Can a small nodal metastasis reliably alter intraoperative risk/benefit decision making in breast cancer surgery?

Surgeons treating breast cancer patients make repeated decisions as they select from an array of complex management options. The end point of any recommendation to our patients is, do the potential benefits of surgery outweigh the potential risks? Whether to perform an axillary lymphadenectomy and whether to go ahead with autologous tissuebased immediate breast reconstructive surgery immediately after total mastectomy is determined by intraoperative evaluation of the sentinel node or nodes removed from the axilla. Regarding the decisions surrounding the staging and treatment of axillary lymph nodes, the elements of decision making on the benefits side include: (1) the goals of surgery (diagnosis of metastases, regional disease control, and increasing survival rates), (2) staging information on the natural history of disease that affects survival outcomes (e.g., number of nodal metastases, extracapsular invasion), and (3) improved cosmetic and rehabilitation benefits of immediate breast reconstruction using autologous flaps. The elements of decision making on the risk side include: (1) the morbidity of a level I and II lymphadenectomy (e.g., wound complications, lymphedema, numbness), (2) patient comorbidity risk factors (e.g., obesity, older age), (3) risk of not performing a lymphadenectomy, which may increase the future risk of regional recurrence, and (4) the risk of poor outcome after reconstruction followed by irradiation to the reconstructed breast. One central component of this decision-making is getting complete and reliable information on the status of nodal metastases, which in turn influences intraoperative decisions on whether to perform a more complete lymphadenectomy and decisions on the type of immediate breast reconstructive surgery. The staging information regarding nodal status will also influence postoperative decisions regarding the type and intensity of adjuvant systemic therapy and the deployment of adjuvant radiation therapy to the remaining axillary/supraclavicular lymph nodes and the chest wall. Some tenets of lymph nodes metastases are being reexamined as sentinel lymph node (SLN) technology is increasingly being used in the staging of and treatment planning for breast cancer and melanoma. Samoilova et al. ask a provocative question: is it necessary to perform a more complete axillary node dissection in patients with small micrometastases in the SLN? Alternatively, could the treatment safely be limited to the sentinel node excision or a limited dissection of level I lymph nodes? And what is the lower threshold of metastatic cells in a SLN for which we should stage patients as N+ instead of N(mic), or dismiss the finding as isolated tumor cells of no clinical significance? One of the important questions addressed in this study is whether any factors would predict an incidence of four or more metastatic nodes for which adjuvant radiation therapy would be indicated and for which extensive reconstructive breast surgery might have to be deferred until this is completed. The authors performed a retrospective review of 467 patients who underwent SLN biopsy, 126 (27%) of whom were found to have metastases in the SLN. They then correlated clinicopathological variables Received July 11, 2007; accepted July 13, 2007; published online: September 19, 2007. Address correspondence and reprint requests to: Lisa K. Jacobs, MD; E-mail: ljacob14@jhmi.edu