Top Line: When—if ever—are completion axillary dissections performed these days for breast cancer..?
Top Line: We’re at a point where many clinically apparent nodes get neoadjuvant systemic therapy and the rest undergo sentinel node sampling where large study after large study has demonstrated proceeding to adjuvant radiation without further axillary surgery maintains excellent locoregional control. Even though completion axillary dissection potentially identifies a subset of patients with more extensive nodal disease who might benefit from the addition of CDK 4/6 inhibitors, a secondary analysis of the SENOMAC trial found that the morbidity of axillary dissection for diagnostic purposes would greatly outweigh the potential benefit. Another preplanned secondary analysis of the SENOMAC trial asks if, instead, we can more use the information gained from sentinel node sampling alone in a more sophisticated manner. A model was created using information learned from 804 women in the completion dissection arm and calculates risk of further nodal involvement based on number of sentinel node macro- versus micrometastases, ratio of involved versus uninvolved sentinel nodes, presence of extracapsular extension, and tumor size. When applied to the remaining 201 women in the completion dissection arm, at a sensitivity threshold of 80%, the model identified 111 (55.2%) as high risk. This would still mean alot of women would get an unnecessary completion dissection since only 13.5% were found to have pN2+ disease, only 5 women with pN2+ disease would have been missed. What may turn out to provide the biggest therapeutic window is redefining eligibility for systemic therapy escalation based on information gathered with sentinel node assessment alone.
TBL:”Use of the nomogram may facilitate systemic treatment decisions without exposing patients to completion axillary dissection.” | Skarping, JAMA Surg 2024
Top Line: We’re at a point where many clinically apparent nodes get neoadjuvant systemic therapy and the rest undergo sentinel node sampling where large study after large study has demonstrated proceeding to adjuvant radiation without further axillary surgery maintains excellent locoregional control. Even though completion axillary dissection potentially identifies a subset of patients with more extensive nodal disease who might benefit from the addition of CDK 4/6 inhibitors, a secondary analysis of the SENOMAC trial found that the morbidity of axillary dissection for diagnostic purposes would greatly outweigh the potential benefit. Another preplanned secondary analysis of the SENOMAC trial asks if, instead, we can more use the information gained from sentinel node sampling alone in a more sophisticated manner. A model was created using information learned from 804 women in the completion dissection arm and calculates risk of further nodal involvement based on number of sentinel node macro- versus micrometastases, ratio of involved versus uninvolved sentinel nodes, presence of extracapsular extension, and tumor size. When applied to the remaining 201 women in the completion dissection arm, at a sensitivity threshold of 80%, the model identified 111 (55.2%) as high risk. This would still mean alot of women would get an unnecessary completion dissection since only 13.5% were found to have pN2+ disease, only 5 women with pN2+ disease would have been missed. What may turn out to provide the biggest therapeutic window is redefining eligibility for systemic therapy escalation based on information gathered with sentinel node assessment alone.
TBL:”Use of the nomogram may facilitate systemic treatment decisions without exposing patients to completion axillary dissection.” | Skarping, JAMA Surg 2024