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Is Axillary Dissection Always Indicated in Invasive Breast Cancer?

Is Axillary Dissection Always Indicated in Invasive Breast Cancer?

The authors provide a comprehensive overview of the role of axillary lymphadenectomy in the treatment of early-stage breast cancer. They do not argue against lymphadenectomy for patients with clinical T2 and 3 tumors and clinical N1 and 2 nodes. However, for clinical N0 cancers and for postmenopausal patients with hormone-receptor-positive tumors, the authors propose radiotherapy to the axilla as a modality less expensive than surgery and with fewer complications. They suggest observation only for lesions associated with a less than 10% to 15% chance of axillary metastasis (T1a cancers, tubular carcinomas, ductal carcinoma in situ [DCIS] with microinvasion). However, for patients with lesionsless than 1 cm with “high-risk features (presence of tumor emboli in vessels, poor nuclear grade, etc),” axillary lymphadenectomy “should continue to serve as a refined prognostic indicator for selection of patients for adjuvant therapy.”

Axillary Lymphadenectomy

Although countless studies have attempted to define a group of patients with no risk for axillary metastases, none has been found, except women with DCIS only. Thus, we may well miss an N1 cancer if an axillary lymphadenectomy is omitted. The authors imply that this risk is irrelevant for postmenopausal women, since tamoxifen and/or axillary radiotherapy will suffice for those with clinically occult nodal metastases. However, recent trials have proven tamoxifen plus chemotherapy to be superior to tamoxifen alone, particularly in node-positive but also in node-negative patients. Even if medical oncologists were unwilling to recommend chemotherapy and tamoxifen for all patients, there would still be a need for accurate surgical staging for this group.

As for those with a “low” (10% to 15%) risk for metastases, we are given a socioeconomic argument from Cady that it would cost $1 million per life saved via axillary lymphadenectomies for these women.[1] I believe his assumptions to be incorrect ($10,000 per axillary lymphadenectomy, only 1 of 15 with positive nodes identified “saved”), and would argue that the actual cost (not charge) would be closer to $6,000, with potentially five lives saved by appropriate adjuvant treatment. This would reduce the cost per life saved from $1 million to $120,000—much less than the $300,000 per life saved that our society approved with auto air bag legislation and well within the economic guidelines justifying medical procedures.

Clearly, the status of axillary lymphadenectomy would improve if fewer complications and fewer “unnecessary” lymphadenectomies were to be performed. We believe that the incidence of lymphedema can be maintained below 3% with careful surgery that avoids the lymphatics coursing along the axillary vein. The numbness can be reduced to a minimum with avoidance of most intercostobrachial nerves. As for the obviation of axillary lymphadenectomy for patients with truly uninvolved nodes, many are working toward this end with studies of sentinel lymphadenectomy. This procedure can be performed under sedation accompanying lumpectomy in the outpatient setting.

If the sentinel node or nodes found are uninvolved, there is strong evidence suggesting that the remainder of the axilla is also uninvolved.[2] The procedure is much less accurate after excisional breast biopsy. Thus, if this technology is to be accepted, more stereotactic core-needle or fine-needle biopsies will need to be done. Given the obvious savings in morbidity and cost, as well as the increased accuracy over observation alone, sentinel lymphadenectomy would seem to be the technique of choice for all patients with a clinically negative axilla. As for the relative therapeutic value and morbidity of axillary radiotherapy and surgical lymphadenectomy, perhaps they could be formally tested (as they never have been) in patients with involved sentinel nodes.

References

1. Cady, B: The need to reexamine axillary lymph node dissection in invasive breast cancer. Cancer 73:505-508, 1994.

2. Giuliano AE, Barth AM, Spivack B, et al: Incidence and predictors of axillary metastasis in T1 carcinoma of the breast. J Am Coll Surg 183:185-189, 1996.

 
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