The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials

Danushka Seneviratne; Laura Vallow; Jinny Gunn; Tammeza Gibson; Emmanuel Gabriel; Sanjay Bagaria; Sarah McLaughlin

doi:doi:10.11648/j.js.20210903.14

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The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials

Danushka Seneviratne, Laura Vallow, Jinny Gunn, Tammeza Gibson, Emmanuel Gabriel, Sanjay Bagaria, Sarah McLaughlin

Published in Journal of Surgery (Volume 9, Issue 3)

Received: 9 March 2021 Accepted: 5 May 2021 Published: 26 May 2021

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Abstract

Axillary nodal dissections (ALND) were historically performed in the management of early stage, node-positive breast cancer. Since the ACOSOG Z0011 landmark study demonstrated that patients with clinically negative axillae and 1-2 positive sentinel lymph nodes could be spared the morbidity of an axillary dissection, surgeons have widely adopted the omission of ALND. However, the practice patterns in the adjuvant setting remain less clear, and our current work wishes to address this gap by assessing the management of early stage breast cancer at our institution. We performed a retrospective analysis of 504 women with cT1/T2 N0 breast cancer undergoing breast conserving therapy (BCT) between 5/2011-6/2016 and collected data regarding the clinico-pathological characteristics of the tumors and the adjuvant therapies received. Overall, 97% patients completed a SLNB, while 3% underwent upfront ALND. None of SLNB positive patients had further axillary surgery. In the SLNB positive cohort however, adjuvant therapies consisted of 61.5% patients receiving regional nodal irradiation. Further analysis revealed that factors such as tumor type, T and N stage, hormone receptor status, tumor grade, the presence of LVSI, patient age, and patient race, did not correlate with clinician decisions to deviate from ACOSOG protocol recommendations regarding adjuvant therapy. Our work suggests that although ACOSOG Z0011 recommendations for minimizing axillary surgery in patients with limited nodal disease has largely been adopted at our institution, node directed radiation therapy continues to be relatively commonplace. Interestingly, the delivery of nodal irradiation was not associated with common clinic-pathological factors.

Published in	Journal of Surgery (Volume 9, Issue 3)
DOI	10.11648/j.js.20210903.14
Page(s)	114-120
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2021. Published by Science Publishing Group

Keywords

Axillary Management, Early Stage Breast Cancer, ACOSOG Z0011

References

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[2]	Ayala de la Pena, F., et al., SEOM clinical guidelines in early stage breast cancer (2018). Clin Transl Oncol, 2019. 21 (1): p. 18-30.
[3]	Furrukh, M. and A. Qureshi, Treatment Of Breast Cancer; Review And Updates. J Ayub Med Coll Abbottabad, 2018. 30 (2): p. 264-274.
[4]	Braunstein, L. Z. and J. R. Bellon, Contemporary Issues in Breast Cancer Radiotherapy. Hematol Oncol Clin North Am, 2020. 34 (1): p. 1-12.
[5]	Wong, J. S., L. E. Warren, and J. R. Bellon, Management of the Regional Lymph Nodes in Early-Stage Breast Cancer. Semin Radiat Oncol, 2016. 26 (1): p. 37-44.
[6]	Giuliano, A. E., et al., Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA, 2011. 305 (6): p. 569-75.
[7]	Giuliano, A. E., et al., Locoregional Recurrence After Sentinel Lymph Node Dissection With or Without Axillary Dissection in Patients With Sentinel Lymph Node Metastases: Long-term Follow-up From the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial. Ann Surg, 2016. 264 (3): p. 413-20.
[8]	Donker, M., et al., Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol, 2014. 15 (12): p. 1303-10.
[9]	Caudle, A. S., et al., American College of Surgeons Oncology Group (ACOSOG) Z0011: impact on surgeon practice patterns. Ann Surg Oncol, 2012. 19 (10): p. 3144-51.
[10]	Krag, D. N., et al., Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol, 2010. 11 (10): p. 927-33.
[11]	Purushotham, A. D., et al., Morbidity after sentinel lymph node biopsy in primary breast cancer: Results from a randomized controlled trial. Journal of Clinical Oncology, 2005. 23 (19): p. 4312-4321.
[12]	McCready, D., et al., Surgical management of early stage invasive breast cancer: a practice guideline. Can J Surg, 2005. 48 (3): p. 185-94.
[13]	Jagsi, R., et al., Radiation field design in the ACOSOG Z0011 (Alliance) Trial. J Clin Oncol, 2014. 32 (32): p. 3600-6.
[14]	Mann, J. M., et al., National Practice Patterns of Axillary Management and Adjuvant Radiation After ACOSOG Z0011. International Journal of Radiation Oncology, 2016.
[15]	Hildebrandt, G., et al., Central Review of Radiation Therapy Planning Among Patients with Breast-Conserving Surgery: Results from a Quality Assurance Process Integrated into the INSEMA Trial. Int J Radiat Oncol Biol Phys, 2020. 107 (4): p. 683-693.

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APA Style

Danushka Seneviratne, Laura Vallow, Jinny Gunn, Tammeza Gibson, Emmanuel Gabriel, et al. (2021). The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials. Journal of Surgery, 9(3), 114-120. https://doi.org/10.11648/j.js.20210903.14

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ACS Style

Danushka Seneviratne; Laura Vallow; Jinny Gunn; Tammeza Gibson; Emmanuel Gabriel, et al. The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials. J. Surg. 2021, 9(3), 114-120. doi: 10.11648/j.js.20210903.14

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AMA Style

Danushka Seneviratne, Laura Vallow, Jinny Gunn, Tammeza Gibson, Emmanuel Gabriel, et al. The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials. J Surg. 2021;9(3):114-120. doi: 10.11648/j.js.20210903.14

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@article{10.11648/j.js.20210903.14,
  author = {Danushka Seneviratne and Laura Vallow and Jinny Gunn and Tammeza Gibson and Emmanuel Gabriel and Sanjay Bagaria and Sarah McLaughlin},
  title = {The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials},
  journal = {Journal of Surgery},
  volume = {9},
  number = {3},
  pages = {114-120},
  doi = {10.11648/j.js.20210903.14},
  url = {https://doi.org/10.11648/j.js.20210903.14},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.js.20210903.14},
  abstract = {Axillary nodal dissections (ALND) were historically performed in the management of early stage, node-positive breast cancer. Since the ACOSOG Z0011 landmark study demonstrated that patients with clinically negative axillae and 1-2 positive sentinel lymph nodes could be spared the morbidity of an axillary dissection, surgeons have widely adopted the omission of ALND. However, the practice patterns in the adjuvant setting remain less clear, and our current work wishes to address this gap by assessing the management of early stage breast cancer at our institution. We performed a retrospective analysis of 504 women with cT1/T2 N0 breast cancer undergoing breast conserving therapy (BCT) between 5/2011-6/2016 and collected data regarding the clinico-pathological characteristics of the tumors and the adjuvant therapies received. Overall, 97% patients completed a SLNB, while 3% underwent upfront ALND. None of SLNB positive patients had further axillary surgery. In the SLNB positive cohort however, adjuvant therapies consisted of 61.5% patients receiving regional nodal irradiation. Further analysis revealed that factors such as tumor type, T and N stage, hormone receptor status, tumor grade, the presence of LVSI, patient age, and patient race, did not correlate with clinician decisions to deviate from ACOSOG protocol recommendations regarding adjuvant therapy. Our work suggests that although ACOSOG Z0011 recommendations for minimizing axillary surgery in patients with limited nodal disease has largely been adopted at our institution, node directed radiation therapy continues to be relatively commonplace. Interestingly, the delivery of nodal irradiation was not associated with common clinic-pathological factors.},
 year = {2021}
}

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TY  - JOUR
T1  - The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials
AU  - Danushka Seneviratne
AU  - Laura Vallow
AU  - Jinny Gunn
AU  - Tammeza Gibson
AU  - Emmanuel Gabriel
AU  - Sanjay Bagaria
AU  - Sarah McLaughlin
Y1  - 2021/05/26
PY  - 2021
N1  - https://doi.org/10.11648/j.js.20210903.14
DO  - 10.11648/j.js.20210903.14
T2  - Journal of Surgery
JF  - Journal of Surgery
JO  - Journal of Surgery
SP  - 114
EP  - 120
PB  - Science Publishing Group
SN  - 2330-0930
UR  - https://doi.org/10.11648/j.js.20210903.14
AB  - Axillary nodal dissections (ALND) were historically performed in the management of early stage, node-positive breast cancer. Since the ACOSOG Z0011 landmark study demonstrated that patients with clinically negative axillae and 1-2 positive sentinel lymph nodes could be spared the morbidity of an axillary dissection, surgeons have widely adopted the omission of ALND. However, the practice patterns in the adjuvant setting remain less clear, and our current work wishes to address this gap by assessing the management of early stage breast cancer at our institution. We performed a retrospective analysis of 504 women with cT1/T2 N0 breast cancer undergoing breast conserving therapy (BCT) between 5/2011-6/2016 and collected data regarding the clinico-pathological characteristics of the tumors and the adjuvant therapies received. Overall, 97% patients completed a SLNB, while 3% underwent upfront ALND. None of SLNB positive patients had further axillary surgery. In the SLNB positive cohort however, adjuvant therapies consisted of 61.5% patients receiving regional nodal irradiation. Further analysis revealed that factors such as tumor type, T and N stage, hormone receptor status, tumor grade, the presence of LVSI, patient age, and patient race, did not correlate with clinician decisions to deviate from ACOSOG protocol recommendations regarding adjuvant therapy. Our work suggests that although ACOSOG Z0011 recommendations for minimizing axillary surgery in patients with limited nodal disease has largely been adopted at our institution, node directed radiation therapy continues to be relatively commonplace. Interestingly, the delivery of nodal irradiation was not associated with common clinic-pathological factors.
VL  - 9
IS  - 3
ER  -

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Author Information

Danushka Seneviratne

Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, United States
Laura Vallow

Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, United States
Jinny Gunn

Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
Tammeza Gibson

Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
Emmanuel Gabriel

Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
Sanjay Bagaria

Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
Sarah McLaughlin

Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States

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APA Style

Danushka Seneviratne, Laura Vallow, Jinny Gunn, Tammeza Gibson, Emmanuel Gabriel, et al. (2021). The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials. Journal of Surgery, 9(3), 114-120. https://doi.org/10.11648/j.js.20210903.14

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ACS Style

Danushka Seneviratne; Laura Vallow; Jinny Gunn; Tammeza Gibson; Emmanuel Gabriel, et al. The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials. J. Surg. 2021, 9(3), 114-120. doi: 10.11648/j.js.20210903.14

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AMA Style

Danushka Seneviratne, Laura Vallow, Jinny Gunn, Tammeza Gibson, Emmanuel Gabriel, et al. The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials. J Surg. 2021;9(3):114-120. doi: 10.11648/j.js.20210903.14

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@article{10.11648/j.js.20210903.14,
  author = {Danushka Seneviratne and Laura Vallow and Jinny Gunn and Tammeza Gibson and Emmanuel Gabriel and Sanjay Bagaria and Sarah McLaughlin},
  title = {The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials},
  journal = {Journal of Surgery},
  volume = {9},
  number = {3},
  pages = {114-120},
  doi = {10.11648/j.js.20210903.14},
  url = {https://doi.org/10.11648/j.js.20210903.14},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.js.20210903.14},
  abstract = {Axillary nodal dissections (ALND) were historically performed in the management of early stage, node-positive breast cancer. Since the ACOSOG Z0011 landmark study demonstrated that patients with clinically negative axillae and 1-2 positive sentinel lymph nodes could be spared the morbidity of an axillary dissection, surgeons have widely adopted the omission of ALND. However, the practice patterns in the adjuvant setting remain less clear, and our current work wishes to address this gap by assessing the management of early stage breast cancer at our institution. We performed a retrospective analysis of 504 women with cT1/T2 N0 breast cancer undergoing breast conserving therapy (BCT) between 5/2011-6/2016 and collected data regarding the clinico-pathological characteristics of the tumors and the adjuvant therapies received. Overall, 97% patients completed a SLNB, while 3% underwent upfront ALND. None of SLNB positive patients had further axillary surgery. In the SLNB positive cohort however, adjuvant therapies consisted of 61.5% patients receiving regional nodal irradiation. Further analysis revealed that factors such as tumor type, T and N stage, hormone receptor status, tumor grade, the presence of LVSI, patient age, and patient race, did not correlate with clinician decisions to deviate from ACOSOG protocol recommendations regarding adjuvant therapy. Our work suggests that although ACOSOG Z0011 recommendations for minimizing axillary surgery in patients with limited nodal disease has largely been adopted at our institution, node directed radiation therapy continues to be relatively commonplace. Interestingly, the delivery of nodal irradiation was not associated with common clinic-pathological factors.},
 year = {2021}
}

Copy | Download

TY  - JOUR
T1  - The Management of Positive Axillary Nodes in Early Stage Breast Cancer: Analysis of Practice Pattern Concordance with Landmark Trials
AU  - Danushka Seneviratne
AU  - Laura Vallow
AU  - Jinny Gunn
AU  - Tammeza Gibson
AU  - Emmanuel Gabriel
AU  - Sanjay Bagaria
AU  - Sarah McLaughlin
Y1  - 2021/05/26
PY  - 2021
N1  - https://doi.org/10.11648/j.js.20210903.14
DO  - 10.11648/j.js.20210903.14
T2  - Journal of Surgery
JF  - Journal of Surgery
JO  - Journal of Surgery
SP  - 114
EP  - 120
PB  - Science Publishing Group
SN  - 2330-0930
UR  - https://doi.org/10.11648/j.js.20210903.14
AB  - Axillary nodal dissections (ALND) were historically performed in the management of early stage, node-positive breast cancer. Since the ACOSOG Z0011 landmark study demonstrated that patients with clinically negative axillae and 1-2 positive sentinel lymph nodes could be spared the morbidity of an axillary dissection, surgeons have widely adopted the omission of ALND. However, the practice patterns in the adjuvant setting remain less clear, and our current work wishes to address this gap by assessing the management of early stage breast cancer at our institution. We performed a retrospective analysis of 504 women with cT1/T2 N0 breast cancer undergoing breast conserving therapy (BCT) between 5/2011-6/2016 and collected data regarding the clinico-pathological characteristics of the tumors and the adjuvant therapies received. Overall, 97% patients completed a SLNB, while 3% underwent upfront ALND. None of SLNB positive patients had further axillary surgery. In the SLNB positive cohort however, adjuvant therapies consisted of 61.5% patients receiving regional nodal irradiation. Further analysis revealed that factors such as tumor type, T and N stage, hormone receptor status, tumor grade, the presence of LVSI, patient age, and patient race, did not correlate with clinician decisions to deviate from ACOSOG protocol recommendations regarding adjuvant therapy. Our work suggests that although ACOSOG Z0011 recommendations for minimizing axillary surgery in patients with limited nodal disease has largely been adopted at our institution, node directed radiation therapy continues to be relatively commonplace. Interestingly, the delivery of nodal irradiation was not associated with common clinic-pathological factors.
VL  - 9
IS  - 3
ER  -

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