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The Landmark Series: Axillary Management in Breast Cancer

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The Landmark Series: Axillary Management in Breast Cancer Ann Surg Oncol (2020) 27:724–729 https://doi.org/10.1245/s10434-019-08154-5 ORIGINAL ARTICLE – BREAST ONCOLOGY The Landmark Series: Axillary Management in Breast Cancer Carla S. Fisher, MD1, Julie A. Margenthaler, MD2, Kelly K. Hunt, MD3, and Theresa Schwartz, MD4 1Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; 2Department of Surgery, Washington University School of Medicine, St. Louis, MO; 3Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; 4Department of Surgery, St. Louis University, St. Louis, MO ABSTRACT The evolution in axillary management for AXILLARY MANAGEMENT IN PATIENTS patients with breast cancer has resulted in multiple dra- UNDERGOING PRIMARY SURGICAL THERAPY matic changes over the past several decades. The end result has been an overall deescalation of surgery in the axilla. For many patients with breast cancer, surgery is the first Landmark trials that have formed the basis for the current line of therapy for treatment and staging. When the Halsted treatment guidelines are reviewed herein. radical mastectomy was introduced, the axilla was seen as a transit point between the breast and distant metastatic disease, and it was believed that removal of axillary nodes Axillary management for patients with newly diagnosed was necessary to prevent distant metastatic spread. As breast cancer has undergone several practice-changing understanding of breast cancer evolved, removal of these paradigm shifts over the last few decades with the ultimate lymph nodes was not viewed as a necessary procedure to goal of reducing morbidity without compromising onco- prevent spread but rather an important component of breast logic outcomes or staging. Historically, surgical cancer staging and prognosis. Identification of lymph node management of the axilla was viewed as a prognostic metastases directed clinicians to offer systemic therapy and indicator of disease, and long-term survival and the axillary to consider radiation therapy to the chest wall and/or the nodal status significantly impacted adjuvant therapy rec- regional lymph node basins. Approximately 20 years ago, ommendations. The impact on local–regional control of breast cancer subtypes emerged as important determinants surgically resecting any axillary nodal metastasis was also in breast cancer prognosis. While the initial studies were of importance in the era prior to screening mammography performed with gene expression profiling, receptor testing and a trend towards early-stage breast cancer diagnosis. (estrogen receptor, progesterone receptor, and human epi- More recently, there has been a shift towards less extensive dermal growth factor receptor 2) to determine axillary surgery in both the clinically node-negative and approximated breast cancer subtypes emerged as critical in clinically node-positive patient populations. The increasing directing therapy and determining prognosis. It is now use of neoadjuvant therapy in early-stage breast cancer routine to consider approximated subtypes to inform sys- patients has presented a challenge in determining the extent temic therapy recommendations, and therefore, the role of of axillary surgery necessary for axillary staging and local– axillary staging has become less important. In this review, regional control in both clinically node-negative patients published studies that address the deescalation of surgical and node-positive patients. The landmark trials that have therapy of the axilla in patients undergoing upfront surgery impacted the evolution of axillary management for breast are discussed. cancer patients are reviewed herein. NSABP B-04 Ó Society of Surgical Oncology 2019 Initiated in 1971, the goal of the B-04 trial was to determine whether less extensive surgery with or without First Received: 13 October 2019; Published Online: 20 December 2019 radiation therapy was as effective as the Halsted radical mastectomy.1 A total of 1079 patients with clinically J. A. Margenthaler, MD e-mail: [email protected] negative axillary nodes were randomized to radical The Landmark Series: Axillary Management in Breast Cancer 725 mastectomy, total mastectomy without axillary dissection Both 99mtechnetium sulfur colloid and isosulfan blue were but with postoperative radiation, and total mastectomy used to perform the SLNB. In the assessment of sentinel alone. In terms of axillary management, these patients were nodes, pathologists were instructed to use 2-mm sectioning essentially randomized to complete axillary lymph node of the nodes with routine hematoxylin and eosin (H&E) dissection (ALND), axillary radiation, or no axillary stains of each section. Immunohistochemistry was not treatment upfront. The trial showed no difference in overall permitted for routine patient care, except to confirm sus- survival, distant-disease-free survival, relapse-free sur- picious findings seen on routine H&E stains. vival, or disease-free survival in this group of patients. The The trial was designed to detect a 2% difference in last follow-up that was published showed these results survival between the treatment arms. Regional recurrence consistent at 25-year follow-up.2 Of note, the trial had a rates were less than 1% for both groups, and the trial separate arm that included patients with clinically positive confirmed a low rate of regional node recurrences after nodes who were randomized to radical mastectomy or total SLNB surgery. mastectomy with axillary radiation only. Patients with NSABP B-32 investigators also reported that patient- clinically positive nodes did not present any differences in reported outcomes and morbidity related to range of survival whether the axilla was treated with surgery or motion, edema, pain, and sensory deficits were lower in the radiation therapy. SLNB arm compared with ALND. A similar study, the In women with negative nodes, there was a difference in ALMANAC trial, was published in 2006 and also noted the cumulative incidence of local or regional recurrence, and it lower morbidity of SLNB.5 They did not specifically was lowest in the patients treated with total mastectomy address survival but did conclude that SLNB should be the and radiation therapy. There was no difference in these treatment of choice for patients with early-stage breast groups related to cumulative incidence of distance recur- cancer and clinically negative nodes. rence as a first event. A total of 68 of the 365 women who underwent total mastectomy alone (18.6%) subsequently ACOSOG Z0011 had axillary recurrences. Median time to axillary recur- rence was 14.8 months (2–134.5 months). The The ACOSOG Z0011 trial was designed to assess the investigators estimated (based on those randomized to role of completion ALND in patients found to have one or axillary dissection at initial surgery) that approximately two positive sentinel nodes. Z0011 was a phase 3 nonin- 40% of patients who had mastectomy alone had positive feriority trial conducted at 115 sites and enrolled patients nodes that were not removed at the time of initial surgery. from 1999 to 2004. The trial enrolled women with clinical These data are important because they indicated that T1 or T2 invasive breast cancer with clinically negative leaving positive nodes, without surgery or radiation ther- nodes who were planned for breast conservation therapy apy, did not significantly increase the rate of distant with whole breast irradiation. Patients with one or two recurrence or breast-cancer-related mortality. These data positive sentinel lymph nodes were randomized intraoper- were important in the development of American College of atively or postoperatively to undergo ALND or not. Surgeons Oncology Group (ACOSOG) Z0011 trial (dis- Patients with metastases identified initially or solely with cussed below).3 immunohistochemical staining, three or more positive SLNs, matted nodes, gross extranodal disease, and patients NSABP B-32 who underwent neoadjuvant chemotherapy or endocrine therapy were not eligible. The trial sought to determine NSABP B-32 confirmed that overall survival, disease- whether there was a difference in overall survival between free survival, and regional control were statistically the two groups. equivalent between patients with negative sentinel nodes Targeted enrollment was 1900 women with final anal- who underwent either sentinel lymph node biopsy (SLNB) ysis after 500 deaths, but the trial closed early because the alone or ALND.4 B-32 was a randomized controlled phase mortality rate was much lower than expected. The inves- 3 trial which was performed at 80 centers in Canada and tigators ultimately enrolled and randomized 989 patients. the USA between 1999 and 2005. It was the largest ran- In addition to showing no difference in survival between domized surgical trial performed in breast cancer patients. the two groups, they showed very low rates of local–re- The trial enrolled 5611 women with invasive breast cancer gional recurrence. This trial was a game changer for and clinically negative nodes. Investigators reported on management of node-positive patients undergoing breast outcome data for the 3989 patients with pathologically conservation. The trial was criticized for several reasons, negative nodes. Surgeons were proctored in SLNB, and pathologists were required to follow specific protocols. 726 C. S. Fisher et al. including not meeting the target enrollment. The ten-year were randomized to receive either ALND or axillary follow-up data continued to show no difference in overall
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