Avoidance of axillary lymph node dissection in selected patients with node-positive breast cancer

Abstract 

Aims

Currently, it is standard practice to avoid ALND in patients with negative SLN, whereas this procedure is mandated for those with positive SLN. However, there has been some debate regarding the necessity of complete ALND in all patients with positive SLN. This review article discusses the issues related to eliminating the need for ALND in selected patients with positive nodes.

Methods

A review of the English language medical literature was performed using the MEDLINE database and cross-referencing major articles on the subject, focusing on the last 10 years.

Results

Currently, complete ALND is mandated in patients with SLN macrometastases as well as those with clinically positive nodes. It is not clear whether SLN biopsy is appropriate for axillary staging in patients with initially clinically positive nodes (N1) that become clinically node-negative (N0) after neoadjuvant chemotherapy. Although there is debate regarding whether ALND should be performed in patients with micrometastases in the SLN, it seems premature to abandon ALND in clinical practice. Moreover, it remains unclear whether it is appropriate to avoid complete ALND in patients with ITC-positive SLN alone.

Conclusions

In the absence of data from randomised trials, the long-term impact of SLN biopsy alone on axillary recurrence and survival rate in patients with SLN micrometastases as well as those with ITC-positive SLN remains uncertain. These important issues must be determined by careful analysis of the results of ongoing clinical trials.

Keywords: Breast cancer, Axillary lymph node dissection, Sentinel lymph node biopsy

Abbreviations: ALND, axillary lymph node dissection, BCT, breast-conserving treatment, NSABP, National Surgical Adjuvant Breast and Bowel Project, SLN, sentinel lymph node, ITC, isolated tumour cells, UICC, International Union Against Cancer, ACOSOG, American College of Surgeons Oncology Group, ALMNAC, axillary lymphatic mapping against nodal clearance, AJCC, American Joint Committee on Cancer, EORTC, European Organisation for Research and Treatment of Cancer