Waiving Subsequent Complete Lymph Node Dissection in Melanoma Patients with Positive Sentinel Lymph Node Does Not Result in Worse Outcome on 20-Year Analysis

Complete lymph node dissection (CLND) following positive sentinel lymph node (SLN) biopsy has been the standard of care for decades. We aimed to study melanoma patients with an emphasis on the outcome of patients with versus without CLND following positive SLN biopsy. SLN-positive patients with or without CLND were compared regarding important prognostic clinical and histological characteristics. Ten-year and 20-year survival curves for melanoma relapse and melanoma-specific survival (MSS) were determined by the Kaplan-Meier method and Cox proportional-hazards regression. We studied 258 patients who had micrometastases in their SLN biopsy. CLND was performed in 209 of 258 patients (81%). Hence, in 49 of 258 patients (19%) with SLN micrometastases, CLND was not performed. These patients did not significantly (p > 0.05) differ from patients with CLND in regard to age, gender, tumor thickness, tumor ulceration, capsule infiltration of SLN, or invasion level of SLN. On 10-year analysis, we did not observe a significantly increased risk for melanoma relapse and worse in MSS in patients who did not undergo CLND (hazard ratio: 1.1 (95% CI 0.67 to 1.7) and 1.1 (95% CI 0.67 to 1.9), respectively). On 20-year survival analysis, we confirmed that the risk of melanoma relapse and impaired MSS does not significantly increase in patients without CLND (hazard ratio: 1.2 (95% CI 0.8 to 1.9) and 1.3 (95% CI 0.8 to 2.3), respectively). On 10-year as well as 20-year multivariable follow-up analysis (including several important prognostic factors), Cox proportional-hazards regression showed that the status of CLND did not remain in the regression model (p > 0.1). Our 10-year data give conclusive support to previous investigations indicating that waiving CLND in patients with SLN micrometastases does not affect MSS. More importantly, our long-term follow-up data confirm for the first time the 10-year survival data of previous investigations.

Axillary Ultrasound Evaluation in Breast Cancer Patients: A Multidisciplinary Viewpoint and Middle Ground

Over the past decade, there has been a trend toward de-escalation of axillary surgery. Certain patients may now forego axillary lymph node dissection even in the setting of a positive sentinel lymph node biopsy (SLNB), and some patients may not even undergo a SLNB. However, there is wide variability in the imaging approach to assessing axillary lymph nodes in patients with breast cancer. Approaches range from performing axillary US in all patients with newly diagnosed breast cancer to omitting axillary imaging evaluation in all patients. This article provides a multidisciplinary middle ground approach for axillary nodal evaluation. The clinical impact and rationale for appropriate axillary nodal imaging are discussed and an imaging algorithm is proposed.

Analysis of Axillary Management Following Mastectomy With a Positive Sentinel Lymph Node Biopsy

BACKGROUND: Axillary lymph node dissection (ALND) with or without postmastectomy radiation therapy (PMRT) was traditionally the standard of care for patients with a positive sentinel node following mastectomy. However, recent clinical trial data has led to an interest in de-escalating therapy and a debate over optimal axillary management. We sought to assess current practice patterns and the impact of different approaches to managing positive sentinel nodes following mastectomy. METHODS: Using the National Cancer Database (NCDB), patients with clinical T1-2 N0 M0 breast cancer from 2012-2015 treated with a mastectomy who were found to have a single positive sentinel node were analyzed. A logistic regression model stratified by patients’ characteristics in association to the type of axillary treatment received was performed.RESULTS: We identified 12,137 women with a positive sentinel lymph node biopsy (SLNB) at the time of mastectomy. Of these, 4,221 had an ALND; 1,609 received PMRT; 1,565 underwent combination therapy, and 4,742 had no further treatment following SLNB (NFT). Factors associated with an increased likelihood of further axillary treatment included younger age (<40), Midwest location, larger primary tumor size (T2), and high grade. There was no difference in short-term overall survival among these approaches. CONCLUSION: Our study indicates significant practice variation in the axillary management of patients with metastasis limited to a single sentinel node undergoing mastectomy. The clinical variation observed raises the possibility of unnecessary or overtreatment of the axilla. These findings suggest a need to expand the adoption of evidenced-based clinical protocols to improve quality of care.