A Conservative Approach to Lymph Node Removal

A Conservative Approach to Lymph Node Removal

Until recently, guidelines recommended complete axillary node dissection in women with breast cancer for whom their sentinel node biopsy was positive. However, patients who undergo this procedure routinely experience complications. The introduction of sentinel lymph node biopsy in the 1990s included the benefit of avoiding complete axillary node dissection if two or three sentinel nodes tested negative for cancer, thus reducing morbidity. However, complete axillary node dissection was still used in patients with positive sentinel nodes. The recently completed American College of Surgeons Oncology Group Z0011 (Z-11) trial indicated that women with positive sentinel nodes scheduled for lumpectomy and whole-breast radiation could safely avoid complete axillary lymph node dissection. A Need for Clarity Few studies have compared the risks and benefits of the various axillary interventions for patients with breast cancer. To address this research gap, Roshni Rao, MD, and colleagues performed a systematic review of 17 studies. The analysis, published in JAMA, reviewed studies of women with breast cancer who mostly had benign axilla and received surgical treatment that ranged from removal of one lymph node to removal of all axillary lymph nodes. Outcomes of these procedures were compared with each other as well as with nonsurgical interventions, such as radiation. Women with no suspicious, palpable axillary nodes who underwent breast-conserving therapy did not experience a benefit with complete axillary node dissection when compared with sentinel node biopsy alone. Complete axillary node dissection was associated with a 1% to 3% reduction in axillary lymph node metastases recurrence but was also associated with a 14% risk of lymphedema. Complete axillary lymph node dissection was well suited for patients with...

Staging Melanoma With SLNB

One of the most important prognostic factors in patients with early-stage melanoma is the presence of metastasis to regional nodes. Determining which patients have nodal metastases and who may benefit from resection of involved regional lymph nodes is of key importance. Sentinel lymph node biopsy (SLNB) is a minimally invasive surgical technique that involves removal of the node(s) most likely to demonstrate metastases (the “sentinel” node) from melanoma. When cancer is found, the remaining nodes in that area are also at risk for metastases. In most cases, no cancer is detected in the sentinel node, allowing patients to avoid the pain, discomfort, expense, and side effects of unnecessary procedures or therapies. In an effort to clarify which patients should undergo SLNB, the American Society of Clinical Oncology and the Society for Surgical Oncology published clinical practice guidelines in the Journal of Clinical Oncology. Key Recommendations for Melanoma Recommendations were made based on the three main stages of melanoma: 1. Intermediate-thickness melanomas: SLNB is recommended for patients with cutaneous melanomas with Breslow thickness of 1 to 4 mm at any anatomic site. 2. Thick melanomas: SLNB may be used for staging purposes and to facilitate regional disease control in patients with melanomas greater than 4 mm in Breslow thickness. 3. Thin melanomas: There is insufficient evidence to support routine SLNB for patients with melanomas that are less than 1 mm in Breslow thickness, although it may be considered in selected high-risk patients. It’s recommended that complete lymph node dissection be performed for all patients with a positive SLNB. If sentinel nodes are positive, additional nodes should be removed for complete...