Annals of Surgical Oncology

, Volume 17, Issue 4, pp 1063–1068

Predictors of Completion Axillary Lymph Node Dissection in Patients With Immunohistochemical Metastases to the Sentinel Lymph Node in Breast Cancer

  • Matthew S. Pugliese
  • Amer K. Karam
  • Meier Hsu
  • Michelle M. Stempel
  • Sujata M. Patil
  • Alice Y. Ho
  • Tiffany A. Traina
  • Kimberly J. Van Zee
  • Hiram S. CodyIII
  • Monica Morrow
  • Mary L. Gemignani
Breast Oncology



Axillary lymph node dissection (ALND) in patients with immunohistochemistry (IHC)-determined metastases to the sentinel lymph node (SLN) is controversial. The goal of this study was to examine factors associated with ALND in IHC-only patients.


Retrospective review of an institutional SLN database from July 1997 to July 2003 was performed. We compared sociodemographic, pathologic, and therapeutic variables between IHC-only patients who had SLN biopsy alone and those that had ALND.


Our study group consisted of 171 patients with IHC-only metastases to the SLN. Young age, estrogen receptor negative status, high Memorial Sloan-Kettering Cancer Center nomogram score, and chemotherapy were associated with ALND. Among patients who had ALND (n = 95), 18% had a positive non-SLN. Rates of systemic therapy were similar between those with and without positive non-SLNs at ALND. No axillary recurrences were observed in this series with a median follow-up of 6.4 years. The percentage of patients who were recurrence-free after 5 years was 97% (95% confidence interval, 92.1–98.6).


On the basis of our findings and the lack of prospective randomized data, the practice of selectively limiting ALND to IHC-only patients thought to be at high risk and to patients for whom the identification of additional positive nodes may change systemic therapy recommendations seems to be a safe and reasonable approach.


  1. 1.
    Adair F, Berg J, Joubert L, et al. Long-term followup of breast cancer patients: the 30-year report. Cancer. 1974;33:1145–50.CrossRefPubMedGoogle Scholar
  2. 2.
    NIH Consensus Conference (1991) Treatment of early-stage breast cancer. JAMA. 265:391–5.CrossRefGoogle Scholar
  3. 3.
    Cabanas RM. An approach for the treatment of penile carcinoma. Cancer. 1977;39:456–66.CrossRefPubMedGoogle Scholar
  4. 4.
    Giuliano AE, Kirgan DM, Guenther JM, et al. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Krag DN, Weaver DL, Alex JC, et al. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol. 1993;2:335–9.CrossRefPubMedGoogle Scholar
  6. 6.
    McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol. 2008;26:5213–9.CrossRefPubMedGoogle Scholar
  7. 7.
    McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008;26:5220–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Silverstein MJ, Lagios MD, Recht A, et al. Image-detected breast cancer: state of the art diagnosis and treatment. J Am Coll Surg. 2005;201:586–97.CrossRefPubMedGoogle Scholar
  9. 9.
    Dowlatshahi K, Fan M, Snider HC, et al. Lymph node micrometastases from breast carcinoma: reviewing the dilemma. Cancer. 1997;80:1188–97.CrossRefPubMedGoogle Scholar
  10. 10.
    Cote RJ, Peterson HF, Chaiwun B, et al. Role of immunohistochemical detection of lymph-node metastases in management of breast cancer. International Breast Cancer Study Group. Lancet. 1999;354(9182):896–900.Google Scholar
  11. 11.
    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.CrossRefPubMedGoogle Scholar
  12. 12.
    Cody HS 3rd, Fey J, Akhurst T, et al. Complementarity of blue dye and isotope in sentinel node localization for breast cancer: univariate and multivariate analysis of 966 procedures. Ann Surg Oncol. 2001;8:13–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Piccirillo JF, Tierney RM, Costas I, et al. Prognostic importance of comorbidity in a hospital-based cancer registry. JAMA. 2004;291:2441–7.CrossRefPubMedGoogle Scholar
  14. 14.
    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.CrossRefPubMedGoogle Scholar
  15. 15.
    Czerniecki BJ, Scheff AM, Callans LS, et al. Immunohistochemistry with pancytokeratins improves the sensitivity of sentinel lymph node biopsy in patients with breast carcinoma. Cancer. 1999;85:1098–103.CrossRefPubMedGoogle Scholar
  16. 16.
    Schreiber RH, Pendas S, Ku NN, et al. Microstaging of breast cancer patients using cytokeratin staining of the sentinel lymph node. Ann Surg Oncol. 1999;6:95–101.CrossRefPubMedGoogle Scholar
  17. 17.
    Teng S, Dupont E, McCann C, et al. Do cytokeratin-positive-only sentinel lymph nodes warrant complete axillary lymph node dissection in patients with invasive breast cancer? Am Surg. 2000;66:574–8.PubMedGoogle Scholar
  18. 18.
    Singletary E. Early-stage invasive breast cancer: isolated tumor cells in axillary lymph nodes, peripheral blood, and bone marrow. Gen Surg News. 2006;33:17–20.Google Scholar
  19. 19.
    Gray RJ, Pockaj BA, Conley CR. Sentinel lymph node metastases detected by immunohistochemistry only do not mandate complete axillary lymph node dissection in breast cancer. Ann Surg Oncol. 2004;11:1056–60.CrossRefPubMedGoogle Scholar
  20. 20.
    Jakub JW, Diaz NM, Ebert MD, et al. Completion axillary lymph node dissection minimizes the likelihood of false negatives for patients with invasive breast carcinoma and cytokeratin positive only sentinel lymph nodes. Am J Surg. 2002;184:302–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Early Breast Cancer Trialists’ Collaborative Group. Polychemotherapy for early breast cancer: an overview of the randomised trials. Lancet. 1998;352(9132):930–42.Google Scholar
  22. 22.
    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.CrossRefPubMedGoogle Scholar
  23. 23.
    Freneaux P, Nos C, Vincent-Salomon A, et al. Histological detection of minimal metastatic involvement in axillary sentinel nodes: a rational basis for a sensitive methodology usable in daily practice. Mod Pathol. 2002;15:641–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Marin C, Mathelin C, Neuville A, et al. Sentinel lymph node biopsy with micrometastases in breast cancer: histological data and surgical implications. About a series of 201 axillary dissections after peroperative sentinel node identification. Bull Cancer. 2003;90:459–65.PubMedGoogle Scholar
  25. 25.
    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.CrossRefPubMedGoogle Scholar
  26. 26.
    Bergkvist L, Frisell J, Liljegren G, et al. Multicentre study of detection and false-negative rates in sentinel node biopsy for breast cancer. Br J Surg. 2001;88:1644–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Mignotte H, Treilleux I, Faure C, et al. Axillary lymph-node dissection for positive sentinel nodes in breast cancer patients. Eur J Surg Oncol. 2002;28:623–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Cserni G, Gregori D, Merletti F, et al. Meta-analysis of non–sentinel node metastases associated with micrometastatic sentinel nodes in breast cancer. Br J Surg. 2004;91:1245–52.CrossRefPubMedGoogle Scholar
  29. 29.
    van Deurzen CH, de Boer M, Monninkhof EM, et al. Non–sentinel lymph node metastases associated with isolated breast cancer cells in the sentinel node. J Natl Cancer Inst. 2008;100:1574–80.CrossRefPubMedGoogle Scholar
  30. 30.
    Calhoun KE, Hansen NM, Turner RR, et al. Nonsentinel node metastases in breast cancer patients with isolated tumor cells in the sentinel node: implications for completion axillary node dissection. Am J Surg. 2005;190:588–91.CrossRefPubMedGoogle Scholar
  31. 31.
    Langer I, Marti WR, Guller U, et al. Axillary recurrence rate in breast cancer patients with negative sentinel lymph node (SLN) or SLN micrometastases: prospective analysis of 150 patients after SLN biopsy. Ann Surg. 2005;241:152–8.PubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2009

Authors and Affiliations

  • Matthew S. Pugliese
    • 1
  • Amer K. Karam
    • 1
  • Meier Hsu
    • 1
  • Michelle M. Stempel
    • 1
  • Sujata M. Patil
    • 2
  • Alice Y. Ho
    • 3
  • Tiffany A. Traina
    • 4
  • Kimberly J. Van Zee
    • 1
  • Hiram S. CodyIII
    • 1
  • Monica Morrow
    • 1
  • Mary L. Gemignani
    • 1
  1. 1.Breast Service, Department of SurgeryMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  2. 2.Department of Epidemiology and BiostatisticsMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  3. 3.Department of Radiation OncologyMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  4. 4.Department of MedicineMemorial Sloan-Kettering Cancer CenterNew YorkUSA

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