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Extent of regional lymph node surgery and impact on outcomes in patients with early-stage breast cancer and limited axillary disease undergoing mastectomy

  • Epidemiology
  • Published:
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Abstract

Purpose

Management of the axilla in patients with early-stage breast cancer (ESBC) has evolved. Recent trials support less extensive axillary surgery in patients undergoing mastectomy. We examine factors affecting regional lymph node (RLN) surgery and outcomes in patients with ESBC undergoing mastectomy.

Methods

Women with clinical T1/2 N0 M0 invasive BC who underwent mastectomy with 1–2 positive nodes were selected from the National Cancer Database (2004–2015). Axillary surgery was defined by number of RLNs examined: 1–5 sentinel LN dissection (SLND), and ≥ 10 axillary LND (ALND). Binary logistic regression and survival analyses were performed to assess the association between axillary surgery and clinical characteristics, and overall survival (OS), respectively.

Results

34,243 patients were included: 13,821 SLND (40%) and 20,422 ALND (60%). SLND significantly increased from 21% (2004) to 45% (2015) (p < .001). Independent factors associated with SLND were treatment year, non-Academic centers, geographic region, tumor histology, and postmastectomy radiotherapy (PMRT). Multivariable survival analysis showed that ALND was associated with better OS (HR 0.78, 95% CI 0.72–0.83, p < .001) relative to SLND; however, there was no difference in patients with LN micrometastases treated without RT (HR 0.87, 95% CI 0.73–1.05, p = .153) or patients receiving PMRT (HR 0.92, 95% CI 0.76–1.13, p = .433).

Conclusions

SLND has significantly increased in patients undergoing mastectomy with limited axillary disease and is influenced by patient, tumor, and treatment factors. Survival outcomes did not differ by axillary treatment for patients with LN micrometastases treated without RT or patients who received PMRT. SLND may be considered in select patients with ESBC and limited axillary disease undergoing mastectomy.

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References

  1. Jatoi I, Benson JR, Toi M (2016) De-escalation of axillary surgery in early breast cancer. Lancet Oncol 17(10):e430–e41

    Article  Google Scholar 

  2. Giuliano AE, Hunt KK, Ballman K, Beitsch P, Whitworth PW, Blumencranz P et al (2011) Sentinel lymph node dissection with and without axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA 305(6):569–575

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  3. Yao K, Liederbach E, Pesce C, Wang C, Winchester DJ (2015) Impact of the American College of Surgeons Oncology Group Z0011 randomized trial on the number of axillary nodes removed for patients with early-stage breast cancer. J Am Coll Surg 221(1):71–81

    Article  PubMed  Google Scholar 

  4. Caudle AS, Hunt KK, Tucker SL, Hoffman K, Gainer SM, Lucci A et al (2012) American College of Surgeons Oncology Group (ACOSOG) Z0011: impact on surgeon practice patterns. Ann Surg Oncol 19(10):3144–3151

    Article  PubMed  PubMed Central  Google Scholar 

  5. Galimberti V, Cole BF, Zurrida S, Viale G, Luini A, Veronesi P et al (2013) Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol 14(4):297–305

    Article  PubMed  PubMed Central  Google Scholar 

  6. Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJ, Mansel RE et al (2014) Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 15(12):1303–1310

    Article  PubMed  PubMed Central  Google Scholar 

  7. Bilimoria KY, Stewart AK, Winchester DP, Ko CY (2008) The National Cancer Data Base: a powerful initiative to improve cancer care in the United States. Ann Surg Oncol 15(3):683–690

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ong CT, Thomas SM, Blitzblau RC, Fayanju OM, Park TS, Plichta JK et al (2017) Patient age and tumor subtype predict the extent of Axillary Surgery among breast cancer patients eligible for the American College of Surgeons Oncology Group Trial Z0011. Ann Surg Oncol 24(12):3559–3566

    Article  PubMed  PubMed Central  Google Scholar 

  9. NCDB PUF (2015) Data Dictionary. http://ncdbpuf.facs.org/node/259

  10. United States Census Bureau GD. Census Regions and Divisions of the United States.https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf

  11. Kaplan E, Meier P (1958) Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457–481

    Article  Google Scholar 

  12. Breslow NE (1975) Analysis of survival data under the proportional hazards model. Int Stat Rev 43(1):45–57

    Article  Google Scholar 

  13. Cox D (1972) Regression models and life tables. J R Stat Soc 34:187–220

    Google Scholar 

  14. Bergkvist L, de Boniface J, Jonsson PE, Ingvar C, Liljegren G, Frisell J et al (2008) Axillary recurrence rate after negative sentinel node biopsy in breast cancer: three-year follow-up of the Swedish Multicenter Cohort Study. Ann Surg 247(1):150–156

    Article  PubMed  Google Scholar 

  15. Giuliano AE, Ballman K, McCall L, Beitsch P, Whitworth PW, Blumencranz P et al (2016) Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial. Ann Surg 264(3):413–420

    Article  PubMed  PubMed Central  Google Scholar 

  16. Giuliano AE, Haigh PI, Brennan MB, Hansen NM, Kelley MC, Ye W et al (2000) Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer. J Clin Oncol 18(13):2553–2559

    Article  PubMed  CAS  Google Scholar 

  17. Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V et al (2003) A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med 349(6):546–553

    Article  PubMed  Google Scholar 

  18. Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP et al (2010) Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol 11(10):927–933

    Article  PubMed  PubMed Central  Google Scholar 

  19. Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR et al (2017) Effect of axillary dissection versus no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA 318(10):918–926

    Article  PubMed  PubMed Central  Google Scholar 

  20. Robinson K, Pockaj BA, Wasif N, Kaufman K, Gray (2014) Richard. Have the American College of Surgeons Oncology Group Z0011 trial results inluenced the number of lymph nodes removed during sentinel lymph node dissection? Am J Surg 208(6):1060–1064

    Article  PubMed  Google Scholar 

  21. FitzSullivan E, Bassett RL, Kuerer HM, Mittendorf EA, Yi M, Hunt KK et al (2017) Outcomes of sentinel lymph node-positive breast cancer patients treated with mastectomy without axillary therapy. Ann Surg Oncol 24(3):652–659

    Article  PubMed  Google Scholar 

  22. Milgrom S, Cody H, Tan L, Morrow M, Pesce C, Setton J et al (2012) Characteristics and outcomes of sentinel node-positive breast cancer patients after total mastectomy without axillary-specific treatment. Ann Surg Oncol 19(12):3762–3770

    Article  PubMed  Google Scholar 

  23. Snow R, Reyna C, Johns C, Lee MC, Sun W, Fulp WJ et al (2015) Outcomes with and without axillary node dissection for node-positive lumpectomy and mastectomy patients. Am J Surg 210(4):685–693

    Article  PubMed  Google Scholar 

  24. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N (2002) Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med 347(8):567–575

    Article  PubMed  Google Scholar 

  25. Joyce DP, Manning A, Carter M, Hill AD, Kell MR, Barry M (2015) Meta-analysis to determine the clinical impact of axillary lymph node dissection in the treatment of invasive breast cancer. Breast Cancer Res Treat 153(2):235–240

    Article  PubMed  CAS  Google Scholar 

  26. Houvenaeghel G, Boher JM, Reyal F, Cohen M, Garbay JR, Classe JM et al (2016) Impact of completion axillary lymph node dissection in patients with breast cancer and isolated tumour cells or micrometastases in sentinel nodes. Eur J Cancer 67:106–118

    Article  PubMed  CAS  Google Scholar 

  27. Sanghani M, Balk EM, Cady B (2009) Impact of axillary lymph node dissection on breast cancer outcome in clinically node negative patients: a systematic review and meta-analysis. Cancer 115(8):1613–1620

    Article  PubMed  Google Scholar 

  28. de Boniface J, Frisell J, Andersson Y, Bergkvist L, Ahlgren J, Ryden L et al (2017) Survival and axillary recurrence following sentinel node-positive breast cancer without completion axillary lymph node dissection: the randomized controlled SENOMAC trial. BMC Cancer 17(1):379

    Article  PubMed  PubMed Central  Google Scholar 

  29. van Roozendaal LM, de Wilt JH, van Dalen T, van der Hage JA, Strobbe LJ, Boersma LJ et al (2015) The value of completion axillary treatment in sentinel node positive breast cancer patients undergoing a mastectomy: a Dutch randomized controlled multicentre trial (BOOG 2013-07). BMC Cancer 15:610

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  30. Savolt A, Peley G, Polgar C, Udvarhelyi N, Rubovszky G, Kovacs E et al (2017) Eight-year follow up result of the OTOASOR trial: the Optimal treatment of the axilla—surgery or radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: a randomized, single centre, phase III, non-inferiority trial. Eur J Surg Oncol 43(4):672–679

    Article  PubMed  CAS  Google Scholar 

  31. Sola M, Alberro JA, Fraile M, Santesteban P, Ramos M, Fabregas R et al (2013) Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastasis: final results from the multicenter clinical trial AATRM 048/13/2000. Ann Surg Oncol 20(1):120–127

    Article  PubMed  Google Scholar 

  32. Galimberti V, Cole BF, viale G, veronesi P, Vicini E, Intra M et al (2017) Axillary dissection vs. no axillary dissection in patients with cT1-T2cN0M0 breast cancer and only micrometastases in the sentinel node(s): ten-year results of the IBCSG 23-01 Trial. San Antonio Breast Cancer Symposium

  33. Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Jackson SM, Wilson KS et al (2005) Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst 97(2):116–126

    Article  PubMed  Google Scholar 

  34. Overgaard M, Nielsen HM, Overgaard J (2007) Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 b&c randomized trials. Radiother Oncol. 82(3):247–253

    Article  Google Scholar 

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Funding

There was no external funding for this work.

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Authors and Affiliations

  1. Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, 1120 N.W. 14th Street, CRC Room 410T, Miami, FL, 33136, USA

    Kristina Khazeni, Casey Allen, Danny Yakoub, Eli Avisar & Susan B. Kesmodel

  2. Sylvester Comprehensive Cancer Center, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA

    Omar Picado, Danny Yakoub, Eli Avisar & Susan B. Kesmodel

Authors
  1. Omar Picado
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  2. Kristina Khazeni
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  3. Casey Allen
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  4. Danny Yakoub
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  5. Eli Avisar
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  6. Susan B. Kesmodel
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Contributions

OP and SK contributed for study conception and design; OP and SK analyzed the data. OP, KK, CA, and SK prepared the manuscript. DY, EA, and SK provided critical revisions to the manuscript. OP, KK, CA, DY, EA, and SK reviewed the manuscript.

Corresponding author

Correspondence to Susan B. Kesmodel.

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All the authors declare that they have no conflict of interest.

Informed consent

This study utilizes retrospective, de-identified information. Informed consent was not necessary.

Research involving human and animal participants

This article does not contain any studies with human participants or animals performed by any of the authors.

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Picado, O., Khazeni, K., Allen, C. et al. Extent of regional lymph node surgery and impact on outcomes in patients with early-stage breast cancer and limited axillary disease undergoing mastectomy. Breast Cancer Res Treat 171, 461–469 (2018). https://doi.org/10.1007/s10549-018-4840-9

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  • DOI: https://doi.org/10.1007/s10549-018-4840-9

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