title: When is a completion axillary lymph node dissection necessary in the presence of a positive sentinel lymph node?
abstract: BACKGROUND
  The management of the axilla in the presence of positive sentinel lymph node (SLN) remains controversial. Many centres forgo completion axillary lymph node dissection (cALND) in the presence of micrometastatic disease. The American College of Surgeons Oncology Group (ACOSOG) Z0011 trialists argue for extending this to macrometastasis. The aim of this study was to correlate tumour burden in SLNs with that in the residual lymph node basin to determine the likelihood of residual disease in patients with micro- and macrometastasis in the SLN.
  
  
  METHODS
  Patients who underwent cALND following a positive SLN were analysed for histopathological features of the primary tumour and burden of axillary disease.
  
  
  RESULTS
  Of 155 patients, 115 (74%) had macrometastases and 40 (26%) micrometastases in the SLNs. Residual axillary disease was detected in 55/155 (35%) patients with macrometastases and 4/40 (10%) with micrometastases. Generally, with increasing size of metastasis in the SLN there was an increasing risk of further disease in residual lymph nodes. Logistic regression analysis showed increased odds ratios for further disease for all groups when compared with the <2mm (micrometastasis) SLN group.
  
  
  CONCLUSIONS
  Patients may be advised to forgo cALND where the SLN contains isolated tumour cells or micrometastasis. Recommendations for proceeding to cALND can be based on the size of metastasis in the SLN, which relates to the risk of further disease in the residual axillary lymph nodes and subsequent regional recurrence.
authors: Guy's & St. Thomas' NHS Foundation Trust, United Kingdom.
authors: A
authors: A
authors: Suyoi
authors: Guy's & St. Thomas' NHS Foundation Trust, United Kingdom; Division of Cancer Studies, King's College London, United Kingdom.
authors: S K
authors: SK
authors: Bains
authors: Guy's & St. Thomas' NHS Foundation Trust, United Kingdom.
authors: A
authors: A
authors: Kothari
authors: Guy's & St. Thomas' NHS Foundation Trust, United Kingdom; Division of Cancer Studies, King's College London, United Kingdom.
authors: M
authors: M
authors: Douek
authors: Division of Cancer Studies, King's College London, United Kingdom.
authors: O
authors: O
authors: Agbaje
authors: Guy's & St. Thomas' NHS Foundation Trust, United Kingdom.
authors: H
authors: H
authors: Hamed
authors: Guy's & St. Thomas' NHS Foundation Trust, United Kingdom.
authors: I
authors: I
authors: Fentiman
authors: Guy's & St. Thomas' NHS Foundation Trust, United Kingdom; Division of Cancer Studies, King's College London, United Kingdom.
authors: S
authors: S
authors: Pinder
authors: Guy's & St. Thomas' NHS Foundation Trust, United Kingdom; Division of Cancer Studies, King's College London, United Kingdom. Electronic address: claire.arnold@kcl.ac.uk.
authors: A D
authors: AD
authors: Purushotham
mesh_terms: D001365:Axilla; D001943:Breast Neoplasms / Q000453:epidemiology / Q000473:pathology* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods* / Q000706:statistics & numerical data; D008207:Lymphatic Metastasis; D008408:Mastectomy / Q000706:statistics & numerical data; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D021701:Sentinel Lymph Node Biopsy / Q000706:statistics & numerical data; D047368:Tumor Burden
keywords: Completion axillary lymph node dissection; Positive sentinel lymph node