The New England Journal of MedicineAxillary Dissection — The Bell Tolls for Thee

The Evolving Paradigm of Axillary Management in Breast Cancer: Navigating Towards Less Invasive Approaches

The management of axillary lymph nodes in breast cancer has undergone significant evolution, moving away from axillary-lymph-node dissection (ALND) towards less invasive techniques like sentinel-node biopsy (SNB). This shift, driven by a series of pivotal trials, underscores a growing consensus that less invasive staging can offer comparable outcomes in specific patient cohorts. This summary encapsulates the key findings from recent research, highlighting the nuanced decision-making process in axillary management that aligns with the broader trend of personalized, minimally invasive cancer care.

Key Points:

• Axillary-lymph-node dissection (ALND) was the traditional standard for axillary staging in breast cancer but has been increasingly replaced by sentinel-node biopsy (SNB) for patients with clinically node-negative disease.
• The ACOSOG Z0011 trial marked a significant turning point, showing that patients with 1 or 2 positive sentinel nodes undergoing breast-conserving surgery could avoid ALND without compromising survival or recurrence rates, given concurrent adjuvant radiotherapy and systemic therapy.
• Critiques of the ACOSOG Z0011 and AMAROS trials included their patient demographics, with a focus on older patients who generally have a lower risk of axillary recurrence, potentially skewing the applicability of results.
• The SENOMAC trial further bolstered the case against routine ALND, demonstrating no statistical advantage in recurrence-free survival with ALND over SNB alone in a specific patient group, underlining the need for personalized treatment strategies.
• Current National Comprehensive Cancer Network guidelines support the use of targeted axillary dissection in certain contexts, offering a less invasive option while maintaining diagnostic accuracy.
• The CALGB 9343 trial’s findings suggest that axillary surgery may not provide additional benefit in older women with early-stage, hormone receptor–positive breast cancer, influencing guidelines to recommend against routine ALND in this group.
• The SOUND trial introduces a potential paradigm shift, questioning the necessity of SNB in patients with negative axillary ultrasonography, pointing towards a future where axillary surgery might be further minimized or even eliminated in select cases.
• Despite the move away from routine ALND, axillary staging remains crucial for guiding therapeutic decisions, emphasizing the balance between invasiveness and informative value in breast cancer treatment.

“Given the consistent data showing little value to axillary dissection in diverse clinical scenarios, the question remains: In an era of advanced diagnostic imaging, genomic assays, and ever-improving adjuvant and neoadjuvant therapies, is any axillary surgery necessary?”
– Kandace P. McGuire, MD

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