Abstract
BackgroundThe decision making process for axillary dissection has changed in recent years for patients with early breast cancer and positive sentinel lymph nodes (LN). The question now arises, what is the optimal surgical treatment for patients with positive axillary LN (pN+). This article tries to answer the following questions:Is there a survival benefit for breast cancer patients with 3 or more positive LN (pN3+) and with more than 10 removed LN?Is there a survival benefit for high risk breast cancer patients (triple negative or Her2 + breast cancer) and with 3 or more positive LN (pN3+) with more than 10 removed LN?In pN + patients is the prognostic value of the lymph node ratio (LNR) of pN+/pN removed impaired if 10 or less LN are removed?MethodsA retrospective database analysis of the multi center cohort database BRENDA (breast cancer under evidence based guidelines) with data from 9625 patients from 17 breast centers was carried out. Guideline adherence was defined by the 2008 German National consensus guidelines.Results2992 out of 9625 patients had histological confirmed positive lymph nodes. The most important factors for survival were intrinsic sub types, tumor size and guideline adherent chemo- and hormonal treatment (and age at diagnosis for overall survival (OAS)). Uni-and multivariable analyses for recurrence free survival (RFS) and OAS showed no significant survival benefit when removing more than 10 lymph nodes even for high-risk patients. The mean and median of LNR were significantly higher in the pN+ patients with ≤10 excised LN compared to patients with > 10 excised LN. LNR was in both, uni-and multivariable, analysis a highly significant prognostic factor for RFS and OAS in both subgroups of pN + patients with less respective more than 10 excised LN. Multivariable COX regression analysis was adjusted by age, tumor size, intrinsic sub types and guideline adherent adjuvant systemic therapy.ConclusionThe removal of more than 10 LN did not result in a significant survival benefit even in high risk pN + breast cancer patients.
Highlights
The decision making process for axillary dissection has changed in recent years for patients with early breast cancer and positive sentinel lymph nodes (LN)
Uni-and multivariable analyses for recurrence free survival (RFS) and overall survival (OAS) showed no significant survival benefit when removing more than 10 lymph nodes even for high-risk patients
The mean and median of lymph node ratio (LNR) were significantly higher in the pN+ patients with ≤10 excised LN compared to patients with > 10 excised LN
Summary
The decision making process for axillary dissection has changed in recent years for patients with early breast cancer and positive sentinel lymph nodes (LN). In order to evaluate the nodal status surgical staging was routinely done for breast cancer patients with positive lymph nodes. In order to define an adequate removal of lymph nodes a minimum number of 10 nodes in the final pathological report is recommended by the German S3 guidelines [1]. This number has not yet been confirmed by high quality studies, but the morbidity of an adequate axillary dissection is high [2]. Our previous general analysis on guideline adherent treatment, subgroups and average removed lymph nodes showed no superiority for a higher number of removed lymph nodes [6]
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