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Meta-Analysis
. 2025 Jun:81:104453.
doi: 10.1016/j.breast.2025.104453. Epub 2025 Mar 20.

CADONOT: Comparing axillary dissection or not in breast cancer surgery

André Mattar  1 , Marcelo Antonini  2 , Francisco Pimentel Cavalcante  3 , Felipe Zerwes  4 , Eduardo de Camargo Millen  5 , Fabricio Palermo Brenelli  6 , Antônio Luiz Frasson  7 , Patrícia Carvalho Baruel  8 , Lucas Miyake Okumura  9 , Leonardo Ribeiro Soares  10 , Marcelo Madeira  11 , Marina Diógenes Teixeira  12 , Andressa Gonçalves Amorim  13 , Larissa Chrispim de Oliveira  14 , Marcellus do Nascimento Moreira Ramos  15 , Gil Facina  16 , Ruffo de Freitas Junior  17 , Henrique Lima Couto  18 , Sabrina Monteiro Rondelo  19 , Renata Montarroyos Leite  20 , Renata Arakelian  21 , Luiz Henrique Gebrim  22 , Juliana Monte Real  23
Affiliations
Meta-Analysis

CADONOT: Comparing axillary dissection or not in breast cancer surgery

André Mattar et al. Breast. 2025 Jun.

Abstract

Introduction: Sentinel lymph node biopsy (SLNB) is the gold standard for the axillary evaluation of clinically node-negative early breast cancer. The ACOSOG Z0011 study demonstrated the safety of omitting axillary dissection for limited SLNB disease, with other trials confirming SLNB alone or with axillary radiotherapy (AR) as non-inferior.

Methods: We followed PRISMA guidelines and registered at PROSPERO. Using Medline, Embase, and Cochrane, we reviewed randomized controlled trials (2010-2024). Outcomes, including 5-, 8-, and 10-year OS, DFS, recurrence rates, and lymphedema, were analyzed with R software and assessed for bias (Cochrane RoB) and evidence quality (GRADE). The focus was ALND vs. SLNB, alone or with AR, in cT1-T3 BC with 1-2 metastatic SLNs.

Results: Thirteen articles from seven randomized controlled trials (RCTs) were included, covering 7338 women with a follow-up period of 2.8-10 years. SLNB was associated with a 65 % lower risk of lymphedema than ALND, with no significant differences in the 5-, 8-, or 10-year OS, DFS, or recurrence rates. A meta-analysis comparing micrometastasis and macrometastasis showed no impact on outcomes, indicating that ALND may be unnecessary in either case. Recurrence rates also did not differ between SLNB and ALND, reinforcing SLNB's significantly lower lymphedema risk of SLNB.

Conclusions: This systematic review and meta-analysis support SLNB as a safe and effective alternative to ALND in early-stage BC with 1-2 positive SLNs, providing comparable survival and recurrence outcomes, with fewer complications.

Keywords: Axillary lymph node dissection; Breast cancer; Breast neoplasm; Mastectomy; Radiotherapy; Segmental mastectomy; Sentinel lymph node biopsy.

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Conflict of interest statement

Declaration of competing interest AM received honoraria from Roche, AstraZeneca, Novartis, Exact Siences, and Eli Lilly. The other authors have no conflicts of interest to declare.

Figures

Fig. 1
Fig. 1
Prisma flow diagram.
Fig. 2
Fig. 2
Five-year local recurrence.
Fig. 3
Fig. 3
Five-year disease-free survival. Events: number of patients that are without recurrence.
Fig. 4
Fig. 4
Five-year overall survival. Events: number of patients that are without recurrence.
See this image and copyright information in PMC

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