Certain patients with breast cancer could avoid lymph node surgery
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More than 40% of patients with lymph node involvement at breast cancer diagnosis could be spared lymph node surgery, according to study results published in Annals of Surgical Oncology.
Factors that appeared to predict which patients could avoid the surgical procedure included tumor size, lobular histology and nodal metastasis size, researchers noted.
“One of the more disabling side effects of breast cancer surgery is arm swelling or lymphedema, which can occur in up to 25% of patients after complete removal of the lymph nodes in the armpit,” Maggie L. DiNome, MD, associate clinical professor of surgery and chief of breast surgery at David Geffen School of Medicine at University of California, Los Angeles, told Healio. “Historically, this procedure was thought to be necessary to evaluate whether lymph nodes were involved with cancer and then to remove those nodes for improved survival outcome. However, as our medical and radiation therapies for breast cancer treatment have improved, we have been learning that less surgery can be better for some patients without an adverse effect on survival and can lead to fewer complications. As surgeons, we have been asking whether we could de-escalate lymph node surgery without negatively affecting a patient's survival.”
In the past few years, data have emerged that support omission of complete lymph node dissection for patients who have minimal nodal disease, DiNome added.
“However, we do not have this same data for women with lymph node involvement at the time of diagnosis, so we subject these women routinely to complete lymph node removal,” she said. “Our study was a first step in asking the question of whether women with lymph node disease upfront can also be spared complete lymph node removal.”
For the retrospective review, investigators sought to assess the extent of lymph node involvement on final pathology among 111 patients (median age, 61.6 years; 99.1% women; 78.9% postmenopausal; 62.1% white) with breast cancer who underwent complete lymph node dissection at surgery between 2010 and 2019.
More than half of patients (61.3%) had a palpable node on exam and 41.4% had minimal nodal (pN1) disease. Most (91.5%) had ER-positive disease and 21.7% had invasive lobular cancers.
Researchers found associations between higher nodal stage and lobular histology (P = .02), tumor size (P = .04) and nodal metastasis size (P = .05).
Patients with larger T3 tumors had significantly lower odds of pN1 disease than those with T1 tumors (OR = 0.14; 95% CI, 0.03-0.6).
Results of a multivariable analysis that included 49 patients with reported nodal metastasis size showed those with nodal metastasis greater than 10 mm (OR = 0.12; 95% CI, 0.02-0.69) had significantly lower odds of having pN1 disease.
Tumor size and histology remained significantly associated with nodal stage in a subset analysis of 56 patients with palpable nodes, researchers noted.
The significance of lobular histology appeared to be driven by the higher prevalence of this histology in pN3 disease and not the ability to differentiate between pN1 and higher than pN1 disease.
“Having a positive lymph node at the time of a breast cancer diagnosis should not necessarily obligate a woman to complete lymph node removal, because up to 40% of these women will only have a few lymph nodes involved at surgery,” DiNome said. “This is a positive first step toward possibly de-escalating axillary surgery for these patients, which could significantly reduce the risks [for] lymphedema. Future research could involve a prospective clinical trial evaluating the safety of omitting complete lymph node dissection in these patients who have lymph node disease at the time of surgery.”
For more information:
Maggie L. DiNome, MD, can be reached at University of California, Los Angeles, 10833 Le Conte Ave., CHS 72-215, Los Angeles, CA 90095; email: mdinome@mednet.ucla.edu.
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