Of course there is a guideline statement and some trial data to support the abortion of ALND, but in what scenario will you be most comfortable about the decision?
To the guideline in our hospital and St Gallen consensus, you could do ALND or irradiation of axillae.
We all know that positiv node means spreading deasease and surgery is not therapeutic more paliative. If you predict that is more harm than by surgery is better choose irradiation. It is still big discusion with oncologist.
Dear Dr. Kok,
It is hard to answer since it is not specified which group of patients is involved. Do you mean, for instance, SNB in patients with early breast cancer undergoing breast conserving surgery or in patients who received SNB before NACT?
Dear Dr. Ricciardi, thanks for your further elucidation question. Here, this discussion is focusing on SNB in patients with EBC undergoing either MRM or BCS. Again, thanks.
The first group includes women undergoing BCS plus WBRT after SNB. The guidelines suggest that it is suitable not offering ALND also when 1-2 sentinel nodes at hematoxylin and eosin pathology evaluation were positive. This level of evidence is stated as high and the recommendation as strong. This results were provided by ACOSOG Z0011 and IBCSG 23-01 Trials. Both are Phase III trials which compared ALND vs no ALND in patients with axillary LNDs metastases.
The IBCSG 23-01 study limited enrollment to patients with micrometastases or ITCs in the sentinel lymph nodes, different from the Z0011 eligibility criteria which allowed micrometastatic or macrometastatic disease and in which 50% of patients had macrometastatic disease, 35% had micrometastases and the remainder no or unknown extent of nodal disease. Additionally, in the IBCSG study, 95% of patients had only one positive SLN whereas in the Z0011 study 79% of the SLN only group had zero or one positive SLN. Thus, nodal burden was lower in the IBCSG 23-01 study than ACOSOG Z0011. Therefore, in the context of Z0011, the results of the IBCSG 23-01 study, in which 95.6% of patients had only one positive SLN limited to ITCs or micrometastatic disease, are not surprising. Namely, local control and disease-free survival were not different with or without ALND after a median follow-up of 5 years in this highly selected group of patients. The study provides additional data to confirm that for this limited group of patients, mainly those with small ER-positive tumors with low nodal disease burden undergoing breast conservation with radiation, ALND might be avoided safely. It is important to note that in both of these studies, more than 90% of patients received systemic therapy.
Therefore, when metastatic extra-nodal disease is already spread in the axilla or the nodes that were harvested appeared clinically enlarged ( predicting extra nodal spread), caution should be used. Patients might also be selected preoperatively evaluating the presence of factors that may predict extra-nodal spread for instance using ultrasounds and FNAB.
One important pitfall is anyway the follow-up time. As the long term outcomes are unknown, we should be careful specially with younger patients with a prospective long survival.
Regarding the case of a patient who undergo mastectomy, the data are not clear and therefore not sufficient to give a definitive answer. Patient were too few and no evidence might be therefore provided.
This topic is debatable...but from our local experience its better to go for Axillary dissection even for EBC
The correct answer is what is your protocol?
1. My philosophy of frozen section is if lymph nodes are positive, ALND is necessary.
2. When frozen are negative and final histology shows micro-metastasis, ALND may not be done.
3. The fact that, there is gross metastasis in 2 sentinel lymph node; my protocol is ALND!
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