title: Recommendation for axillary lymph node dissection in women with early breast cancer and sentinel node metastasis: A systematic review and meta-analysis of randomized controlled trials using the GRADE system.
abstract: BACKGROUND
  In 2014, the American Society of Clinical Oncology published an updated clinical practice guideline on axillary lymph node dissection (ALND) for early-stage breast cancer patients. However, these recommendations have been challenged because they were based on data from only one randomized controlled trial (RCT). We evaluated the rationale of these recommendations by systematically reviewing RCTs using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system.
  
  
  METHODS
  We searched articles in the PubMed, EMBASE, CINAHL, Scopus, and Cochrane databases. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were recurrence rate and surgical complications of axillary dissection. The quality of evidence was assessed using the GRADE profiler.
  
  
  RESULTS
  Five eligible studies were retrieved and analyzed. We divided sentinel lymph node (SLN) metastasis into two categories: SLN micrometastasis and SLN macrometastasis. In patients with 1 or 2 SLN micrometastasis, no significant difference was observed in OS, DFS, or recurrence rate between the ALND and non-ALND groups. For patients with 1 or 2 SLN marcometastasis, only one trial with a moderate risk of bias was included, and non-ALND was the preferred management overall. However, ALND might be appropriate for patients who placed a greater emphasis on longer-term survival at any cost.
  
  
  CONCLUSIONS
  We recommend non-ALND management for early breast cancer patients with 1 or 2 SLN micrometastasis or macrometastasis on the basis of a systematic review of the current evidence conducted using the GRADE system. However, the optimal practice of evidence-based medicine should incorporate patient preferences, particularly when evidence is limited.
authors: Department of Nursing, College of Medicine and Nursing, HungKuang University, Taichung City, Taiwan.
authors: Tsai-Wei
authors: TW
authors: Huang
authors: Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
authors: Ken N
authors: KN
authors: Kuo
authors: Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.
authors: Kee-Hsin
authors: KH
authors: Chen
authors: Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Plastic Surgery, Department of Surgery, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan.
authors: Chiehfeng
authors: C
authors: Chen
authors: Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan; School of Gerontology Healthcare Management, College of Nursing, Taipei Medical University, Taipei, Taiwan.
authors: Wen-Hsuan
authors: WH
authors: Hou
authors: Department of Pathology, Taipei Medical University - Shuang Ho Hospital, New Taipei City, Taiwan.
authors: Wei-Hwa
authors: WH
authors: Lee
authors: Division of Hematology/Oncology, Department of Medicine, Taipei Medical University - Shuang Ho Hospital, New Taipei City, Taiwan.
authors: Tsu-Yi
authors: TY
authors: Chao
authors: Department of Radiation Oncology, Taipei Medical University - Shuang Ho Hospital, New Taipei City, Taiwan; Department of Radiation Oncology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
authors: Jo-Ting
authors: JT
authors: Tsai
authors: Division of General Surgery, Department of Surgery, Taipei Medical University - Shuang Ho Hospital, New Taipei City, Taiwan.
authors: Chih-Ming
authors: CM
authors: Su
authors: Division of General Surgery, Department of Surgery, Taipei Medical University - Shuang Ho Hospital, New Taipei City, Taiwan; Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
authors: Ming-Te
authors: MT
authors: Huang
authors: Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Division of General Surgery, Department of Surgery, Taipei Medical University - Shuang Ho Hospital, New Taipei City, Taiwan; Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. Electronic address: kelvintam@h.tmu.edu.tw.
authors: Ka-Wai
authors: KW
authors: Tam
mesh_terms: D001365:Axilla / Q000473:pathology / Q000601:surgery; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000592:standards*; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery*; D008207:Lymphatic Metastasis; D008875:Middle Aged; D061206:Neoplasm Micrometastasis; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D000071036:Sentinel Lymph Node / Q000473:pathology / Q000601:surgery; D021701:Sentinel Lymph Node Biopsy
keywords: Axillary lymph node dissection; Breast cancer; Clinical practice guideline; GRADE; Meta-analysis; Recommendation; Sentinel lymph node metastases