Axillary Dissection Vs No Axillary Dissection

Summary:

One of the most important topic in breast Cancer. Much awaited ACOSOG Z0011 study

Axillary Dissection Vs No Axillary Dissection

Nikhilesh Patil 13 Feb 2011 22:15

64/ postmenopausal lady, presented with a lump in right breast. Metastatic Work up negative. Clinically mobile 4cm tumor with no axillary ln. Bx=IDC.
Sx: Lumpectomy with sentinel lymph node dissection done.
HPR: 4.6 cms IDC, Grade 3, NO EIC, LVI focally positive. ER/PR strong positive. Her2 neu Negative. Clear Margins.
LN: 3/4 positive no ECE.

Was sent to us for adjuvant radiation, my teaching was that this lady needs complete axillary ln dissection however things have changed and our breast surgeons do not do it anymore. This publication is an excellent example.
This study is published in full paper form and is ready to be discussed.
http://jama.ama-assn.org/content/305/6/569.full.pdf+html

Please feel free to discuss and tell us how your breast team is handling this issue.

Last edited on 13 Feb 2011 22:57 by Nikhilesh Patil Show more

Re: Axillary Dissection Vs No Axillary Dissection

AAM 15 Feb 2011 11:54

by my reading of the JAMA study, this lady was not eligible ("Women were ineligible if they had 3 or more positive SLNs"). We need to see the detail of the JAMA trial and keep to that patient profile very closely.

I would be very uneasy about not having adjuvant nodal irradiation. She would have been eligible for the Danish and Canadian trials that show a survival improvement. The trial result tells us about axillary surgery, but nothing about axillary radiotherapy. Clearly the previous assumptions about 'good'/'bad' or 'adequate'/'inadequate' axillary surgery are incorrect. Either 2 nodes is enough, or axillary dissection just tells you about risk of further axillary disease. It also seems to suggest that another 10-14 LNs is insufficient to greatly affect the risk.

Maybe we were wrong all along and nodes are now irrelevant except as a marker of metastatic risk?

Last edited on 15 Feb 2011 12:04 by AAM Show more

Re: Axillary Dissection Vs No Axillary Dissection

Nikhilesh Patil 16 Feb 2011 04:22

I agree Andrew, we are doing whole breast radiotherapy and axillary RT for this lady, infact unlike my training back home people in Canada routinely treat axilla (if indicated) based on the British Columbia data.

Re: Axillary Dissection Vs No Axillary Dissection

Nikhilesh Patil 08 Mar 2011 02:14

I attended a JC on this paper and had to read the full paper again.
about 200 patients lost to follow-up (didn't know it can happen in USA too) and about 170 cases did not have LVSI commented upon and complete pathology missing in a good number of cases.
But Iam surprised that many breast surgeons have changed there practice even before the data was published.
Would be interesting to know how other breast surgeons in rest of the world are reacting to this.

Last edited on 08 Mar 2011 02:15 by Nikhilesh Patil Show more

Re: Axillary Dissection Vs No Axillary Dissection

Nikhilesh Patil 25 Mar 2011 01:41

Any comment from the house if they have adopted sentinel LN and stopped complete axillary clearance?