Overall Survival After Sentinel Lymph Node Biopsy Versus Axillary Lymph Node Dissection in Patients With Three...

Randomized trials support omission of completion axillary lymph node dissection (ALND) in selected patients with 1 or 2 positive sentinel lymph nodes, but evidence for 3 positive sentinel nodes is limited. We evaluated the association between the extent of axillary surgery and overall survival (OS) in patients with 3 recorded positive nodes.

Female patients with cT1-2N0M0 unilateral invasive breast cancer who underwent breast-conserving surgery between 2012 and 2016 and had 3 positive lymph nodes were identified in the National Cancer Database. The sentinel lymph node biopsy (SLNB) group had 3 positive sentinel nodes without completion ALND; the ALND group had 3 total positive nodes after completion dissection. The primary outcome was OS.

Among 700 patients, 217 (31%) underwent SLNB alone and 483 (69%) underwent completion ALND. Thirty-six deaths occurred. Irradiation to breast/chest-wall lymph-node regions was recorded in 59.4% and 57.6%, respectively (P = .56), although specific nodal basins were unavailable. At a median follow-up of 51.6 months, 5-year OS was similar between the SLNB and ALND groups (94.3% vs. 93.8%, P = .85). Omission of ALND was not significantly associated with OS after adjustment (adjusted HR 0.94, 95% CI 0.44-2.01, P = .85). Hormone receptor-negative disease and omission of adjuvant therapy were independently associated with worse survival.

Omission of ALND was not associated with inferior OS in patients with 3 positive lymph nodes. These findings support prospective evaluation and should not be interpreted as evidence that all additional axillary treatment can be omitted.