The Decline of Axillary Lymph Node Dissection in Breast Cancer

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In recent decades, the treatment of breast cancer has evolved and requires a multidisciplinary perspective that provides adequate systemic control of the disease, a conservative surgical approach and a greater concern for the satisfaction and quality of life of these women. In this context, staging procedures and axillary treatment have also been modified, and the systematic indication of axillary lymph node dissection (ALND) has been replaced by an easily reproducible procedure with lower morbidity: sentinel lymph node biopsy (SLNB). Several clinical trials have analyzed the feasibility of this technique for lymph node staging and reported a sensitivity greater than 88%, a specificity of 100% and a false negative (FN) rate of less than 10%.
Recently, the published results from the ACOSOG Z0011 clinical trial have demonstrated similar overall and disease-free survival in a select group of patients with metastatic involvement of the sentinel lymph node (SLN) without ALND. These findings have been corroborated by other studies and have modified routine clinical practice by omitting lymph node dissection in a large number of patients with metastatic involvement in the axilla.

A prospective observational study that included women with breast cancer who were treated surgically between 2001 and 2017. Four groups were identified according to the therapeutic regimen and 3 study periods defined by the lymph node dissection.
1319 patients met the inclusion criteria. Primary conservative surgery was the most frequent therapy (54.13%), and 615 (46.62%) axillary lymph node dissections (ALND) were performed in the 20-year study period. The percentage of ALND decreased progressively over time, going from 91% in the first period to 34% in the last period. The futile ALND fell to 6.6% in the last year. In the primary conservative surgery, no futile ALND was performed in the last two years.

In conclusion, our study reflects the changes that have occurred in the last 2 decades in the staging procedures and axillary treatment of breast cancer. Evolution in breast cancer treatment has decreased the indication of ALND, thereby reducing the number of futile ALND. Women with primary breast-conserving surgery gain the greatest benefit, since futile ALND is no longer performed in this group. Presently, several clinical trials are underway40–49 that will contribute to making decisions about the indication of ALND in different scenarios. Lymph node dissection should be limited to women who will benefit from it in terms of overall survival, thus reducing the morbidity associated with this technique (lymphedema, neuralgia, paresthesia, etc.).