Feb. 9, 2011 –
One of the most unpleasant aspects of breast cancer treatment may be
coming to an end. A new study finds certain patients with early-stage
breast cancer that had spread to a nearby lymph node, and who received
treatment removing lymph nodes from the armpit, had no better chance of
survival than women who just had the sentinel lymph node removed (the
first lymph node to which cancer is likely to spread from the primary
The study is
reported in today’s issue of the Journal of the American Medical
node dissection (ALND) - surgery to remove lymph nodes found in the
armpit - has been part of breast cancer surgery since the use of radical
mastectomy and reliably identifies nodal metastases.
node dissection (SLND) accurately identifies nodal metastasis of early
breast cancer, but it is not clear whether further nodal dissection
(removal) affects survival," the authors write in explaining why
they pursued the study.
"ALND, as a
means for achieving local disease control, carries an indisputable and
often unacceptable risk of complications such as seroma (a mass or
swelling caused by the localized accumulation of serum within a tissue
or organ), infection, and lymphedema (condition in which excess fluid
called lymph collects in tissues and causes swelling)."
Giuliano, M.D., of the John Wayne Cancer Institute at Saint John's
Health Center, Santa Monica, Calif., and colleagues conducted a study to
determine the effects of ALND on overall survival in patients with SLN
metastases treated with lumpectomy (surgical removal of a tumor without
removing much of the surrounding tissue or lymph nodes) and radiation
The trial was
conducted at 115 sites and enrolled patients from May 1999 to December
2004. Patients were women with T1-T2 (stage of tumor) invasive breast
cancer, no palpable adenopathy (enlarged lymph nodes), and 1 to 2 SLNs
SLN metastases identified by SLND were randomized to undergo ALND or no
further axillary treatment. Those randomized to ALND underwent
dissection of 10 or more nodes. Of 891 patients, 445 were randomly
assigned to the ALND group and 446 to the SLND-alone group.
there was a difference between ALND and SLND-alone treatment groups in
total number of removed lymph nodes and total number of tumor-involved
nodes; the median (midpoint) total number of nodes removed was 17 in the
ALND group and 2 in the SLND-alone group.
At a median
follow-up of 6.3 years, there were 94 deaths (SLND-alone group, 42; ALND
group, 52). The use of SLND alone compared with ALND did not appear to
result in statistically inferior survival, with the 5-year over all
survival rates being 92.5 percent in the SLND-alone group and 91.8
percent in the ALND group.
survival did not differ significantly between treatment groups, with
5-year disease-free survival being 83.9 percent for the SLND-alone group
and 82.2 percent for the ALND group.
The rate of
wound infections, axillary seromas, and paresthesias (prickly, tingling
sensations) among patients in the trial was higher for the ALND group
than for the SLND-alone group (70 percent vs. 25 percent).
The authors note
that these results suggest that breast cancer patients, such as those in
this study, do not benefit from the addition of ALND in terms of local
control, disease-free survival, or overall survival, and that ALND may
no longer be justified for certain patients.
of this practice change would improve clinical outcomes in thousands of
women each year by reducing the complications associated with ALND and
improving quality of life with no diminution in survival."
colleagues have made an important contribution to the surgical
management of SLN metastasis in breast cancer," write Grant Walter
Carlson, M.D., and William C. Wood, M.D., of Emory University, Atlanta,
in an accompanying editorial that the adage that less is more may be
applicable regarding surgery for breast cancer.
lead of other clinical investigators, "these randomized clinical trials
have shown that less surgery combined with more radiation and
chemotherapy have improved survival for women with breast cancer. Taken
together, findings from these investigators provide strong evidence that
patients undergoing partial mastectomy, whole-breast irradiation, and
systemic therapy for early breast cancer with microscopic SLN metastasis
can be treated effectively and safely without ALND."
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