Axillary surgery in women with sentinel node-positive operable breast cancer: a systematic review with meta-analyses

Abstract

Traditionally, women with node-positive operable breast cancer have received complete axillary lymph node dissection (ALND), which is associated with significant morbidity, but recently less invasive alternatives have been explored. We conducted a systematic review of randomised controlled trials assessing alternative approaches to axillary surgery in patients with pathologically-confirmed sentinel node-positive operable breast cancer. We searched on 16/3/15 the Specialized Register of the Cochrane Breast Cancer group; CENTRAL; MEDLINE; PreMEDLINE; EMBASE; WHO International Clinical Trials Registry Portal; ClinicalTrials.gov; conference proceedings from ASCO and the San Antonio Breast Cancer meetings; checked reference lists and contacted authors to identify relevant studies. Double, independent study sifting, extraction, appraisal and summarising were undertaken using standard Cochrane Collaboration methodology. We included three studies (2020 patients) comparing ALND with sentinel lymph node dissection (SLND) to SLND alone, and two studies (1899 patients) comparing ALND to axillary radiotherapy (aRT). No differences in survival or recurrence were observed between ALND and SLND or aRT, but morbidity may have been increased in ALND, and all the results were subject to different biases, such as recruitment bias, performance bias, and outcome-reporting bias. Whilst it is encouraging that there appears to be no adverse effect on recurrence or survival, it will be appropriate to confirm these findings and provide additional data confirming quality of life effects and long term outcomes.

Keywords: Axillary surgery; Breast cancer; Node positive; Operable; Radiotherapy; Sentinel lymph node dissection.

Fig. 1

Overall survival and disease-free survival in the studies comparing SLND + ALND to SLND alone

Fig. 2

Breast cancer recurrence in the studies comparing SLND + ALND to SLND alone. Please note the following regarding the data included for ACOSOG ZOO11 for regional breast cancer recurrence: Regional recurrence defined as recurrence in the axillary, supraclavicular or internal mammary nodes. The authors only report local recurrence, axillary recurrence and locoregional recurrence. We have subtracted the local recurrence data from locoregional recurrence data to obtain the regional recurrence data, which is equal to the disease recurrence in the axilla data, suggesting that no patients recurred in the supraclavicular or internal mammary nodes, provided all these data only count each patient once. An entry of 0 in the total number of events column signifies that the study did not report this outcome