Abstract P2-01-21: Management of the axilla in breast cancer patients: Do we over treat patients with preoperative diagnosis of nodal metastasis?
Authors: Michalakis Ioannis , Krupa Jaroslaw , Dunk Louisa 
Published: May 2015

Introduction: Axillary lymph node status is the most significant single prognostic factor in breast cancer patients. Axillary ultrasound scan (AUS) followed by fine needle aspiration (FNA) is the gold standard modality in preoperative staging of the axilla and spares the patient a possible second operation. Sentinel lymph node biopsy (SLNB) accurately stages the axilla with low axillary recurrence rates and reduced morbidity. Increasing evidence suggests that surgical removal of the axillary lymph nodes (completion ALND) in early breast cancer with limited nodal disease yields no advantage in terms of either overall or disease-free survival.The purpose of this audit is to identify possible changes in management of the axilla in patients having preoperative diagnosis of nodal metastasis.

Methods: We reviewed the available data from breast cancer patients that had positive FNA after AUS (441) or positive nodes at a SLNB (324) in our unit from 2007 to 2013.

Results:410 of the 441 (93%) patients with a preoperative diagnosis of nodal metastasis received completion ALND. 147 of the 410 (36%) patients had neoadjuvant chemotherapy and of these 34 (23%) had complete pathological response at the axilla. 101 of the 263 (38%) patients who did not receive neoadjuvant chemotherapy had 1 or 2 nodes involved and also had a T1 or T2 tumour.

Patients with positive axillary FNA and ALNDNumper of patientsALND without neoadjuvant chemotherapy:263ALND after neoadjuvant chemotherapy:147Age (median)6448Tumor size (T)T1:56 T2:190 T3:16 Histological GradeG1:11 G2:105 G3:144G1:15 G2:84 G3:28ER status positive200 (76%)96 (65%)Her 2 status positive49 (19%)44 (30%)Median nodes removed2017Median positive nodes33Patients with &lt;3 nodes positive103 (39%)72 (49%)Total number of patients 410

161 of the 324 (47%) patients with positive SLNB had completion ALND. 67 of the 161 (42%) patients received chemotherapy prior the completion ALND. All the patients who had a positive SLNB and who did not receive completion ALND received radiotherapy to the axilla.

Patients with positive SLNBNumber of patientsRadiotherapy to the axilla:163With completion ALND after chemotherapy:67With completion ALND before chemotherapy:94Age (median)645059Tumor size (T)T1:83 T2:73 T3:5T1:20 T2:39 T3:8T1:37 T2:48 T3:7Histological GradeG1:27 G2:93 G3:40G1:8 G2:31 G3:28G1:13 G2:60 G3:21ER status positive144 (88%)57 (85%)90 (96%)Her 2 status positive10 (6%)16 (24%)14 (15%)Median nodes removed 1617Median positive nodes122Patients with &lt;3 nodes positive at the SLNB150 (92%)50 (75%)72 (77%)Patients with &lt;3 nodes positive in total after completion ALND 40 (60%)58 (62%)Total number of patients 324

Conclusions: Breast cancer patients with a preoperative diagnosis of nodal metastasis are treated in a different way than the patients with positive SLNB. Axillary treatment may be improved if we could identify patients with a preoperative diagnosis of nodal metastasis that fulfil the criteria of the Z11 trial and so potentially save patients unnecessary axillary surgery.

Citation Format: Ioannis Michalakis, Jaroslaw Krupa, Louisa Dunk. Management of the axilla in breast cancer patients: Do we over treat patients with preoperative diagnosis of nodal metastasis? [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-21.