ASO Author Reflections: Moving the Ball Forward Toward De-Escalation of Axillary Surgery for Patients with Clinically No
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Moving the Ball Forward Toward DeEscalation of Axillary Surgery for Patients with Clinically NodePositive Disease Stephanie Angarita, MD, and Maggie DiNome, MD Department of Surgery, University of California Los Angeles, Los Angeles, CA
PAST With the development of effective multimodality therapies for breast cancer, the surgical management of the axilla has undergone a notable shift away from axillary lymph node dissection (ALND). Data has shown that this procedure does not improve recurrence rates or overall survival for patients with minimal nodal disease.1,2 As even more women are cured, the impact of this procedure on long-term morbidity and quality of life notoriously rises to the fore. The rates of lymphedema, a potentially disabling complication, increase significantly after ALND.3 Because no recent study has proven a survival benefit for ALND, it is essential to ask which patients can be safely spared the morbidity of this procedure. Historically, patients with palpable adenopathy have been subject to ALND, even though the NSABP B04 study did not demonstrate a survival benefit,4 because these patients are assumed to have a higher burden of nodal disease. PRESENT In our study,5 we sought to assess the pathologic nodal burden of patients who present with clinically node-positive disease and to determine if any variables exist that can predict higher nodal stage. We demonstrated that more than 40% of patients who were diagnosed with a positive axillary node before surgery had low pathologic nodal
Ó Society of Surgical Oncology 2020 First Received: 30 September 2020 Accepted: 4 October 2020 M. DiNome, MD e-mail: [email protected]
burden (pN1) at surgery. Of significance, palpable adenopathy did not predict for higher nodal stage. We then performed a subset analysis of patients with palpable nodes and excluded patients with ER-negative or Her2-positive disease, who would otherwise be treated with neoadjuvant chemotherapy (NAC). We were able to identify a subset of patients (44.6%) who had pN1 disease. Lobular histology, tumor size, and nodal metastasis size appeared to be predictors of higher nodal stage. Our data suggest that more than 40% of patients with clinically positive nodes who proceed straight to surgery may be overtreated with ALND and that palpable adenopathy is not associated with higher nodal stage. FUTURE The de-escalation of axillary surgery is rapidly keeping pace with the escalation of multimodality therapy for the treatment of patients with breast cancer. Given the morbidity associated with ALND, it is imperative that studies continue to move forward to investigate which patients may be candidates for omission of ALND. Our data suggest that future studies should not exclude patients with clinically positive nodes, including those with palpable lymphadenopathy. REFERENCES 1. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomize
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