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Basis and Outcome of Axillary Dissection for Node Negative Axilla Gurpreet Singh Dept. Of Surgery P.G.I.M.E.R. These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website. • Moynihan stated at the turn of the last century that "surgery of malignant disease is not the surgery of organs; it is the anatomy of the lymphatic system...“ Rationale for ALND in Breast Cancer • • • • Accurate staging Regional control of the disease Prognostic information Influence of the information on the adjuvant therapy • Improved survival Need for Revaluation of ALND • Screening mammography • Adjuvant systemic therapy to node negative patients • Financial implications of ALND – Saving of OT time – Saving in admission costs • Complications of ALND Complications of ALND 50% to 70% of patients undergoing ALND will have some complaints Early • Skin erythema • Seroma • Wound infection Complications of ALND Delayed • • • • Shoulder motion (17%) Arm edema (16%) Pain (25%) Intercostobrachial nerve numbness (78%) Patients Perception of Complications of ALND Ann Surg 2004;240: 1–6 Staging Frequency of Tumor + Nodes No. of patients Silverstein 1031 T1a T1b T1c T2 3 17 32 44 McGee 3077 12 23 33 54 Giuliano 259 10 13 30 - Cady 570 - 17 31 44 Average 4937 7 19 32 51 World J Surg 2001; 25:761–766 Staging of the Axilla • Clinical examination • Imaging methods • Preoperative prediction of nodal involvement • Axillary node sampling • Sentinel lymph node biopsy Local Control Axillary Failure in Clinically Node – Patients: No Axillary Treatment Axillary Failure in Clinically Node – Patients: Axillary RT Adjuvant Treatment Will ALND Change Treatment • Two hundred eighty-two women with clinically negative axillae were analyzed using a model treatment algorithm • Systemic therapy was assigned with and without data from axillary dissection • Treatment shifts based on axillary dissection data were scored Will ALND Change Treatment • For women 50 to 60 years of age, – 10% with tumors <1 cm, – 17% with tumors 1 to 2 cm with positive prognostic features – 4% with poor prognostic features • For women older than 60 years – 3% of those with tumors <1 cm – none of those with tumors >1 cm Ann Surg 1997, 226: 279-287 Is Axillary Lymph Node Dissection Indicated for Early-Stage Breast Cancer? A Decision Analysis Two examples • Patient A is 60 years old, with a primary tumor size between 0.5 and 1 cm • Patient B is 38 years old, with a primary tumor size between 3 and 4 cm • Both have ER-positive tumors and clinically negative axillae Parmigiani; J Clin Oncol 1999, 17:1465 Additional Life Expectancy Survival • Halsted – centrifugal spread of breast cancer – radical surgical approach to encompass all local and regional disease • Fisher – “breast cancer is a systemic disease involving a complex spectrum of hosttumor interactions and variations in effective local treatment are unlikely to affect survival substantially” Long Term Survival • In radical mastectomy series, it has been shown that long-term survival is possible in patients who do not receive adjuvant systemic treatment – Among 1458 patients, 43% were free of cancer at 30-years follow-up – Among 1425 patients with positive axillary nodes, 30% of patients were alive at 25 years follow-up Cancer 1974; 33: 1145–50 Mastologı´a Dina´mica 1995: 421–30 Long Term Survival • Mammographic screening for women > 50 years reduces breast cancer mortality by around 30% • Post-operative radiotherapy reduces mortality rates Lancet 2000; 355:1757-70 J Clin Oncol 2000; 18:1220-29 NSABP – 04 Trial (1971-1974) • 1079 women with clinically negative axillae – radical mastectomy – total mastectomy without axillary dissection but with postoperative irradiation – total mastectomy plus axillary dissection only if their nodes became positive • None of the women received adjuvant systemic therapy N Engl J Med 2002;347:567-75 Distribution of All First Events Criticism of NSABP-04 • 35% of the patients randomized to receive total mastectomy alone had a limited axillary dissection as well. Of the patients who actually had a total mastectomy, 21% had an axillary recurrence compared with 12% of patients who had 1-5 nodes removed and 0% for those who had 6 or more nodes removed Breast Cancer Res Treat 1985; 5:17 Criticism of NSABP-04 • The conclusion to be derived from the B-04 study is not that ALND does not have any effect on survival but that the study does not have enough patients to detect this benefit Curr Probl Surg 1995; 32: 257 Breast Cancer Survival According to Number of Nodes Removed • SEER database of 72,102 patients with breast cancer who – had been diagnosed in 1988 or later – were aged 40–79 years at diagnosis – had a single primary lesion – had 0 to 3 positive lymph nodes • Cases were separated into – age groups (40 to 49 and 50 to 79 years) – node-negative cases and those with 1-3 positive nodes Krag, Ann Surg Oncol 2003 10:1152 Survival According to Nodes Excised Hazard Ratio Per 5 Nodes Removed The Impact of Prophylactic Axillary Node Dissection on Breast Cancer Survival—A Bayesian Meta-Analysis • Six randomized controlled trials were identified, consisting of nearly 3000 patients and spanning four decades Orr, Ann Surg Oncol, 1999 6:109 The Impact of Prophylactic Axillary Node Dissection on Breast Cancer Survival—A Bayesian Meta-Analysis TRIAL YEAR No. % St-I %N+ Copenhagen 1951-57 425 68 - Guy’s I 1961-71 370 60 54 SES 1964-71 498 55 41 B-04 1971-74 727 100 39 Guy’s II 1971-75 258 100 31 Curie 1982-87 658 100 18 The Impact of Prophylactic Axillary Node Dissection on Breast Cancer Survival—A Bayesian Meta-Analysis • All six trials showed that prophylactic axillary node dissection improved survival, ranging from 4% to 16%, corresponding to a risk reduction of 7%-46% • Combining the six trials showed an average survival benefit of 5.4% (95% CI 5 2.7-8.0) Orr, Ann Surg Oncol, 1999 6:109 • Hellman - Spectrum Theory – Breast cancer is a heterogeneous disease presenting a spectrum ranging from a disease that remains locoregional throughout its course to a disease which is systemic when first detected – Based on this assumption, prophylactic axillary dissection seems to be beneficial to a certain proportion of patients Conclusions • Significant number of clinically N0 patients are pN1 • Adjuvant therapy may be different for N0 and N1 patients • Excellent local control with ALND or RT • Possibility of survival advantage Maximizing Benefits • Identify patients who are pN1 and treat them with ALND • SLNB is one method for doing this • Drawbacks – False negative