title: Conservative axillary surgery in breast cancer patients undergoing mastectomy: long-term results.
abstract: BACKGROUND
  Recently, the American College of Surgeons Oncology Group Z0011 trial demonstrated that axillary lymph node dissection (ALND) could be safely avoided in selected breast cancer patients with limited nodal disease and having breast conservation therapy. However, for node positive (N+) mastectomy patients, full ALND remains the standard of care. Hypothesizing that omission of complete ALND is safe in many N+ breast cancer patients, a hybrid procedure called conservative axillary regional excision (CARE) was developed, consisting of removal of sentinel nodes and other palpable nodes (without intraoperative frozen section or reoperation for N+).
  
  
  METHODS
  A retrospective review of patients undergoing mastectomy with CARE between 2002 and 2010 was performed. Data collected included demographics; staging; number of lymph nodes removed; adjuvant, antihormonal, and radiation therapies; recurrence; lymphedema; and survival data. Recurrence-free survival was estimated using the Kaplan-Meier method and compared using Cox proportional hazards.
  
  
  RESULTS
  Five hundred and eighty-seven patients underwent mastectomy with CARE. Mean follow-up was 5.1 years. A median of 8 nodes were removed. There were 7 patients with local recurrence, of which 3 were axillary recurrences. Lymphedema developed in 20 (3.4%) patients, 75% of which had neoadjuvant chemotherapy. Lymphedema development was associated with the number of lymph nodes removed (p = 0.05) and radiation therapy (p = 0.004).
  
  
  CONCLUSIONS
  Conservative axillary regional excision is an excellent model for understanding the role of limited axillary surgery in mastectomy patients. The locoregional recurrence rate among N1 patients having CARE is low (3.4%). Conservative axillary regional excision is also associated with low rates of lymphedema. These data support the use of limited ALND in selected N+ mastectomy patients.
authors.affiliation: Division of Surgical Oncology and Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH. Electronic address: cowherm@ccf.org.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Cowher
authors.affiliation: Division of Surgical Oncology and Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Grobmyer
authors.affiliation: Division of Surgical Oncology and Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Joanne
authors.initials: J
authors.lastname: Lyons
authors.affiliation: Division of Surgical Oncology and Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Colin
authors.initials: C
authors.lastname: O'Rourke
authors.affiliation: Division of Surgical Oncology and Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Deborah
authors.initials: D
authors.lastname: Baynes
authors.affiliation: Division of Surgical Oncology and Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Crowe
mesh_terms: D001365:Axilla; D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008197:Lymph Node Excision / Q000379:methods*; D008207:Lymphatic Metastasis; D008209:Lymphedema / Q000453:epidemiology / Q000209:etiology; D008408:Mastectomy; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology / Q000517:prevention & control; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D021701:Sentinel Lymph Node Biopsy; D016019:Survival Analysis; D016896:Treatment Outcome