Content area
Full Text
REVIEWS
Is axillary lymph node clearance required innode-positive breast cancer?
Nigel J. Bundred, Nicola L. P. Barnes, Emiel Rutgers and Mila Donker
Abstract | Although the majority of patients with breast cancer have clinically negative axillary nodes at preoperative assessment, around 1520% of these women will have metastatic disease within the lymph nodes at operative sentinel node biopsy, and additional selective treatment to the axilla might be required. Local treatment to the axilla can include axillary node clearance or axillary radiotherapy. The recent results of the American College of Surgeons Oncology Group Z0011 trial suggested that some women would be safe from recurrence without further axillary treatment if they have less than three involved sentinel nodes, with no extracapsular spread. We review the evidence base for management of the axilla after detection of a positive sentinel node, discuss the evidence for why micrometastatic disease requires systemic but not axillary therapy, and present data suggesting that axillary irradiation for macrometastases gives equivalent control to axillary node clearance, but causes less morbidity such as lymphoedema. Ongoing trials will confirm whether any further therapy can be omitted for all patients with low volume, sentinel-node macrometastases.
Bundred, N. J. etal. Nat. Rev. Clin. Oncol. 12, 5561 (2015); published online 4 November 2014; http://www.nature.com/doifinder/10.1038/nrclinonc.2014.188
Web End =doi:10.1038/nrclinonc.2014.188
Introduction
Recent trials of sentinel node biopsy (SNB), such as the ALMANAC1 and NSABP (National Surgical Adjuvant Breast and Bowel Project) B322 studies, identified the value of the SNB procedure in patients with invasive breast cancer with clinically negative axilla, and SNB has now become the standard of care. These trials, in addition to many other retrospective studies,3 reported very low rates of axillary recurrence at 5years of follow-up evaluation for patients with a negative sentinel node in whom axillary node clearance was omitted. In patients with a positive sentinel node, axillary node clearance has long been the treatment of choice to achieve regional disease control; thepresence and number of cancer-containing lymph nodes detected has been used to inform decisions regarding adjuvant chemotherapy and radiotherapy.4 However, axillary node clearance is often associated with harmful adverse effects, such as lymphoedema, dys aesthesia and impaired s houlder function.2 These adverse effects, particu larly lymph-oedema, can be a major cause of deterioration in quality of life.5...