Regional Nodal Management in the Setting of Up-Front Surgery

Abstract

Historically, axillary lymph node dissection was considered necessary for regional control of breast cancer. Moreover, nodal status was the major determinant of the need for chemotherapy. The increased use of systemic therapy coupled with expanding indications for nodal irradiation has led to interest in optimizing patient outcomes by leveraging the local control benefits of radiotherapy and systemic therapy to decrease the extent of surgery. A series of landmark surgical and radiotherapeutic trials has demonstrated low rates of disease recurrence with concomitant improvements in treatment-associated lymphedema and quality of life with the use of sentinel node biopsy and nodal irradiation as opposed to complete axillary dissection in the management of node positive breast cancer. This chapter will explore the evolution of regional nodal management, culminating in current approaches to tailored patient selection for axillary lymph node dissection, sentinel lymph node biopsy, and adjuvant regional nodal irradiation.

Figure 1.

Surgical management of the axilla. SLNB, sentinel lymph node biopsy; FNA, fine needle aspiration; breast-conserving therapy; ALND, axillary lymph node dissection; mECE, microscopic extracapsular extension; NAC, neoadjuvant chemotherapy; HR, hormone receptor; HER2, human epidermal growth factor receptor 2

Figure 2.

Memorial Sloan Kettering Cancer Center approach to risk factor consideration for regional nodal irradiation. (NB: Based on internal institutional multidisciplinary consensus. May not be appropriate for application at other institutions.) TNBC, triple negative breast cancer; LVI, lymphovascular invasion; ER, estrogen receptor; NOS, not otherwise specified; ECE, extracapsular extension; Micromets, micrometastases; RNI, regional nodal irradiation