Breast Cancer ChoicesTM |
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| Scrutinizing the evidence for breast cancer procedures and treatments |
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| What is the procedure most regretted by breast cancer patients? |
| Lymph Node Removal |
Link to medical articles on lymph node surgery |
| Can factors from the tumor biology (pathology report ) yield sufficient yield sufficient allow me to avoid information to axillary lymph node dissection? |
NY Times Feb 8, 2011 Lymph Node Study Shakes Pillar of Cancer Care Read Article JUNE 2010 NY TIMES Read Article Lymph Node Dissection Provides No Benefit to Lumpectomy Patients Some 82.2 percent of the women who had the dissection were alive and disease free compared with 83.8 percent of those who did not. Cancer recurred in the breast or nearby in 4.3 percent of those who had the operation and 3.4 percent in those who did not. |
Patients had more distant recurrences with axillary dissection. excerpt from full text To the surprise of most, Fisher's study of 1700 patients failed to reveal any statistically significant survival advantage for patients undergoing ELND. Although the lymph node dissection group experienced fewer recurrences in the treated lymph node basin, this improvement in local control did not translate to a benefit in overall survival. In fact, when these patients did have recurrences, these were more likely to be distant disease. Since Fisher's landmark study, five RCTs evaluating ELND in breast cancer patients have failed to reveal a statistically significant survival advantage for patients treated with ELND.[16] The lack of evidence supporting the value of ELND for breast cancer patients in these five trials raised significant questions regarding the dogmatic but unproven traditional approach to surgical management in patients with cancer. |
Lymphedema patient |
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| Lymph Node FAQ |
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From the Manual of Clinical Oncology, page 250: "Removal of the axillary nodes does not affect the frequency of recurrence, the development of distant metastasis or survival rates." |
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The biopsy on my tumor was positive for cancer. My doctor has recommended a sentinel lymph node biopsy (SLNB) or sentinel lymph node dissection (SNLD) to see if the cancer has spread. How invasive is this procedure?
the lymph nodes tested was one of the most important, life-altering decisions they made. One of the major reasons for setting up the Breast Cancer Choices website was the suffering of members who had some or all of their axillary nodes removed.
by nerve-severing, lymphedema, or phlebitis. The lymph node dissection procedure has resulted in some women's inability to pick up children, trouble carrying groceries, arm weakness and swelling as well as numbness and limited range of motion. At least two of our members had nerves severed. LYMPH NODE DISABILITIES ARE NOT CURABLE. The lymph node dissection is done as a diagnostic, not a therapeutic procedure. However, many surgeons still believe removing cancerous nodes is therapeutic despite the evidence. Even though the sentinel lymph node biopsy is a more limited procedure than a full axillary dissection of the nodes, you may nonetheless be required in advance to grant your surgeon permission to remove other nodes if the sentinel node is cancerous. The complication rate for sentinel node biopsy, including reactions to the radioactive dye, must also be considered. See additional articles if you are considering this procedure. The decision to give permission to dissect the lymph nodes is a major one. Ask your surgeon why you need your lymph nodes tested. The answer will probably be one of the following: "It's standard procedure, "We need to stage you." "If there is cancer in the nodes we will remove it." All of the above statements are true. Most patients get this procedure done because it is the standard package and they don't question whether it will improve their odds of survival., But staging via the lymph node evaluation may have no value to the patient if she is going to pursue conventional or alternative treatments aggressively anyway. Are there any safety issues with a sentinel lymph node biopsy? Dr. Robert Rosser recommends that the SLND should be done without massage or any other attempt to hasten the flow of lymph to the lymph nodes. Dr. Rosser contends that occult micrometastases (CK-IHC-positive micrometastases) in the sentinel lymph nodes may be the result of the sentinel node procedure itself. "Medical practioners routinely massage the breast, sometimes with heat, to increase the flow of lymph, radiosotope, and blue dye to the axilla. Scrub nurses massage the breast to prepare the skin for the surgical skin incisions. Surgeons grasp breast tumors with clamps and forceps to retract them while completing the tumor's excision. It should not be surprising that cellular fragments of less cohesive tumors are disrupted and are caught in the flow of lymph. The danger to the patient comes from those traumets that do not get trapped in the sentinel lymph node but enter the systemic circulation." (See "Safety of Sentinel Lymph Node Dissection and Signficance of Cytokeratin Micrometastases" on the Robert Rosser, MD page.) Dr. Rosser recommends that the SLND should be done without massage or any other attempt to hasten the flow of lymph to the lymph nodes. But what if the cancer has spread to the lymph nodes? Won't removing them improve my survival chances? That seems like common sense. Yes, it does seem like common sense that the removal of cancerous lymph nodes would improve the survival rate, but the evidence seems to show a different role for the lymph nodes than was expected. That evidence hasn't yet impacted current surgical practice. The Management of Regional Lymph Nodes in Cancer D.B. Pharis; J.A. Zitelli Br J Dermatol 149(5):919-925, 2003. © 2003 Blackwell Publishing [excerpts] Management of the regional lymph nodes (RLNs) in potentially metastatic cancer is fraught with controversies and misunderstandings. Early surgical oncologists observed many times that the RLNs were enlarged in advanced cancers before distant disease appeared, leading to the theory that the RLNs served as mechanical barriers temporarily preventing systemic dissemination of tumour. Based on this theory, surgeons removed these enlarged lymph nodes along with the primary tumour, an approach known as therapeutic lymph node dissection (TLND), in an attempt at surgical cure of locally advanced disease. Unacceptable cure rates, believed to be a result of unresected microscopic disease, led to the removal of clinically normal RLNs, a procedure known as elective lymph node dissection (ELND), in an effort to remove these nonpalpable tumour deposits. By the early twentieth century, routine dissections of the regional lymphatics in an effort to remove all microscopic disease had become the dogma of surgical oncology based exclusively on observation and theory rather than sound scientific evidence. This barrier theory of lymph node biology continues to influence the management of the RLNs in cancer surgery today....[excerpt] The theoretical benefit of ELND seemed unassailable when considered in the context of the belief that the RLNs served as physical barriers to tumour dissemination. During a time when little else could be offered to cancer patients, this seemingly rational theory and the chance of a surgical cure for this dreaded disease captured the attention of surgeons around the world. Numerous retrospective and single institutional studies were published that supported the widespread use of ELND in nearly all forms of cancer with the potential for nodal metastasis including cancer of the breast, uterus, cervix, vulva, prostate, head and neck, penis and, of course, melanoma.[6-14] Advocates of ELND used the results of these uncontrolled studies to validate the theory that the RLNs were in fact barriers to systemic tumour dissemination. Consequently, the role of ELND in cancer surgery remained unchallenged in surgical oncology until late in the twentieth century. A turning point in this story began in 1960 when Bernard Fisher, then the director of the National Surgical Adjuvant Breast and Bowel Program, began an ambitious study that was to be the first randomized controlled trial (RCT) investigating the value of the ELND in breast cancer patients.[15] To the surprise of most, Fisher's study of 1700 patients failed to reveal any statistically significant survival advantage for patients undergoing ELND. Although the lymph node dissection group experienced fewer recurrences in the treated lymph node basin, this improvement in local control did not translate to a benefit in overall survival. In fact, when these patients did have recurrences, these were more likely to be distant disease. Since Fisher's landmark study, five RCTs evaluating ELND in breast cancer patients have failed to reveal a statistically significant survival advantage for patients treated with ELND.[16] The lack of evidence supporting the value of ELND for breast cancer patients in these five trials raised significant questions regarding the dogmatic but unproven traditional approach to surgical management in patients with cancer.
For more complete references and more studies see Medical Articles on Lymph Node Removal What about the risk of lymphedema after node surgery? The risk of lympedema can depend on how many nodes were taken or if you have radiation after surgery. Lymphedema can develop immediately or occur years later. A 2003 study showed that there is a significantly lower rate of lymphedema in patients who have had SLND than full axillary dissection. (See Golshan, et al., Am Surg, [2003], in the Medical Articles Lymph page.)
Society publishes an extensive list of activities patients should avoid for the rest of their lives. See below:
Although there are no scientific studies to show that people can prevent lymphedema, most experts recommend following these basic guidelines, which may lower your risk of developing lymphedema or delay its onset: Avoid Infections, Burns and Injuries. Try to avoid infections, burns, or injuries to the affected area. Your body responds to these by making extra fluid. Burns and injuries canal so lead to infections. Removal of or damage to lymph nodes and vessels makes it more difficult to transport this extra fluid, and this can trigger lymphedema. Keep the affected limb clean. Careful skin care may reduce the risk of lymphedema by helping you to avoid infections. Dry creases between your toes after bathing. Keep your hands, feet, and cuticles soft and moist by regularly applying moisturizing lotion or cream. Push cuticles back with a cuticle stick rather than cutting them with scissors. Clean and protect any openings in the skin caused by cuts, abrasions,insect bites, hangnails or torn cuticles by washing with soap and water. Use an over- the-counter antibacterial cream on any opening once they are cleaned, and then cover with a clean bandage. For burns, apply a cold pack or cold water for 15 minutes, then wash with soap and water and apply a clean, dry dressing. Watch for early signs of infection: rash, red blotches, swelling,increased heat, tenderness, or fever. Call your doctor right away if you develop an infection. Use an electric shaver for removing underarm and leg hair; these maybe less likely to cut or break the skin than straight razors or hair removal creams. If necessary, use an insect repellent when outdoors to avoid bug bites. If a bee stings you in the affected limb, clean and elevate the limb,apply ice, and contact your doctor if it becomes infected. Avoid activities that irritate or chap the skin. Protect your limb from sunburn. Use sunscreen that is labeled SPF15 or higher and try to stay out of the sun during the hottest part of the day. Avoid oil splash burns from frying and steam burns from microwaved foods or boiling liquids. Your affected limb may not detect temperatures as well as it did in the past. Test bath water temperatures with an unaffected limb. Avoid excessive heat, such as from hot tubs and saunas, since heat can increase fluid build-up. Copyright American Cancer Society, Inc.
the time patients, who had had full axillary dissection, reached the 20 year mark. Cancer. 2001 Sep 15;92(6):1368-77. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Petrek JA, Senie RT, Peters M, Rosen PP. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York BACKGROUND: To the authors' knowledge, there are no long-term cohort studies of lymphedema, despite the substantial morbidity of arm swelling. The goal of this study was to identify prevalence of breast carcinoma-related lymphedema, time of onset, and associated predictive factors. METHODS:A cohort of 923women consecutively treated with mastectomy and complete axillary dissection at our center between 1976 and 1978 was observed intensively for 20 years. Two hundred sixty-three study subjects (28.5%) who were alive and recurrence free constituted the cohort for the current study. A subset of 52 women (20% of study population) with contralateral mastectomy was analyzed separately. Subjects reported circumferential arm measurements taken using a validated instrument. In addition to providing analysis of clinical and treatment variables, this study is the first to the authors' knowledge to analyze possible etiologic factors in the posttreatment years, such as occupation, general physical activity, and sports/leisure activities. Univariate and multivariate analytic methods were used. RESULTS: At 20 years after treatment, 49% (128 of 263) reported the sensation of lymphedema. Arm swelling measurements were severe (> or = 2.0 in [5.08 cm]; patients reported measurement in inches) for 13% (33 of 263 women). Seventy-seven percent (98 of 128) noted onset within 3 years after theoperation; the remaining percentage developed arm swelling at a rate of almost 1% per year. Of the 15 potential predictive factors analyzed, only 2 were statistically significantly associated with lymphedema: arm infection/injury and weight gain since operation (P < 0.001 and P = 0.02, respectively). CONCLUSIONS: This defined cohort, treated by axillary dissection 20 years ago, documents the high prevalence of lymphedema and its time course. Two significantly associated factors, both potentially controllable, are identified. The current study provides further support for treatments that limit lymph node dissection. The authors are prospectively evaluating patients undergoing sentinel lymph node biopsy. Copyright 2001 American Cancer Society.
Can factors from the tumor biology --from the pathology report-- yield sufficient information to allow me to avoid axillary lymph node dissection? The Parmigiani study, cited below, suggests especially with respect to breast cancer patients who are considering undergoing conventional treatments, that it may not be beneficial for those with early stage breast cancer who are ER negative to have axillary node dissection. The rationale for this suggestion is that the standard of care recommends chemotherapy whether or not cancer has spread to the nodes. Women with early stage breast cancer who are ER positive may be the only ones who might benefit from axillary node dissection, since they may not require any treatment. Considering the axillary node procedure's potentially negative impact on the patient's quality of life, Parmigiani, et al., call for a reevaluation of this procedure, but surgeons have been slow to question what they have done routinely for so many years. J Clin Oncol. 1999 May;17(5):1465-73. Is axillary lymph node dissection indicated for early-stage breast cancer? A decision analysis. Parmigiani G, Berry DA, Winer EP, Tebaldi C, Iglehart JD, Prosnitz LR. Institute of Statistics and Decision Sciences and Center for Clinical Health Policy Research, Duke University, Durham, NC. PURPOSE: Axillary lymph node dissection (ALND) has been a standard procedure in the management of breast cancer. In a patient with a clinically negative axilla, ALND is performed primarily for staging purposes, to guide adjuvant treatment. Recently, the routine use of ALND has been questioned because the results of the procedure may not change the choice of adjuvant systemic therapy and/or the survival benefit of a change in adjuvant therapy would be small. We constructed a decision model to quantify the benefits of ALND for patients eligible for breast-conserving therapy. METHODS: Patients were grouped by age, tumor size, and estrogen receptor (ER) status. The model uses the Oxford overviews and three combined Cancer and Leukemia Group B studies. We assumed that patients who did not undergo ALND received axillar yradiation therapy and that the two procedures are equally effective. All chemotherapy combinations were assumed to be equally efficacious. RESULTS: The largest benefits from ALND are seen in ER-positive women with small primary tumors who might not be candidates for adjuvant chemotherapy if their lymph nodes test negative. Virtually no benefit results in ER-negative women, almost all of whom would receive adjuvant chemotherapy. When adjusted for quality of life (QOL), ALND may have an overall negative impact. In general, the benefits of ALND increase with the expected severity of adjuvant therapy on QOL. CONCLUSION: Our model quantifies the benefits of ALND and assists decision making by patients and physicians. The results suggest that the routine use of ALND in breast cancer patients should be reassessed and may not be necessary in many patients.
In a study sponsored by the American Cancer Society, Viale et al. agreed with Parmigiani in their Feb 2005 conclusions, claiming tumor size and vascular invasion around the tumor were the most reliable predictors of sentinel node spread. |
