Annals of Surgical Oncology

, Volume 25, Issue 9, pp 2612–2619 | Cite as

The Potential Impact of AMAROS on the Management of the Axilla in Patients with Clinical T1-2N0 Breast Cancer Undergoing Primary Total Mastectomy

  • Martine Moossdorff
  • Faina Nakhlis
  • Jiani Hu
  • William T. Barry
  • Katya Losk
  • Courtney Haskett
  • Marjolein L. Smidt
  • Tari A. KingEmail author
Breast Oncology



Recent trials have demonstrated that axillary observation or axillary radiation therapy (AxRT) is equivalent to axillary node dissection (ALND) for patients with one or two positive sentinel lymph nodes (SLNs). These strategies have been widely adopted for patients having breast conservation. This report demonstrates the potential impact of the AMAROS trial on axillary therapy in a retrospective cohort of mastectomy patients.


Patients undergoing primary mastectomy for cT1-2N0 breast cancer who had one or two positive SLNs were identified from institutional databases (2005–2015). Locoregional management strategies were evaluated, and variables predictive of the use of postmastectomy radiation therapy (PMRT) were identified.


Among 2594 mastectomies, 193 (7%) met the AMAROS eligibility criteria. The median patient age was 50 years (range 22–83 years). Locoregional treatment consisted of ALND + PMRT for 102 patients (53%), ALND alone for 66 patients (34%), PMRT alone for 11 patients (6%), and observation for 14 patients (7%). Overall, 59 ALND patients (35%) had additional positive nodes. In the multivariate analysis, age younger than 50 years (odds ratio [OR] 3.55; 95% confidence interval [CI] 1.57–8.45), lymphovascular invasion (LVI) (OR 5.78; 95% CI 2.53–4.78), macrometastases (OR 3.99; 95% CI 1.54–10.97), and extracapsular extension (OR 11.66; 95% CI 2.55–88.34) were associated with receipt of PMRT.


In this cohort of AMAROS-eligible patients, 168 (87%) underwent ALND, 102 (61%) of whom also received PMRT, suggesting that AxRT could have been used instead of ALND for a significant number of patients. Preoperative factors associated with the receipt of PMRT, such as young age and LVI, may be useful for defining a multidisciplinary decision-making framework for axillary management in this population.



William T. Barry reports research funding (institutional) from Pfizer.

Supplementary material

10434_2018_6519_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 29 kb)


  1. 1.
    Giuliano AE, McCall L, Beitsch P, et al. 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. 2010;252:426–32; discussion 32–3.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569–75.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Giuliano AE, Ballman KV, McCall L, et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017;318:918–26.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Giuliano AE, Ballman K, McCall L, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial. Ann Surg. 2016;264:413–20.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Galimberti V, Cole BF, Zurrida S, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013;14:297–305.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Donker M, van Tienhoven G, Straver ME, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014;15:1303–10.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Early Breast Cancer Trialists’ Collaborative Group, McGale P, Taylor C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383:2127–35.CrossRefGoogle Scholar
  8. 8.
    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.CrossRefPubMedGoogle Scholar
  9. 9.
    Morrow M, Van Zee KJ, Patil S, et al. Axillary dissection and nodal irradiation can be avoided for most node-positive Z0011-eligible breast cancers: a prospective validation study of 793 patients. Ann Surg. 2017;266:457–62.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Gainer SM, Hunt KK, Beitsch P, Caudle AS, Mittendorf EA, Lucci A. Changing behavior in clinical practice in response to the ACOSOG Z0011 trial: a survey of the American Society of Breast Surgeons. Ann Surg Oncol. 2012;19:3152–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Caudle AS, Hunt KK, Tucker SL, et al American College of Surgeons Oncology Group (ACOSOG) Z0011: impact on surgeon practice patterns. Ann Surg Oncol. 2012;19:3144–51.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Camp MS, Greenup RA, Taghian A, et al. Application of ACOSOG Z0011 criteria reduces perioperative costs. Ann Surg Oncol. 2013;20:836–41.CrossRefPubMedGoogle Scholar
  13. 13.
    Recht A, Comen EA, Fine RE, et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. Ann Surg Oncol. 2017;24:38–51.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Recht A, Edge SB, Solin LJ, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;19:1539–69.CrossRefPubMedGoogle Scholar
  15. 15.
    Voduc KD, Cheang MC, Tyldesley S, Gelmon K, Nielsen TO, Kennecke H. Breast cancer subtypes and the risk of local and regional relapse. J Clin Oncol. 2010;28:1684–91.CrossRefPubMedGoogle Scholar
  16. 16.
    Colleoni M, Sun Z, Price KN, et al. Annual hazard rates of recurrence for breast cancer during 24 years of follow-up: results from the International Breast Cancer Study Group Trials I to V. J Clin Oncol. 2016;34:927–35.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Lowery AJ, Kell MR, Glynn RW, Kerin MJ, Sweeney KJ. Locoregional recurrence after breast cancer surgery: a systematic review by receptor phenotype. Breast Cancer Res Treat. 2012;133:831–41.CrossRefPubMedGoogle Scholar
  18. 18.
    El-Sabawi B, Ho AL, Sosin M, Patel KM. Patient-centered outcomes of breast reconstruction in the setting of post-mastectomy radiotherapy: a comprehensive review of the literature. J Plast Reconstr Aesthet Surg. 2017;70:768–80.CrossRefPubMedGoogle Scholar
  19. 19.
    Magill LJ, Robertson FP, Jell G, Mosahebi A, Keshtgar M. Determining the outcomes of post-mastectomy radiation therapy delivered to the definitive implant in patients undergoing one- and two-stage implant-based breast reconstruction: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2017;70:1329–35.CrossRefPubMedGoogle Scholar
  20. 20.
    Kunkler IH, Canny P, van Teinhoven G, Russell NS: MRC/EORTC (BIG 2-04) SUPREMO Trial Management Group: elucidating the role of chest wall irradiation in “intermediate-risk” breast cancer: the MRC/EORTC SUPREMO trial. Clin Oncol R Coll Radiol. 2008;20:31–4.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Martine Moossdorff
    • 1
  • Faina Nakhlis
    • 2
    • 3
  • Jiani Hu
    • 4
  • William T. Barry
    • 4
  • Katya Losk
    • 5
  • Courtney Haskett
    • 2
  • Marjolein L. Smidt
    • 1
  • Tari A. King
    • 2
    • 3
    Email author
  1. 1.Department of Surgery, GROW School for Oncology and Developmental BiologyMaastricht University Medical CenterMaastrichtThe Netherlands
  2. 2.Department of SurgeryBrigham and Women’s HospitalBostonUSA
  3. 3.Dana-Farber/Brigham and Women’s Cancer CenterBostonUSA
  4. 4.Department of Biostatistics and Computational BiologyDana-Farber Cancer InstituteBostonUSA
  5. 5.Medical OncologyDana-Farber Cancer InstituteBostonUSA

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