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Axillary lymph node dissection in node-positive breast cancer: are ten nodes adequate and when is enough, enough?

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Abstract

Purpose

National guidelines define adequate axillary lymph node dissections as those yielding ≥ 10 lymph nodes (LNs). We aimed to identify the optimal LN yield among node-positive patients.

Methods

Using the National Cancer Data Base (2010–2015), we categorized node-positive patients as follows: (1) neoadjuvant chemotherapy (NAC, cN1–3 or ypN1mi-3) or (2) upfront surgery (pN1–3). A restricted cubic splines model was used to estimate LN retrieval thresholds associated with change in overall survival (OS).

Results

129,685 patients were identified: 21.2% NAC, 78.8% upfront surgery. Low, moderate, and high retrieval thresholds were estimated to be 1–6, 7–21, and > 21 LNs (upfront surgery), and 1–7, 8–22, and > 22 LNs (NAC). In an adjusted model, high versus low LN yield was associated with greater receipt of adjuvant chemotherapy (upfront surgery OR 1.96, p < 0.001) and greater use of adjuvant radiation (upfront surgery OR 1.08, p = 0.02; NAC OR 1.23, p = 0.002). After adjustment, high versus low LN retrieval was associated with improved OS (upfront surgery HR 0.86, p < 0.001; NAC HR 0.77, p < 0.001). Worse OS was associated with retrieving fewer LNs, likely as a result of an under-staged axilla and missed opportunity for adjuvant therapy, while better OS was independently associated with retrieval of up to approximately 20 LNs, after which survival did not improve.

Conclusion

In node-positive breast cancer, the number of nodes retrieved is significantly associated with an increased positive nodal count and greater use of adjuvant therapy. Removal of approximately 20 LNs may improve survival by both more accurate nodal staging and increased adjuvant therapy use.

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Funding

Dr. O. Fayanju is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under Award Number 1KL2TR002554 (PI: Svetkey). Dr. R. Greenup is supported by the NIH BIRCWH K12HD043446 (PI: Andrews). This work is also supported by the Duke Cancer Institute through NIH Grant P30CA014236 (PI: Kastan).

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Authors and Affiliations

  1. Department of Surgery, Duke University Medical Center, Durham, NC, USA

    Laura H. Rosenberger, Rachel A. Greenup, Oluwadamilola M. Fayanju, E. Shelley Hwang & Jennifer K. Plichta

  2. Duke Cancer Institute, Duke University, Durham, NC, USA

    Laura H. Rosenberger, Yi Ren, Samantha M. Thomas, Rachel A. Greenup, Oluwadamilola M. Fayanju, E. Shelley Hwang & Jennifer K. Plichta

  3. Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA

    Yi Ren & Samantha M. Thomas

  4. Department of Surgery, Duke University, DUMC 3351, Durham, NC, 27710, USA

    Laura H. Rosenberger

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  1. Laura H. Rosenberger
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  7. Jennifer K. Plichta
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Corresponding author

Correspondence to Laura H. Rosenberger.

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Conflict of interest

All authors declare that they have no conflict of interest to disclose.

Ethical approval

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.

Informed consent

Due to use of national de-identified data (National Cancer Data Base, NCDB), our institutional review board granted the study exempt status and no individual informed consent was needed.

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Rosenberger, L.H., Ren, Y., Thomas, S.M. et al. Axillary lymph node dissection in node-positive breast cancer: are ten nodes adequate and when is enough, enough?. Breast Cancer Res Treat 179, 661–670 (2020). https://doi.org/10.1007/s10549-019-05500-9

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  • DOI: https://doi.org/10.1007/s10549-019-05500-9

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