title: Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases: commentary on the IBCSG 23-01 Trial.
abstract: Breast surgical oncologists have rapidly and successfully transitioned from the routine use of axillary lymph node dissection (ALND) to sentinel lymph node (SLN) biopsy for staging the axilla in clinically node negative patients. This approach limits the use of ALND to those patients with pathologically-proven axillary lymph node metastases and has prompted great current interest in whether or not all SLN-positive patients benefit from a completion ALND. Analysis of population-based data shows a decades-long trend towards omitting ALND in patients with low volume axillary disease. Thus, even prior to publication of the results of the ACOSOG Z0011 study and the IBCSG 23-01 study, completion ALND was being performed less frequently for selected patients with nodal micrometastases. Herein we review the contribution of the recently published IBCSG 23-01 study which provides additional data to confirm that for selected patients, mainly those with small, estrogen receptor-positive tumors with low nodal disease burden undergoing breast conservation with radiation and adjuvant systemic therapy, ALND might be avoided safely. This trial, which included small numbers of patients treated by mastectomy without radiation, and lumpectomy with partial breast irradiation, suggests interest in further clinical trials investigating these important patient populations. The study's short median follow-up however, cautions us to be clear in discussion, especially with younger patients who have otherwise biologically favorable tumors, that the long-term outcomes of SLN biopsy alone for low volume axillary disease remains unknown.
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
authors.forename: Tina J
authors.initials: TJ
authors.lastname: Hieken
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
authors.forename: Judy C
authors.initials: JC
authors.lastname: Boughey
keywords: Breast cancer; axillary lymph node dissection (ALND); micrometastatic disease; sentinel lymph node (SLN) biopsy
references.citation: J Am Coll Surg. 2013 Jan;216(1):105-13
references.pmid: 23122536
references.citation: JAMA. 2011 Feb 9;305(6):569-75
references.pmid: 21304082
references.citation: Surgery. 2013 Oct;154(4):831-8; discussion 838-40
references.pmid: 24074422
references.citation: Ann Surg Oncol. 2010 Oct;17 Suppl 3:343-51
references.pmid: 20853057
references.citation: Lancet. 2005 Dec 17;366(9503):2087-106
references.pmid: 16360786
references.citation: Ann Surg. 2010 Sep;252(3):426-32; discussion 432-3
references.pmid: 20739842
references.citation: Breast. 2013 Oct;22(5):733-5
references.pmid: 23290275
references.citation: Lancet Oncol. 2013 Apr;14(4):297-305
references.pmid: 23491275
references.citation: Ann Surg Oncol. 2013 Aug;20(8):2556-61
references.pmid: 23456432
references.citation: N Engl J Med. 2011 Feb 3;364(5):412-21
references.pmid: 21247310
references.citation: Ann Surg Oncol. 2010 Oct;17(10):2685-9
references.pmid: 20390457
references.citation: Breast. 2000 Feb;9(1):5-8
references.pmid: 14731577
references.citation: J Clin Oncol. 2009 Jun 20;27(18):2946-53
references.pmid: 19364968
references.citation: Ann Surg. 2004 Sep;240(3):462-8; discussion 468-71
references.pmid: 15319717