Delaying axillary node dissection for a few weeks does not appear to be detrimental in breast cancer patients with positive sentinel nodes, according to a report in the July 20th Journal of Clinical Oncology.
"Increasingly, women with breast cancer are able to make choices about their treatment," Dr. John A. Olson, Jr. from Duke University Medical Center, Durham, North Carolina told Reuters Health. "While we certainly do not want to turn one operation into two for most women with breast cancer and sentinel node metastasis, these data suggest that taking a stepwise approach to axillary management is a safe and reasonable option for women who do want to consider other options than axillary node dissection."
Dr. Olson and colleagues compared pathological results and short-term complications between patients undergoing immediate versus delayed completion axillary lymph node dissection (cALND) after a positive sentinel lymph node biopsy. Timing of cALND was at the discretion of the patient and surgeon.
The median interval between sentinel node biopsy and cALND in the delayed group was 19 days (range, 1 to 93 days), the report indicates. In the immediate cALND group, mean tumor size was larger and the rate of estrogen-receptor-negative tumors was greater, compared to the delayed group.
Women who underwent immediate cALND had additional nodal metastasis identified 42% of the time, compared with 27% of the time in women who had delayed cALND.
Women who underwent immediate cALND also had significantly more total positive lymph nodes and a higher pathologic N stage than did women in the delayed cALND group.
Besides immediate cALND, other factors associated with increasing numbers of positive lymph nodes identified on cALND included tumor size, presence of lymphovascular invasion, and more than one positive sentinel lymph node.
When complications were compared according to the timing of cALND, axillary paresthesia and impaired range of motion were significantly more common at 30 days (but not at 1 year) in the immediate cALND group, the investigators say. Patients who had delayed cALND had more lymphedema at 6 months, but not at 1 year.
"Our data indicate that concern of increased complications in a delayed cALND (compared with immediate cALND) should not be used to justify nonoperative treatment," the authors conclude.
But, they point out, "there is considerable added cost and emotional stress to the patient associated with additional surgical procedures, so we emphasize that it is best to use intraoperative sentinel lymph node assessment and perform cALND when sentinel lymph node metastases are found intraoperatively."
In his email to Reuters Health, Dr. Olsen added, "Further, in the circumstance where the metastasis is not detected at the initial sentinel node procedure and a return trip to the operating room is needed, there is no clear physical or treatment detriment to the patient other than the potential added cost and concern over a second operative procedure."
"We will continue to follow patients in the American College of Surgeons Oncology Group sentinel node trials to determine long-term effects of immediate and delayed axillary dissection," Dr. Olson said. "We are in the planning stages of a study designed to assess cost-effectiveness of the immediate versus delayed approach. We will extend this analysis to compare cost effectiveness of completion axillary dissection versus axillary radiation therapy."
J Clin Oncol 2008;26:3530-3535.
Reviewed by Ramaz Mitaishvili, MD
