Omitting Axillary Lymph Node Dissection in Early-Stage Breast Cancer

Patients with Negative Sentinel Lymph Nodes

The American Society of Clinical Oncology recommends that completion axillary lymph node dissection (ALND) should not be performed in patients with early-stage breast cancer who have negative sentinel lymph nodes, as 15-year follow-up data shows no statistically significant differences in event-free survival or overall survival between SLNB alone and ALND 1, 2
SLNB alone results in an 11.5% reduction in postsurgical complications compared to routine ALND, according to the American College of Surgeons 1

The American College of Radiology recommends that ALND can be omitted in patients with clinically node-negative early-stage breast cancer who have 1-2 positive sentinel nodes and will receive breast-conserving surgery with whole-breast radiotherapy, based on the ACOSOG Z0011 trial eligibility criteria 1, 3, 4
The American Society for Radiation Oncology states that long-term outcomes demonstrate equivalent survival without completion ALND in this population 1, 3
For patients undergoing mastectomy with 1-2 positive sentinel nodes, the National Comprehensive Cancer Network suggests that post-mastectomy radiation with regional nodal irradiation may be offered in place of completion ALND, with significantly lower lymphedema rates compared to ALND 1, 2

The American Cancer Society recommends that ALND followed by regional nodal irradiation radiation therapy should be recommended in patients who receive mastectomy and have ≥3 positive sentinel nodes 1, 2
The Society of Surgical Oncology states that patients with clinically suspicious or palpable axillary nodes after sentinel node removal, failed or technically unsatisfactory SLNB procedure, or inflammatory breast cancer or N2/N3 stage disease require ALND 4, 5
The American Society of Breast Surgeons suggests that SLNB may be performed in select special circumstances, including clinically node-negative patients with cT3-T4c tumors, multicentric tumors, DCIS treated with mastectomy, patients who are obese, male, or pregnant, or prior breast or axillary surgery 1, 6

The European Society for Medical Oncology recommends that SLNB should not be routinely recommended in highly select patients who are postmenopausal, ≥50 years of age, with negative preoperative axillary ultrasound, grade 1-2, small (≤2 cm), hormone receptor-positive, HER2-negative breast cancer who undergo breast-conserving therapy 6
The American Society of Clinical Oncology advises against performing ALND based solely on imaging findings of suspicious nodes, and defaulting to ALND for micrometastases, and ensures that SLNB is only performed by surgeons with demonstrated low false-negative rates and high successful mapping rates 4, 5, 7