Evolution of the Management of the
Axilla with Breast Cancer
Ralph L. Corsetti, MD, FACS
Medical Director
Lieselotte Tansey Breast Center
Ochsner Health System
Associate Professor of Surgery
University of Queensland School of Medicine
Ochsner Clinical School
Background
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The status of the axillary lymph nodes is one of the most
important prognostic factors in women with early stage
breast cancer.
Axillary lymph node dissection (ALND) has/had
traditionally been a routine component of the
management of early breast cancer.
The benefits of ALND include its impact on regional
disease control, its prognostic value through staging, and
its role in treatment selection
Axillary Asessment For Lymph Nodes (LN)
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PE not very sensitive or reliable
LN’s w/ mets often not palpable
Negative predictive value 50 to 60 %
Palpable LN’s may be reactive ones
Positive predictive value 61 to 84 %
Therefore, surgical staging is indicated IF it will change
management
Background
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However, ALND may result in:
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Lymphedema
Nerve Injury
Shoulder Dysfunction
Function and Quality of Life
With clinically negative LN’s or without histologic
confirmation of CA in a palpable LN, Sentinel Lymph
Node Dissection) SLND allows axillary staging with less
morbidity.
ALND used when node clinically palpable or positive
LN’s by US guided FNA.
Levels of Axilla
Sentinel Lymph Node Biopsy
Sentinel Lymph Node Biopsy
Lymphedema
Axillary Ultrasound
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For clinically palpable or suspicious LN(s), then US
guided FNA or core biopsy may identify patients who
could go to ALND
ALND vs SLND
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Traditionally ALND had been routine for staging and
management of invasive breast cancer.
Now SLND accepted as initial approach and standard of
care for women with early stage breast cancer.
The use of full ALND in clinically node negative patients
with early stage disease is contraindicated.
ALND Potential Benefits
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Impact on disease control
– Axillary recurrence
– Survival
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Prognastic (staging) value
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Role in treatment selection
ALND Impact on Survival
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DOUBTFUL
NSABP B-04, clinically negative axillae
Mastectomy w/ ALND, mastectomy w/ nodal radiation, or
mastectomy with ALND delayed until positive LN’s
developed.
No difference in disease free or overall survival
@ 10 years. N Engl J Med 1985; 312:674.
@ 25 years. N Engl J Med 2002; 347:567.
Impact on Survival
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Meta-analysis of three randomized trials between 200
and 2007 comparing ALND to no ALND
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No difference in survival.
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WHY?
– Improved targeted and more widespread use of chemotherapy
– Breast radiation for breast conservation includes at least low
axillary fields.
Impact on Regional (Axillary Recurrence)
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NSABP B-04
Axillary failure significantly higher (18%) in those without
ALND
3.1% with Radiation
1.4% with ALND
18 % high
– No widespread use of MMG so mean tumor size larger in early
1970’s
– Improved targeted chemotherapy.
– So by 1990’s axillary failure rate 8-10%.
Radiation Therapy (RT) vs. ALND
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Tumors <1 cm, clincally negative axilla
381 women
Breast conservation plus RT or ALND
F/U 26 months
One axillary recurrence in each arm
Int J radiat Oncolo Biol Phys 1998; 42:250
SLND
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Identifies patients without axillary LN involvement
Obviates need for more extensive surgery
Decision about proceeding with ALND based on results
of SLND
Axillary recurrence 0.5% if SLND negative and no
subsequent ALND. Many randomized controlled trials.
Typically proceed with ALND if SLND is positive.
Until ACoSOG Z0011 (Z11)
Z11
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891 women randomized after positive SLNB
All women had breast conservation (lumpectomy) with RT
and systemic therapy (96%)
Half with ALND and half no ALND
Local-regional recuurence
– 4% for no ALND
– 3% for ALND
– Axillary recurrence: 0.5% w/ ALND; 1% w/o ALND.
Ann Surg. 2010; 252(3): 426-32.
Z11
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Excluded patients with SLN metastasis only identifiable
by immunohistochemistry (IHC).
Could only have one or two positive SLN’s.
Does not apply to mastectomy patients.
No pre-op axillary ultrasound.
Present
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SWOG S1007 (RxPONDER)
Women w/ hormone receptor positive / HER2 negative
breast CA
N1 disease (1 – 3 positive LN) by SLNB or ALND
Oncotype DX score assessment on primary tumor
Score of 25 or less eligible
Chemotherapy and endocrine therapy vs. endocrine
therapy alone.
ACoSOG Z1071
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Clinically N1 received neoadjuvant chemotherapy
Followed by SLND and ALND
7.1% SLN could not be identified
41% complete nodal response
False negative rate of 12.6%
JAMA. 2013;310(14):1455-1461.
Future
NSABP B-51
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Randomized phase III trial evaluating post-mastectomy
chestwall and regional nodal RT and post-lumpectomy
regional nodal RT in patients with positive axillary nodes
before neoadjuvant chemotherapy who convert to
pathologically negative axillary lymph nodes after
neoadjuvant chemotherapy.
Assess recuurence free intervals.
NSABP B-51
NSABP B-51
Alliance A011202
A RANDOMIZED PHASE III TRIAL EVALUATING THE ROLE OF
AXILLARY LYMPH NODE DISSECTION IN
BREAST CANCER PATIENTS (CT1-3 N1) WHO HAVE POSITIVE
SENTINEL LYMPH NODE DISEASE AFTER
NEOADJUVANT CHEMOTHERAPY
Clinical stage T1-3 N1 M0 breast cancer at Dx prior to start of
neoadjuvant chemotherapy
Patients must have clinically negative axilla on physical examination
documented at completion of
neoadjuvant chemotherapy.
No neoadjuvant endocrine therapy or neoadjuvant radiation therapy.
No SLN surgery/excisional biopsy for pathological confirmation of
axillary status prior to initiation of
chemotherapy
Alliance A011202
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Schema:
For positive SLNB on intra-operative or final pathology
then randomize:
– ALND and Nodal RT
– vs
– Axillary and Nodal RT
Axillary Assessment for DCIS
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No role for ALND
? Role for SLNB
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High grade lesions
Comedo necrosis
Presentation as a mass
?UOQ lesions
When performing a mastectomy
SLND for Prophylactic Mastectomy
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Risk of incidental finding of cancer in prophylactic
mastectomy
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About 2 - 3 %
As high as 8 % with higher risk features (lobular carcinoma)
Risk of lymphedema with SLNB 1 - 2%
Risk of lymphedema with ALND 15 -20 %
Risk assessment
?MRI?
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?Bloodless future for axillary staging?
Ultrasmall paramagnetic iron oxide (USPIO)
Injected subareolar as for SLND
False positive 6.3% vs. <0.5% with SLNB
Sensitivity and specificity about 90% and 95%
respectively
MRI with USPIO
Questions?

Pro: Felix G. Fernandez, MD

Florian A, Rösch S, Bietenbeck M, Engelen M, Stypmann J

Genomic Profiling of Tumors and Loco