Limited breast cancer surgery results in fewer arms being swollen

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We want to try to carry out more precise interventions to spare patients from annoying side effects. “But we have to know it's safe,” he says. Jana de Bonifacea breast cancer surgeon at Capio St. Goran Hospital and a researcher at Department of Molecular Medicine and Surgery At Karolinska Institutet.

When it is known before breast cancer surgery that there are metastases in the armpit, different treatment paths unfold. These patients were not included in this study. But when there is no known spread, the surgeon usually removes the so-called sentinel glands (the gland or glands where lymph fluid first reaches from the chest).

Leave the lymph nodes safe

If they contain single tumor cells or metastases of a maximum size of 2 mm, the rest of the lymph nodes are left in the armpit. Previous studies have shown that it is safe for the patient. Now, a large study, led by the Karolinska Institutet, has corrected the situation even for larger metastases.

The study includes approximately 2,800 patients from five different countries. All of them had metastases larger than 2 millimeters, called macrometastases, in one or two of the gatekeeper glands that were removed.

After gatekeeper surgery, patients were randomly assigned to have the axilla evacuated (which was the practice of all), or to leave the rest of the axilla alone.

Most of them were subsequently treated with cytostatics and/or antihormonal therapy plus radiation according to the guidelines in each country. More than one in three patients who underwent axillary evacuation were found to have more than two metastases in the sentinel glands.

Post-processing seems sufficient

It is plausible that the same should have been the case in those who were allowed to retain other lymph nodes. However, disease recurrence was equally common in both groups, so it appears that subsequent treatment was sufficient to remove remaining cancer cells.

Meanwhile, a previous publication of the study found that 13% of those who underwent axillary dissection reported serious or very serious problems with their arm function, compared to 4% of those who only had their sentinel glands removed.

Our assessment is that it is safe for patients to refrain from axillary evacuation if there are a maximum of two large metastases in the sentinel glands. In these cases, axillary evacuation is replaced by radiation therapy to the axilla, which causes less discomfort in the arm. Jana de Boniface says it has already been introduced into clinical practice in Sweden.

The study is called SENOMAC and is funded by the Swedish Research Council, the Norwegian Cancer Fund, the Nordic Cancer Consortium, and the Breast Cancer Society.

Publishing

“Deletion of axillary dissection in breast cancer with sentinel node metastases“, Jana de Boniface, Tove Feltenborg Tvedskov, Lisa Ryden, Robert Schulkin, Toralf Reimer, Thorsten Kuhn, Michalis Kontos, Oresti David Gentilini, Roger Olofsson Bagge, Malin Sund, Dan Lundstedt, Matilda Appelgren, Johan Ahlgren, Sophie Nornstedt, Voat Celebioglu … New England Journal of Medicineonline 3 April 2024, doi: 10.1056/NEJMoa2313487