Sentinel Lymph Node Biopsy and Axillary Dissection in Early Breast Cancer

  • Sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND):
    • As the primary method of axillary staging for patients with early stage breast cancer
  • Changes in patient presentation and advancements in systemic therapy:
    • Have led clinicians to question the utility of ALND even in the presence of involved nodes
  • The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial:
    • Randomized women with T1 / T2 tumors undergoing breast conservation with one or two positive sentinel nodes to undergo ALND vs. no additional axillary surgery
    • Results showed no difference in local recurrence, disease-free survival (DFS), or overall survival (OS) between the groups
      • The authors concluded that ALND was not indicated in this setting
  • One of the major advantages of SLNB compared to ALND:
    • Is the ability to stage the axilla with reduced rates of lymphedema
  • A recent meta-analysis of five randomized controlled trials (including the Z0011 trial):
    • Reported a 70% reduction in risk of lymphedema with SLNB compared to ALND
  • Multi-gene assays such as the 21-gene recurrence score (RS):
    • Have provided prognostic information regarding risk of distant recurrence:
      • For patients with node-negative, ER+ breast cancers
    • Although evidence suggests that adding chemotherapy to endocrine therapy does result in improved DFS and OS for node-positive patients:
      • Exploratory data suggest that this may not be true for all patients
    • A retrospective analysis of the RS performed on 367 specimens from the SWOG 8814 trial:
      • Showed that RS was prognostic for DFS and OS in node-positive patients
    • The National Comprehensive Cancer Network:
      • Allows patients with 1 to 3 positive nodes to consider the 21-gene recurrence score to determine benefit from chemotherapy
  • References
    • Giuliano AE, Ballman K, McCall L, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 randomized trial. Ann Surg. 2016; 264(3):413-420.
    • Glechner A, Wockel A, Gartlehner G, et al. Sentinel lymph node dissection only versus complete axillary lymph node dissection in early invasive breast cancer: a systematic review and meta-analysis. Eur J Cancer. 2013;49(4):812-825.
    • Albain KS, Barlow WE, Shak S, et al. Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal women with node-positive, estrogen-receptor-positive breast cancer on chemotherapy: a retrospective analysis of a randomised trial. Lancet Oncol. 2010;11(1):55-65.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #BreastCancer #CASO #Miami #CenterforAdvancedSurgicalOncology

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