Annals of Surgical Oncology

, Volume 16, Issue 7, pp 1952–1958 | Cite as

Predictors of Completion Axillary Lymph Node Dissection in Patients with Positive Sentinel Lymph Nodes

  • Amer K. Karam
  • Meier Hsu
  • Sujata Patil
  • Michelle Stempel
  • Tiffany A. Traina
  • Alice Y. Ho
  • Hiram S. Cody
  • Elisa R. Port
  • Monica Morrow
  • Mary L. Gemignani
Breast Oncology

Abstract

Background

Completion axillary lymph node dissection (CALND) is routinely performed in breast cancer patients with positive sentinel lymph nodes (SLN). We sought to determine the sociodemographic, pathologic, and therapeutic variables that were associated with CALND.

Methods

From 7/1997 to 7/2003, 1,470 patients with invasive breast cancer were SLN positive by intraoperative frozen section or final pathologic exam by hematoxylin–eosin and/or immunohistochemistry (IHC). A comorbidity score was assigned using Adult Comorbidity Evaluation-27 system. Fisher’s exact, Wilcoxon tests, and multivariate logistic regression analysis were used.

Results

CALND was performed less often in patients with age ≥ 70 years compared with age < 70 years, moderate or severe comorbidities compared with no or mild, IHC-only positive SLN and breast conservation therapy (BCT compared with mastectomy. Patients who did not undergo CALND were less likely than CALND patients to have grade III disease, lymphovascular invasion multifocal disease, tumor size > 2 cm or to receive adjuvant chemotherapy. However, they were more likely to undergo axillary radiotherapy (RT). On multivariate analysis, age ≥ 70 years [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.26–0.63], IHC-only positive SLN (OR 0.13, 95%CI 0.09–0.19), presence of moderate to severe comorbidities (OR 0.64, 95%CI 0.41–0.99), tumor size ≤ 2 cm (OR 0.44, 95%CI 0.29–0.66), axillary RT (OR 0.39, 95%CI 0.20–0.78), and BCT (OR 0.54, 95%CI 0.37–0.79) were all independently associated with lower odds of CALND.

Conclusions

The decision to perform CALND following positive SLN biopsy was multifactorial. Patient factors were a primary determinant for the use of CALND in our study. The decreased use of CALND in the BCT patients probably reflects reliance on the radiotherapy tangents to maintain local control in the axilla.

References

  1. 1.
    Tan LK, Giri D, Hummer AJ, et al. Occult axillary node metastases in breast cancer are prognostically significant: results in 368 node-negative patients with 20-year follow-up. J Clin Oncol. 2008;26:1803–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Bear HD. Completion axillary lymph node dissection for breast cancer: immediate versus delayed versus none. J Clin Oncol. 2008;26:3483–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Krag DN, Julian TB, Harlow SP, et al. NSABP-32: phase III, randomized trial comparing axillary resection with sentinel lymph node dissection: a description of the trial. Ann Surg Oncol. 2004;11:208S–10.PubMedGoogle Scholar
  4. 4.
    Chu KU, Turner RR, Hansen NM, et al. Do all patients with sentinel node metastasis from breast carcinoma need complete axillary node dissection? Ann Surg. 1999;229:536–41.PubMedCrossRefGoogle Scholar
  5. 5.
    Chu KU, Turner RR, Hansen NM, et al. Sentinel node metastasis in patients with breast carcinoma accurately predicts immunohistochemically detectable nonsentinel node metastasis. Ann Surg Oncol. 1999;6:756–61.PubMedCrossRefGoogle Scholar
  6. 6.
    Grube BJ, Giuliano AE. Observation of the breast cancer patient with a tumor-positive sentinel node: implications of the ACOSOG Z0011 trial. Semin Surg Oncol. 2001;20:230–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Park J, Fey JV, Naik AM, et al. A declining rate of completion axillary dissection in sentinel lymph node-positive breast cancer patients is associated with the use of a multivariate nomogram. Ann Surg. 2007;245:462–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Piccirillo JF, Tierney RM, Costas I, et al. Prognostic importance of comorbidity in a hospital-based cancer registry. JAMA. 2004;291:2441–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Giuliano AE, Dale PS, Turner RR, et al. Improved axillary staging of breast cancer with sentinel lymphadenectomy. Ann Surg. 1995;222:394–399; discussion 399–401.Google Scholar
  10. 10.
    Giuliano AE, Kirgan DM, Guenther JM, et al. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391–398; discussion 398–401.Google Scholar
  11. 11.
    Burak WE, Hollenbeck ST, Zervos EE, et al. Sentinel lymph node biopsy results in less postoperative morbidity compared with axillary lymph node dissection for breast cancer. Am J Surg. 2002;183:23–27.PubMedCrossRefGoogle Scholar
  12. 12.
    Fleissig A, Fallowfield LJ, Langridge CI, et al. 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. 2006;95:279–93.PubMedCrossRefGoogle Scholar
  13. 13.
    Graversen HP, Blichert-Toft M, Andersen JA, et al. Breast cancer: risk of axillary recurrence in node-negative patients following partial dissection of the axilla. Eur J Surg Oncol. 1988;14:407–12.PubMedGoogle Scholar
  14. 14.
    Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol. 2005;23:7703–20.PubMedCrossRefGoogle Scholar
  15. 15.
    Abdessalam SF, Zervos EE, Prasad M, et al. Predictors of positive axillary lymph nodes after sentinel lymph node biopsy in breast cancer. Am J Surg. 2001;182:316–20.PubMedCrossRefGoogle Scholar
  16. 16.
    Degnim AC, Griffith KA, Sabel MS, et al. Clinicopathologic features of metastasis in nonsentinel lymph nodes of breast carcinoma patients. Cancer. 2003;98:2307–15.PubMedCrossRefGoogle Scholar
  17. 17.
    Kamath VJ, Giuliano R, Dauway EL, et al. Characteristics of the sentinel lymph node in breast cancer predict further involvement of higher-echelon nodes in the axilla: a study to evaluate the need for complete axillary lymph node dissection. Arch Surg. 2001;136:688–92.PubMedCrossRefGoogle Scholar
  18. 18.
    Turner RR, Chu KU, Qi K, et al. Pathologic features associated with nonsentinel lymph node metastases in patients with metastatic breast carcinoma in a sentinel lymph node. Cancer. 2000;89(3):574–81.PubMedCrossRefGoogle Scholar
  19. 19.
    Weiser MR, Montgomery LL, Tan LK, et al. Lymphovascular invasion enhances the prediction of non-sentinel node metastases in breast cancer patients with positive sentinel nodes. Ann Surg Oncol. 2001;8:145–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group trial Z0011. J Clin Oncol. 2007;25:3657–63.PubMedCrossRefGoogle Scholar
  21. 21.
    Furukawa T, Kubota T, Tanino H, et al. Chemosensitivity of breast cancer lymph node metastasis compared to the primary tumor from individual patients tested in the histoculture drug response assay. Anticancer Res. 2000;20:3657–8.PubMedGoogle Scholar
  22. 22.
    Singletary SE. Systemic treatment after sentinel lymph node biopsy in breast cancer: who, what, and why? J Am Coll Surg. 2001;192:220–30.PubMedCrossRefGoogle Scholar
  23. 23.
    Fisher B, Brown A, Mamounas E, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol. 1997;15:2483–93.PubMedGoogle Scholar
  24. 24.
    Van Zee KJ, Manasseh DM, Bevilacqua JL, et al. A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003;10:1140–51.PubMedCrossRefGoogle Scholar
  25. 25.
    Hughes KS, Schnaper LA, Berry D, et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med. 2004;351:971–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Hurria A, Leung D, Trainor K, et al. Factors influencing treatment patterns of breast cancer patients age 75 and older. Crit Rev Oncol Hematol. 2003;46:121–6.PubMedCrossRefGoogle Scholar
  27. 27.
    International Breast Cancer Study G. Randomized trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: first results of International Breast Cancer Study Group trial 10–93. J Clin Oncol. 2006;24:337–44.CrossRefGoogle Scholar
  28. 28.
    Engel J, Kerr J, Schlesinger-Raab A, et al. Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients. Breast Cancer Res Treat. 2003;79:47–57.PubMedCrossRefGoogle Scholar
  29. 29.
    Orr RK. The impact of prophylactic axillary node dissection on breast cancer survival—a Bayesian meta-analysis. Ann Surg Oncol. 1999;6:109–16.PubMedCrossRefGoogle Scholar
  30. 30.
    Schlembach PJ, Buchholz TA, Ross MI, et al. Relationship of sentinel and axillary level I–II lymph nodes to tangential fields used in breast irradiation. Int J Radiat Oncol Biol Phys. 2001;51:671–8.PubMedGoogle Scholar
  31. 31.
    Pejavar S, Wilson LD, Haffty BG. Regional nodal recurrence in breast cancer patients treated with conservative surgery and radiation therapy (BCS + RT). Int J Radiat Oncol Biol Phys. 2006;66:1320–7.PubMedGoogle Scholar
  32. 32.
    Gadd M, Harris J, Taghian A, et al. Prospective study of axillary radiation without axillary dissection for breast cancer patients with a positive sentinel node. San Antonio Breast Cancer Symposium Conference Paper December 8–11, 2005. 2005; Abstract 22.Google Scholar
  33. 33.
    European Organization for Research and Treatment of Cancer. EORTC-10981/AMAROS: after mapping of the axilla: radiotherapy or surgery. A phase III randomized study of complete axillary lymph node dissection versus axillary radiotherapy in sentinel lymph node-positive women with operable invasive breast cancer. http://www.cancer.gov/clinicaltrials/EORTC-10981. Accessed 22 Aug 2008.
  34. 34.
    Hurkmans CW, Borger JH, Rutgers EJ, et al. Quality assurance of axillary radiotherapy in the EORTC AMAROS trial 10981/22023: the dummy run. Radiother Oncol. 2003;68:233–40.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2009

Authors and Affiliations

  • Amer K. Karam
    • 1
  • Meier Hsu
    • 1
  • Sujata Patil
    • 2
  • Michelle Stempel
    • 1
  • Tiffany A. Traina
    • 3
  • Alice Y. Ho
    • 4
  • Hiram S. Cody
    • 1
  • Elisa R. Port
    • 1
  • Monica Morrow
    • 1
  • Mary L. Gemignani
    • 1
  1. 1.Breast Service, Department of SurgeryMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  2. 2.Department of BiostatisticsMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  3. 3.Department of MedicineMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  4. 4.Department of Radiation OncologyMemorial Sloan-Kettering Cancer CenterNew YorkUSA

Personalised recommendations