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Lymph Node Dissection in Early Breast Cancer

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Lymph Node Dissection in Early Breast Cancer

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    1. Lymph Node Dissection in Early Breast Cancer Parvin F. Peddi, MD March 25, 2011 No Financial Disclosures

    3. Outline Lymphatic drainage of the breast Halsted radical mastectomy NSABP-B04 The sentinel lymph node Z0011 Trial Conclusions

    4. Lymphatic Drainage Axillary Lymph Nodes 85% of drainage from all quadrants of the breast Subdivided into level I, II, III surgically Internal Mammary Lymph Nodes The other 15% drain to the IM nodes. Supraclavicular Lymph Nodes Rarely the first site of drainage.

    6. Non-Axillary LN dissection: Supraclavicular : Involvement usually synonymous with extensive axillary involvement. In one series, supraclavicular involvement found in 18 and 0.7 percent of those with and without axillary LN metastases, respectively1. Internal Mammary : In one series about 5% occurred without axillary LN met. Routine dissection abandoned given no survival benefit in several randomized studies2.

    7. Risk of Axillary Lymph Node Involvement

    8. Radical Mastectomy Axillary dissection introduced in 19th century: Charles H. Moore treaty (1867): On the Influence of Inadequate Operations on the Theory of Cancer Pioneered by William Stewart Halsted (1852-1922). Described in 1882: Removal of breast tissue + axillary lymph nodes (I-III) + both pectoral muscles

    9. Fear of mistaken kindness Quickly adopted despite significant subsequent deformity, diminished upper ext. function and intraoperative blood loss. In the 1930s, D. H. Patey of London popularized Modified radical mastectomy: Sparing pectoral muscles and level III ALNs. Long term followup did not show any recurrence in the preserved muscles and rarely in level III nodes. Was adopted by part of the surgical community while Halsted was still commonly used by the rest.

    10. To Dissect or Not to Dissect To dissect: Firmly establish extent of disease Remove more foci of malignancy in hopes of better survival/recurrence rate Not to dissect: High risk of lymphedema, seroma, decreased arm mobility Does knowledge of node positivity affect management? Does removing these extra foci of cancer improve survival or risk of recurrence?

    11. NSABP-04 National Surgical Adjuvant Breast and Bowel Project B04 1971-1974 Purpose: Do either clinically node positive or negative breast cancer patients benefit from ALND? 1079 patients with clinically neg nodes randomized to (1) radical mastectomy (w ALND) (2) total mastectomy + radiation, (3) total mastectomy with delayed ALND if later clinically positive nodes developed. 586 patients with clinically positive nodes randomized to radical mastectomy (w ALND) vs total mastectomy with postop radiation.

    12. NSABP-04

    13. NSABP-04 - The Forgotten Study Practice however did not change: There was still need for confirming lymph node involvement to guide practice. Study criticized that many surgeons had still included some ALNs in the mastectomy only arm even though the extent of dissection was very different. ALND continued to be included for most breast cancer patients.

    14. Sentinel Lymph Node In 1994, Giuliano and colleagues first described the use of sentinel lymph node biopsy in breast cancer. Initially just using blue dye, gradually both dye and radioisotopes were used to map the draining lymph nodes. Anecdotal evidence suggested sentinel lymph node status could predict axillary lymph node involvement.

    15. Tumors less than or equal to 2cm; no palpable LNs Randomized to SLN and ALND or SLN followed by ALND only if SLN positive. + SLN in 32-35% SLN was 91% sensitive (83 of 91 + ALNs identified) Negative predictive value of 95.4% Less pain, lymphedema (75% vs 7%) or effect on arm mobility (21% vs 0%).

    16. 10 Year Follow-up 2 cases of overt axillary met occurred in SLN group. Overall survival greater in SLN arm (P 0.15). Standard became sentinel lymph node biopsy followed by axillary dissection only if SLN positive. Spared 65% of patients from ALND.

    17. What if SLN is positive? The knowledge of additional positive axillary lymph node did not change management. Does removal of positive axillary lymph nodes provide a survival benefit to justify the side effects?

    19. Design Prospective randomized non-inferiority trial. Inclusion criteria: Tumors less than or equal to 5cm, no palpable LNs, + SLN (1 to 2) by hematoxylin-eosin staining. Exclusion criteria: SLN positive only by immunohistochemical staining Matted or palpable nodes 3 or more positive SLNs

    20. Patient Characteristics 1999-2004 Terminated prematurely due to lower than expected mortality rate (90% vs predicted 80% five year OS). 891 patients randomized instead of desired 1900. Median age 50, followed for median of 6.3 yrs. All patients had lumpectomy and SLND followed by either ALND (level I and II) vs none. Most received whole breast radiation. Systemic tx left to individual physicians.

    21. Overall Survival

    22. Disease Free Survival The 5-yr DFS: 83.9% for the SLND-only group vs 82.2% in the ALND group (P=.14).

    23. Discussion Did surgeons still remove axillary lymph nodes? The median number of lymph nodes removed was 17 in the ALND group vs only 2 in the SLND group. Did ALND reveal more positive lymph nodes? In the ALND group, 27.3% had additional mets identified by axillary dissection.

    24. Discussion Statistical power Follow up duration Why include only patients with less than 3 positive SLNs? What about patients with palpable lymph nodes? Should this change current standard of care?

    25. Conclusions Breast cancer surgery started as radical and has continuously become more conservative. Axillary dissection has long been a controversial part of breast surgery. Significant morbidities argue for presence of a clear benefit to justify this procedure in the modern era. SLN has already spared ~ 65% of patients from axillary dissection who have negative sentinel lymph nodes. NSABP and Z0011 trial both argue that ALND is also not beneficial for most patients with positive SLNs. More may be less.

    26. Additional References Jacobs L, Finlayson C. Early Diagnosis and Treatment of Cancer Series: Breast Cancer: Expert Consult. 1st ed. Saunders; 2010. Alphonse GT, Smith BL, Erban JK. Breast Cancer: A Multidisciplinary Approach to Diagnosis and Management. Demos Medical Publishing; 2009. Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. Scribner; 2010.

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