Findings in JAMA suggest new standard of breast-cancer care with limited lymph node removal

By Debbie Bolles and Russell Rian / Feb. 19-28, 2011

Some women undergoing surgery for breast cancer may not necessarily need all their lymph nodes removed, according to Dr. Marilyn Leitch, co-author of a new “practice-changing” study appearing in the Feb. 9 issue of the Journal of the American Medical Association.

Data from the study were initially reported in June 2010 at a meeting of the American Society of Clinical Oncology. Dr. Leitch said UT Southwestern has revised its recommendations for lymph node removal.

Dr. Marilyn Leitch in the operating room

“This study is practice-changing and will be viewed as a landmark study in breast cancer care,” she said. “The significance of this research is that women who have an involved sentinel node in the armpit do not necessarily have to have all of the lymph nodes removed, which was the standard of care in the past.”

Partial node removal, she said, can result in faster recovery times and may avert troubles such as arm swelling and numbness or tingling.

“In this study, having more limited surgery did not result in worse survival or local recurrence at five years,” said Dr. Leitch, professor of surgical oncology in the Harold C. Simmons Cancer Center, the only National Cancer Institute-designated center in North Texas, and principal investigator for the local portion of the study.

UT Southwestern was among the five medical institutions that recruited patients for the study, and Dr. Leitch was a member of the committee that designed the study when it started in 1999. She also was involved in acquisition and analysis of the data, which nationally included results from 891 patients at 115 institutions.

The study involved women who had undergone a lumpectomy and sentinel node biopsy and were found to have cancer in one or two lymph nodes. Half were assigned to have further lymph node removal and half received no additional lymph node surgery.

“The only treatment difference between the two groups was whether they had complete lymph node removal,” Dr. Leitch said. “An average of 17 nodes were removed in women having the rest of the lymph nodes removed [axillary lymph node dissection] compared to an average of two for those having sentinel node surgery only. All women had breast conserving surgery and whole breast radiation.”

UT Southwestern’s trial group involved 40 women enrolled between 2000 and 2004. They continue in long-term follow-up.

“We have adopted this data in the care of our patients here, but it doesn’t fit everybody. We have been offering women the opportunity to avoid axillary node dissection if they have only one or two sentinel nodes with cancer and they are having lumpectomy and whole breast radiation,” she said.

Dr. Leitch said patients who have invasive breast cancer should confer with their doctors about sentinel node surgery and whether avoiding removal of all lymph nodes is a viable option.

“The exception would be that during the operation, the surgeon may find that many of the lymph nodes are involved and then removal of the rest is necessary,” she said.

If more than two of the sentinel lymph nodes are involved with cancer, then removal of all the lymph nodes is still recommended. That’s an important distinction that should not be lost in the excitement of the study’s findings, she cautioned. In addition, this study pertained to women with planned breast-conserving surgery with radiation to the breast. Women with plans for mastectomy may not be candidates for the limited node surgery.

Adverse effects of having two-thirds or more of the lymph nodes removed can include arm swelling, called lymphedema, which can be unsightly and painful. In addition, removal of more lymph nodes can limit range of motion due to scar tissue formation, as well as causing tingling or numbness in the upper arm due to dissection of a skin nerve. By limiting the lymph node surgery, a drainage tube is avoided, reducing recovery time from several weeks to several days.

As a follow-up to the study, UT Southwestern is participating in an American College of Surgeons Oncology Group clinical trial to determine the accuracy of sentinel node biopsy after chemotherapy is given prior to surgery to reduce the size of the tumor in the breast and lymph nodes.

“The hope is that in the future, limited lymph node surgery may be possible for women who are currently not considered candidates for this minimally invasive surgery,” she said.

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Dr. Leitch holds the S.T. Harris Family Distinguished Chair in Breast Surgery.
 

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