Role Of Axillary Dissection Research Articles

Micrometastases in the sentinel node after neoadjuvant therapy. Is axillary dissection still required?

The present review intends to discuss the controversies and strengths in clinically node-positive patients with axillary nodal status ypNi+/mi after neoadjuvant chemotherapy. Over the past 20 years, a de-escalation approach toward axillary surgery has been observed in patients with breast cancer. The worldwide use of sentinel node biopsy in the upfront setting and after primary systemic therapy substantially reduced surgical complications or late sequelae and eventually improving quality of life of patients. However, the role of axillary dissection is still unclear in patients with low residual disease post-chemotherapy, namely those with micrometastases in the sentinel node, and its prognostic role is still not very clear. The aim of the present narrative review is to report the available evidence on this topic, discussing the pros and cons of performing axillary lymph node dissection in the infrequent finding of micrometastases in the sentinel node after neoadjuvant chemotherapy. We will also describe the ongoing prospective studies which are expected to shed light and guide future decisions.

Complications of Level I and II Axillary Dissection in the Treatment of Carcinoma of the Breast

Background: The role of axillary dissection as an effective means of controlling regionalnodal disease, has long been recognized. It is associated with significant complicationsand might be more selectively applied only to patients harboring micrometastases to thesentinel nodes.
 Objective: To assess the complications of level I and II axillary lymph node dissection inthe treatment of stage I and II breast cancer, with mastectomy.
 Methods: One hundred patients having total mastectomy with axillary dissection, wereevaluated for more than 1 year after surgery for arm swelling as well as non-edemacomplications. All patients had measurements of circumference of upper limb at 4 siteson both the operated and non operated sides.
 Results: No patient had an axillary recurrence, difference in circumference of upperlimb at the midbiceps level >2 cm - 13% (p <0.001), difference at the antecubitalfossa>12% (p < 0.001), at the mid forearm>2cm - 8% (p < 0.005), and at the wrist 4%(n.s.). Four patients (4%) had mild swelling of the hand. Seventy seven (77%) patientshad numbness or paresthesias of the medial arm and/or axilla after surgery; in 63(82%) of these, the problem had lessened or had resolved on follow-up assessment.Medical therapy with anti-tubercular drugs ranging from 9 to 12 months with follow upmonthly was the mainstay of treatment. Surgical intervention reserved for selectedrefractory cases. Extension of anti-tubercular therapy from 9 to 12 or 18 monthsrequired in fifty-eight(58) patients on the basis of slow clinical response. Completeresolution obtained in 92 patients but residual tiny mass in eight patients confirmed byrepeated FNAC to be fibrotic.
 Conclusion: Level I and II axillary dissection is associated with various complications.Sentinel lymphadenectomy may be proposed as an alternative to elective axillarydissection.
 Journal of Surgical Sciences (2017) Vol. 21 (1) :24-28

Low-grade adenosquamous carcinoma of the breast: A diagnostic and clinical challenge

Adenosquamous carcinoma of the breast (ASBC) is a rare variant of metaplastic breast cancer with both glandular as well as squamous differentiation. Their lack of distinct imaging characteristics, sometimes subtle histological characteristics and overlapping features with other benign lesions pose a diagnostic challenge. Unlike other forms of metaplastic breast cancer, low-grade adenosquamous carcinoma (LGAC) tends to follow an indolent course with favourable prognosis. We reviewed eight cases of LGAC in our institution from June 2005 to March 2014. In six cases, LGAC was only found after excisional biopsy. In our patients, LGAC frequently co-existed with other forms of breast pathology. Two patients had incidental findings of LGAC alongside their primary malignant tumour (adenoid cystic carcinoma and invasive ductal carcinoma in one, four foci between 0.5 and 4.0 mm within a radial sclerosing lesion adjacent to a malignant phyllodes tumour in the other). A further four patients had LGAC within a complex sclerosing lesion. One patient had a focus of LGAC within a fibroadenoma. One had a focus of LGAC within a benign phyllodes tumour. None of the patients had evidence of nodal involvement. A high degree of suspicion is recommended as such lesions tend to be incidental histological findings within benign tumours or within complex sclerosing lesions. Although the risk of nodal and distant metastasis is low, the potential for local recurrence necessitates aggressive local excision with margin clearance. The role of axillary dissection has yet to be defined and routine sentinel node biopsy and axillary clearance may not be necessary in view of rarity of nodal metastasis in literature. Benefit from adjuvant radiotherapy or chemotherapy is not clearly defined. All eight patients in our study have shown no evidence of recurrence after definitive surgery but longer periods of surveillance is required.

Sentinel node biopsy and axillary dissection in breast cancer: the evidence and its limits.

Increasing evidence suggests that surgical removal of the axillary lymph nodes (axillary dissection, ALD) in early breast cancer yields no advantage in terms of either overall or disease-free survival, even in women with involvement of sentinel nodes. The optimal role of sentinel node biopsy (SNB) in neo-adjuvant therapy is currently under discussion. This review is based on a selective search in the Medline, EMBASE, Cochrane Library, and G.I.N. (Guidelines International Network) databases for relevant articles on the role of axillary dissection in node-positive breast cancer and the role of SNB in neo-adjuvant chemotherapy. Although no single study provides adequate evidence, the available literature increasingly casts doubt on the putative therapeutic benefit of ALD as part of a multimodal treatment strategy for breast cancer. It is currently unclear what group of patients, if any, might benefit from ALD. Nor is any definitive judgment possible, from the available evidence, regarding the optimal role of SNB in neo-adjuvant therapy. The most recent evidence indicates that SNB after neo-adjuvant chemotherapy in ycN0 patients who had suspect lymph nodes before systemic treatment has a low rate of sensitivity. Current evidence indicates that the radicality of lymph node surgery in the treatment of breast cancer can be reduced, even if the node status is positive.

Unanswered Questions About the Role of Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastasis

Giuliano et al 1 recently published the results of the American College of Surgical Oncology Group (ACSOG) Z0011 trial, which evaluated 891 women with clinical T1-T2 invasive breast cancer, no palpable adenopathy, and either 1 or 2 sentinel lymph nodes (SLN) that contained metastases on frozen section (hematoxylin and eosin, or touch preparation), randomized to undergo only SLN biopsy (SLNB) or SLNB with axillary lymph node dissection (ALND). Five-year overall survival (OS) was 91.8% (95% CI, 89.1%-94.5%) after ALND and 92.5% (95% CI, 90.0%-95.1%) after SLNB only. Disease-free survival (DFS) was 82.2% (ALND) and 83.9% (SLNB only). These investigators concluded that ALND did not alter survival in women with limited SLN metastatic breast cancer who underwent breast conservation and received systemic therapy. 1 ACSOG Z0011 trial represents a landmark trial in the surgical management of clinically node negative breast cancer; however, their resultsaremarkedlydifferentfromotherreportssuchastheNational Surgical Adjuvant Breast and Bowel Project (NSABP) B04 with respect to locoregional recurrence (LRR). Before these recommendations are widely adopted, several additional questions that may contribute to LRR remain, either due to 1. Tumor burden and non-SLN involvement 2. Receptor status

A 10-Year Trend Analysis of Sentinel Lymph Node Frozen Section and Completion Axillary Dissection for Breast Cancer: Are These Procedures Becoming Obsolete?

Recent results from the ACOSOG Z0011 trial question the use of intraoperative frozen section (FS) during sentinel lymph node (SLN) biopsy and the role of axillary dissection (ALND) for SLN-positive breast cancer patients. Here we present a 10-year trend analysis of SLN-FS and ALND in our practice. We reviewed our prospective SLN database over 10years (1997-2006, 7509 SLN procedures) for time trends and variation between surgeons in the use of SLN-FS and ALND in patients with cN0 invasive breast cancer. Use of SLN-FS decreased from 100% to 62% (P<0.0001) and varied widely by surgeon (66% to 95%). There were no statistically significant trends in the performance of ALND for patients with SLN metastases detected by FS (n=1370, 99-99%) or routine hematoxylin and eosin (H&E) (n=333; 69-77%), but only for those detected by serial section H&E with or without immunohistochemistry (n=438; 73-48%; P=0.0054) or immunohistochemistry only (n=294; 48-28%; P<0.0001). These trends coincided with an increase in the proportion of completion versus immediate ALND (30-40%; P=0.0710). Over 10years, we have observed a diminishing rate of SLN-FS and, for patients with low-volume SLN metastases, fewer ALND, trends that suggest a more nuanced approach to axillary management. If the Z0011 selection criteria had been applied to our cohort, 66% of SLN-FS (4159 of 6327) and 48% of ALND (939 of 1953) would have been avoided, sparing 13% of all patients the morbidity of ALND.

T1a breast carcinoma and the role of axillary dissection.

Axillary dissection (AD) does not affect recurrence or survival in T1a breast cancer. Cohort study comparing patients who underwent AD and those who did not. Provincial cancer agency. Six hundred ninety-one women with pathologically diagnosed T1a tumors. Rates of axillary metastases stratified according to grade and lymphovascular and/or neural invasion, rates of relapse, and disease-specific survival. Grade 1, 2, and 3 tumors without lymphovascular and/or neural invasion had axillary nodal involvement rates of 0.7%, 7%, and 7.8% of patients, respectively; with lymphovascular and/or neural invasion, axillary nodes were involved in 9.1%, 39.3%, and 44.4%, respectively. No statistically significant differences were found between the cohorts in relapse rates (P =.70) or survival (P =.84). Higher tumor grade and lymphovascular and/or neural invasion increased the rate of nodal metastases in T1a tumors, but AD did not improve relapse rates or breast cancer-specific survival.

The Diagnosis and Treatment of Ductal Carcinoma In Situ of the Breast.

Ductal carcinoma in situ of the breast is the most favorable presentation of breast cancer; therefore appropriate local treatment is imperative. Intraductal carcinoma is being diagnosed more frequently with the increasing use of screening mammography. A number of pathologic features have been identified which are useful for classification and for prognostic information. In addition, the molecular pathology and its relationship to tumor behavior and prognosis is becoming more well understood. The role of axillary dissection has been examined in a number of series and is generally agreed to be unnecessary for this presentation of breast cancer, allowing many women to avoid the sequela of axillary surgery. This review discusses the use of breast conservation treatment and the evolving indications for excision alone in the treatment of ductal carcinoma in situ. The outcomes for breast conservation therapy from both randomized trials and institutional series have confirmed excellent survival rates. Salvage therapy for local recurrence is frequently successful, resulting in nearly equivalent survivals in women undergoing breast conservation therapy compared to mastectomy. In addition, intriguing but preliminary results from both breast cancer prevention studies and trials looking at the use of tamoxifen for intraductal cancer suggest a local control benefit in women using the drug.

The role of axillary dissection in surgical treatment of early breast cancer

The role of axillary dissection in surgical treatment of early breast cancer

Role of CD44 in nonpalpable T1a and T1b breast cancer

Primary infiltrating ductal carcinomas (IDCs) of the breast which measure less than 0.5 cm (T1a lesions) and between 0.5 and 1.0 cm (T1b lesions) are associated with a small risk of nodal metastasis. The role of axillary dissection in T1a and T1b breast cancer is controversial. In the absence of axillary dissection, comparable prognostic information might be obtained by examination of the primary cancer. The adhesion molecule CD44 represents a family of transmembrane proteins that mediate cell-cell and cell-matrix interactions. Previous investigators have correlated expression of CD44 and its isoforms with prognosis in breast cancer. We investigated the value of CD44 isoform expression as a predictor of nodal metastases in nonpalpable T1a and T1b IDC. Monoclonal antibody against the standard form of CD44 (CD44s) and polyclonal antibody directed against the variant isoform (CD44v6) was tested on 34 cases of nonpalpable node-negative infiltrating ductal carcinoma (IDC) less than 1.0 cm and 9 cases of nonpalpable node-positive IDC less than 1.0 cm. The expression of CD44s was significantly decreased in node-positive Tla and T1b IDC versus node-negative T1a and T1b IDC (11% vs 65%). In contrast, 97% of the node-negative IDC and 100% of the node-positive IDC expressed the CD44v6 isoform. We conclude that CD44s expression is significantly altered in T1a and T1b IDC with nodal metastases but that the CD44v6 isoform does not correlate with nodal metastases in nonpalpable stage T1a and T1b IDC.

Role of Axillary Dissection in Mammographically Detected Breast Cancer

The traditional rationale for axillary lymphadenectomy in patients with breast cancer was that the procedure was therapeutic, diagnostic, and needed to determine adjuvant therapy. Recent data have shown that there is little, if any, therapeutic value to this procedure and that the decision to use adjuvant chemotherapy or hormonal therapy may no longer be absolutely contingent on axillary node status. Increasingly, primary tumor factors are being used to establish the aggressiveness of cancers. Therefore, the widespread use of axillary lymphadenectomy especially in small, mammographically detected breast cancers is questioned.

The Biologic and Clinical Significance of Lymphatic Metastases in Breast Cancer

The best treatment approach for the regional lymph nodes in breast cancer patients continues to undergo debate and reassessment. Most patients with invasive breast cancers are currently being treated by axillary dissections, in part because pathologic staging of the axillary nodes is the most important prognostic factor in patients with primary operable breast cancer and helps select patients for systemic therapy. As is discussed in this article, however, many factors are leading surgeons to become increasingly selective in choosing patients for axillary dissection. Emerging technology may soon lead to accurate axillary staging of many patients without full axillary dissection, and it is quite probable that the role of axillary dissection will continue to be redefined during the next few years.

The role of axillary dissection in operable breast cancer

This paper presents arguments for and against the performance of complete axillary dissection in patients with operable breast cancer. The arguments in favour of this are that complete axillary dissection is a simple surgical procedure which provides excellent local tumour control with minimal morbidity, that it provides complete staging and the best widely available prognostic information, and that it accurately selects patients who will benefit from the administration of adjuvant cytotoxic chemotherapy. The arguments against are that axillary irradiation provides comparable rates of local tumour control to axillary surgery, and that decisions regarding adjuvant systemic therapy can be made without a knowledge of axillary nodal status. The evidence for and against lesser surgical procedures in the axilla is also presented and in the light of this overview we have attempted to make valid recommendations about axillary treatment in patients with operable breast cancer.

The role of axillary dissection in early stage breast cancer.

(1992). The Role of Axillary Dissection in Early Stage Breast Cancer. Cancer Investigation: Vol. 10, No. 5, pp. 461-470.