Axillary management for young women with breast cancer varies between patients electing breast-conservation therapy or mastectomy
- 30 Downloads
Axillary treatment strategies for the young woman with early-stage, clinically node-negative breast cancer undergoing upfront surgery found to have 1–3 positive sentinel lymph nodes (SLNs) differ significantly after BCT and mastectomy. Here we compare axillary lymph node dissection (ALND) and regional nodal irradiation (NRI) rates between women electing breast-conservation therapy (BCT) versus mastectomy.
From 2010 to 2016, women age < 50 years with clinical T1-T2N0 breast cancer having upfront surgery and found to have a positive SLN were identified. ALND and/or NRI receipt were compared between groups.
192 women undergoing BCT and 165 undergoing mastectomy were identified (median age: 44 years). 5.2% (10/192) of women undergoing BCT had an ALND versus 87% (144/165) of women undergoing mastectomy (p < 0.01). NRI was given to 48% (78/165) of mastectomy patients compared to 30% (57/192) of BCT patients (p < 0.01). Of the 75 mastectomy patients with 1–2 total positive lymph nodes after completion ALND, 44% received NRI. Women undergoing mastectomy were significantly more likely to receive both ALND and NRI than women undergoing BCS (45% vs 6%, p < 0.01).
Young cT1-2N0 breast cancer patients found to have 1–3 SLN metastases received ALND, NRI, and combined ALND/NRI more frequently if they elected mastectomy over BCT. Use of both ALND and postmastectomy radiotherapy (PMRT) in this population could be reduced in the future by omitting ALND in patients for whom the need for PMRT is clear with the finding of 1–2 SLN metastases.
KeywordsBreast cancer Axillary lymph node dissection Regional nodal irradiation Breast-conservation therapy Mastectomy
ABT, TAM, AK, and MM were involved in the conception and design of the study. ABT and MM were involved in the acquisition of data. ABT and MM were involved in study supervision. ABT, TAM, MS, ECZ, AK, and MM were involved in the analysis and interpretation of data. All authors were involved in the writing, review, and/or revision of this manuscript and approved the final manuscript.
The preparation of this manuscript was funded in part by NIH/NCI Cancer Center Support Grant No. P30 CA008748 to Memorial Sloan Kettering Cancer Center.
Compliance with ethical standards
Conflict of interest
First author Dr. Audree B. Tadros declares that she has no conflict of interest. Second author Dr. Tracy-Ann Moo declares that she has no conflict of interest. Third author Michelle Stempel declares that she has no conflict of interest. Fourth author Dr. Emily C. Zabor declares that she has no conflict of interest. Fifth author Dr. Atif Khan declares that he has no conflict of interest. Sixth author Dr. Monica Morrow declares the receipt of speaking honoraria from Genomic Health and Roche.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent was obtained from all individual participants included in the study.
- 1.American Cancer Society (2017) Breast Cancer Facts & Figures 2017–2018. American Cancer Society, Inc., AtlantaGoogle Scholar
- 2.Truong PT, Olivotto IA, Kader HA, Panades M, Speers CH, Berthelet E (2005) Selecting breast cancer patients with T1–T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy. Int J Radiat Oncol Biol Phys 61(5):1337–1347CrossRefGoogle Scholar
- 3.Yang PS, Chen CM, Liu MC, Jian JM, Horng CF, Liu MJ, Yu BL, Lee MY, Chi CW (2010) Radiotherapy can decrease locoregional recurrence and increase survival in mastectomy patients with T1 to T2 breast cancer and one to three positive nodes with negative estrogen receptor and positive lymphovascular invasion status. Int J Radiat Oncol Biol Phys 77(2):516–522CrossRefGoogle Scholar
- 6.Mahmood U, Morris C, Neuner G, Koshy M, Kesmodel S, Buras R, Chumsri S, Bao T, Tkaczuk K, Feigenberg S (2012) Similar survival with breast conservation therapy or mastectomy in the management of young women with early-stage breast cancer. Int J Radiat Oncol Biol Phys 83(5):1387–1393CrossRefGoogle Scholar
- 10.Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR, Ollila DW, Hansen NM, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, Hunt KK, Morrow M (2017) Effect of axillary dissection vs 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):918–926CrossRefGoogle Scholar
- 12.Whelan TJ, Olivotto IA, Parulekar WR, Ackerman I, Chua BH, Nabid A, Vallis KA, White JR, Rousseau P, Fortin A, Pierce LJ, Manchul L, Chafe S, Nolan MC, Craighead P, Bowen J, McCready DR, Pritchard KI, Gelmon K, Murray Y, Chapman JA, Chen BE, Levine MN (2015) Regional nodal irradiation in early-stage breast cancer. N Engl J Med 373(4):307–316CrossRefGoogle Scholar
- 13.Gradishar WJ, Anderson BO, Balassanian R, Blair SL, Burstein HJ, Cyr A, Elias AD, Farrar WB, Forero A, Giordano SH, Goetz M, Goldstein LJ, Hudis CA, Isakoff SJ, Marcom PK, Mayer IA, McCormick B, Moran M, Patel SA, Pierce LJ, Reed EC, Salerno KE, Schwartzberg LS, Smith KL, Smith ML, Soliman H, Somlo G, Telli M, Ward JH, Shead DA, Kumar R (2016) Invasive breast cancer Version 1.2016, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw 14(3), 324–354.Google Scholar
- 14.Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW Jr, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB (2017) Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. Ann Surg Oncol 24(1):38–51CrossRefGoogle Scholar
- 16.Tendulkar RD, Rehman S, Shukla ME, Reddy CA, Moore H, Budd GT, Dietz J, Crowe JP, Macklis R (2012) Impact of postmastectomy radiation on locoregional recurrence in breast cancer patients with 1–3 positive lymph nodes treated with modern systemic therapy. Int J Radiat Oncol Biol Phys 83(5):e577–581CrossRefGoogle Scholar
- 17.Galimberti V, Cole BF, Viale G, Veronesi P, Vicini E, Intra M, Mazzarol G, Massarut S, Zgajnar J, Taffurelli M, Littlejohn D, Knauer M, Tondini C, Di Leo A, Colleoni M, Regan MM, Coates AS, Gelber RD, Goldhirsch A (2018) Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23–01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol 19(10):1385–1393CrossRefGoogle Scholar
- 18.Poodt IGM, Spronk PER, Vugts G, van Dalen T, Peeters M, Rots ML, Kuijer A, Nieuwenhuijzen GAP, Schipper RJ (2018) Trends on axillary surgery in nondistant metastatic breast cancer patients treated between 2011 and 2015: a Dutch Population-based Study in the ACOSOG-Z0011 and AMAROS Era. Ann Surg 268(6):1084–1090CrossRefGoogle Scholar
- 24.Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJ, Mansel RE, Cataliotti L, Westenberg AH, Klinkenbijl JH, Orzalesi L, Bouma WH, van der Mijle HC, Nieuwenhuijzen GA, Veltkamp SC, Slaets L, Duez NJ, de Graaf PW, van Dalen T, Marinelli A, Rijna H, Snoj M, Bundred NJ, Merkus JW, Belkacemi Y, Petignat P, Schinagl DA, Coens C, Messina CG, Bogaerts J, Rutgers EJ (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):1303–1310CrossRefGoogle Scholar
- 28.Magill LJ, Robertson FP, Jell G, Mosahebi A, Keshtgar M (2017) Determining the outcomes of post-mastectomy radiation therapy delivered to the definitive implant in patients undergoing one- and two-stage implant-based breast reconstruction: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 70(10):1329–1335CrossRefGoogle Scholar
- 29.Grossmith S, Nguyen A, Hu J, Plichta JK, Nakhlis F, Cutone L, Dominici L, Golshan M, Duggan M, Carter K, Rhei E, Barbie T, Calvillo K, Nimbkar S, Bellon J, Wong J, Punglia R, Barry W, King TA (2018) Multidisciplinary management of the axilla in patients with cT1-T2 N0 breast cancer undergoing primary mastectomy: results from a prospective single-institution series. Ann Surg Oncol 25(12):3527–3534CrossRefGoogle Scholar
- 30.McGale P, Taylor C, Correa C, Cutter D, Duane F, Ewertz M, Gray R, Mannu G, Peto R, Whelan T, Wang Y, Wang Z, Darby S (2014) Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet 383(9935):2127–2135CrossRefGoogle Scholar
- 31.Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F, Kjaer M, Gadeberg CC, Mouridsen HT, Jensen MB, Zedeler K (1997) Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 337(14), 949–955.CrossRefGoogle Scholar
- 32.McBride A, Allen P, Woodward W, Kim M, Kuerer HM, Drinka EK, Sahin A, Strom EA, Buzdar A, Valero V, Hortobagyi GN, Hunt KK, Buchholz TA (2014) Locoregional recurrence risk for patients with T1,2 breast cancer with 1–3 positive lymph nodes treated with mastectomy and systemic treatment. Int J Radiat Oncol Biol Phys 89(2):392–398CrossRefGoogle Scholar