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Optimizing Axillary Management in Clinical T1-2N0 Mastectomy Patients with Positive Sentinel Lymph Nodes

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Following publication of the AMAROS trial, we sought to optimize axillary lymph node dissection (ALND) or postmastectomy radiation therapy (PMRT) + axillary radiation (AxRT) utilization in cT1-2N0 patients with 1–2 positive sentinel lymph nodes (SLNs) after mastectomy.

Methods

In November 2015, our multidisciplinary group implemented a protocol to omit intraoperative SLN evaluation for mastectomy patients with cT1-2N0 breast cancer likely to be recommended PMRT if found to have 1–2 positive SLNs (age ≤ 60 years and/or high-risk features defined as estrogen receptor-negative and/or positive for lymphovascular invasion). We prospectively evaluated axillary management, short-term complications, and oncologic outcomes in patients with 1–2 positive SLNs.

Results

From November 2015 to December 2018, 479 of 560 (85%) cT1-2N0 breast cancers treated with mastectomy were potential candidates for PMRT. Intraoperative SLN evaluation was omitted in 344 (72%), thus following the protocol. Overall, 121 cases had 1–2 positive SLNs: 17 (14%) were managed with observation, 5 (4%) PMRT alone, 59 (49%) PMRT + AxRT, 16 (13%) ALND alone, and 24 (20%) ALND + PMRT. Protocol compliance resulted in less ALND (8% vs. 24%) and less ALND + PMRT (9% vs. 41%, p < 0.01). At median follow-up of 24 months, there was one regional and four distant recurrences, with no regional recurrences or differences in disease-free survival in patients treated with ALND versus PMRT + AxRT (100% vs. 98%, p = 0.67). Similarly, there were no differences in complication rates (p = 0.18).

Conclusions

Omitting intraoperative SLN evaluation in cT1-2N0 mastectomy patients who would be candidates for PMRT if found to have positive nodes decreased rates of ALND and minimized use of ALND + PMRT without compromising outcomes.

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Acknowledgment

J. Means acknowledges the Pamela and Nick Gelsomini Breast Surgical Oncology Fellowship Fund for support. The authors acknowledge Kaitlyn Bifolck, full-time editor at Dana-Farber Cancer Institute, for her editorial and submission support.

Funding

J. Means acknowledges the Pamela and Nick Gelsomini Breast Surgical Oncology Fellowship Fund for support.

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Author notes

  1. Olga Kantor and Jessica Means have contributed equally to this work.

Authors and Affiliations

  1. Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA

    Olga Kantor MD, MS, Jessica Means MD, Samantha Grossmith BA, Elizabeth A. Mittendorf MD, PhD & Tari A. King MD

  2. Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, USA

    Olga Kantor MD, MS, Elizabeth A. Mittendorf MD, PhD & Tari A. King MD

  3. Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA

    Tanujit Dey PhD

  4. Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, MA, USA

    Jennifer R. Bellon MD

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  1. Olga Kantor MD, MS
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Corresponding author

Correspondence to Tari A. King MD.

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Disclosures

T.A. King reports Speakers honoraria and advisory board participation for Exact Sciences (formerly Genomic Health); and Faculty, PrecisCA cancer information service. E.A. Mittendorf reports scientific advisory board participation for Exact Sciences (formerly Genomic Health).

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Kantor, O., Means, J., Grossmith, S. et al. Optimizing Axillary Management in Clinical T1-2N0 Mastectomy Patients with Positive Sentinel Lymph Nodes. Ann Surg Oncol 29, 972–980 (2022). https://doi.org/10.1245/s10434-021-10726-3

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