The Dilemma After an Unforeseen Positive Sentinel Node in Primary Breast Cancer: Is Completion Axillary Dissection Necessary?

backgroundIn the majority of cases, the sentinel node is the only positive node in the axilla and completion ALND (cALND) is a futile procedure. However, refraining from cALND will lead to less accurate staging and, possibly, undertreatment. To help resolve this dilemma, we examined the clinical value of cALND in staging and determining adjuvant treatment.

methodsIn a retrospective cohort, all consecutive patients over a five-year period with primary breast cancer who received ALND were identified and grouped based on timing of ALND. Total nodal yield and positive lymph nodes were defined and factors with possible impact identified. In the case of cALND, N-status upstaging and possible impact on adjuvant treatment were studied in detail.

resultsA total of 280 patients were selected of whom 204 underwent primary ALND (pALND) and 76 cALND. pALND resulted in a significantly higher total nodal yield and more positive nodes when compared to cALND (p = 0.003, and p < 0.001, respectively). Neoadjuvant chemotherapy (NAC) had no effect on total nodal yield (p = 0.413), but resulted in fewer positive nodes (p < 0.001). Due to the results of cALND, only 11 patients (14%) had upstaging of N-status. All these patients were advised more extensive adjuvant radiotherapy.

conclusionIn the majority of patients, cALND does not lead to upstaging. cALND should be performed only after a careful discussion with the patient about the pros and cons of this procedure, and most probably only in the presence of multiple risk factors for axillary disease in the absence of systemic therapy.