After Neoadjuvant Therapy for Node-Positive Breast Cancer: Is ALND Always Necessary?

By: Celeste L. Dixon
Posted: Friday, October 13, 2023

Additional insight has been gained into the value—or, potentially, relative lack thereof—of axillary lymph node dissection (ALND) when it is performed with targeted axillary dissection after neoadjuvant systemic therapy in patients with clinically node-positive breast cancer, according to work published in JAMA Surgery. SenTa—a prospective registry study conducted between January 2017 and October 2018—assessed the 3-year clinical outcomes of 199 such patients from 50 centers in Germany. Targeted axillary dissection alone was not significantly associated with an increased risk of recurrence or death in 119 patients compared with 80 patients who underwent targeted axillary dissection with ALND.

Sherko Kuemmel, MD, PhD, of Kliniken Essen-Mitte, Germany, and colleagues emphasized that axillary staging based on targeted axillary dissection without ALND was associated with excellent clinical outcomes in selected patients, mainly those with good response to neoadjuvant systemic therapy and at least three targeted axillary dissection lymph nodes. “The increasing use of neoadjuvant systemic therapy has led to substantial pathologic complete response rates in patients with initially node-positive, early breast cancer, thereby questioning the need for ALND,” which has known associated morbidities, explained the authors.

The study participants underwent clipping of the most suspicious lymph node before neoadjuvant systemic therapy, the investigators continued. After that therapy, the marked lymph nodes and sentinel lymph nodes were excised—completing targeted axillary dissection —and this was followed, or not, by ALND, according to the clinician’s choice.

Comparing the 80 patients who underwent targeted axillary dissection with ALND with the 119 patients who underwent targeted axillary dissection alone, the unadjusted invasive disease–free survival rate was 82.4% with targeted axillary dissection plus ALND and 91.2% with targeted axillary dissection alone (P = .04); axillary recurrence rates were 1.4% and 1.8%, respectively (P = .56). Additionally, targeted axillary dissection alone was not associated with an increased risk of recurrence (P = .69) or death (P = .91).

Disclosure: The study authors’ disclosure information can be found at jamanetwork.com.

JAMA Surgery