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Axillary Node Interventions in Breast Cancer A Systematic Review

Roshni Rao, MD1; David Euhus, MD1; Helen G. Mayo, MLS2; Charles Balch, MD1
[+] Author Affiliations
1Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
2Library, University of Texas Southwestern Medical Center, Dallas
JAMA. 2013;310(13):1385-1394. doi:10.1001/jama.2013.277804.
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Importance  Recent data from clinical trials have challenged traditional thinking about axillary surgery in patients with breast cancer.

Objectives  To summarize evidence regarding the role of axillary interventions (surgical and nonsurgical) in breast cancer treatment and to review the association of these axillary interventions with recurrence of axillary node metastases, mortality, and morbidity outcomes in patients with breast cancer.

Evidence Review  Ovid MEDLINE (1946–July 2013), Cochrane Database of Systematic Reviews (2005–July 2013), Cochrane Database of Abstracts of Reviews of Effects (1994–July 2013), and Cochrane Central Register of Controlled Trials (1989–July 2013) were searched for publications on axillary interventions in breast cancer. Clinical trials, observational studies, and meta-analyses with at least 2-year follow-up were included. A total of 1070 publications were reviewed, 17 of which met final inclusion criteria.

Findings  Partial mastectomy followed by whole breast radiation is breast-conserving therapy. For women with no suspicious, palpable axillary nodes who undergo breast-conserving therapy, there is little evidence of benefit from surgical complete axillary node dissection compared with sentinel node biopsy alone. Complete axillary node dissection in patients with no palpable lymph nodes, compared with sentinel node biopsy, provides no survival benefit and is associated with a 1% to 3% reduction in recurrence of axillary lymph node metastases, but is associated with a 14% risk of lymphedema. Surgical axillary staging via sentinel node biopsy in patients with benign axillary nodes on radiological and clinical examination helps to inform decisions regarding adjuvant systemic and radiation therapy. Patients and physicians should tailor axillary lymph node interventions to maximize regional disease control and minimize morbidity. Complete axillary lymph node dissection is indicated in patients who present with palpable or needle biopsy–proven axillary metastases, patients with positive sentinel nodes undergoing mastectomy (who do not, as a standard, receive adjuvant radiation), patients with more than 3 positive sentinel nodes undergoing breast-conserving therapy, and patients not meeting eligibility criteria for recent trials establishing the safety of sentinel node biopsy alone in patients with breast cancer and metastases in their sentinel nodes.

Conclusion and Relevance  Available evidence suggests that axillary node dissection is associated with more harm than benefit in women undergoing breast-conserving therapy who do not have palpable, suspicious lymph nodes, who have tumors 3.0 cm or smaller, and who have 3 or fewer positive nodes on sentinel node biopsy.

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Figure 1.
Anatomical Landmarks of the Axilla and Lymphatic Drainage of the Breast

Sentinel nodes are identified within levels 1 and 2. Anatomical landmarks of the thoracodorsal bundle, long thoracic nerve, and axillary vein are used to delineate tissue removed during a level 1 and 2 complete axillary lymph node dissection.

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Figure 2.
Proposed Treatment Algorithm for Patients With Breast Cancer Who Present With No Palpable, Suspicious Axillary Nodes Based on the Results of the Systematic Reviewa

aIf initial tumor size is >3.0 cm or patient is to undergo neoadjuvant chemotherapy, algorithm does not apply.

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