Presentation
Nonsentinel node metastases in breast cancer patients with isolated tumor cells in the sentinel node: implications for completion axillary node dissection

Presented at the Sixth Annual Meeting of the American Society of Breast Surgeons, Los Angeles, California, March 16–20, 2005
https://doi.org/10.1016/j.amjsurg.2005.06.018Get rights and content

Abstract

Background

Controversy exists regarding axillary dissection (ALND) for sentinel node (SLN) metastases detected as isolated tumor cells (ITC). We hypothesized that the number of positive non-SLNs is low and ALND is unnecessary for most patients with ITC.

Methods

From 1995 to 1999, 634 breast cancer patients underwent SLND. SLNs were examined using immunohistochemistry if hematoxylin and eosin was negative. ALND was recommended for ITC-positive SLNs.

Results

Seventy-eight patients (12.3%) with ITC-positive SLNs were offered ALND. Sixty-one consented, whereas 17 refused. Fifty-eight (95.1%) had negative non-SLNs. Three (4.9%) had non-SLN metastases. One patient (1.6%) had macrometastatic disease, whereas 2 (3.3%) had micrometastases. No ITC-only–positive SLN patient experienced axillary recurrence.

Conclusions

When ALND was performed for ITC, 1.6% of non-SLNs harbored macrometastases and 3.3% had micrometastases. When ALND was not performed, axillary recurrence was not seen. The low risk of non-SLN disease in this study fails to support the routine use of ALND for ITC-positive SLNs.

Section snippets

Methods

Between January 1995 and December 1999, patients with invasive breast cancer underwent SLND at the John Wayne Cancer Institute instead of traditional ALND. All specimens were examined using cytokeratin IHC if traditional H&E analysis was negative. ALND was recommended for all positive SLNs, including those with ITC. The existence of metastatic disease in non-SLN was determined by routine H&E testing. After publication of the 2002 AJCC staging system, all SLN specimens were reexamined and

Results

A total of 634 women with invasive breast cancer underwent SLND during the study period and had their SLNs examined with IHC when initial H&E staining was negative. Seventy-eight patients (12.3%) had at least 1 ITC-positive SLN and were offered axillary clearance. Sixty-one women consented to ALND, whereas 17 did not.

Of the 61 patients subjected to ALND, 58 (95.1%) had non-SLNs free of additional metastatic disease by H&E examination. Patients with negative non-SLNs had an average age of 56.4

Comments

Before the application of SLN biopsy to breast cancer, all patients with invasive disease required level I and II axillary dissections to achieve adequate nodal staging and regional control [6]. In the early 1990s, SLND was introduced as an equally accurate, less morbid alternative to full axillary dissection, which was reserved for patients with positive SLNs [7]. To address the growing use of the SLN procedure, as well as more sophisticated evaluation techniques, the AJCC staging system was

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