Giuliano - Value of Surgical Stagiing of The Axilla

Revista de Senología y Patología Mamaria 35 (2022) 219–220
www.elsevier.es/senologia
EDITORIAL
The value of surgical staging of the axilla

El valor de la estadificación quirúrgica de la axilla
It is an honor to have my comments accompany the excellent and that equivalent regional control may be achieved with
consensus of the Sociedad Española de Senologia y Patologia axillary irradiation. These statements are not entirely true.
Mamaria for sentinel node biopsy and management of the While it is true that axillary lymph node dissection may
axilla for breast cancer. Axillary management has become itself impart no survival advantage for the clinically node
far more complicated over the years. As late as the 1970's negative patient, those who have limited axillary nodal
and early 1980's, axillary management was quite simple. disease such as women who would be eligible for American
Every patient with any form of breast cancer was treated College of Surgeons Oncology Group (ACOSOG) Z00112 or the
with axillary dissection as part of a modified radical AMAROS3 trial, axillary dissection may be therapeutic for
mastectomy. Even patients with DCIS or LCIS were treated women with involved lymph nodes or those whose nodes
with modified radical mastectomy. After axillary dissection remain involved after being treated with neoadjuvant
was appropriately eliminated for the noninvasive malignancies, systemic therapy. The staging information provided by
sentinel node biopsy became the first major advance in axillary surgical staging often guides the selection of systemic
surgery and remains the cornerstone of axillary management. therapy which does impact survival. No imaging modality
But even the use of this procedure has evolved a great deal and no procedure short of operation can provide such
since it was first introduced. I first attempted sentinel node definitive information.
biopsy as a diagnostic test in 1991 merely to determine No image-guided procedures can rule out metastasis
whether a patient was node negative and could be spared the because they lack the sensitivity needed to accurately
morbidity of an axillary dissection.1 Currently the use of stage the axilla. A core biopsy guided by ultrasonography
sentinel node biopsy has expanded, and the management of which indicates metastases is entirely reliable, but an
the axilla has become nuanced. Variations in axillary operations ultrasound-guided biopsy showing a lack of metastasis
and the use of radiation therapy as well as the increasing use of cannot be relied upon.
neoadjuvant chemotherapy have added to the complexity and Some women, in fact, may be managed without surgical
difficulty of axillary management. axillary staging. Elderly women with small hormone
Accurate evaluation of the axilla is essential to the receptor-positive tumors and clinically tumor-free lymph
assessment of the patient with breast cancer. Axillary nodes can often avoid axillary staging, but even elderly
staging begins with a careful physical examination followed women with large tumors, those who undergo neoadjuvant
by axillary ultrasonography. All patients with invasive breast chemotherapy, those with suspicious nodes or hormone
cancer benefit from sonographic examination of the axilla, receptor-negative tumors or HER2-positive tumors may, in
infraclavicular and supraclavicular nodal regions. Nodes that fact, require axillary staging. Axillary radiation can achieve
appear suspicious either on imaging or palpation should be excellent regional control similar to axillary lymph node
further evaluated by image-guided core needle biopsy. dissection with a lower lymphedema rate for women with
Women with involved nodes may require neoadjuvant clinically negative lymph nodes and a low axillary burden
chemotherapy depending on a number of clinical features. found on sentinel node biopsy, but women with palpable
Indications for neoadjuvant hormone therapy are not yet nodes, more than two positive lymph nodes, or nodal
clearly defined, and the management of the axilla after involvement post-neoadjuvant chemotherapy cannot be
neoadjuvant hormone therapy is even less clearly defined. treated with radiation alone. Ongoing studies may show
Some oncologists are suggesting that axillary operations the efficacy of nodal irradiation for women with residual
are no longer necessary. They base this statement on the nodal disease after neoadjuvant chemotherapy, but these
fact that axillary operations do not impact overall survival studies are not yet complete.
https://doi.org/10.1016/j.senol.2022.07.001
0214-1582/n 2022 SESPM. Published by Elsevier España, S.L.U. All rights reserved.
Descargado para Anonymous User (n/a) en Valencian School of Health Studies de ClinicalKey.es por Elsevier en marzo 03, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
A.E. Giuliano
Postmenopausal women with clinically node-negative Funding

breast cancer and genomic risk scores that are low or women
with severe comorbidities for whom decisions for adjuvant This work has not received any funding.
therapy will not change regardless of axillary status may be
managed without sentinel node biopsy. The pre-menopausal
woman requires axillary staging regardless of her genomic risk Conflict of interest
score since any nodal metastasis in a pre-menopausal woman is
an indication for systemic chemotherapy. Armando E. Giuliano is Associate Editor Surgery, Plastic
Nodal status is important for all biologic subtypes of Surgery and Gynecology of the journal Revista de Senología y
breast cancer. In women with HER2-overexpressing tumors, Patología Mamaria.
the APT4 study demonstrated the safety of de-escalation of
systemic therapy for women with T1 or small T2 tumors and References
pathologically tumor-free nodes. Pathologic nodal status
must be determined by sentinel node biopsy in these 1. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic
patients. For women with HER2-overexpressing tumors mapping and sentinel lymphadenectomy for breast cancer. Ann
treated with neoadjuvant systemic therapy, the KATHERINE5 Surg. 1994 Sep;220(3):391–8 discussion 398–401.
trial demonstrated that residual disease in the breast or 2. Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB,
nodes warrants systemic therapy with T-DM1 rather than Kelemen PR, et al. Effect of axillary dissection vs no axillary
dissection on 10-year overall survival among women with
Trastuzumab so knowledge of status of nodes is essential for
invasive breast cancer and sentinel node metastasis: the
these women as well. Most patients with triple negative ACOSOG Z0011 (Alliance) randomized clinical trial. JAMA. 2017
tumors are treated with neoadjuvant chemotherapy, and Sep 12;318(10):918–26.
their nodal status postoperatively is necessary to rule out 3. Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde
residual disease for management with capecitabine. CJ, Mansel RE, et al. Radiotherapy or surgery of the axilla after a
Clearly axillary surgery and sentinel node biopsy are positive sentinel node in breast cancer (EORTC 10981-22023
relevant and contribute to treatment decisions and out- AMAROS): a randomised, multicentre, open-label, phase 3 non-
comes. Axillary dissection itself still remains critical in the inferiority trial. Lancet Oncol. 2014 Nov;15(12):1303–10 Epub
management for women post-neoadjuvant chemotherapy 2014 Oct 15.
with involved lymph nodes and selected women not treated 4. Tolaney SM, Barry WT, Dang CT, Yardley DA, Moy B, Marcom PK,
et al. Adjuvant paclitaxel and trastuzumab for node-negative,
with neoadjuvant chemotherapy such as those with bulky
HER2-positive breast cancer. N Engl J Med. 2015;372(2):134–41.
disease or multiple involved lymph nodes, perhaps even 5. von Minckwitz G, Huang CS, Mano MS, Loibl S, Mamounas EP,
those with limited nodal disease managed with mastectomy. Untch M, et al. Trastuzumab emtansine for residual invasive
Future studies, of course, will always change the manage- HER2-positive breast cancer. N Engl J Med. 2019;380(8):617–28.
ment algorithm for patients with breast cancer, but despite
systemic therapy and imaging advances, surgical manage- Armando E. Giuliano
ment of the axilla currently remains critical for optimal Department of Surgery, Cedars-Sinai Medical Center, Los
care. Sentinel node biopsy is the heart of axillary manage- Angeles, California, United States of America
ment. With these guidelines the Sociedad Española de E-mail address: [email protected]
Senología y Patologia Mamaria contributes greatly to the
care of patients, and this consensus should be a document
often referred to by the practicing oncologist.
220
Descargado para Anonymous User (n/a) en Valencian School of Health Studies de ClinicalKey.es por Elsevier en marzo 03, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.

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Revista de Senología y Patología Mamaria 35 (2022) 219–220

The value of surgical staging of the axilla

Postmenopausal women with clinically node-negative Funding

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