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“The knowledge gained so far from randomized trials cannot provide an absolute answer to that question. However, a qualified response is that a complete ALND [axillary lymph node dissection] may not be necessary for all breast cancer patients with positive SLNs [sentinel lymph nodes].
Thirty percent or more of women with a positive SLN will have negative NSLNs [nonsentinel lymph nodes] and are not likely to benefit from ALND. In addition, the prescribed systemic therapy and RT may sterilize the axilla, although prospective data are inconclusive.”
Avoiding a full dissection can avoid a painful, lifelong condition known as lymphedema.
The question of whether to proceed with removing all lymph nodes (ALND) after finding a positive sentinel lymph node is interesting. Historically that is exactly what has been done. This article brings that practice into question, at least for some cases of breast cancer.
It touches on an issue that came up for my friend with a very advanced Stage 3. She wanted to look at statistics from women who had elected not to have a lymph node dissection at all and leave the diseased lymph nodes intact, hoping that the chemotherapy and radiation would take care of the cancer, but we could not readily find any research before her surgery. Perhaps this is because so few women make such a decision or have doctors who would allow them to make such a decision. In this article, they are not considering women with such obviously advanced cancer, but there is some indication that at least some forms of chemotherapy might “sterilize” the nodes and allow them to be left intact. In my friend’s case, she had preoperative chemotherapy and at the time of surgery, the lymph nodes had seemingly dissolved.
The article also touches on the subject of micro-metastases but seems to conclude that it is a subject that needs to be considered separately.
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Abstract-Sentinel node excision has been widely accepted as the initial surgical step for evaluating the axilla for metastatic breast cancer. When the nodes are positive, the standard of care is to complete the axillary node dissection, a more extended procedure that carries an increased risk for morbidity. This article reviews data from sentinel lymph node trials, case series reports of outcomes when axillary node dissection was not performed in the setting of positive sentinel nodes, models for predicting the status of non-sentinel nodes, and the morbidity associated with axillary operations. Despite an approximate 10% false-negative rate, early results indicate that there is a much lower local recurrence rate after sentinel node excision alone and that systemic therapy may sterilize the axilla. In selected patients, it may be appropriate to forgo an axillary node dissection, although there are no randomized clinical trial data to support or refute this suggestion.
Conclusion-For the breast cancer patient who, despite these efforts, is found to have metastases in the SLN after her primary operation, treatment can be individualized based on her wishes, the characteristics of her tumor, and her physician’s perception of the risks and benefits of the various options discussed in this review. It appears that for older women with T1a or T1b primary estrogen receptor-positive tumors, a solitary positive node, and no LVI, a low local or distant recurrence rate may be expected if an ALND is not performed. Results from trials such as AMAROS and NSABP B-32 may provide future guidelines.