The changing landscape of axillary surgery: which breast cancer patients may still benefit from complete axillary lymph node dissection?

BACKGROUND AND OBJECTIVES

Many breast cancer patients undergoing completion axillary lymph node dissection (CALND) for sentinel lymph node (SLN) metastases have no further disease. Predicting patients at high risk of non-sentinel lymph node (NSLN) metastasis may help guide effective utilization of CALND.

METHODS

SLN+ breast cancer patients undergoing frozen section (FS) analysis at a single institution (2004-2010) were studied retrospectively. Factors associated with NSLN metastases were identified.

RESULTS

Two-hundred forty SLN+ patients were identified. The incidence of NSLN metastases was 45% in FS(+) patients undergoing CALND, compared to 10% of FS(-) patients following CALND (P < 0.001). Multivariate analysis revealed that FS positivity, tumor size, and the presence of angiolymphatic invasion were significant factors associated with NSLN metastases (all P < 0.05). Further analysis of FS(+) patients revealed that tumor size, ER(-) status, and lymph node metastasis size were also associated with risk of NSLN metastases. An algorithm for the management of the axilla in SLN+ breast cancer patients was devised, based on clinic-pathologic predictors of NSLN metastases.

CONCLUSION

A SLN+ biopsy by FS predicts the presence of NSLN metastases and, in combination with other factors, may justify immediate CALND. CALND may, however, be avoided in selected low-risk SLN+ patients.