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Safety of avoiding routine use of axillary dissection in early stage breast cancer: a systematic review

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Abstract

Physicians are moving away from routine axillary lymph node dissection (ALND) in clinically node-negative breast cancer. We conducted a systemic review on the safety of this policy. Pubmed and Cochrane library were searched for. Sixty-eight studies were included: studies of clinically node-negative patients in the pre-sentinel node (SN) era; observational studies of SN-negative patients, without ALND; comparative studies of SN-negative patients, with a non-ALND and an ALND group; SN-positive studies, of patients without ALND. Primary endpoint was the pooled axillary recurrence rate (ARR) of each category; secondary endpoint was overall survival (OS) rate. In pre-SN studies, with larger tumors and less systemic therapy, ARR without ALND after 5–10 years follow-up was 12–18%, with 5% reduced OS. In the observational SN-negative studies, with median follow-up of 36 months, the pooled ARR was 0.6% (95% CI 0.6–0.8). In the comparative SN-negative studies, pooled ARR was 0.4% (95% CI 0.2–0.6) without ALND versus 0.3% (95% CI 0.1–0.6) with ALND at 31 and 47 months, respectively, and no survival disadvantage. In SN-positive studies, ARR was up to 1.7% (95% CI 1.0–2.7) at 30 months. For patients with an H&E positive SN the ARR without ALND was 5% after 23 months, which may imply rates as high as 13 and 18% after 5 and 8 years. In conclusion, this systematic review confirms the safety of omitting ALND in SN-negative patients. There is a potential role for avoiding ALND in selected SN-positive patients, but eligibility criteria and the role of systemic therapy need further to be elucidated.

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Acknowledgments

The authors thank Wim A. J. G. Lemmens for his assistance with statistical analyses. The authors thank the reviewer for his/her helpful comments regarding an earlier version of this article. We also thank the Netherlands Organization for Health Research and Development (ZonMw 945-06-509).

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  1. Division of Medical Oncology, Department of Internal Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands

    Manon J. Pepels, Johanna H. M. J. Vestjens, Maaike de Boer & Vivianne C. G. Tjan-Heijnen

  2. Department of Surgery, GROW—School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands

    Marjolein Smidt

  3. University Medical Centre Utrecht, Utrecht, The Netherlands

    Paul J. van Diest

  4. Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

    George F. Borm

  5. Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

    Maaike de Boer

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  1. Manon J. Pepels
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Pepels, M.J., Vestjens, J.H.M.J., de Boer, M. et al. Safety of avoiding routine use of axillary dissection in early stage breast cancer: a systematic review. Breast Cancer Res Treat 125, 301–313 (2011). https://doi.org/10.1007/s10549-010-1210-7

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