Axillary lymph node dissection discouraged in many breast cancer patients

By Will Boggs MD

NEW YORK (Reuters Health) - Updated guidelines from the American Society of Clinical Oncology Breast say axillary lymph node dissection (ALND) should be avoided in many women with early-stage breast cancer.

ASCO last published clinical practice guidelines on the use of sentinel node biopsy (SNB) for patients with early-stage breast cancer in 2005. In the Journal of Clinical Oncology, online March 24, the group now offers four recommendations based on the latest research.

First, clinicians should not recommend ALND for women with early-stage breast cancer if they do not have sentinel lymph node (SLN) metastases, write Dr. Gary H. Lyman from Fred Hutchinson Cancer Research Center in Seattle and colleagues.

Second, clinicians should not recommend ALND for women with early-stage breast cancer if they have only one or two SLN metastases and will receive breast-conserving surgery followed by conventionally fractionated whole-breast radiotherapy.

"The results of the randomized trial ACOSOG Z0011 was particularly influential in assuring the panel that many women with 1-2 positive nodes on SNB do not require ALND as previously recommended," Dr. Lyman told Reuters Health by email.

Third, clinicians may offer SNB for women with operable breast cancer who have multicentric tumors, ductal carcinoma in situ (DCIS) when mastectomy is performed, prior breast and/or axillary surgery, or preoperative/neoadjuvant systemic therapy.

Finally, the group found insufficient data to change the 2005 recommendation that clinicians should not perform SNB for women who have early-stage breast cancer and have any of the following circumstances: large or locally advanced invasive breast cancers, inflammatory breast cancer, DCIS when breast-conserving surgery is planned, or pregnancy.

"Candidates for avoiding ALND are those with microscopic involvement of 1-2 sentinel nodes with smaller tumors and undergoing lumpectomy and local radiation therapy," Dr. Lyman explained.

The rationale, he said, is that in the unlikely circumstance that a few additional axillary lymph nodes are involved, radiation therapy appears to be as effective at treating them as surgery.

"If mastectomy is planned without radiation therapy, then full ALND should still be done," Dr. Lyman added. "While some local complications, e.g., infection, can still occur with SNB alone, the risk is significantly less. Importantly the risk of major arm swelling (lymphedema) is dramatically reduced compared to ALND as are the risks of arm weakness, numbness, and shoulder pain."

Dr. Lyman said some clinicians are already using the approaches recommended in the new guidelines, although there is a lot of variation in practice.

"Hopefully, these guidelines updated on the basis of recent clinical studies will bring more uniformity and consistency in practice and raise the overall quality of care of women presenting with newly diagnosed early-stage breast cancer. Quality of life considerations are a major reason for wishing to avoid full lymph node dissection when it is not necessary," he said.

Dr. Chiun-Sheng Huang, who directs the Breast Care Center at the National Taiwan University College of Medicine and was not involved in the new work, agreed.

"Lymphedema of the upper limb, the major side effects of ALND, will persist for years and even become worse," Dr. Huang told Reuters Health by email.

"When there are no palpable lymph nodes, ALND is simply a staging procedure and should be replaced by SNB," he said. "The local recurrence rate, disease free survival, and overall survival are not different between patients undergoing SNB and ALND."

Dr. Lyman underscored the need for additional studies.

"Much more research is needed to better define special circumstances when SNB alone may replace the need for full ALND such as in pregnant patients, many patients with DCIS, those with inflammatory breast cancer, and at what size of primary tumor is the SNB no longer adequate to evaluate the risk of involvement of the axillary lymph nodes," he said.

SOURCE: http://bit.ly/1dreDGN

J Clin Oncol 2014.

(c) Copyright Thomson Reuters 2014. Click For Restrictions - http://about.reuters.com/fulllegal.asp