To Perform an Axillary Lymph Node Dissection or Not? That Is (Still) the Question
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EDITORIAL – BREAST ONCOLOGY
To Perform an Axillary Lymph Node Dissection or Not? That Is (Still) the Question Carla S. Fisher, MD, MBA, FACS Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
Management of the axilla is a topic very familiar, and perhaps frustrating, to surgeons treating breast cancer. Historically, the way we manage the axilla has been dictated by our view of the role it plays in breast cancer outcomes. Dr. William Halstead popularized the idea that the axilla provides a ‘‘bridge’’ for the spread of cancer from the breast to the rest of the body. By intervening early with radical surgery, surgeons could effectively stop the spread of cancer. This view was challenged based on retrospective data that failed to show a survival advantage for aggressive nodal surgery.1 The randomized, prospective National Surgical Adjuvant Breast Project B-04 trial confirmed that the addition of axillary lymph node dissection (ALND) to mastectomy did not improve distant disease-free or overall survival (OS), but ALND continued because nodal status was important for making adjuvant chemotherapy decisions. The sentinel lymph node biopsy (SLNB) technique then allowed nodal status to be determined with less morbidity. Finally, the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial highlighted the diminishing role of the axilla in treatment decision-making. Therefore, in the modern era, what is the role of the axilla in the treatment of breast cancer? This issue of Annals of Surgical Oncology reports the findings of a team from Memorial Sloan Kettering Cancer Center (MSKCC) that retrospectively analyzed T1-T2cN0 breast cancer patients undergoing SLNB and ALND.2 In a
Ó Society of Surgical Oncology 2020 First Received: 19 May 2020 C. S. Fisher, MD, MBA, FACS e-mail: [email protected]
study of patients between 2010 and 2018, Mamtani et al. identified a specific pathologic finding that significantly predicted an increased risk for patients with four or more positive non-sentinel lymph nodes (NSLNs). Among 1114 patients who underwent both SLNB and ALND, 113 (10%) were noted to have extracellular tumor deposits (ETDs), defined as intravascular tumor emboli or metastatic deposits in the axillary fat. Of these patients, 925 met the Z0011 criteria, specifically with one or two positive SLNs, and 122 (13%) of these patients ultimately had four or more NSLNs. Based on the strong and significant association of ETDs with four or more positive NSLNs, the authors concluded that the presence of ETDs indicates a need or consideration for ALND. What this study did not demonstrate is whether removal and identification of additional NSLNs is necessary for improving patient outcomes and/or choosing adjuvant therapy. A study of 9521 patients using the Surveillance, Epidemiology, and End Results (SEER) database showed no difference in breast cancer-specific survival or OS between ALND and SLNB used to treat T1–T2 breast cancer patients with three or more metastatic lymph nodes.3 Based on this, they conc
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