Abstract

Traditionally, women with node-positive operable breast cancer have received complete axillary lymph node dissection (ALND), which is associated with significant morbidity, but recently less invasive alternatives have been explored. We conducted a systematic review of randomised controlled trials assessing alternative approaches to axillary surgery in patients with pathologically-confirmed sentinel node-positive operable breast cancer. We searched on 16/3/15 the Specialized Register of the Cochrane Breast Cancer group; CENTRAL; MEDLINE; PreMEDLINE; EMBASE; WHO International Clinical Trials Registry Portal; ClinicalTrials.gov; conference proceedings from ASCO and the San Antonio Breast Cancer meetings; checked reference lists and contacted authors to identify relevant studies. Double, independent study sifting, extraction, appraisal and summarising were undertaken using standard Cochrane Collaboration methodology. We included three studies (2020 patients) comparing ALND with sentinel lymph node dissection (SLND) to SLND alone, and two studies (1899 patients) comparing ALND to axillary radiotherapy (aRT). No differences in survival or recurrence were observed between ALND and SLND or aRT, but morbidity may have been increased in ALND, and all the results were subject to different biases, such as recruitment bias, performance bias, and outcome-reporting bias. Whilst it is encouraging that there appears to be no adverse effect on recurrence or survival, it will be appropriate to confirm these findings and provide additional data confirming quality of life effects and long term outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-016-1712-9) contains supplementary material, which is available to authorized users.

Highlights

  • Current NICE Guidance for patients treated in the United Kingdom National Health Service makes the following recommendations: Offer further axillary treatment to patients with early invasive breast cancer who: have macrometastases or micrometastases shown in a sentinel lymph node. have a preoperative ultrasound-guided needle biopsy with histologically proven metastatic cancer.The preferred technique is axillary lymph node dissection (ALND) because it gives additional staging information. Do not offer further axillary treatment to patients found to have only isolated tumour cells in their sentinel lymph nodes

  • Since a number of studies have evaluated whether all patients identified as having metastatic breast cancer in the axillary sentinel nodes require completion axillary lymph node dissection (ALND) and whether radiotherapy might be an effective alternative to ALND in patients where further treatment is recommended following the identification of a positive axillary node

  • 5 trials reported in 13 publications met the inclusion criteria, two studies were still ongoing (comparing ALND to SLNB [NCT01796444 (Wang 2013), and ALND or axillary radiotherapy [aRT] + adjuvant treatment versus adjuvant treatment alone [POSNOC (Goyal 2014a, b)], respectively) while the remaining 147 records were excluded because they were: not a randomised trial (n = 20), ineligible population (n = 101), unclear intervention (n = 2) and ineligible intervention (n = 24); See Additional file 2)

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Summary

Introduction

Current NICE Guidance for patients treated in the United Kingdom National Health Service makes the following recommendations:•• Offer further axillary treatment to patients with early invasive breast cancer who:• have macrometastases or micrometastases shown in a sentinel lymph node.• have a preoperative ultrasound-guided needle biopsy with histologically proven metastatic cancer.The preferred technique is axillary lymph node dissection (ALND) because it gives additional staging information.• Do not offer further axillary treatment to patients found to have only isolated tumour cells in their sentinel lymph nodes. These patients should be regarded as lymph node-negative (NICE 2009).This guidance was last updated in 2009 and is currently under review. Since then a number of studies have evaluated whether all patients identified as having metastatic breast cancer in the axillary sentinel nodes require completion axillary lymph node dissection (ALND) and whether radiotherapy might be an effective alternative to ALND in patients where further treatment is recommended following the identification of a positive axillary node. Traditionally complete or partial excision of axillary lymph

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