Management of the Axilla

On this page you will find information about and links to relevant management of the axilla publications

 

Summary

The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) randomised control trial investigated whether omission of axillary surgery is non-inferior to sentinel lymph node biopsy (SLNB) in patients with small breast cancer and a negative axillary ultrasound scan (USS). Total of 1463 women (ITT; n=1405) of any age with tumour size up to 2cm and a negative USS were recruited across 4 countries (2012-2017). The study primary endpoint was 5 year distant DFS, with secondary endpoint of cumulative incidence of distant recurrence and axillary recurrence, DFS, OS, and adjuvant treatment recommendations. Median age of the ITT cohort was 60 years old with 708 patients randomised to SLNB, and 697 patients to no axillary surgery group. Median tumour size was 1.1cm and 1234 patients had ER+HER2- breast cancer. In the SLNB group, 97 patients (13.7%) had positive axillary nodes. With median follow up of 5.7 years, the 5 year distant DFS was 97.7% in the SLNB group and 98% in the no axillary surgery group (p=0.67). In the SLNB group, 1.7% suffered from LRR, 1.8% from distant metastasis, and 3% died. In the no axillary surgery group, 1.6% suffered from LRR, 2% from distant metastasis, and 2.6% died. Therefore, SOUND trial demonstrates that omission of axillary surgery was non-inferior to SLNB in patients with tumour size <2cm and negative axillary USS.

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Summary

The AMAROS trial evaluated axillary lymph node dissection (ALND; n=744) vs. axillary radiotherapy (ART; n=681) in patients with cT1-2 breast cancer with positive sentinel lymph node biopsy (SLNB). The pre-planned 10 year analysis examines axillary recurrence rate (ARR), overall survival (OS), and disease free survival (DFS), as well as an updated 5 year analysis of morbidity and quality of life. The 10 year cumulative ARR was 0.93% after ALND and 1.82% after ART (HR 1.71; 95% CI, 0.67 to 4.39). There was no difference in OS (HR 1.17; 95% CI, 0.89 to 1.52) or DFS (HR 1.19; 95% CI, 0.97 to 1.46). ALND resulted in higher lymphoedema rate (24.5% vs. 11.9%; p<0.001). Quality of life scales did not differ between the two groups. 

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Summary

Targeted axillary dissection (TAD) involves targeted lymph node biopsy and SLNB. SenTa study is a prospective registry study conducted across 50 centres which aims to investigate the feasibility and accuracy of TAD in patients undergoing neoadjuvant systemic therapy (NST). Patients had clip inserted into the biopsy-confirmed positive lymph nodes. After NST, the clipped node was resected in 329 of 423 patients (77.8%). TAD was successful in 199 of 229 patients (detection rate of 86.9%) with sentinel lymph node and targeted lymph node identical in 129 patients (64.8%). The FNR was 4.3% for TAD followed by ALND.  

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