Moving Away From Axillary Lymph Node Dissection Indicates Practice-Changing Trials
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- Batsis, C. & Zoras, O. Ann Surg Oncol (2011) 18: 281. doi:10.1245/s10434-011-1884-z
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Axillary lymph node dissection (ALND) during breast-conserving surgery (BCS) or mastectomy has been the standard practice for the surgical treatment of breast cancer. To reduce side effects of ALND, sentinel lymph node dissection (SLND) has been developed and standardized for early-stage breast cancer. Until recently, micrometastases or metastases in one or more sentinel nodes was considered as indication for ALND. However, recent, large-scale, randomized trials have showed no survival benefit or improved locoregional control of ALND compared with no ALND when micrometastatic or metastatic disease is detected in sentinel lymph nodes (SLN).1,2 Therefore, ALND can be considered an overtreatment in selected patients. Under these new practice-changing results, new recommendations for multidisciplinary treatment of early breast cancer also require modification.
To highlight potential consequences by omitting complete ALND (cALND) after the publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 Study,2 Caudle and colleagues3 evaluated and shaped the new landscape for the multidisciplinary treatment of selected patients with early breast cancer.
Based on the eligibility criteria and results from ACOSOG Z0011 trial,2 a multidisciplinary team at MD Anderson now counsels the majority of women with clinical T1/T2, N0 tumors with a positive SLN who are undergoing breast-conserving surgery with whole breast irradiation that they may omit cALND with no significant impact on their rate of local-regional recurrence or overall survival.3
Although this general guidance may benefit most of these women, there are some concerns. The ACOSOG Z0011 trial closed early because of slow accrual with a total of 891 patients, instead of 1,900 initially planned to enroll. At a relatively short median follow-up of 6.3 years, ipsilateral axillary recurrences were noted in 0.5% (n = 2) of patients after ALND versus 0.9% (n = 4) in the SLND-only arm and longer follow-up is needed to determine whether this difference will be increased.
Two different trends are now seen in the United States: a reduction in ALND rate and a dramatic increase in bilateral mastectomy by simultaneous decrease in the rate of BCS for various reasons including family history with positive or even negative BRCA1/2 testing, young age and others.3,4
The ACOSOG Z0011 trial raises important questions about the origin of metastatic cancer cells. This study suggests that the primary tumor is similar to those of metastatic cells at axilla lymph nodes regarding their sensitivity to multimodal treatment.2 Perhaps systemic treatment and radiation are able to kill potential residual disease in axilla lymph nodes. However, a recent whole-genome sequencing study in a woman with breast cancer regarding distant metastasis suggests that a different small subpopulation of cells within the primary tumor acquires the capacity of metastasis at distant organs.
Emerging biomedical research using modern powerful genome-wide mapping technological advances in both cancer whole-genome sequencing and understanding how genetic and epigenetic changes deregulate gene expression patterns in cancer, provide rational optimism for personalized management of cancer.5–12
Conflict of interest