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LBI Updates Guidance for Axillary Dissection Surgery

The Breast Institute has recently updated its guidelines regarding the management of the axilla in patients who are found to have a positive sentinel node biopsy that contains a metastatic deposit, measuring more than 2mm in diameter. According to the updated guidelines, patients undergoing breast conserving surgery in the form of lumpectomy plus sentinel node biopsy for clinical node-negative, invasive breast cancer, will no longer be advised to undergo complete axillary node dissection, if the number of positive sentinel nodes is less than three.

This new guidance has been based on the recent randomised clinical trial, conducted by the American College of Surgeons Oncology Group (Z0011 Trial). The five year overall survival and disease-free survival were similar in women who have sentinel node biopsy only, compared with those who subsequently had complete axillary node dissection. Therefore, all women who fulfil the eligibility criteria for this trial, ie, invasive breast cancer less than 5 cm in diameter, no clinical evidence of lymph node involvement of the axillary lymph nodes prior to surgery and the number of sentinel nodes that contain metastatic disease = 1-2, will be able to avoid radical surgery to the axilla, which is associated with a significant risk of complications including pain, stiffness and lymphoedema of the arm, without compromising the chances of cure. These patients will have radiotherapy to the whole breast, in view of having breast conserving surgery. Complete axillary lymph node dissection is still indicated for women who have breast conserving surgery and sentinel node involvement affecting three or more lymph nodes and those who undergo mastectomy and are found to have positive sentinel node biopsy, regardless of the number of lymph nodes involved. Complete axillary node dissection is still required in women who are known to have clinical evidence of breast cancer spread to the axillary lymph node prior to surgery. In a further shift towards less radical surgery to the axilla, The London Breast Institute will offer patients who require complete axillary node dissection the option of axillary radiotherapy as an alternative to complete axillary node dissection.

This new guidance has been based on the final analysis of the EORTC AMAROS Trial. The trial involved over 1500 patients, with a positive sentinel node biopsy who were randomised to surgical axillary lymph node dissection or to radiotherapy to the axilla. There was no significant difference between the two treatment groups regarding overall survival and disease free survival. However, the incidence of lymphoedema was significantly lower in patients undergoing axillary radiotherapy compared with surgery. There was a non-significant trend towards a higher incidence of shoulder stiffness after radiotherapy, compared with surgery, in the short-term.

Professor Mokbel believes that such guidelines should be adopted nationwide, so that thousands of patients can avoid more radical surgery to the axilla and this will lead to a lower incidence of complications such as lymphoedema, shorter hospitilisation and better quality of life with significant cost savings.