Loading
Over thirty years surgeons went from clearing every lymph node in the armpit, to taking only the first one or two, to leaving even a cancerous node in place, to not operating on the armpit at all in low-risk cases. At each step the cancer outcome stayed the same and the arm got better.
This is the clearest example in cancer surgery of a field doing less and getting the same result, and it is worth reading as a sequence rather than as a list.
NSABP B-04 showed at twenty-five years that removing occult positive nodes did not save lives. NSABP B-32 randomised 5,611 women with clinically negative nodes and found eight-year overall survival of 90.3 percent with sentinel node biopsy alone against 91.8 percent with added clearance (hazard ratio 1.20, 0.96 to 1.50, p=0.12). ALMANAC measured what that saved: lymphoedema at twelve months fell from 13 to 5 percent and sensory loss from 31 to 11 percent.
Then the field went after the positive node. IBCSG 23-01 found ten-year disease-free survival of 76.8 percent without clearance against 74.9 percent with it for micrometastases, with lymphoedema of 4 against 13 percent. ACOSOG Z0011 found ten-year overall survival of 86.3 against 83.6 percent for one or two positive sentinel nodes after lumpectomy and whole-breast radiotherapy. AMAROS showed radiotherapy to the axilla is an alternative to clearance, with ten-year axillary recurrence of 1.82 against 0.93 percent and lymphoedema halved, 11.9 against 24.5 percent. SENOMAC extended the result to macrometastases, mastectomy and T3 tumours in 2,540 patients, with five-year recurrence-free survival of 89.7 against 88.7 percent.
Then it went after the sentinel node itself. SOUND randomised 1,405 women with tumours up to 2 cm and a clear axillary ultrasound and found five-year distant disease-free survival of 98.0 percent without any axillary surgery against 97.7 percent with sentinel node biopsy. INSEMA randomised 4,858 and found five-year invasive disease-free survival of 91.9 against 91.7 percent, with axillary recurrence of 1.0 against 0.3 percent.
Two things are still open. POSNOC is the only trial in which the experimental arm receives no axillary treatment at all, radiotherapy included, and it has not reported. And when a woman has no nodal information, the decisions that used to rest on it, whether to give chemotherapy and what radiotherapy fields to use, have to be made from tumour biology instead, which is why SOUND states its condition explicitly: axillary surgery can be spared whenever its absence does not change the postoperative plan.
In England NICE NG101 recommendation 1.4.9 makes sentinel node biopsy the staging operation, 1.4.14 says not to offer further axillary treatment for micrometastases, 1.4.15 classifies isolated tumour cells as node-negative, and 1.4.13 asks for a discussion of the benefits and risks of no further treatment after one or two macrometastases when whole-breast radiotherapy and systemic therapy are planned.
Showing the technology this term belongs to: Sentinel lymph node biopsy.
Shares Targeted axillary dissection, ATNEC, Sentinel node biopsy, Sentinel lymph node biopsy.
Shares Targeted axillary dissection, ATNEC, Sentinel node biopsy, Sentinel lymph node biopsy.
Shares Targeted axillary dissection, ATNEC, HER2-positive breast cancer, Breast cancer (all types).
Shares Targeted axillary dissection, ATNEC, HER2-positive breast cancer, Breast cancer (all types).
Shares Sentinel node biopsy, Lymphadenectomy (lymph node dissection), Breast cancer (all types).
Shares NSABP B-04, NSABP B-32, Sentinel lymph node biopsy, HER2-positive breast cancer.
Shares Sentinel node biopsy, Lymphadenectomy (lymph node dissection), Breast cancer (all types).
Shares NSABP B-04, HER2-positive breast cancer, Breast cancer (all types), Triple-negative breast cancer (TNBC).