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Surgical Complications Associated With Sentinel Lymph Node Dissection (SLND) Plus Axillary Lymph Node Dissection Compared With SLND Alone in the American College of Surgeons Oncology Group Trial Z0011
Surgical Complications Associated With Sentinel Lymph Node Dissection (SLND) Plus Axillary Lymph Node Dissection Compared With SLND Alone in the American College of Surgeons Oncology Group Trial Z0011 Lucci A, McCall LM, Beitsch PD, et al (Univ of Texas M. D. Anderson Cancer Ctr, Houston; Univ of Texas Southwestern, Dallas; American College of Surgeons Oncology Group, Durham, NC; et al) J Clin Oncol 25:3657-3663, 2007
Purpose.—The American College of Surgeons Oncology Group trial Z0011 was a prospective, randomized, multicenter trial comparing overall survival between patients with positive sentinel lymph nodes (SLNs) who did and did not undergo axillary lymph node dissection (ALND). The current study compares complications associated with SLN dissection (SLND) plus ALND, versus SLND alone. Patients and Methods.—From May 1999 to December 2004, 891 patients were randomly assigned to SLND + ALND (n = 445) or SLND alone (n = 446). Information on wound infection, axillary seroma, paresthesia, brachial plexus injury (BPI), and lymphedema was available for 821 patients. Results.—Adverse surgical effects were reported in 70% (278 of 399) of patients after SLND + ALND and 25% (103 of 411) after SLND alone (P ≤ .001). Patients in the SLND + ALND group had more wound infections (P ≤. 0016), seromas (P ≤ .0001), and paresthesias (P ≤ .0001) than those in the SLND-alone
group. At 1 year, lymphedema was reported subjectively by 13% (37 of 288) of patients after SLND + ALND and 2% (six of 268) after SLND alone (P ≤ .0001). The difference between the two groups’ lymphedema, assessed by arm measurements at 30 days (P = .36), 6 months (P = .22), and 1 year (P = .078), although close to the cutoff for significance at 1 year, was not significant. BPIs occurred in less than 1% of patients. Conclusion.—In trial Z0011, the use of SLND + ALND resulted in more wound infections, axillary seromas, and paresthesias than SLND alone. Lymphedema was more common after SLND + ALND but was significantly different only by subjective report. The use of SLND alone resulted in fewer complications. In the current report, the authors compared the complications associated with SLND plus ALND with those associated with SLND alone in patients with histologically proven nodepositive T1/T2N0M0 breast cancer. Metastases in SLNs were identified by frozen section analysis, touch preparation, or hematoxylin and eosin staining of permanent sections but not by immunohistochemical analysis. Lymphedema was reported subjectively and defined as a minimum 2-cm postoperative increase in ipsilateral compared with contralateral arm measurements at 30-day and 6-month intervals from the time of surgery. The results confirmed the hypothesis that SLND alone, compared with does SLND plus ALND, results in fewer postoperative complications, such as paresthesias, infections, and seromas. At 12 months after surgery, lym-
phedema (as defined by arm measurements) was found in 26 (11%) of 242 patients having undergone SLND plus ALND and 14 (6%) of 226 patients having undergone SLND alone, approaching but not achieving statistical significance (P = 0.078). In this trial, the number of lymph nodes removed was not correlated with risk of lymphedema. The results of this study also reconfirmed that patients with high body mass indices had higher rates of wound infection than did those with low body mass indices. Other factors that have been reported to increase the risk of arm edema include advanced regional node disease at diagnosis, the presence of breast or axillary wound infection, the use of adjuvant chemotherapy, and tumor location in the upper-outer quadrant of the breast.1 Furthermore, lymphedema after breast surgery may be either acute or chronic. Acute edema occurs shortly after the procedure and is commonly transient. Chronic edema may develop months or years after primary treatment and is more resistant to therapy. The patients reported here should probably be regarded as having acute lymphedema. Longer follow-up will better define the evolution of chronic forms of edema in this patient cohort. S. F. Sener, MD
Reference 1. Sener SF, Winchester DJ, Martz CH, et al. Lymphedema after sentinel lymphadenectomy for breast carcinoma. Cancer. 2001;92:48-52.
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Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
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Purpose.—The American College of Surgeons Oncology Group trial Z0011 was a prospective, randomized, multicenter trial comparing overall survival between patients with positive sentinel lymph nodes (SLNs) who did and did not undergo axillary lymph node dissection (ALND). The current study compares complications associated with SLN dissection (SLND) plus ALND, versus SLND alone. Patients and Methods.—From May 1999 to December 2004, 891 patients were randomly assigned to SLND + ALND (n = 445) or SLND alone (n = 446). Information on wound infection, axillary seroma, paresthesia, brachial plexus injury (BPI), and lymphedema was available for 821 patients. Results.—Adverse surgical effects were reported in 70% (278 of 399) of patients after SLND + ALND and 25% (103 of 411) after SLND alone (P ≤ .001). Patients in the SLND + ALND group had more wound infections (P ≤. 0016), seromas (P ≤ .0001), and paresthesias (P ≤ .0001) than those in the SLND-alone
group. At 1 year, lymphedema was reported subjectively by 13% (37 of 288) of patients after SLND + ALND and 2% (six of 268) after SLND alone (P ≤ .0001). The difference between the two groups’ lymphedema, assessed by arm measurements at 30 days (P = .36), 6 months (P = .22), and 1 year (P = .078), although close to the cutoff for significance at 1 year, was not significant. BPIs occurred in less than 1% of patients. Conclusion.—In trial Z0011, the use of SLND + ALND resulted in more wound infections, axillary seromas, and paresthesias than SLND alone. Lymphedema was more common after SLND + ALND but was significantly different only by subjective report. The use of SLND alone resulted in fewer complications. In the current report, the authors compared the complications associated with SLND plus ALND with those associated with SLND alone in patients with histologically proven nodepositive T1/T2N0M0 breast cancer. Metastases in SLNs were identified by frozen section analysis, touch preparation, or hematoxylin and eosin staining of permanent sections but not by immunohistochemical analysis. Lymphedema was reported subjectively and defined as a minimum 2-cm postoperative increase in ipsilateral compared with contralateral arm measurements at 30-day and 6-month intervals from the time of surgery. The results confirmed the hypothesis that SLND alone, compared with does SLND plus ALND, results in fewer postoperative complications, such as paresthesias, infections, and seromas. At 12 months after surgery, lym-
phedema (as defined by arm measurements) was found in 26 (11%) of 242 patients having undergone SLND plus ALND and 14 (6%) of 226 patients having undergone SLND alone, approaching but not achieving statistical significance (P = 0.078). In this trial, the number of lymph nodes removed was not correlated with risk of lymphedema. The results of this study also reconfirmed that patients with high body mass indices had higher rates of wound infection than did those with low body mass indices. Other factors that have been reported to increase the risk of arm edema include advanced regional node disease at diagnosis, the presence of breast or axillary wound infection, the use of adjuvant chemotherapy, and tumor location in the upper-outer quadrant of the breast.1 Furthermore, lymphedema after breast surgery may be either acute or chronic. Acute edema occurs shortly after the procedure and is commonly transient. Chronic edema may develop months or years after primary treatment and is more resistant to therapy. The patients reported here should probably be regarded as having acute lymphedema. Longer follow-up will better define the evolution of chronic forms of edema in this patient cohort. S. F. Sener, MD
Reference 1. Sener SF, Winchester DJ, Martz CH, et al. Lymphedema after sentinel lymphadenectomy for breast carcinoma. Cancer. 2001;92:48-52.
®
Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
61 61