Rethinking Axillary Management in Breast Cancer (Podcast)

Traditionally, removal of lymph nodes was part of the evaluation of patients with breast cancer in order to accurate stage the disease.

“Staging traditionally is based on the AJCC guidelines, TNM, so we start with a clinical diagnosis whether or not patients have abnormal lymph nodes detected on exam or by imaging. And then we also have pathologic nodal staging, which we get that result from actually removing some lymph nodes as part of our surgery. So traditionally, our lymph node assessment would always start with a clinical exam that gives us that clinical staging. And then we, historically, really early in breast cancer treatment assess the lymph nodes by a pretty radical approach by removing all of the lymph nodes, what we call an axillary lymph node dissection in all patients, even if they did not have any clinical evidence of lymph node disease.

So we were subjecting women to a pretty extensive surgery without any evidence that the lymph nodes were involved really to use that information to guide additional treatments such as our radiation planning or chemotherapy. And so thankfully, we've over the years developed or improved our processes to reduce the burden of surgery, particularly in the axilla for women. So the sentinel lymph node biopsy was a major improvement allowing us to reduce the amount of surgery on the lymph nodes for patients who did not have any clinical evidence of lymph node disease.”

In a recent episode of Cleveland Clinic's Cancer Advances podcast, breast surgical oncologist Lauren Kopicky, DO, discussed:

• Risk of lymphedema with axillary lymph node dissection, pain and decreased range of motion
• Study data informing axillary lymph node dissection decisions
• Emerging conversations around omitting lymph node removal entirely in some patients

Click the podcast player above to listen to the episode now, or read on for a short edited excerpt. Check out more Cancer Advances episodes at clevelandclinic.org/podcasts/cancer-advances or wherever you get your podcasts.

Excerpt from the podcast:

Dale Shepard, MD, PhD: How has management of the axilla changed in patients who get neoadjuvant treatment?

Lauren Kopicky, DO: It's changed a lot. So we have looked at historically patients who had lymph nodes involved, even though they went through neoadjuvant chemotherapy, were still subjected to a bigger axillary surgery. And now, we're looking at patients through treatment and saying, "Okay, who's responding?" So I frequently check patients during chemotherapy reassessing with imaging to look at those lymph nodes and say, "Okay, are they normalizing? Are they responding?" And if we are getting a good clinical response, then now we can do what we call a targeted sentinel lymph node biopsy.

A lot of these patients who have had lymph nodes positive before chemotherapy have had that node biopsied and had a clip placed. So fast-forward, go through chemotherapy, get a good response. We do this targeted sentinel lymph node excision and map the lymph nodes the same way we do with radiotracer, dyes or combination, and really just remove those couple and reassess them.

So what we're looking for is, are there any gross bits of tumor left? Are there microscopic cells left or have we had a complete response? And now, we're waiting on some data from the Alliance 11202 study looking at, if somebody does have residual microscopic disease after chemotherapy, meaning that we did not get a complete response in the lymph nodes, are those patients still needing to be subjected to a completion x-ray lymph node dissection or can they go on to planned nodal radiation? And so I think there's a lot of discussion there of, say somebody had four abnormal nodes by imaging, we get a really great response.

They have a micrometastasis left and one lymph node, the others are negative, meaning they completely responded. Do we feel that that's an accurate representation of the lymph nodes that remain? Meaning we don't need to go and remove the rest of them to know for sure that they're negative. And again, a lot of the data from these studies have also looked at quality of life, morbidity. And we know that with less axillary surgery, we see less lymphedema and less negative side effects, such as decreased range of motion and pain.