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Axilla lymph node dissection can be safely omitted in patients with 1–2 positive sentinel nodes receiving mastectomy: a large multi-institutional study and a systemic meta-analysis

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Abstract

Purpose

This study aimed to evaluate whether axillary lymph node dissection (ALND) can be omitted in patients with 1–2 positive sentinel lymph nodes (SLNs) who received total mastectomy (TM).

Methods

Consecutive breast cancer patients with 1–2 positive SLNs were retrospectively reviewed from a multi-institutional database. Patients were divided into sentinel lymph node biopsy (SLNB) group and ALND group. Administration of adjuvant chemotherapy and survival were compared between groups. To further verify the results, a meta-analysis was also conducted.

Results

Among the 1161 enrolled patients, 893 (76.9%) received ALND and 268 (23.1%) underwent SLNB alone. Administration of chemotherapy was comparable between the two groups (91.1% vs. 90.6%, P = 0.798), which was consistent in TM (P = 0.638) and BCS cohort (P = 0.576). After a median follow-up of 36 months, no significant difference was observed between the two groups in recurrence-free survival (P = 0.583) regardless of surgery of breast. During further meta-analysis, 13 out of 4733 relative studies reported the association of axillary surgery and disease-free survival (DFS) or overall survival (OS) in 1–2 positive SLNs patients. Pooled analysis showed no difference in adjusted DFS (HR 0.84, 95% CI 0.70–1.02) or OS (HR 1.02, 95% CI 0.93–1.11) between SLNB and ALND groups. Survival benefit of ALND remained non-significant after restricting the analysis in four studies with patients only receiving BCS, or in three studies with patients only receiving TM.

Conclusion

Further ALND does not impact adjuvant chemotherapy administration or disease outcome in breast cancer patients with 1–2 positive SLNs treated with TM.

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Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ALND:

Axillary lymph node dissection

SLNB:

Sentinel lymph node biopsy

SLN:

Sentinel lymph node

ACOSOG:

American College of Surgeons Oncology Group

BCS:

Breast-conserving surgery

TM:

Total mastectomy

SJTU-BCDB:

Shanghai Jiao Tong University-Breast Cancer Database

DCIS:

Ductal carcinoma in situ

IDC:

Invasive ductal carcinoma

ILC:

Invasive lobular cancer

non-SLN:

non-sentinel lymph node

RFS:

Recurrence-free survival

ACT:

Adjuvant chemotherapy

HR:

Hazard ratio

DFS:

Disease-free survival

OS:

Overall survival

CI:

Confidence interval

ER:

Estrogen receptor

PR:

Progesterone receptor

HER-2:

Human epidermal growth factor receptor-2

SLNR:

Sentinel lymph node ratio

OR:

Odds ratio

LRR:

Local–regional recurrence

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Funding

This work was supported by the National Natural Science Foundation of China (No. 81772797); Shanghai Municipal Education Commission—Gaofeng Clinical Medicine Grant Support (No. 20172007); and Ruijin Hospital, Shanghai Jiao Tong University School of Medicine—“Guangci Excellent Youth Training Program” (No. GCQN-2017-A18). The funders had no role in study design, data collection, data analysis, article writing, or article submission.

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Author notes

  1. Weiqi Gao, Shuangshuang Lu and Yufei Zeng have contributed equally to this work.

Authors and Affiliations

  1. Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Second Road, Shanghai, 200025, China

    Weiqi Gao, Shuangshuang Lu, Yufei Zeng, Xiaosong Chen & Kunwei Shen

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  1. Weiqi Gao
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by WG, SL, XC and YZ. The first draft of the manuscript was written by WG, SL and YZ, and XC and KS revised the manuscript. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Xiaosong Chen or Kunwei Shen.

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The authors declare that they have no conflict of interest.

Ethical approval

Current study was reviewed and approved by independent ethical committees of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. 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.

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Informed consent was obtained from all individual participants included in the study.

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Gao, W., Lu, S., Zeng, Y. et al. Axilla lymph node dissection can be safely omitted in patients with 1–2 positive sentinel nodes receiving mastectomy: a large multi-institutional study and a systemic meta-analysis. Breast Cancer Res Treat 196, 129–141 (2022). https://doi.org/10.1007/s10549-022-06727-9

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