Skip to main content

Advertisement

SpringerLink
Log in

Omission of Axillary Dissection According to ACOSOG Z0011: Impact on Adjuvant Treatment Recommendations

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Objective

A recent, randomized trial (ACOSOG Z0011) has demonstrated that omission of completion axillary lymph node dissection (ALND) in patients with one or two sentinel lymph node (SLN) metastases treated with breast conserving therapy (BCT) does not have a negative impact on survival. This study evaluates the impact of omitting ALND on adjuvant treatment recommendations.

Methods

Performing a search of our clinical database, we identified patients meeting the main inclusion and exclusion criteria of ACOSOG Z0011 treated at the University of Heidelberg Breast Center. We performed blinded mock interdisciplinary tumor boards based on patient and tumor characteristics as well as (1) SLN information or (2) final nodal status after ALND. Differences between treatment recommendations were noted and analyzed.

Results

A total of 132 patients were included; 80.3 % of these had one and 19.7 % had two metastatic sentinel nodes with a rate of micrometastases only of 19.7 %, and 39.7 % of patients had additional nonsentinel node metastases upon ALND. Overall, there was a change in adjuvant chemotherapy in 18.2 % of cases. Treatment recommendations based on ALND lead to a more aggressive therapy in 16.6 % of cases, all of them with additional metastatic nonsentinel nodes. Chemotherapy was not recommended in only two cases (1.5 %) based on ALND. Based on ALND, irradiation of the supraclavicular and infraclavicular nodes was added in 5.3 % of patients.

Conclusions

Completion ALND for patients with one or two metastatic sentinel nodes in pT1-2 cN0 PBC treated with BCT does have a relevant impact on adjuvant treatment. This should be considered in shared decision making.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Krag DN, Anderson SJ, Julian TB, et al. 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. 2010;11:927–33.

    Article  PubMed  Google Scholar 

  2. Krag DN, Anderson SJ, Julian TB, et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 2007;8:881–8.

    Article  PubMed  CAS  Google Scholar 

  3. Giuliano AE, Haigh PI, Brennan MB, et al. Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer. J Clin Oncol. 2000;18:2553–9.

    PubMed  CAS  Google Scholar 

  4. Yi M, Giordano SH, Meric-Bernstam F, et al. Trends in and outcomes from sentinel lymph node biopsy (SLNB) alone vs. SLNB with axillary lymph node dissection for node-positive breast cancer patients: experience from the SEER database. Ann Surg Oncol. 2010;17(Suppl 3):343–51.

    Article  PubMed  Google Scholar 

  5. Moebus V, Jackisch C, Lueck HJ, et al. Intense dose-dense sequential chemotherapy with epirubicin, paclitaxel, and cyclophosphamide compared with conventionally scheduled chemotherapy in high-risk primary breast cancer: mature results of an AGO phase III study. J Clin Oncol. 2010;28:2874–80.

    Article  PubMed  CAS  Google Scholar 

  6. Goldhirsch A, Wood WC, Coates AS, et al. Strategies for subtypes–dealing with the diversity of breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2011. Ann Oncol. 2011;22:1736–47.

    Article  PubMed  CAS  Google Scholar 

  7. Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg. 2010;252:426–32; discussion 432–3.

    Google Scholar 

  8. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs. no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569–75.

    Article  PubMed  CAS  Google Scholar 

  9. AGO_Breast_Commission. Diagnosis and treatment of patients with primary and metastatic breast cancer. In version 1 2012 Edition. http://www.ago-online.de: 2012.

  10. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)® Version I.2012. In version I.2012 Edition. http://www.NCCN.org: 2012.

  11. Fisher B, Jeong JH, Anderson S, et al. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567–75.

    Article  PubMed  Google Scholar 

  12. Veronesi U, Orecchia R, Zurrida S, et al. Avoiding axillary dissection in breast cancer surgery: a randomized trial to assess the role of axillary radiotherapy. Ann Oncol. 2005;16:383–8.

    Article  PubMed  CAS  Google Scholar 

  13. Citron ML, Berry DA, Cirrincione C, et al. Randomized trial of dose-dense versus conventionally scheduled and sequential versus concurrent combination chemotherapy as postoperative adjuvant treatment of node-positive primary breast cancer: first report of Intergroup Trial C9741/Cancer and Leukemia Group B Trial 9741. J Clin Oncol. 2003;21:1431–9.

    Article  PubMed  CAS  Google Scholar 

  14. Berry DA, Cirrincione C, Henderson IC, et al. Estrogen-receptor status and outcomes of modern chemotherapy for patients with node-positive breast cancer. JAMA. 2006;295:1658–67.

    Article  PubMed  CAS  Google Scholar 

  15. Wasif N, Maggard MA, Ko CY, Giuliano AE. Underuse of axillary dissection for the management of sentinel node micrometastases in breast cancer. Arch Surg. 2010;145:161–6.

    Article  PubMed  Google Scholar 

  16. Heil J, Gondos A, Rauch G, et al. Outcome analysis of patients with primary breast cancer initially treated at a certified academic breast unit. Breast. 2012;21:303–8.

    Article  PubMed  CAS  Google Scholar 

  17. Vinh-Hung V, Verkooijen HM, Fioretta G, et al. Lymph node ratio as an alternative to pN staging in node-positive breast cancer. J Clin Oncol. 2009;27:1062–8.

    Article  PubMed  Google Scholar 

  18. Van Belle V, Van Calster B, Wildiers H, et al. Lymph node ratio better predicts disease-free survival in node-positive breast cancer than the number of positive lymph nodes. J Clin Oncol. 2009;27:e150–1; author reply e152.

    Google Scholar 

  19. Whelan T. NCIC-CTG MA.20: an intergroup trial of regional nodal irradiation in early breast cancer. J Clin Oncol. 2011;abstr LBA1003.

  20. Katz A, Smith BL, Golshan M, et al. Nomogram for the prediction of having four or more involved nodes for sentinel lymph node-positive breast cancer. J Clin Oncol. 2008;26:2093–8.

    Article  PubMed  Google Scholar 

  21. Haffty BG, Hunt KK, Harris JR, Buchholz TA. Positive sentinel nodes without axillary dissection: implications for the radiation oncologist. J Clin Oncol. 2011;29:4479–81.

    Article  PubMed  Google Scholar 

  22. Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg. 2010;252:426–32. Discussion 32-3.

    PubMed  Google Scholar 

  23. Cody HS 3rd. Does the rapid acceptance of ACOSOG Z0011 compromise selection of systemic therapy? Ann Surg Oncol. 2012;19:3643–5.

    Article  PubMed  Google Scholar 

  24. Montemurro F, Maggiorotto F, Valabrega G, et al. Omission of axillary dissection after a positive sentinel node dissection may influence adjuvant chemotherapy indications in operable breast cancer patients. Ann Surg Oncol. 2012;19:3755–61.

    Article  PubMed  Google Scholar 

  25. Mittendorf EA, Hunt KK, Boughey JC, et al. Incorporation of sentinel lymph node metastasis size into a nomogram predicting nonsentinel lymph node involvement in breast cancer patients with a positive sentinel lymph node. Ann Surg. 2012;255:109–15.

    Article  PubMed  Google Scholar 

  26. Van Zee KJ, Manasseh DM, Bevilacqua JL, et al. A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003;10:1140–51.

    Article  PubMed  Google Scholar 

  27. Hessman CJ, Naik AM, Kearney NM, et al. Comparative validation of online nomograms for predicting nonsentinel lymph node status in sentinel lymph node-positive breast cancer. Arch Surg. 2011;146:1035–40.

    Article  PubMed  Google Scholar 

  28. Kamath VJ, Giuliano R, Dauway EL, et al. Characteristics of the sentinel lymph node in breast cancer predict further involvement of higher-echelon nodes in the axilla: a study to evaluate the need for complete axillary lymph node dissection. Arch Surg. 2001;136:688–92.

    Article  PubMed  CAS  Google Scholar 

  29. Memorial Sloan-Kettering Cancer Center. Breast Cancer Nomogram: breast additional non-SLN metastases. In: http://nomograms.mskcc.org/Breast/BreastAdditionalNonSLNMetastasesPage.aspx.

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University Hospital, Heidelberg, Germany

    Julia Aigner, Katharina Smetanay, Christof Sohn, Andreas Schneeweiss & Frederik Marmé

  2. National Center for Tumour Diseases, University Hospital, Heidelberg, Germany

    Julia Aigner, Katharina Smetanay, Andreas Schneeweiss & Frederik Marmé

  3. Department of Radiotherapy, University Hospital, Heidelberg, Germany

    Holger Hof PhD

  4. Institute of Pathology, University of Heidelberg, Heidelberg, Germany

    Hans-Peter Sinn

Authors
  1. Julia Aigner
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Katharina Smetanay
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Holger Hof PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hans-Peter Sinn
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christof Sohn
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Andreas Schneeweiss
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Frederik Marmé
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Frederik Marmé.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Aigner, J., Smetanay, K., Hof, H. et al. Omission of Axillary Dissection According to ACOSOG Z0011: Impact on Adjuvant Treatment Recommendations. Ann Surg Oncol 20, 1538–1544 (2013). https://doi.org/10.1245/s10434-012-2798-0

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-012-2798-0

Keywords

Search

Navigation