Olga Kantor1,2, Jessica Means1, Samantha Grossmith1, Tanujit Dey3, Jennifer R Bellon4, Elizabeth A Mittendorf1,2, Tari A King5,6. 1. Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. 2. Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA. 3. Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA. 4. Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA. 5. Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. tking7@bwh.harvard.edu. 6. Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA. tking7@bwh.harvard.edu.
Abstract
BACKGROUND: Following publication of the AMAROS trial, we sought to optimize axillary lymph node dissection (ALND) or postmastectomy radiation therapy (PMRT) + axillary radiation (AxRT) utilization in cT1-2N0 patients with 1-2 positive sentinel lymph nodes (SLNs) after mastectomy. METHODS: In November 2015, our multidisciplinary group implemented a protocol to omit intraoperative SLN evaluation for mastectomy patients with cT1-2N0 breast cancer likely to be recommended PMRT if found to have 1-2 positive SLNs (age ≤ 60 years and/or high-risk features defined as estrogen receptor-negative and/or positive for lymphovascular invasion). We prospectively evaluated axillary management, short-term complications, and oncologic outcomes in patients with 1-2 positive SLNs. RESULTS: From November 2015 to December 2018, 479 of 560 (85%) cT1-2N0 breast cancers treated with mastectomy were potential candidates for PMRT. Intraoperative SLN evaluation was omitted in 344 (72%), thus following the protocol. Overall, 121 cases had 1-2 positive SLNs: 17 (14%) were managed with observation, 5 (4%) PMRT alone, 59 (49%) PMRT + AxRT, 16 (13%) ALND alone, and 24 (20%) ALND + PMRT. Protocol compliance resulted in less ALND (8% vs. 24%) and less ALND + PMRT (9% vs. 41%, p < 0.01). At median follow-up of 24 months, there was one regional and four distant recurrences, with no regional recurrences or differences in disease-free survival in patients treated with ALND versus PMRT + AxRT (100% vs. 98%, p = 0.67). Similarly, there were no differences in complication rates (p = 0.18). CONCLUSIONS: Omitting intraoperative SLN evaluation in cT1-2N0 mastectomy patients who would be candidates for PMRT if found to have positive nodes decreased rates of ALND and minimized use of ALND + PMRT without compromising outcomes.
BACKGROUND: Following publication of the AMAROS trial, we sought to optimize axillary lymph node dissection (ALND) or postmastectomy radiation therapy (PMRT) + axillary radiation (AxRT) utilization in cT1-2N0 patients with 1-2 positive sentinel lymph nodes (SLNs) after mastectomy. METHODS: In November 2015, our multidisciplinary group implemented a protocol to omit intraoperative SLN evaluation for mastectomy patients with cT1-2N0 breast cancer likely to be recommended PMRT if found to have 1-2 positive SLNs (age ≤ 60 years and/or high-risk features defined as estrogen receptor-negative and/or positive for lymphovascular invasion). We prospectively evaluated axillary management, short-term complications, and oncologic outcomes in patients with 1-2 positive SLNs. RESULTS: From November 2015 to December 2018, 479 of 560 (85%) cT1-2N0 breast cancers treated with mastectomy were potential candidates for PMRT. Intraoperative SLN evaluation was omitted in 344 (72%), thus following the protocol. Overall, 121 cases had 1-2 positive SLNs: 17 (14%) were managed with observation, 5 (4%) PMRT alone, 59 (49%) PMRT + AxRT, 16 (13%) ALND alone, and 24 (20%) ALND + PMRT. Protocol compliance resulted in less ALND (8% vs. 24%) and less ALND + PMRT (9% vs. 41%, p < 0.01). At median follow-up of 24 months, there was one regional and four distant recurrences, with no regional recurrences or differences in disease-free survival in patients treated with ALND versus PMRT + AxRT (100% vs. 98%, p = 0.67). Similarly, there were no differences in complication rates (p = 0.18). CONCLUSIONS: Omitting intraoperative SLN evaluation in cT1-2N0 mastectomy patients who would be candidates for PMRT if found to have positive nodes decreased rates of ALND and minimized use of ALND + PMRT without compromising outcomes.
Authors: Olga Kantor; Cecilia Chang; Katharine Yao; Judy Boughey; Christina Roland; Amanda B Francescatti; Sarah Blair; Diana Dickson Witmer; Kelly K Hunt; Heidi Nelson; Anna Weiss; Tawakalitu Oseni Journal: Ann Surg Oncol Date: 2021-01-09 Impact factor: 5.344