Full Node Dissection?
Back in 1993 when I was diagnosed for the first time with breast cancer, the standard of care included a full axillary node dissection for everyone. Therefore, in conjunction with a wide excision, I had this procedure done. I well remember the difficulties with accumulating fluid in my armpit, the sensation that I was holding a softball there, and several trips to the surgeon's office to have it drained. I have been fortunate (knocking on wood as I write this) that lymphedema and range of motion have not been problems, but I do have an area of numbness that will forever be weird.
Beginning a few years later, the standard of surgical care shifted to sentinel node dissection for most women. If cancer is found in the sentinel node, a second surgery to do the full axillary node dissection has been recommended. This approach spares many women the larger surgery and subsequent risks. As you know, the reasoning behind doing any axillary node dissection at all is to find out if the cancer has spread to that area (although, frankly, unfortunately, there are other ways breast cancer can spread, too, and negative axillary lymph nodes are not a guarantee of future good health) and to assist in making the right decision about the need for chemotherapy.
At the ASCO meeting in Chicago last month, a study was presented by the American College of Surgeons Oncology Group (ACSOG) that suggests that a full dissection may not always be needed even if the sentinel node is found to be positive. From Komen, here is a summary:
A study from the American College of Surgeons Oncology Group (ACOSOG) looked at women with early stage breast cancer who had undergone a sentinel node biopsy. Those women with a positive sentinel node, meaning a sentinel node that contained cancer, were randomized to undergo a full node dissection or to have no further treatment to the axilla. For many years, the standard treatment for women with a positive sentinel
biopsy has been to perform a lymph node dissection. Unfortunately, the study had to be closed early because the investigators had a difficult time recruiting patients to participate. Nevertheless, they found that women who did NOT undergo further surgery did as well as those who did. It would have been optimal to have a larger study so we could be more certain of the results, but the study suggests at least for some women with a positive sentinel biopsy, a full lymph node dissection is not necessary. We must be careful, however, before abandoning lymph node dissections. Women who had palpable lymph nodes (those that could be found on physical examination by a doctor) were not included in the study, nor were women with large tumors. In general, the women included in the study were at relatively low risk of having additional positive lymph nodes,
and therefore the study results should not be applied to women who are at very high risk of having additional positive lymph nodes. That said, the study does open the door to avoid lymph node dissections for some women with a positive sentinel lymph node. As in all cases, this decision has to be individualized and needs to be made on a case by case basis after a discussion between a patient and doctor.
If you want to read more: