Defining complete axillary node burden in cT1/T2 cN0 patients undergoing primary surgery with mastectomy and 3 positive sentinel nodes

Document Type

Conference Proceeding

Publication Date

7-8-2025

Publication Title

Ann Surg Oncol

Keywords

Oncology, Surgery

Abstract

Background/Objective: Multiple landmark trials have been published in the past decade identifying opportunities to safely minimize axillary surgery in cases of limited nodal metastasis. This led the American Society of Breast Surgeons (ASBrS) to release official consensus guidelines on axillary management for breast cancer patients in 2022. Within these guidelines, sentinel lymph node biopsy (SLNB) without axillary lymph node dissection (ALND) is deemed appropriate for those with cT1- 2N0 disease having primary mastectomy with 1-3 positive SLNs and receiving axillary radiotherapy, as these patients meet AMAROS and OTOASOR criteria to defer ALND. However, the consensus statement does note that the data for 3 positive SLNs may be insufficient, as 95% of patients in the AMAROS trial only had 1-2 positive SLNs. We aim to define our institution’s final axillary burden in patients undergoing mastectomy with 3 positive SLNs to investigate the possibility of omitting ALND in this cohort. Methods: Our institutional IRB approved prospective breast cancer database was queried for all cT1- T2, cN0 cases who underwent primary surgery with mastectomy, SLNB and ALND from 1996 to 2023. Patient demographics, clinical characteristics, tumor biology, and clinical/pathologic staging were recorded. Results: We identified 189 cT1/T2 cN0 patients who underwent mastectomy with SLN biopsy revealing 1-3 positive SLNs with completion ALND. Across the cohort, the total nodes removed per case following ALND ranged from 1 to 40 (mean 14.6 additional nodes removed). Of these 189 patients, 102 (54%) had additional nodal disease on ALND, which is consistent with published data (ranging from 40-60%). The number of additional positive non-sentinel nodes, if present, ranged from 1-28 (mean 4.1). When stratified by pathologic N-stage, final surgical pathology defined 67 cases as pN1 (65.7%), 22 as pN2 (21.6%), and 13 as pN3 (12.7%). When stratified by number of positive SLNs, 137 cases had 1 positive SLN (72.5%), 41 had 2 positive SLNs (21.7%), and 11 had 3 positive SLNs (5.8%). Of the 11 cases with 3 positive SLNs, 8 cases (72.7%) had non-sentinel node disease on completion ALND, ranging from 3 to 28 additional positive nodes. Conclusions: At our institution, 189 patients undergoing primary mastectomy with positive SLNs met AMAROS/OTOASOR criteria to safely avoid ALND. Of the patients with 3 positive SLNs, the cohort noted to potentially have insufficient data within the available trials, 8 patients (72.7%) had non-sentinel node disease. Although our numbers are low, our data suggests non-sentinel node disease burden is high in patients with 3 positive SLNs. Larger, multicenter studies are needed to more thoroughly investigate the locoregional recurrence and long-term survival of patients with 3 positive SLNs who undergo axillary radiotherapy without ALND.

Volume

32

First Page

770

Last Page

771

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