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Can We Avoid Axillary Lymph Node Dissection (ALND) in Patients with 1-2 Positive Sentinel/Low Axillary Lymph Nodes
A Reddy1, Nita S Nair1, Smruti Mokal2
1Department of Surgical Oncology, Breast Service, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
The ACOSOG Z0011 trial results may not apply to Indian breast cancer patients. Over 30% of patients with 1-2 positive lymph nodes required further axillary lymph node dissection (ALND).
Area of Science:
- Oncology
- Surgical Oncology
- Breast Cancer Research
Background:
- The ACOSOG Z0011 trial suggested omitting axillary lymph node dissection (ALND) for early-stage breast cancer patients with limited lymph node involvement.
- However, the applicability of these findings to diverse populations, particularly in the Indian setting, remains uncertain due to differing clinicopathological characteristics.
Purpose of the Study:
- To evaluate the necessity of ALND in Indian breast cancer patients by comparing outcomes to the ACOSOG Z0011 trial.
- To determine the rate of additional positive lymph nodes in patients who would have met ACOSOG Z0011 criteria but underwent ALND.
Main Methods:
- A retrospective audit of 2350 clinically node-negative (cN0) early breast cancer (EBC) patients who underwent Level I/II axillary dissection (LAS) between 2013 and 2018.
- Analysis of final histopathology to determine the number and extent of lymph node metastasis (LN+).
- Comparison of patient demographics and tumor characteristics with the ACOSOG Z0011 trial cohort.
Main Results:
- Of 2350 cN0 EBC patients, 687 (29%) had positive lymph nodes.
- Among those with positive nodes, 86.9% had 1-2 positive nodes, 5.8% had 3, and 7.3% had 4 or more.
- Significant differences were observed between the study cohort and ACOSOG Z0011, including larger tumor size (3 cm vs. 1.7 cm), higher rate of macrometastasis (99.16% vs. 45%), and more grade 3 tumors (73.7% vs. 28-30%).
- Crucially, 31.82% of patients with 1-2 positive lymph nodes in this cohort had additional positive nodes found upon ALND.
Conclusions:
- The clinicopathological differences between the Indian cohort and the ACOSOG Z0011 trial population suggest that direct application of the trial's findings may not be appropriate.
- A significant proportion of patients (31.82%) with 1-2 positive lymph nodes had further nodal involvement, indicating potential under-treatment if ALND is omitted.
- Observation of the axilla or the use of validated nomograms to identify high-risk patients may be more suitable for select Indian breast cancer patients, rather than a blanket application of the ACOSOG Z0011 recommendations.
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