- Email: [email protected]
Long-term prognosis of patients with axillary recurrence after axillary dissection for invasive breast cancer
EJSO (2005) 31, 485–489
www.ejso.com
Long-term prognosis of patients with axillary recurrence after axillary dissection for invasive breast cancer A.C. Voogda,b,*, S. Cranenbroekc, R. de Boerd, R.M.H. Roumene, H.J.T. Ruttenf, M.J.C. van der Sangeng a
Department of Epidemiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands Eindhoven Cancer Registry, Comprehensive Cancer Centre South, P.O. Box 231, 5600 AE Eindhoven, The Netherlands c Faculty of Medicine, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands d Department of Radiotherapy, Nijmegen University Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands e ´xima Medical Centre, P.O. Box 7777, 5500 MB Veldhoven, The Netherlands Department of Surgery, Ma f Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands g Department of Radiotherapy, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands b
Accepted for publication 23 December 2004 Available online 19 February 2005
KEYWORDS Breast carcinoma; Axillary recurrence; Prognosis
Abstract Aim. To investigate the long-term prognosis of patients with axillary recurrence after axillary dissection for invasive breast cancer and describe the longterm survivors. Methods. Between 1984 and 1994, 4669 patients with invasive breast cancer underwent axillary dissection in eight community hospitals in the south–eastern part of The Netherlands. Using follow-up data of the population-based Eindhoven Cancer Registry, 59 patients with axillary recurrence were identified. Results. The median interval between treatment of the primary tumour and diagnosis of axillary recurrence was 2.6 years (range 0.3–10.7). The median length of follow-up after diagnosis of axillary recurrence was 11.1 years (5.7–15.6). Distant metastases occurred in 38 of the 59 patients. The 5- and 10-year distant recurrencefree survival rates were 39% (95% CI: 25–52%) and 29% (95% CI: 16–42%). Conclusions. Axillary recurrence following axillary dissection is associated with a high rate of subsequent distant metastasis and poor overall prognosis but is not always a fatal event. Our results show that it is possible to cure about one-third of the patients. q 2005 Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Department of Epidemiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands. Tel.: C31 43 3882387; fax: C31 43 3884128. E-mail address: [email protected] (A.C. Voogd). 0748-7983/$ - see front matter q 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2004.12.017
486
Figure 1 Distant disease-free survival for patients with axillary recurrence, calculated from the date of diagnosis of axillary recurrence.
Introduction The introduction of sentinel node biopsy has changed the staging of the breast cancer patients. Many patients with invasive breast cancer still undergo full axillary clearance or dissection of the lower and middle parts of the axilla (levels I and II), either because one or more sentinel nodes have proven to be positive or because they do not meet the criteria to undergo sentinel node biopsy or because units have not yet adopted the technique. The reported cumulative risk of developing axillary recurrence after axillary dissection will vary from 0.5 to 3.0%.1–9 In a previous study, we addressed the detection, treatment and prognosis of axillary recurrence after axillary dissection.10 This study included 59 patients with axillary recurrence. The follow-up after diagnosis of axillary recurrence was complete until 1 January 1998 and the median length of follow-up was 4.4 years (range 0.3–9.2) years for the patients who were still alive. Five years after the diagnosis of axillary recurrence 35% (95% CI, 21–50) of these patients were free of distant disease. We now report the follow-up information collected until January 2004 and present the 10-year survival rates of the same patient series and a description of the long-term survivors.
Patients and methods Patients Patient data were retrieved from the populationbased Eindhoven Cancer Registry, which serves a
A.C. Voogd et al. population of almost one million inhabitants in the south-eastern part of The Netherlands. During the period 1984–1994, 4669 (86 percent) of the 5408 patients with invasive breast cancer underwent axillary dissection in one of the eight general hospitals covered by the Eindhoven Cancer Registry. In the treatment guidelines of the regional Breast Cancer Study Group, the borders of axillary dissection are the latissimus dorsi muscle (dorsal), the thoracic wall below the major and minor pectoral muscles (ventral) and the lower border of the axillary vein (cranial). Axillary dissection was not always considered necessary for patients with a tumour measuring 0.5 cm or less and was usually omitted in the case of inoperable cancer and for the very elderly. The mean number of lymph nodes reported by the pathologist was 10. Fewer than six nodes were reported in 14% and more than 15 in 12% of the cases. Follow-up data of the population-based Eindhoven Cancer Registry were used, which were provided by the pathologists, the radiotherapists and the majority of surgeons. Due to the fact that follow-up information has only been recorded in the cancer registry since 1989, documentation was incomplete for early axillary recurrence occurring in the patients diagnosed in the period 1984–1988. These patients constitute 40% of the 4663 patients in the period 1984–1994. As of January 1998, 59 patients were reported to have isolated axillary recurrence after axillary dissection, of whom two had a concurrent recurrence in the breast, four an earlier recurrence in the breast and one an earlier recurrence in the chest wall. The medical records of these 59 patients were reviewed. Follow-up information was obtained until 1 January 2004.
Statistical analysis Survival analysis, using the life-table method, was performed to evaluate the prognosis after axillary recurrence. The primary endpoint was distant disease-free survival. Survival curves were calculated from the date of treatment of axillary recurrence or the date of the diagnosis of axillary recurrence when no treatment was applied.
Results The mean age of the patients at the time of diagnosis of axillary recurrence was 61 years (range 39–99). The median interval between treatment of the primary tumour and diagnosis of axillary recurrence was 2.6 years (range 0.3–10.7).
Long-term prognosis of axillary recurrence in breast cancer Further details on the diagnosis and treatment of axillary recurrence, as well as complications after treatment, have been described in our previous paper.10 Regional control (i.e. complete eradication of AR) was achieved in 34 patients. Twenty-four patients (41%) showed stable or progressive disease.
Long-term prognosis The median length of follow-up after diagnosis of axillary recurrence was 3.4 years (range 0.3–15.6) for the total group and 11.1 years (5.7–15.6) for the patients who were still alive. Distant metastases were observed in 38 of the 59 patients. The 5- and 10-year distant recurrence-free survival rates were 39% (95% CI: 25–52%) and 29% (95% CI: 16–42%), respectively (Fig. 1). Of the 38 distant metastases, 18 were detected within 1 year after the diagnosis of axillary recurrence, 30 within 3 years and 34 within 5 years. The remaining four patients developed distant disease after 5.8, 6.3, 7.0 and 8.3 years, respectively. Of the 59 patients with axillary recurrence, 44 died, 36 after developing distant metastases. Two patients were still alive with distant metastases and 13 were alive without evidence of disease. None of these 13 patients had received radiotherapy to the axillary or supraclavicular field as part of the treatment of their primary tumour. The mean number of nodes in the axillary specimen, as reported by the pathologists, was 9.8 for the patients who were still alive without evidence of disease, compared to 9.2 for the 38 patients in whom distant metastases occurred following the diagnosis of axillary recurrence (pZ0.78).
Prognostic factors The results of the analysis of prognostic variables for overall and distant recurrence-free survival confirmed our earlier findings that axillary nodal status at the time of diagnosis of the primary tumour (pZ0.001) and the success of local treatment of axillary recurrence (p!0.0001) are the most important prognostic factors; of the 22 patients whose axillary recurrence could be eradicated by the treatment and who had negative axillary lymph nodes eight had developed distant disease, whereas of the 12 patients with stable or progressive disease after treatment of axillary recurrence and a positive lymph node status 11 developed distant disease.
487
Discussion We have shown that it is possible to cure about onethird of the patients with axillary recurrence following axillary dissection for invasive breast cancer and that the risk of developing distant disease is very low in patients that have survived the first 5 years after axillary recurrence without evidence of breast cancer relapse.
The risk of axillary recurrence There is convincing evidence in the literature that the risk of axillary recurrence is low for patients with an adequate axillary lymph node dissection. The percentage axillary recurrences found in this study was 1.3% (59/4663). Reported rates after complete or level I and II dissections vary between 0.5 and 3.0%.1–9 In patients with positive lymph nodes, the risk can be reduced by axillary irradiation.11 The effectiveness of axillary dissection and irradiation is reflected by the high risk of recurrence in women with clinically negative nodes whose axilla remained untreated. For example, in the B-04 clinical trial of National Surgical Breast and Bowel Project, the rate of regional recurrence was 24% in women who had undergone only total mastectomy.12 Sentinel lymph node biopsy has been introduced into clinical practice as a mode to determine which patients can potentially be spared an axillary node dissection because they do not have nodal metastases. The accuracy of this procedure is supported by the increasing number of reports showing that patients with a negative sentinel node biopsy have a very small risk of developing axillary recurrence.13–17 These recurrences are more likely to represent the clinical manifestation of metastases that remained undetected due to a false-negative sentinel node procedure and may have a better prognosis than recurrences occurring after axillary dissection. It seems likely that axillary recurrences following a negative sentinel node biopsy are more suitable for surgery and radiotherapy, increasing the chances of complete eradication and cure. Follow-up of the patients with axillary recurrence following a negative sentinel node biopsy is still too short to study long-term prognosis and make comparisons with recurrences following axillary dissection.
The continued utility of axillary dissection In The Netherlands, as in many other European countries, breast cancer patients with non-palpable lymph nodes and a tumour measuring 5 cm or less
488
A.C. Voogd et al.
Table 1 Overview of studies describing the prognosis of patients with isolated axillary recurrence (AR) following axillary lymph node dissection Study
No. of patients
No. of patients with AR (%)
Number of patients with AR developing DM (%)
Fowble et al.6 Renolleau et al.1 Recht et al.18 Newman et al.9 Current study
990 1589 1624 4255 4669
14 26 22 44 59
4 (29%) 9 (35%) 11 (50%) 22 (50%) 38 (64%)
a
(1.4%) (1.6%) (1.4%) (1.0%) (1.3%)a
Due to incomplete follow-up for the patients treated between 1984 and 1989, the real AR rate was estimated to be 2–2.5%.
are now offered sentinel node biopsy instead of axillary lymph node dissection. It is estimated that 70% of all patients with operable breast cancer meet these criteria and that 30% of these patients will appear to have one or more positive sentinel nodes. A rough calculation shows that about half of the patients with operable breast cancer will still need treatment of the axilla, by axillary node dissection with or without radiotherapy, and will thus remain at risk for the physical and psychosocial side-effects of this treatment.
Conclusion Studies on prognosis of axillary recurrence following axillary lymph node dissection are generally small and provide poor estimates of the actual survival rates. Table 1 shows a comparison of our results with those reported in the literature. Part of the differences between the studies might also be explained through the length of follow-up following the diagnosis of axillary recurrence. All together, these data justify the conclusion that axillary recurrence following axillary dissection is associated with a high rate of subsequent distant metastasis and poor overall prognosis but is not always a fatal event. Our updated results show that it is possible to cure about one-third of the patients. Indicators of a good prognosis are a negative lymph node status at the time of diagnosis of the primary tumour and the achievement of durable disease control with multimodality treatment.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
References 14. 1. Renolleau C, Merviel P, Clough KB, Asselain B, Campana F, Durand JC. Isolated axillary recurrences after conservative treatment of breast cancer. Eur J Cancer 1996;32A:617–21. 2. Recht A, Pierce SM, Abner A, et al. Regional nodal failure after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol 1991;9:988–96. 3. Vicini FA, Horwitz EM, Lacerna MD, et al. The role of regional
15.
16.
nodal irradiation in the management of patients with earlystage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 1997;39:1069–76. Siegel BM, Mayzel KA, Love SM. Level I and II axillary dissection in the treatment of early-stage breast cancer. An analysis of 259 consecutive patients. Arch Surg 1990;125: 1144–7. Cabanes PA, Salmon RJ, Vilcoq JR, et al. Value of axillary dissection in addition to lumpectomy and radiotherapy in early breast cancer. The Breast Carcinoma Collaborative Group of the Institut Curie. Lancet 1992;339:1245–8. Fowble B, Solin LJ, Schultz DJ, Goodman RL. Frequency, sites of relapse, and outcome of regional node failures following conservative surgery and radiation for early breast cancer. Int J Radiat Oncol Biol Phys 1989;17:703–10. Harris EE, Hwang WT, Seyednejad F, Solin LJ. Prognosis after regional lymph node recurrence in patients with stage I–II breast carcinoma treated with breast conservation therapy. Cancer 2003;98:2144–51. Dewar JA, Sarrazin D, Benhamou E, et al. Management of the axilla in conservatively treated breast cancer: 592 patients treated at Institut Gustave-Roussy. Int J Radiat Oncol Biol Phys 1987;13:475–81. Newman LA, Hunt KK, Buchholz T, et al. Presentation, management and outcome of axillary recurrence from breast cancer. Am J Surg 2000;180:252–6. de Boer R, Hillen HF, Roumen RM, Rutten HJ, van der Sangen MJ, Voogd AC. Detection, treatment and outcome of axillary recurrence after axillary clearance for invasive breast cancer. Br J Surg 2001;88:118–22. Voogd AC, de Boer R, van der Sangen MJ, Roumen RM, Rutten HJ, Coebergh JW. Determinants of axillary recurrence after axillary lymph node dissection for invasive breast cancer. Eur J Surg Oncol 2001;27:250–5. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med 2002;347:567–75. Giuliano AE, Haigh PI, Brennan MB, et al. Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel nodenegative breast cancer. J Clin Oncol 2000;18:2553–9. Roumen RM, Kuijt GP, Liem IH, van Beek MW. Treatment of 100 patients with sentinel node-negative breast cancer without further axillary dissection. Br J Surg 2001;88: 1639–43. Chung MA, Steinhoff MM, Cady B. Clinical axillary recurrence in breast cancer patients after a negative sentinel node biopsy. Am J Surg 2002;184:310–4. Blanchard DK, Donohue JH, Reynolds C, Grant CS. Relapse
Long-term prognosis of axillary recurrence in breast cancer and morbidity in patients undergoing sentinel lymph node biopsy alone or with axillary dissection for breast cancer. Arch Surg 2003;138:487–8 [discussion 482–7]. 17. Reitsamer R, Peintinger F, Prokop E, Rettenbacher L,
489
Menzel C. 200 Sentinel lymph node biopsies without axillary lymph node dissection—no axillary recurrences after a 3-year follow-up. Br J Cancer 2004;90:1551–4. 18. Recht A. Nodal treatment for patients with early stage breast cancer: guilty or innocent? Radiother Oncol 1992;25: 79–82.
www.ejso.com
Long-term prognosis of patients with axillary recurrence after axillary dissection for invasive breast cancer A.C. Voogda,b,*, S. Cranenbroekc, R. de Boerd, R.M.H. Roumene, H.J.T. Ruttenf, M.J.C. van der Sangeng a
Department of Epidemiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands Eindhoven Cancer Registry, Comprehensive Cancer Centre South, P.O. Box 231, 5600 AE Eindhoven, The Netherlands c Faculty of Medicine, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands d Department of Radiotherapy, Nijmegen University Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands e ´xima Medical Centre, P.O. Box 7777, 5500 MB Veldhoven, The Netherlands Department of Surgery, Ma f Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands g Department of Radiotherapy, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands b
Accepted for publication 23 December 2004 Available online 19 February 2005
KEYWORDS Breast carcinoma; Axillary recurrence; Prognosis
Abstract Aim. To investigate the long-term prognosis of patients with axillary recurrence after axillary dissection for invasive breast cancer and describe the longterm survivors. Methods. Between 1984 and 1994, 4669 patients with invasive breast cancer underwent axillary dissection in eight community hospitals in the south–eastern part of The Netherlands. Using follow-up data of the population-based Eindhoven Cancer Registry, 59 patients with axillary recurrence were identified. Results. The median interval between treatment of the primary tumour and diagnosis of axillary recurrence was 2.6 years (range 0.3–10.7). The median length of follow-up after diagnosis of axillary recurrence was 11.1 years (5.7–15.6). Distant metastases occurred in 38 of the 59 patients. The 5- and 10-year distant recurrencefree survival rates were 39% (95% CI: 25–52%) and 29% (95% CI: 16–42%). Conclusions. Axillary recurrence following axillary dissection is associated with a high rate of subsequent distant metastasis and poor overall prognosis but is not always a fatal event. Our results show that it is possible to cure about one-third of the patients. q 2005 Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Department of Epidemiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands. Tel.: C31 43 3882387; fax: C31 43 3884128. E-mail address: [email protected] (A.C. Voogd). 0748-7983/$ - see front matter q 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2004.12.017
486
Figure 1 Distant disease-free survival for patients with axillary recurrence, calculated from the date of diagnosis of axillary recurrence.
Introduction The introduction of sentinel node biopsy has changed the staging of the breast cancer patients. Many patients with invasive breast cancer still undergo full axillary clearance or dissection of the lower and middle parts of the axilla (levels I and II), either because one or more sentinel nodes have proven to be positive or because they do not meet the criteria to undergo sentinel node biopsy or because units have not yet adopted the technique. The reported cumulative risk of developing axillary recurrence after axillary dissection will vary from 0.5 to 3.0%.1–9 In a previous study, we addressed the detection, treatment and prognosis of axillary recurrence after axillary dissection.10 This study included 59 patients with axillary recurrence. The follow-up after diagnosis of axillary recurrence was complete until 1 January 1998 and the median length of follow-up was 4.4 years (range 0.3–9.2) years for the patients who were still alive. Five years after the diagnosis of axillary recurrence 35% (95% CI, 21–50) of these patients were free of distant disease. We now report the follow-up information collected until January 2004 and present the 10-year survival rates of the same patient series and a description of the long-term survivors.
Patients and methods Patients Patient data were retrieved from the populationbased Eindhoven Cancer Registry, which serves a
A.C. Voogd et al. population of almost one million inhabitants in the south-eastern part of The Netherlands. During the period 1984–1994, 4669 (86 percent) of the 5408 patients with invasive breast cancer underwent axillary dissection in one of the eight general hospitals covered by the Eindhoven Cancer Registry. In the treatment guidelines of the regional Breast Cancer Study Group, the borders of axillary dissection are the latissimus dorsi muscle (dorsal), the thoracic wall below the major and minor pectoral muscles (ventral) and the lower border of the axillary vein (cranial). Axillary dissection was not always considered necessary for patients with a tumour measuring 0.5 cm or less and was usually omitted in the case of inoperable cancer and for the very elderly. The mean number of lymph nodes reported by the pathologist was 10. Fewer than six nodes were reported in 14% and more than 15 in 12% of the cases. Follow-up data of the population-based Eindhoven Cancer Registry were used, which were provided by the pathologists, the radiotherapists and the majority of surgeons. Due to the fact that follow-up information has only been recorded in the cancer registry since 1989, documentation was incomplete for early axillary recurrence occurring in the patients diagnosed in the period 1984–1988. These patients constitute 40% of the 4663 patients in the period 1984–1994. As of January 1998, 59 patients were reported to have isolated axillary recurrence after axillary dissection, of whom two had a concurrent recurrence in the breast, four an earlier recurrence in the breast and one an earlier recurrence in the chest wall. The medical records of these 59 patients were reviewed. Follow-up information was obtained until 1 January 2004.
Statistical analysis Survival analysis, using the life-table method, was performed to evaluate the prognosis after axillary recurrence. The primary endpoint was distant disease-free survival. Survival curves were calculated from the date of treatment of axillary recurrence or the date of the diagnosis of axillary recurrence when no treatment was applied.
Results The mean age of the patients at the time of diagnosis of axillary recurrence was 61 years (range 39–99). The median interval between treatment of the primary tumour and diagnosis of axillary recurrence was 2.6 years (range 0.3–10.7).
Long-term prognosis of axillary recurrence in breast cancer Further details on the diagnosis and treatment of axillary recurrence, as well as complications after treatment, have been described in our previous paper.10 Regional control (i.e. complete eradication of AR) was achieved in 34 patients. Twenty-four patients (41%) showed stable or progressive disease.
Long-term prognosis The median length of follow-up after diagnosis of axillary recurrence was 3.4 years (range 0.3–15.6) for the total group and 11.1 years (5.7–15.6) for the patients who were still alive. Distant metastases were observed in 38 of the 59 patients. The 5- and 10-year distant recurrence-free survival rates were 39% (95% CI: 25–52%) and 29% (95% CI: 16–42%), respectively (Fig. 1). Of the 38 distant metastases, 18 were detected within 1 year after the diagnosis of axillary recurrence, 30 within 3 years and 34 within 5 years. The remaining four patients developed distant disease after 5.8, 6.3, 7.0 and 8.3 years, respectively. Of the 59 patients with axillary recurrence, 44 died, 36 after developing distant metastases. Two patients were still alive with distant metastases and 13 were alive without evidence of disease. None of these 13 patients had received radiotherapy to the axillary or supraclavicular field as part of the treatment of their primary tumour. The mean number of nodes in the axillary specimen, as reported by the pathologists, was 9.8 for the patients who were still alive without evidence of disease, compared to 9.2 for the 38 patients in whom distant metastases occurred following the diagnosis of axillary recurrence (pZ0.78).
Prognostic factors The results of the analysis of prognostic variables for overall and distant recurrence-free survival confirmed our earlier findings that axillary nodal status at the time of diagnosis of the primary tumour (pZ0.001) and the success of local treatment of axillary recurrence (p!0.0001) are the most important prognostic factors; of the 22 patients whose axillary recurrence could be eradicated by the treatment and who had negative axillary lymph nodes eight had developed distant disease, whereas of the 12 patients with stable or progressive disease after treatment of axillary recurrence and a positive lymph node status 11 developed distant disease.
487
Discussion We have shown that it is possible to cure about onethird of the patients with axillary recurrence following axillary dissection for invasive breast cancer and that the risk of developing distant disease is very low in patients that have survived the first 5 years after axillary recurrence without evidence of breast cancer relapse.
The risk of axillary recurrence There is convincing evidence in the literature that the risk of axillary recurrence is low for patients with an adequate axillary lymph node dissection. The percentage axillary recurrences found in this study was 1.3% (59/4663). Reported rates after complete or level I and II dissections vary between 0.5 and 3.0%.1–9 In patients with positive lymph nodes, the risk can be reduced by axillary irradiation.11 The effectiveness of axillary dissection and irradiation is reflected by the high risk of recurrence in women with clinically negative nodes whose axilla remained untreated. For example, in the B-04 clinical trial of National Surgical Breast and Bowel Project, the rate of regional recurrence was 24% in women who had undergone only total mastectomy.12 Sentinel lymph node biopsy has been introduced into clinical practice as a mode to determine which patients can potentially be spared an axillary node dissection because they do not have nodal metastases. The accuracy of this procedure is supported by the increasing number of reports showing that patients with a negative sentinel node biopsy have a very small risk of developing axillary recurrence.13–17 These recurrences are more likely to represent the clinical manifestation of metastases that remained undetected due to a false-negative sentinel node procedure and may have a better prognosis than recurrences occurring after axillary dissection. It seems likely that axillary recurrences following a negative sentinel node biopsy are more suitable for surgery and radiotherapy, increasing the chances of complete eradication and cure. Follow-up of the patients with axillary recurrence following a negative sentinel node biopsy is still too short to study long-term prognosis and make comparisons with recurrences following axillary dissection.
The continued utility of axillary dissection In The Netherlands, as in many other European countries, breast cancer patients with non-palpable lymph nodes and a tumour measuring 5 cm or less
488
A.C. Voogd et al.
Table 1 Overview of studies describing the prognosis of patients with isolated axillary recurrence (AR) following axillary lymph node dissection Study
No. of patients
No. of patients with AR (%)
Number of patients with AR developing DM (%)
Fowble et al.6 Renolleau et al.1 Recht et al.18 Newman et al.9 Current study
990 1589 1624 4255 4669
14 26 22 44 59
4 (29%) 9 (35%) 11 (50%) 22 (50%) 38 (64%)
a
(1.4%) (1.6%) (1.4%) (1.0%) (1.3%)a
Due to incomplete follow-up for the patients treated between 1984 and 1989, the real AR rate was estimated to be 2–2.5%.
are now offered sentinel node biopsy instead of axillary lymph node dissection. It is estimated that 70% of all patients with operable breast cancer meet these criteria and that 30% of these patients will appear to have one or more positive sentinel nodes. A rough calculation shows that about half of the patients with operable breast cancer will still need treatment of the axilla, by axillary node dissection with or without radiotherapy, and will thus remain at risk for the physical and psychosocial side-effects of this treatment.
Conclusion Studies on prognosis of axillary recurrence following axillary lymph node dissection are generally small and provide poor estimates of the actual survival rates. Table 1 shows a comparison of our results with those reported in the literature. Part of the differences between the studies might also be explained through the length of follow-up following the diagnosis of axillary recurrence. All together, these data justify the conclusion that axillary recurrence following axillary dissection is associated with a high rate of subsequent distant metastasis and poor overall prognosis but is not always a fatal event. Our updated results show that it is possible to cure about one-third of the patients. Indicators of a good prognosis are a negative lymph node status at the time of diagnosis of the primary tumour and the achievement of durable disease control with multimodality treatment.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
References 14. 1. Renolleau C, Merviel P, Clough KB, Asselain B, Campana F, Durand JC. Isolated axillary recurrences after conservative treatment of breast cancer. Eur J Cancer 1996;32A:617–21. 2. Recht A, Pierce SM, Abner A, et al. Regional nodal failure after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol 1991;9:988–96. 3. Vicini FA, Horwitz EM, Lacerna MD, et al. The role of regional
15.
16.
nodal irradiation in the management of patients with earlystage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 1997;39:1069–76. Siegel BM, Mayzel KA, Love SM. Level I and II axillary dissection in the treatment of early-stage breast cancer. An analysis of 259 consecutive patients. Arch Surg 1990;125: 1144–7. Cabanes PA, Salmon RJ, Vilcoq JR, et al. Value of axillary dissection in addition to lumpectomy and radiotherapy in early breast cancer. The Breast Carcinoma Collaborative Group of the Institut Curie. Lancet 1992;339:1245–8. Fowble B, Solin LJ, Schultz DJ, Goodman RL. Frequency, sites of relapse, and outcome of regional node failures following conservative surgery and radiation for early breast cancer. Int J Radiat Oncol Biol Phys 1989;17:703–10. Harris EE, Hwang WT, Seyednejad F, Solin LJ. Prognosis after regional lymph node recurrence in patients with stage I–II breast carcinoma treated with breast conservation therapy. Cancer 2003;98:2144–51. Dewar JA, Sarrazin D, Benhamou E, et al. Management of the axilla in conservatively treated breast cancer: 592 patients treated at Institut Gustave-Roussy. Int J Radiat Oncol Biol Phys 1987;13:475–81. Newman LA, Hunt KK, Buchholz T, et al. Presentation, management and outcome of axillary recurrence from breast cancer. Am J Surg 2000;180:252–6. de Boer R, Hillen HF, Roumen RM, Rutten HJ, van der Sangen MJ, Voogd AC. Detection, treatment and outcome of axillary recurrence after axillary clearance for invasive breast cancer. Br J Surg 2001;88:118–22. Voogd AC, de Boer R, van der Sangen MJ, Roumen RM, Rutten HJ, Coebergh JW. Determinants of axillary recurrence after axillary lymph node dissection for invasive breast cancer. Eur J Surg Oncol 2001;27:250–5. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med 2002;347:567–75. Giuliano AE, Haigh PI, Brennan MB, et al. Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel nodenegative breast cancer. J Clin Oncol 2000;18:2553–9. Roumen RM, Kuijt GP, Liem IH, van Beek MW. Treatment of 100 patients with sentinel node-negative breast cancer without further axillary dissection. Br J Surg 2001;88: 1639–43. Chung MA, Steinhoff MM, Cady B. Clinical axillary recurrence in breast cancer patients after a negative sentinel node biopsy. Am J Surg 2002;184:310–4. Blanchard DK, Donohue JH, Reynolds C, Grant CS. Relapse
Long-term prognosis of axillary recurrence in breast cancer and morbidity in patients undergoing sentinel lymph node biopsy alone or with axillary dissection for breast cancer. Arch Surg 2003;138:487–8 [discussion 482–7]. 17. Reitsamer R, Peintinger F, Prokop E, Rettenbacher L,
489
Menzel C. 200 Sentinel lymph node biopsies without axillary lymph node dissection—no axillary recurrences after a 3-year follow-up. Br J Cancer 2004;90:1551–4. 18. Recht A. Nodal treatment for patients with early stage breast cancer: guilty or innocent? Radiother Oncol 1992;25: 79–82.