Fast Facts by Professor Jayant C Vaidya

Author:Professor Jayant C Vaidya
Language: eng
Format: epub
Publisher: Health Press Limited
Published: 2017-11-07T05:00:00+00:00

Treatment of regional lymph nodes

Axillary surgery. The indications for axillary surgery and the extent to which it should be carried out in women with operable breast cancer remain controversial.

• Level I axillary nodes are below and lateral to the pectoralis minor muscle.

• Level II axillary nodes are underneath or posterior to the pectoralis minor muscle.

• Level III axillary nodes are above or medial to the pectoralis minor muscle.

Full axillary clearance (levels I and II) may not be necessary if one or more nodes on the sentinel node biopsy show evidence of micrometastasis alone. If axillary dissection is necessary, the technique used must aim to minimize the morbidity of the procedure. A standard axillary clearance should involve excision of only those tissues anterior and inferior to the axillary vein, leaving behind the lymphatics that drain the arm, which are usually thought to be situated above the vein; reverse lymphatic mapping may help to identify and preserve these.

With increasing use of sentinel node biopsy (see below), lymphedema of the arm is now relatively uncommon. Radiotherapy is usually not given after full axillary clearance; although it is often used in the presence of extranodal spread, its value is not well established.

Is axillary clearance necessary if only one or two sentinel nodes are positive? The Z-11 trial randomly allocated patients to receive either complete axillary clearance or no further surgery. Although over 20% of cases of axillary clearance had further positive nodes, the recurrence in the axilla in those who received no further surgery was less than 1% at 6 years.21 Many centers around the world are therefore adopting a ‘no further surgery’ approach in patients similar to the Z-11 trial cohort (clinical [c]T1–2, cN0 disease, ≤ 2 positive sentinel lymph nodes, treated by breast conservation with whole-breast radiation therapy). The POSNAC trial, currently recruiting in the UK, will address this question further.

Radiotherapy to intramammary nodes. Although it has not been customary to irradiate the intramammary lymphatic basin, a recent large study suggests that in patients with high-risk disease such irradiation can improve overall survival.22

Sentinel node biopsy is the ‘standard of care’ in many parts of the world; it can be used to establish the prognosis and select appropriate systemic therapy. Most breast cancers spread in a predictable path along the axillary lymphatics with the lowermost node in the chain (the sentinel node) being the first to be affected. Radiolabeled colloid, alone or in combination with a patent blue dye, is injected subdermally under the areola. A path can then be traced to the first draining lymph node in the axilla (the sentinel node), which is independent of the location of the tumor in the breast. If intraoperative assessment of the lymph node is negative, further axillary surgery can be avoided.

These intraoperative tests have a false negative rate of up to 30%, but the remainder avoid the need for a second operation. However, the Z-11 trial, which casts doubt on the need for further axillary surgery when 1–2 nodes are involved21 has reduced the utility of sentinel node intraoperative assessment; it has already been abandoned in some centers.

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