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Multicenter Study
. 2017 Sep;143(9):1823-1831.
doi: 10.1007/s00432-017-2425-3. Epub 2017 Apr 24.

Personalized axillary dissection: the number of excised lymph nodes of nodal-positive breast cancer patients has no significant impact on relapse-free and overall survival

Florian Ebner  1 , Achim Wöckel  2 , Wolfgang Janni  3 , Rolf Kreienberg  3 , Lukas Schwentner  3 , Manfred Wischnewsky  4
Affiliations
Multicenter Study

Personalized axillary dissection: the number of excised lymph nodes of nodal-positive breast cancer patients has no significant impact on relapse-free and overall survival

Florian Ebner et al. J Cancer Res Clin Oncol. 2017 Sep.

Abstract

Purpose: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) for the staging of clinically node-negative breast cancer patients (BCP), demonstrating equivalent survival to ALND while resulting in reduced morbidity. ALND has remained the standard of care for the majority of BCP with clinical axillary metastases or metastases found on SLN biopsy. More recently, it is debated whether ALND could be avoided not only in SLN-negative BCP but also in selected SLN-positive disease or even in all patients. This analysis of pN+ BCP shows the impact of the number of excised lymph nodes on RFS and OAS adjusted by age, tumor size, intrinsic subtypes and adjuvant systemic therapy.

Methods: In this retrospective, multicenter cohort study, we investigated data from 2992 pN+ primary BCP recruited from 17 participating certified breast cancer centers in Germany between 2001 and 2008 within the BRENDA study group.

Results: The median number of excised lymph nodes was 17. The number of excised lymph nodes was neither significant for RFS (p = 0.085) nor for OAS (p = 0.285). Adjustments were made for age, tumor size and intrinsic subtypes. The most important significant parameters for RFS were intrinsic subtypes (p < 0.001) and tumor size (p < 0.001) and for OAS age (p < 0.001) and intrinsic subtypes (p < 0.001). There were no significant differences in RFS and OAS in any subgroup stratified by the number of excised lymph nodes. Only for T3/T4 tumors, there is a very small significant advantage of ALND for RFS but not for OAS. After adjusting in addition by guideline adherence of adjuvant systemic therapy (AST), intrinsic subtypes and guideline-adherent AST are the most important significant (p < 0.001) parameters for RFS and OAS.

Conclusions: The number of excised lymph nodes of pN+ BCP neither correlates with RFS nor with OAS. Survival of pN+ BCP is primarily determined by the biology and the guideline-adherent AST based on the corresponding intrinsic subtypes. These results support the omission of a radical ALND at least for pN+ patients scheduled for breast-conserving surgery (not mastectomy), provided they receive whole breast irradiation and guideline-adherent AST.

Keywords: Axillary lymph node dissection; Breast cancer; Lymph node; Sentinel node; Survival.

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Conflict of interest statement

All authors declare that there are no potential conflicts of interest, including any financial, personal or other relationships with people or organizations that could inappropriately influence this work.

Figures

Fig. 1
Fig. 1
a Relapse-free survival of pN+ patients stratified by number of excised lymph nodes and adjusted by age, tumor size and intrinsic subtypes. b Overall survival of pN+ patients stratified by number of excised lymph nodes and adjusted by age, tumor size and intrinsic subtypes
Fig. 2
Fig. 2
a Relapse-free survival of pN+ patients stratified by intrinsic subtypes and adjusted by age, tumor size and number of excised lymph nodes. b Overall survival of pN+ patients stratified by intrinsic subtypes and adjusted by age, tumor size and number of excised lymph nodes
Fig. 3
Fig. 3
a Relapse-free survival of pN+ patients stratified by guideline adherence of AST and adjusted by age, tumor size, intrinsic subtypes and number of excised lymph nodes. b Overall survival of pN+ patients stratified by guideline adherence of AST and adjusted by age, tumor size, intrinsic subtypes and number of excised lymph nodes
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