Clinical Challenges in Breast Surgery: Management of Axilla

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Apr 4, 2022

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ADVICE

Axillary Management in Clinically Node-Negative Patients

Clinically node-negative patients typically undergo sentinel lymph node biopsy (SLNB) for axillary staging.
If the SLNB is negative, no further axillary surgery is needed.

INSIGHT

Z11 Trial and ALND

Historically, a positive SLNB indicated complete axillary lymph node dissection (ALND).
The Z11 trial showed no difference in outcomes between ALND and no further treatment for 1-2 positive SLNBs in clinically node-negative, lumpectomy patients.

INSIGHT

AMAROS Trial and Axillary Radiation

The AMAROS trial showed similar outcomes between ALND and axillary radiation for clinically node-negative patients with positive SLNB, regardless of lumpectomy/mastectomy.
Axillary radiation resulted in lower lymphedema rates compared to ALND.

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Warning! There is magic contained in this podcast. Real magic. The kind of magic that allows you to understand how to manage the axilla in breast cancer patients.

The standard of care approach to management of the axilla in patients with breast cancer has evolved rapidly. While a complete axillary dissection was historically indicated following identification of any positive nodes, that is no longer the case; indeed, axillary dissections are now uncommonly performed. Join Drs. Michael Alvarado, Rita Mukhtar, and Alexa Glencer as they discuss the impact of the ACOSOG Z0011, AMAROS, and ACOSOG Z1071 trials in defining the role of sentinel lymph node dissection and radiotherapy in patients with early-stage breast cancer with limited lymph node involvement as well as the approach when neoadjuvant chemotherapy has been received.

Learning Objectives:
· Describe the study design and results of the ACOSOG Z0011 trial and its impact on the use of sentinel lymph node biopsy as an alternative to complete axillary lymph node dissection in clinically node-negative patients with T1 or T2 breast cancer
· Describe the study design and results of the AMAROS trial and its implications for use of axillary radiation as an alternative to axillary lymph node dissection for patients with clinically node-negative T1 or T2 breast cancer
· Understand the risk of lymphedema related to complete axillary lymph node dissection, as demonstrated by the AMAROS trial
· Describe the study design and results of the ACOSOG Z1071 trial and how interpretation of its subgroup analysis has been applied to our approach of offering sentinel lymph node biopsy as a means of staging the axilla following neoadjuvant chemotherapy in patients with clinical node-positive disease at the time of diagnosis

Journal Article Links:
ACOSOG Z0011: https://jamanetwork.com/journals/jama/article-abstract/2653737

AMAROS: https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)70460-7/fulltext

ACOSOG Z1071: https://jamanetwork.com/journals/jama/fullarticle/1748149%20

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