National surgical patterns of care: regional lymphadenectomy of breast sarcomas

Soft tissue sarcomas (STS) of the breast are rare tumors with few large experiences available regarding their optimal management. Although assessment of the draining lymphatics is not a component of standard surgical treatment of soft tissue sarcomas, we hypothesized that the management of breast STS may present a unique situation: given their experience with the more common epithelial lesions of the breast, surgeons may be more prone to sample lymph nodes (LNs) in these patients than would otherwise be indicated based on histologic subtype. We reviewed national surgical patterns of care for regional lymphadenectomy for breast STS using the Surveillance Epidemiology & End Results (SEER) registry.

SEER data for LN evaluation are available from 1988. The public-access SEER registry was queried for patients presenting between 1988 and 2002 with breast STS. Data were collated by number of LNs examined and further analyzed by histology, grade, and size of the primary lesion where available. For 5-year relative survival calculations, 210 patients with STS from 1988 to 1998 were analyzed. Relative survival in SEER is defined as the observed survival of a cohort divided by the observed survival of an age-, race-, and gender-matched cohort without disease; it thus serves as a surrogate for disease-free survival.

A total of 333 cases of STS were identified for the 15-year period; 39% of patients underwent some degree of regional lymphadenectomy, and the median number of LNs examined in these patients was 10 (range, 1-34). Of all patients, 17.4% underwent lymphadenectomy of 10 LNs or more. More axillary procedures were performed as grade increased (30.8% grade I/II, 53.8% grade III/IV ([chi]2 = 10.8; P < 0.001). The percentage of patients undergoing radical or modified radical mastectomy did not change significantly over the 15-year period (chi2 = 1.25; P < 1.0), although procedures sampling the axilla were significantly more frequent when lesions were larger than 5 cm (chi2 = 4.14; P < 0.05). None of 6 patients with positive LNs survived 5 years. Examination of nodes did not impact survival: 117 patients without LNs sampled had 5-year related survival of 68.7% (SE = 5.5%); 89 patients with LN sampling had 64.3% 5-year related survival (SE = 5.8%).

Lymphadenectomy is frequently performed despite nodal metastasis being an infrequent occurrence in breast STS. LN metastases were rarely identified and lymphadenectomy did not confer a survival benefit.