Original articleArm morbidity following sentinel lymph node biopsy or axillary lymph node dissection: A study from the Danish Breast Cancer Cooperative Group
Introduction
Sentinel lymph node biopsy (SLNB) can predict the lymph node status of patients with early breast cancer.1, 2 The method was implemented in the treatment of breast cancer with the aim of reducing the sequelae following surgery in the axilla. Intraoperative assessment of the lymph node status is achieved by using either imprint cytology or frozen sectioning. If metastases are found, the surgeon can perform a one-step axillary lymph node dissection (ALND). Importantly, patients without metastases to sentinel lymph nodes can avoid an axillary dissection with the aim of reducing the morbidity following ALND. However, neither imprint cytology nor frozen sectioning will identify all metastases in the sentinel lymph nodes.3 After the primary operation, sentinel lymph nodes are examined using serial sectioning and immunohistochemical staining with antibodies against cytokeratin. This identifies between 10% and 20% more patients with metastases.4 These patients often have small volume micrometastases (i.e. isolated tumor cells (ITC) or small clusters <0.2 mm) and rarely have metastases outside the sentinel lymph nodes. Additional 15% of all patients with ITC or cell clusters <0.2 mm will have metastases to non-sentinel lymph node metastases if non-sentinel lymph nodes are examined as meticulously as sentinel lymph nodes. It is recommended that these patients should be treated with ALND unless included in specific clinical trials.5, 6 A subgroup of patients initially having only an SLNB must therefore have a second operation where the remaining lymph nodes in the axilla are removed. These secondary ALND are more difficult to perform than primary ALND depending on the timing from the first operation and subsequent formation of fibrosis.
ALND is a well-known cause of different kinds of sequeale. Lymphedema, reduced mobility of the shoulder and altered sensation, like numbness, tingling and paresthesias are some of the more frequent long-lasting complications caused by ALND. The reported frequencies of the complications differ.7, 8 This can be due to different methods used, but also by different definitions of when a complication is present or not.7, 8, 9 Further, radiotherapy to the axilla can aggravate the complication rates.10, 11, 12 The sequelae are often chronic and have a negative impact on quality of life.13 Studies of the morbidity in patients who underwent SLNB alone compared with patients operated with primary ALND have been published.14, 15, 16, 17, 18, 19, 20, 21, 22 Few of these studies randomized the patients.16, 23 Further, only a limited number of studies have compared the morbidity among patients recieving a secondary ALND after SLNB compared with patients receiving a primary ALND.14, 16, 24
With implementation of SLNB in Denmark, the Danish Breast Cancer Cooperative Group (DBCG) decided to make a controlled cohort study of the arm morbidity. The aim of the present study was to:
- 1.
Compare the arm morbidity among node negative patients staged by SLNB compared with node negative patients who had a level I and II ALND.
- 2.
Compare the arm morbidity among node positive patients with axillary metastases who underwent a primary ALND compared with patients who received a secondary ALND after an initial SLNB.
Section snippets
Patient cohort
Between July 2003 and October 2004, 395 patients with early breast cancer were recruited from seven breast cancer units in Denmark. Of these, five units performed SLNB as standard procedure in clinical and ultrasonographically node negative patients. Control patients were recruited from two of the centers that had not started to avoid ALND in node negative patients and from the five centers if sentinel lymph nodes (SN) could not be found. The study population was divided in four groups as shown
Ethics
The study was in accordance with the Helsinki Declaration and was approved by the Scientific Ethical Committees and the Danish Data Protection Agency. All patients gave informed consents before entering the study.
Results
A total of 395 patients were included in the study. Three hundred and forty-six patients (87%) of the patients completed the study. Totally, 49 (13%) patients dropped out of the study. In group D 20% (n=8) dropped out, whereas in group A 11% (n=18), in group B 12% (n=7) and group C 12% (n=16) dropped out of the study. Only if patients gave a reason for dropping out of the study it was registered. No patients were missed because of loss of follow-up. Patients were missed because they either
Discussion
The published papers comparing arm morbidity on patients with a SLNB vs. ALND can be divided in papers investigating subjective arm morbidity and quality of life using questionnaires14, 18, 24, 29, 30 and papers using both questionnaires and objective measurements of arm morbidity.15, 16, 17, 19, 23, 31
The studies that used questionnaires found that quality of life and self-reported arm morbidity are in favor of SLNB. Blanchard et al.18 and Barranger et al.24 reported similar frequencies with
Conclusion
We conclude from this study that node negative patients have significantly lower self-reported arm morbidity after SLNB than after ALND. Objective measurements of shoulder mobility are slightly more affected in patients where an ALND is used for staging than after SLNB. Furthermore, ALND in comparison with SLND leads to a small increase in arm volume, and more patients will suffer form decreased sensitivity. Subjective complaints are, except for shoulder mobility, in favor of SLNB.
Patients, who
Conflict of Interest statement
None declared
Acknowledgments
The work was supported by grants from The Foundation for Advancement of Clinical, Eksperimental Cancer Research—especially breast cancer; The Clinical Research Unit for Northern Denmark; Foundation for Research at Aarhus Countyhospital; The Foundation of December 17, 1981; The Foundation of Katrine og Vigo Skovgaard; The Foundation for Advancement of Medical Science; The Memorial Foundation of Factory Owner Ejner Willumsen; The Memorial Foundation of Inge & Joergen Larsen; Clinical Institute at
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2019, BreastCitation Excerpt :More specifically, women who underwent axillary surgery were more likely to be unemployed five-years after breast cancer diagnosis. This may be due to a higher morbidity being described following this type of treatment when compared with sentinel lymph node biopsy, with axillary surgery leading to decreased mobility and sensitivity [34]. However, a recent study showed that the association between lymph node biopsy and unemployment was no longer significant six years after diagnosis [33].