Dr. Armando E. Giuliano of the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA, and colleagues note that evolving concepts have led to questions about the need for axillary lymph node dissection (ALND) when sentinel lymph nodes contain metastases.
Consequently, a randomized trial was started in 1999 involving 891 women with T1-T2 breast cancer and one or two positive sentinel lymph nodes who underwent lumpectomy and whole-breast irradiation. After SLN dissection they were randomly assigned to undergo ALND or no further axillary treatment.
The median number of lymph nodes removed was 17 in the ALND group compared with two in the other, according to the report. The rate of wound infections, axillary seromas, and paresthesias was 70% among the women undergoing ALND compared with 25% in the group who only had SLN dissection.
After a median follow-up of 6.3 years, five-year overall survival was 91.8% in the ALND group compared with 92.5% in the other group, the investigators found. Corresponding five-year disease-free survival rates were 82.2% versus 83.9%.
Dr. Giuliano and colleagues emphasize that the trial didn't include women who underwent mastectomy, lumpectomy without radiation or who had partial-breast irradiation or whole-breast irradiation in the prone position in which the low axilla isn't treated, or women who had neoadjuvant therapy. For such patients with positive SLNs, ALND remains standard practice.
For the population included in the study, however, ALND may no longer be justified, the researchers conclude. "Implementation of this practice change would improve clinical outcomes in thousands of women each year by reducing the complications associated with ALND and improving quality of life with no diminution in survival."
In an accompanying editorial, Dr. Grant Walter Carlson and Dr. William C. Wood of Emory University, Atlanta, note that the current results taken together with other findings "provide strong evidence that patients undergoing partial mastectomy, whole-breast irradiation, and systemic therapy for early breast cancer with microscopic SLN metastasis can be treated effectively and safely without ALND."
Source: JAMA 2011;305:569-575,606-607.
Last Updated: 2011-02-08 17:15:48 -0400 (Reuters Health)
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