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.
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“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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