Lymph Node Dissection

The range of reported lymphedema in patient who undergo pelvic lymph node dissection is between 5-30%. However, it is important to note that the range varies widely based on several factors such as the tools to measure lymphedema or the medical comorbidities of the patient such as obesity, diabetes, hypertension, and cardiovascular disease. The range of reported lymphedema in patient who undergo pelvic lymph node dissection is between 5-30%. However, it is important to note that the range varies widely based on several factors such as the tools to measure lymphedema or the medical comorbidities of the patient such as obesity, diabetes, hypertension, and cardiovascular disease.

The paper published in the Feb. 9th 2011 issue of JAMA by Giuliano et al, Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastases JAMA 2011; 305(6):569-575, is a landmark report that has resulted in a change of practice throughout the country.

The study was an American College of Surgeons Oncology Group trial, Z0011, in which patients with axillary nodal metastases found on sentinel lymph node (SLN) biopsy, were randomized to receive full axillary dissection or no additional axillary surgery.

Patients were women with clinical T1 or T2 invasive breast cancer, no palpable enlarged axillary nodes (i.e. a clinically negative axilla), and 1-2 SLNs containing metastases found by frozen section, touch preparation, or H and E staining on permanent section. Patients were matched according to clinical and tumor characteristics. All patients had lumpectomy. 445 patients were randomized to full axillary dissection and 446 to SLN biopsy alone. Median follow up was 6.3 years.

The results showed no difference in survival or disease-free survival between the two groups. The conclusion is, therefore, that full dissection can be omitted in patients undergoing breast conserving surgery with 1-2 involved nodes found at SLN biopsy. Thus fewer axillary dissections are being performed. I add these data and conclusions to my discussions with patients about their surgery.

Note that patients who had mastectomy, those with a clinically involved axilla, larger tumors and those receiving neoadjuvant chemotherapy were not included in the study, and therefore the results should not be extrapolated to apply to those patients.

The number of full dissections being performed has decreased as a consequence of this important work, however full dissection is still appropriate, and the standard of care, for selected patients. The paper published in the Feb. 9th 2011 issue of JAMA by Giuliano et al, Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastases JAMA 2011; 305(6):569-575, is a landmark report that has resulted in a change of practice throughout the country.

The study was an American College of Surgeons Oncology Group trial, Z0011, in which patients with axillary nodal metastases found on sentinel lymph node (SLN) biopsy, were randomized to receive full axillary dissection or no additional axillary surgery.

Patients were women with clinical T1 or T2 invasive breast cancer, no palpable enlarged axillary nodes (i.e. a clinically negative axilla), and 1-2 SLNs containing metastases found by frozen section, touch preparation, or H and E staining on permanent section. Patients were matched according to clinical and tumor characteristics. All patients had lumpectomy. 445 patients were randomized to full axillary dissection and 446 to SLN biopsy alone. Median follow up was 6.3 years.

The results showed no difference in survival or disease-free survival between the two groups. The conclusion is, therefore, that full dissection can be omitted in patients undergoing breast conserving surgery with 1-2 involved nodes found at SLN biopsy. Thus fewer axillary dissections are being performed. I add these data and conclusions to my discussions with patients about their surgery.

Note that patients who had mastectomy, those with a clinically involved axilla, larger tumors and those receiving neoadjuvant chemotherapy were not included in the study, and therefore the results should not be extrapolated to apply to those patients.

The number of full dissections being performed has decreased as a consequence of this important work, however full dissection is still appropriate, and the standard of care, for selected patients.

i think this new research is very exciting and potentially practice changing. normally the tradition has been that if a woman has a positive sentinel lymph node, a full dissection of more nodes needs to be performed. however new data suggest that if a woman with a breast cancer up to 5cm in size and who is having a lumpectomy and radiation, has only one or two positive sentinel lymph nodes, she might not need a complete node dissection. the thought is that she will obviously be getting chemo and that the chemo above all will take care of any other nodes that have cancer. with 6 years of follow-up the two groups of women did equally well. sloan kettering has already begun this for these select women.
p.s. i think sloan kettering was involved but this research was a multi-center trial, headed by dr.giuliano at the john wayne cancer center in LA (the breast surgeon who really started the practice of sentinel node biopsy in the first place) i think this new research is very exciting and potentially practice changing. normally the tradition has been that if a woman has a positive sentinel lymph node, a full dissection of more nodes needs to be performed. however new data suggest that if a woman with a breast cancer up to 5cm in size and who is having a lumpectomy and radiation, has only one or two positive sentinel lymph nodes, she might not need a complete node dissection. the thought is that she will obviously be getting chemo and that the chemo above all will take care of any other nodes that have cancer. with 6 years of follow-up the two groups of women did equally well. sloan kettering has already begun this for these select women.
p.s. i think sloan kettering was involved but this research was a multi-center trial, headed by dr.giuliano at the john wayne cancer center in LA (the breast surgeon who really started the practice of sentinel node biopsy in the first place)