Limited Versus Complete Axillary Lymphatic Dissection as Part of The Overall Procedure of Modified Radical Mastectomy in The Management of Invasive Breast Cancer Patients

Musaa Faisal Al-Mahdawi,Mustafa Adil Abbass,Eman Mohammed Ali
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Keywords : Mastectomy, Axillary lymph node dissection, Breast cancer
Medical Journal of Babylon  13:1 , 2016 doi:1812-156X-13-1
Published :15 April 2016

Abstract

Complete dissection of axillary lymph nodes (DALN) can be sidestepped in chosen cases of invasive breast cancer patients with confined lymph nodal disease and having conventional breast surgery, nevertheless, for node positive mastectomy patients, complete dissection of axillary lymph nodes remains the model procedure, Avoidance of complete dissection of axillary lymph nodes is reliable in many node-positive patients and can be substituted with limited axillary lymph node dissection which consists of elimination of Sentinel lymph nodes and other grossly palpable lymphatics without further axillary devastation. A prospective study of 55 women patients diagnosed with invasive breast cancer underwent mastectomy with conservative dissection of axillary lymph nodes between September 2012 and December 2014 in Al-yarmouk teaching hospital and private hospitals in Baghdad, the recorded information included patient age, menstrual history, drug history, family history, tumour staging, number of axillary lymph nodes excised, postoperative medical therapy, adjuvant radiotherapy, recurrence and local complications including lymphedema, Fifty five patients underwent mastectomy with limited axillary lymph node dissection, all are females, the mean age was 38 years, 43 patient (78.2%) were invasive ductal carcinoma and 12 patients (21.8%) invasive lobular carcinoma, the mean follow-up period was 2 years, a mean number of eight lymph nodes were removed, there were 1 patients (1.8) % with local chest wall recurrence but no single case of axillary recurrence. Lymphedema development occurred in 2 patients (3.6%) and was associated with significant number of the removed lymph nodes (P=0.05) and postoperative radiotherapy (P=0.005).

Introduction

Dissection of axillary lymph nodes (DALN) was performed as a routine part of breast cancer surgery since long time, as it was believed to provide necessary staging information and long-term regional control, and was considered essential for guiding decisions about the use of adjuvant therapy [1]. There was a steady decrease in the extent of radical surgical procedures for breast cancer [2]. It was estimated that there was no contraindication for non complete dissection of axillary lymph nodes in patients with invasive breast cancer with positive sentinel lymph node [3,4]. Axillary lymph node dissection for breast cancer typically results of removal of 17 to 24 lymph nodes [5,6]. However dissection of axillary lymph nodes has been associated with substantial rates of lymphedema, ranging from 12% to 28% depending on the lymphedema definition criteria [7]. The greatest risk period for lymphedema development is in the first 24 months after dissection of axillary lymph nodes, and therefore, all the efforts have been taken to reduce the extent of axillary lymph node surgery [7]. Axillary sentinel lymph node biopsy (SLNB) has been widely accepted as a less radical axillary staging procedure for patients with the clinically node negative invasive breast cancer [8]. The national surgical adjuvant breast and bowel project demonstrated that dissection of axillary lymph nodes can be safely omitted in patients without evidence of metastatic disease involving sentinel lymph nodes (SLNs) [9]. Sentinel lymph node biopsy has since also been demonstrated to be safe and accurate in patients undergoing neoadjuvant therapy for breast cancer [10]. It was suggested that complete dissection of axillary lymph nodes can be safely avoided and select the patient’s having breast conservation surgery with low volume axillary disease confined to 1 or 2 SLNs that are treated with adjuvant medical therapy and whole breast radiation therapy [4], and the complete dissection of axillary lymph nodes in patients with involvement of one or two SLNs did not substantially affect overall or disease free survival. That has been postulated that the use of modern adjuvant medical and radiation therapy effectively controls otherwise occult axillary disease in SLN positive breast cancer patients in whom dissection of axillary lymph nodes is omitted [11]. Complete dissection of axillary lymph node can be avoided in selected patients undergoing lumpectomy for breast cancer with one or two positive axillary SLNs [12,13]. The modern data on the omission of complete node dissection in patients having mastectomy with low volume axillary node disease are limited [14,15]. Crawford and colleague demonstrated low rates of loco regional recurrence for sentinel lymph node-positive mastectomy patients in whom completion axillary node dissection was omitted, However most patients (91%) in this study show only Micro metastasis or immunohistochemical only positive disease in the sentinel lymph node (SLN) [16]. Bilimoria and his colleagues reported lower rates of local recurrence in Sentinel lymph node-positive mastectomy patients in whom dissection of axillary lymph nodes was omitted [17]. Spiguel and colleagues reported no axillary failures among Sentinel lymph node positive mastectomy patients in whom completion DALN was omitted similar to Milgrom and colleagues and Crawford and colleagues, this series also had a high proportion (67%) of patients with Micro metastasis disease [18]. McBride CM demonstrated that patients treated with extended simple mastectomy without adjuvant radiotherapy and medical therapy demonstrated low rate of axillary failure and survival similar to patients at that time with standard radical mastectomy [19]. George Crile began omitting axillary dissection for clinical stage 1 breast cancer patients having mastectomy [20].

Materials and methods

A twenty eight month prospective study of invasive breast cancer patients undergoing mastectomy with conservative dissection of axillary lymph nodes (surgical  excision of only the grossly enlarged and the clinically suspicious  lymph nodes)  between September 2012 and December 2014,the study done in both public hospital ,Al-yarmouk teaching hospital and private hospitals in Baghdad with a mean follow up period of two years
 The collected data included  patient age at diagnosis, clinical and pathological staging, number of axillary lymph nodes removed, adjuvant chemotherapy, antihormonal therapy and postoperative radiotherapy, loco regional recurrence which was defined as chest wall or axillary recurrence and local complications including lymphedema which is defined as decreased function and/or quality of life due to arm swelling or pain.
Four  patients were excluded from the study, (2 patients refused the surgery, 1 case with locally advanced breast tumour and 1 patient with distant metastasis were sent for the oncologist for systemic therapy. Preoperative diagnosis was made by FNAC and/ or Excisional biopsy of the palpable breast mass.
Classical mastectomy procedure was done through the standard skin incision and the conservative axillary procedure is performed through the lateral aspect of the same incision accessing the axillary cavity. After the clavipectoral fascia is incised, the axillary lymph nodes are explored below and above the intercostobracheal nerve, during which individual lymph nodes are not separated from the surrounding axillary fat but are used to define the boundaries of the nodal groups, and this group is then removed en bloc
Cephal axillary dissection to the level of the axillary vein usually not performed in this procedure unless there are additional grossly palpable lymph nodes.
Intra operative frozen section biopsy of the sentinel lymph nodes is not performed and no re-operation for completion axillary node dissection was done for patients found to have LN involvement on their final pathology.
The conservative axillary node excision is technically differs from full dissection  of axillary lymph nodes in few ways, the traditional complete dissection is anatomically based on removing all tissues between the anterolateral latissimus dorsi muscle and the chest wall medially and  proceeds superiorly to the axillary vein, including level one and two with/without level three lymph nodes dissection  and all the axillary fatty tissues are removed completely clearing the inferior border of the axillary vein and all the tissues around the thoracodorsal bundle and the long thoracic nerve. With conservative dissection, all the enlarged and any attached nodes together with any clinically suspicious LNs were identified and excised only while the axillary vein is not skeletonised.




Results

Fifty five patients underwent mastectomy with conservative dissection of axillary lymph nodes for invasive breast carcinoma during the study period (2012-2014)with a mean follow up of 2 years. All patients are females, their age ranging from 32 to 68 years with mean age 38 years, A mean of 8 axillary LNs were removed (ranging between 2 and 16 nodes) table (1), Regarding axillary LN staging, 19patients (34.7%) was N0, 29 patients (52.7%) N1,5 patients (9%) N2, 2 patients (3.6%) N3 as shown in table (1).

Discussions

By more than four decades ago, the old surgical approach for breast cancer patients with clinically node negative was radical mastectomy including complete axillary lymph node dissection, total mastectomy with radiation or total mastectomy alone. Pathology specimen of clinically node negative cases who had axillary dissection showed an approximately 40% nodal metastasis rate, and for those patients in the arm without complete axillary lymph node dissection, there was no survival difference at 25 years follow-up [21]. The axillary recurrence rate for clinically node negative patients undergoing radical mastectomy was similar to patients undergoing mastectomy and radiotherapy (2%), and the axillary recurrence rate for patients with total mastectomy alone was 15%with a mean time to axillary recurrence of 12 months [22], while in our study, the local recurrence was reported in 1 patient with chest wall recurrence (1.8%) but no axillary recurrence reported. The currently reported series of mastectomy patients treated with conservative axillary lymph node dissection supports the concept that complete dissection can be safely avoided in node positive mastectomy patients who receive adjuvant medical therapy with or without radiotherapy [23]. The local recurrence and development of lymphedema as a complication is low among N1 mastectomy group having conservative axillary lymph node dissection (1.8%). In our study Lymphedema was recorded as a loco regional postoperative complication in 2 patients (3.6%) where there was an association between the number of LN removed and its development and also there was a significant association with post operative radiotherapy exposure (P=0.004) and the incidence of lymphedema in our study is low in spite of using postoperative radiotherapy because the majority of our patients are in stage (N0-N1) where N0 group patients was excluded from postoperative radiotherapy. This is similar to other reports of local recurrence in node positive mastectomy patients undergoing complete axillary lymph node dissection with adjuvant medical therapy and selected use of post mastectomy radiation therapy [24, 25]. Other series have described limited axillary surgical procedures for breast cancer patients [26,27] with low axillary recurrence rate but in all cases the limited axillary surgery was combined with radiotherapy. In our study, postoperative radiotherapy was given for 36patients (65.4%) including N1, N2 and N3 groups only while N0 group was excluded. Conservative axillary lymph node dissection procedure involves removal of around 50% of the nodes traditionally removed during classical axillary lymph node dissection and is associated with lower rates of lymphedema (3.6%). In our study, only the grossly palpable lymph nodes and any attached nodes together with any clinically suspicious LNs were identified and excised and it was not necessary to dissect deeply in the axilla to reach the axillary vein. The limitations observed in our study was the limited post operative follow up period (2 years) because it was difficult to keep in contact with the patients for longer period especially when they are referred to complete their medical therapy courses and radiotherapy with their oncologist in other centres, the other draw back was no neo adjuvant radiotherapy was used in this study because of unavailability and limitation of resources. Most of our patients (70%) was included in the first half period of our study while the others (30%) in the second half and therefore our postoperative follow up period for most of our patients was around 28 months especially for those included in the beginning of the study and our mean follow up was 2 years.

Conclusions

Complete axillary lymph node dissection is not necessary in many node positive mastectomy patients, this is because of the low rate of loco regional recurrence and lymphedema as a complication detected in mastectomy patients having conservative axillary lymph node dissection. In addition, adjuvant radiotherapy for majority of the patients (N1) undergoing this procedure not seems to be a requirement or to be justified by the lymph node status only while the role of neo adjuvant radiotherapy in this procedure to be explored by other studies.

References

1. Fischer B, Montague E, Redmond C, Comparison of radical mastectomy with alternative treatment for primary breast cancer. Cancer 1977;39:2827-2839.
2. McLaughlin SA, surgical management of the breast: breast conservation therapy and mastectomy. Surg Clin North Am 2013;93:411-428.
3. Rao R, Euhus D, Maho HG, Axillary node intervention in breast cancer: asystemic review. JAMA 2013; 310:1385-1394.
4. Giuliano AE, Hunt KK, Ballman KV, Axillary dissection versus no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a rondamized clinical trial. JAMA 2011; 305:569-575.
5. Danforth DN Jr, Findlay PA, Mcdonald HD, complete axillary lymph node dissection for stage 1-2 carcinoma of the breast. J Clin Oncol 1986;4:655-662.
6. Veronisi U, Luini A, Galimberti V, Extent of metastatic axillry involvement in 1446 cases of breast cancer. Eur J Surg Oncol 1990;16:127-133.
7. DiSipio T, Rye S, Newman B, Incidence of unilateral arm lymphedema after breast cancer: a systemic review and meta analysis. Lanct Oncol 2013;14:500-515.
8. Amersi F, Giuliano AE, Management of the axilla. Hematol Oncol Clin North Am 2013;27:687-702, vii.
9. Krag DN, Anderson SJ, Julian TB,Sentinel lymph node resection compared with conventional axillary lymph node dissection in clinically node negative patients with breast cancer. Lancet Oncol 2010;11:927-933.
10. Boughey JC, Suman VJ, Mittendorf EA,sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node positive breast cancer. JAMA 2013; 310:1455-1461.
11. Hunt KK, Yi M, Mittendorf EA,sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients. Ann Surg 2009; 250:558-566.
12. Gainer SM, Hunt KK, Beitsch P, changing behaviour in clinical practice. Ann Surg Oncol 2012;19:3152-3158.
13. Forrest AP, Everington D, McDonald CC, the Edinburgh randomised trial of axillary sampling or clearance after mastectomy. Br J Surg 1995; 82:1504-1508.
14. Truong PT, Lee J, Kader HA, loco regional recurrence risk in elderly breast cancer patients treated wiyh mastectomy without adjuvant radiotherapy. Eur J Cancer 2005; 41:1267-1277.
15. Milgrom S, Cody H, Tan L, Characteristics and outcomes of sentinel node positive breast cancer patients after total mastectomy without axillary specific treatment. Ann Surg Oncol 2012;19:3762-3770.
16. Crawford JD, Ansteth M, Barnett J, routine completion axillary lymph node dissection for positive sentinel nodes in patients undergoing mastectomy is not associated with improved local control. Am J Surg 2013;205:581-584.
17. Bilimoria KY, Bentrem DJ, Hansen NM, comparison of sentinel lymph node biopsy alone and completion axillary lymph node dissection for node positive breast cancer. J Clin Oncol 2009;27:2946-2953.
18. Spiguel L, Yao K, Winchester DJ, sentinel node biopsy alone for node positive breast cancer . J Am Coll Surg 2011;213:122-128.
19. McBride CM. Extended simple mastectomy ; anatomic definition and uses. South Med J 1972;65:1427-1431.
20. Crile G Jr. results of simple mastectomy without irradiation in the treatment of operative stage 1 cancer of the breast. Ann Surg 1968;168:330-336.
21. Fischer B, Jeong JH, Anderson S, Twenty five year follow up of a randomized trial comparing radical mastectomy, total mastectomy and total mastectomy followed by irradiation. N Engl J Med 2002;347:567-575.
22. Moo TA, McMillan R, Lee M, Selection criteria for post mastectomy radiotherapy in t1-t2 tumours with 1 to 3 positive lymph nodes. Ann Surg Oncol 2013;20:3169-3174.
23. Kong M, Hong SE. which patients might benefit from post mastectomy radiotherapy in breast cancer patients with t1-2 tumour and 1-3 axillary lymph nodes metastasis. Cancer Res Treat 2013;45:103-111.
24. Crowe JP Jr, Gordon NH, Antunea AR, Local regional breast cancer recurrence following mastectomy. Arch Surg 1991; 126:429-432.
25. Boneti C, Badgwel B, Robertson Y, Axillary Reverse Mapping in preventing lymphedema after lymphadenactomy. Minerva Ginecol 2012; 64:421-430.
26. Salmon RJ, Marcolet A, Vieira M, sentinels node biopsy or limited oriented axillary dissection in early breast cancer. Eur J Surg Oncol 2005;31:949-953.
27. Chetty U, Jack W, Prescott RJ, Management of the axilla in operable breast cancer treated by breast conservation. Br J Surg 200;87:163-169.


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