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Axillary lymph node removal may benefit women at high risk for residual nodal disease
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SAN FRANCISCO — A subset of breast cancer patients with high risk for residual nodal involvement after surgery may be candidates for axillary lymph node removal, according to an analysis of findings from the ACOSOG Z0011 trial.
The trial results suggest that axillary lymph node dissection may not be necessary for patients after positive sentinel lymph node biopsy, said Monica Shalini Krishnan, MD, a resident in the Harvard Radiation Oncology Program.
“Concerns have been raised about the generalizability of this trial,” Krishnan said at a press conference before her presentation. “The concerns revolved around the low-risk patients. We wanted to see if there was a subgroup eligible for this study who may have benefited from axillary lymph node dissection.”
The researchers constructed a decision analysis using a Monte Carlo model to simulate a number of outcomes, including axillary recurrence risk, lymphedema and quality of life.
Eligible women were aged 45, 55 and 75 years and had stage II cancers after breast-conserving surgery with positive sentinel lymph node biopsies. The researchers divided the women into two groups based on risk. One group included women with a risk for residual nodal involvement of 30% to 60% (high risk), and the other included women whose risk was less than 30% (low risk).
The researchers compared outcomes among women who underwent whole-breast radiation alone or whole-breast radiation plus removal of axillary lymph nodes.
Results indicated that radiation alone improved quality-adjusted life expectancy in the low-risk group, whereas radiation and node removal improved quality-adjusted life expectancy in the high-risk group.
The researchers observed similar OS at 5 years with both treatment strategies in both risk groups. However, node removal was associated with superior OS outcomes at 20 years among patients in the high-risk group.
Differences in outcomes decreased as age increased, according to the results.
Sensitivity analysis results indicated that radiation alone is preferred for low-risk patients unless the axillary recurrence risk with radiation is than 1.6% or the lymphedema risk with dissection is less than 10%.
Radiation with axillary node dissection is preferred for the high-risk group unless the axillary recurrence risk with radiation is less than 2.3%.
“Our model shows a high-risk group for whom axillary lymph node dissection could be beneficial,” Krishnan said. “While it is not a substitute for clinical data, this simulation can at least inform what options physicians discuss with their patients and give physicians a basis for considering axillary lymph node surgery in patients with high risk of residual nodal disease.”
For more information:
Krishnan MS. Abstract #151. Presented at: 2012 Breast Cancer Symposium; Sept. 13-15, 2012; San Francisco.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Andrew D. Seidman, MD
This is a study that exemplifies the important need for multimodality planning for patients with early-stage breast cancer. It raises concerns for patients who were eligible for the trial but under-represented in actual trial accrual.
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