with early-stage breast cancer and clinically negative nodes:
        • Because it is associated with reduced arm morbidity and better quality of life when compared with ALND
• The ACOSOG Z0011 trial:
  • Took the results of previous trials on the safety and validity of SLNR and went one step further:
    • To suggest avoiding ALND for small cancers with clinically node-negative, SN-positive disease:
      • Provided that systemic therapy and whole-breast irradiation (WBI):
        • Is incorporated into the treatment strategy for early-stage breast cancer following breast-conserving surgery
  • Adverse surgical effects were reported:
    • In 70% of patients:
      • After SLND plus ALND, and
      • 25% after SLND alone:
        • P≤.001
  • Patients in the SLND plus ALND group had more:
    • Wound infections (P ≤ .0016)
    • Seromas (P≤ .0001), and
    • Paresthesias (P≤.0001):
      • Than those in the SLND alone group
• The NSABP B-32:
  • Demonstrated the superiority of SLNR over ALND:
    • In terms of morbidity
  • Three-year postsurgical morbidity levels were compared:
    • Between patients with negative SLNR alone and those with negative SLNR and negative ALND
  • Shoulder range-of-motion and arm volumes were assessed on:
    • 1975 ALND and
    • 2008 SLND:
      • Node-negative breast cancer patients
  • Shoulder abduction deficits and arm volume differences:
    • Between the affected arm and the contralateral arms were calculated
  • Shoulder abduction deficits greater than or equal to 10%:
    • Peaked at one week for the:
      • ALND (75%) and
      • SLND (41%) groups
  • Arm volume differences greater than or equal to 10% at 36 months:
    • Were 14% for the ALND group and
    • 8% for the SLND groups
  • Numbness and tingling peaked at 6 months:
    • For the ALND:
      • Numbness: 49%
      • Tingling: 23% and
    • SLNR:
      • Numbness: 15%
      • Tingling: 10%
  • These results indicate:
    • The superiority of SLNR compared to ALND:
      • In terms of postsurgical morbidity outcomes over a 3-year follow-up period

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