Abstract
Recent data suggest that axillary lymph node dissection (ALND) may be unnecessary for patients with positive sentinel lymph node biopsy (SLNB) receiving whole-breast irradiation (ACOSOG Z0011). The purpose of this study was to use decision analysis with simulated patients to determine subgroups with positive SLNB who may still benefit from ALND. We performed a decision analysis simulating axillary recurrence (ALR) risk, lymphedema, and quality of life following breast-conserving surgery (BCS) with positive SLNB and either completion ALND and whole-breast radiation (ALND + BRT) or breast radiation (BRT) alone. Simulated patients were divided into two risk groups based on the likelihood of disease in non-sentinel axillary nodes after positive SLNB: those with risk 30–60 % (“high-risk”) and those with risk under 30 % (“low-risk,” similar to average Z0011 patients). In simulated patients aged 55, BRT alone resulted in 1 month of additional QALE in the low-risk group versus ALND + BRT, while ALND + BRT resulted in 9.7 months of additional QALE in the high-risk group versus BRT alone. Overall survival was similar at 5 years in this simulation with either treatment in both groups, but ALND + BRT was superior to BRT alone at 20 years in the high-risk group (42 vs. 38 %). In the low-risk group, BRT alone is preferable unless ALR risk with BRT is greater than 1.6 % or lymphedema risk with ALND is under 10 %. Patients eligible for Z0011 but at a higher risk of residual nodal disease following BCS and positive SLNB may benefit from ALND + BRT, rather than BRT alone.
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Fleissig A, Fallowfield LJ, Langridge CI et al (2006) Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat 95:279–293
Ashikaga T, Krag DN, Land SR et al (2010) Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol 102:111–118
Krag DN, Anderson SJ, Julian TB 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 11:927–933
National Comprehensive Cancer Network (2008) Clinical practice guidelines in oncology: breast, version 2.2008. NCCN, Fort Washington
Lyman GH, Giuliano AE, Somerfield MR et al (2005) American society of clinical oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 23:7703–7720
Giuliano AE, McCall L, Beitsch P et al (2010) 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 252:426–432 (discussion 432–433)
Giuliano AE, Hunt KK, Ballman KV et al (2011) Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. J Am Med Assoc 305:569–575
Haffty BG, Hunt KK, Harris JR et al (2011) Positive sentinel nodes without axillary dissection: implications for the radiation oncologist. J Clin Oncol 29:4479–4481
Caudle AS, Hunt KK, Kuerer HM et al (2011) Multidisciplinary considerations in the implementation of the findings from the American college of surgeons oncology group (ACOSOG) Z0011 study: a practice-changing trial. Ann Surg Oncol 18:2407–2412
Batsis C, Zoras O (2011) Moving away from axillary lymph node dissection indicates practice-changing trials. Ann Surg Oncol 18(Suppl 3):S281–S282
National Comprehensive Cancer Network (2012) Clinical practice guidelines in oncology: breast, version 1.2012. NCCN, Fort Washington
Cox CE, Bass SS, McCann CR et al (2000) Lymphatic mapping and sentinel lymph node biopsy in patients with breast cancer. Annu Rev Med 51:525–542
Kim T, Giuliano AE, Lyman GH (2006) Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis. Cancer 106:4–16
Noguchi M, Motomura K, Imoto S et al (2000) A multicenter validation study of sentinel lymph node biopsy by the Japanese breast cancer society. Breast Cancer Res Treat 63:31–40
Olson JA Jr, Fey J, Winawer J et al (2000) Sentinel lymphadenectomy accurately predicts nodal status in T2 breast cancer. J Am Coll Surg 191:593–599
Anderson BO, Gralow JR (2011) Axillary vs sentinel lymph node dissection for invasive breast cancer. J Am Med Assoc 305:2290 (author reply 2290–2291)
Fayda M, Chen R (2011) Axillary vs sentinel lymph node dissection for invasive breast cancer. J Am Med Assoc 305:2289 (author reply 2290–2291)
Vuthaluru S, Srivastava A (2011) Axillary vs sentinel lymph node dissection for invasive breast cancer. J Am Med Assoc 305:2290 (author reply 2290–2291)
Fisher B, Montague E, Redmond C et al (1977) Comparison of radical mastectomy with alternative treatments for primary breast cancer. A first report of results from a prospective randomized clinical trial. Cancer 39:2827–2839
Axelsson CK, During M, Christiansen PM et al (2009) Impact on regional recurrence and survival of axillary surgery in women with node-negative primary breast cancer. Br J Surg 96:40–46
Pejavar S, Wilson LD, Haffty BG (2006) Regional nodal recurrence in breast cancer patients treated with conservative surgery and radiation therapy (BCS + RT). Int J Radiat Oncol Biol Phys 66:1320–1327
Vujovic O, Yu E, Cherian A et al (2009) The number of axillary nodes removed as a predictor of regional recurrence in node negative breast cancer. Radiother Oncol 91:38–41
Fisher B, Anderson S, Bryant J et al (2002) Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233–1241
Edge SB (2010) AJCC cancer staging manual, softcover. AJCC, Chicago
Gartner R, Jensen MB, Kronborg L et al (2010) Self-reported arm-lymphedema and functional impairment after breast cancer treatment—a nationwide study of prevalence and associated factors. Breast 19:506–515
Lukens JN, Vapiwala N, Hwang WT et al (2009) Regional nodal recurrence after breast conservation treatment with radiotherapy for women with early-stage breast carcinoma. Int J Radiat Oncol Biol Phys 73:1475–1481
Sanpaolo P, Barbieri V, Genovesi D (2011) Prognostic value of breast cancer subtypes on breast cancer specific survival, distant metastases and local relapse rates in conservatively managed early stage breast cancer: a retrospective clinical study. Eur J Surg Oncol 37:876–882
Voogd AC, Cranenbroek S, de Boer R et al (2005) Long-term prognosis of patients with axillary recurrence after axillary dissection for invasive breast cancer. Eur J Surg Oncol 31:485–489
Howlader NNA, Krapcho M, Neyman N, Aminou R, Waldron W, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA, Edwards BK (eds) (1975–2008) SEER cancer statistics review. National Cancer Institute, Bethesda
NCHS (2006) National center for health statistics, 2006. Vital Health Stat 13(162):1–209
Norman SA, Localio AR, Potashnik SL et al (2009) Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol 27:390–397
Petrek JA, Senie RT, Peters M et al (2001) Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 92:1368–1377
TMC (2011) Tufts medical center CEA registry, 2011. Tufts Medical Center, Boston
Galper SR, Lee SJ, Tao ML et al (2000) Patient preferences for axillary dissection in the management of early-stage breast cancer. J Natl Cancer Inst 92:1681–1687
Skedgel C, Rayson D, Younis T (2009) The cost–utility of sequential adjuvant trastuzumab in women with Her2/Neu-positive breast cancer: an analysis based on updated results from the HERA trial. Value Health 12:641–648
Wong SL, Abell TD, Chao C et al (2002) Optimal use of sentinel lymph node biopsy versus axillary lymph node dissection in patients with breast carcinoma: a decision analysis. Cancer 95:478–487
Fu AZ, Kattan MW (2008) Utilities should not be multiplied: evidence from the preference-based scores in the United States. Med Care 46:984–990
Barranger E, Coutant C, Flahault A et al (2005) An axilla scoring system to predict non-sentinel lymph node status in breast cancer patients with sentinel lymph node involvement. Breast Cancer Res Treat 91:113–119
Gur AS, Unal B, Ozbek U et al (2010) Validation of breast cancer nomograms for predicting the non-sentinel lymph node metastases after a positive sentinel lymph node biopsy in a multi-center study. Eur J Surg Oncol 36:30–35
Kohrt HE, Olshen RA, Bermas HR et al (2008) New models and online calculator for predicting non-sentinel lymph node status in sentinel lymph node positive breast cancer patients. BMC Cancer 8:66
Pal A, Provenzano E, Duffy SW et al (2008) A model for predicting non-sentinel lymph node metastatic disease when the sentinel lymph node is positive. Br J Surg 95:302–309
Van Zee KJ, Manasseh DM, Bevilacqua JL et al (2003) A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol 10:1140–1151
Evans SB, Gass J, Wazer DE (2008) Management of the axilla after the finding of a positive sentinel lymph node: a proposal for an evidence-based risk-adapted algorithm. Am J Clin Oncol 31:293–299
Whelan TJ, Olivotto I, Ackerman I, Chapman JW, Chua B, Nabid A, Vallis KA, White JR, Rousseau P, Fortin A, Pierce LJ, Manchul L, Craighead P, Nolan MC, Bowen J, McCready DR, Pritchard KI, Levine MN, Parulekar W (2011) NCIC-CTG MA. 20: an intergroup trial of regional nodal irradiation in early breast cancer. Abstract. J Clin Oncol 29 (suppl; abstr LBA1003)
Darby S, McGale P, Correa C et al (2011) Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 378:1707–1716
Fisher B, Redmond C, Fisher ER et al (1985) Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 312:674–681
Bremnes RM, Andersen K, Wist EA (1995) Cancer patients, doctors and nurses vary in their willingness to undertake cancer chemotherapy. Eur J Cancer 31A:1955–1959
McQuellon RP, Muss HB, Hoffman SL et al (1995) Patient preferences for treatment of metastatic breast cancer: a study of women with early-stage breast cancer. J Clin Oncol 13:858–868
Slevin ML, Stubbs L, Plant HJ et al (1990) Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses, and general public. Br Med J 300:1458–1460
Galimberti VE (2011) Surgical resection with or without axillary lymph node dissection in treating women with node-negative breast cancer and sentinel lymph node micrometastases. Abstract. In: 34th Annual San Antonio breast cancer symposium (SABCS) S3-1. Henry B. Gonzalez Convention Center, San Antonio
Galimberti VCB, Zurrida S, Viale G, Luini A, Veronesi P, Baratella P, Chifu C, Sargenti M, Intra M, Gentilini O, Massarut S, Garbay J-R, Zgajnar J, Galatius H, Recalcati A, Littlejohn D, Bamert M, Price KN, Goldhirsch A, Gelber RD, Veronesi U (2011) Update of international breast cancer study group trial 23-01 to compare axillary dissection versus no axillary dissection in patients with clinically node negative breast cancer and micrometastases in the sentinel node. Presented at the 34th Annual San Antonio breast cancer symposium, abstract S3-1. Henry B. Gonzalez Convention Center, San Antonio
Fodor J, Toth J, Major T et al (1999) Incidence and time of occurrence of regional recurrence in stage I–II breast cancer: value of adjuvant irradiation. Int J Radiat Oncol Biol Phys 44:281–287
Forrest AP, Everington D, McDonald CC et al (1995) The Edinburgh randomized trial of axillary sampling or clearance after mastectomy. Br J Surg 82:1504–1508
Galper S, Recht A, Silver B et al (2000) Is radiation alone adequate treatment to the axilla for patients with limited axillary surgery? Implications for treatment after a positive sentinel node biopsy. Int J Radiat Oncol Biol Phys 48:125–132
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Krishnan, M.S., Recht, A., Bellon, J.R. et al. Trade-offs associated with axillary lymph node dissection with breast irradiation versus breast irradiation alone in patients with a positive sentinel node in relation to the risk of non-sentinel node involvement: implications of ACOSOG Z0011. Breast Cancer Res Treat 138, 205–213 (2013). https://doi.org/10.1007/s10549-013-2418-0
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DOI: https://doi.org/10.1007/s10549-013-2418-0