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National Trends For Axillary Lymph Node Dissections And Survival Outcomes For Clinical T3 Or T4, Node Negative Breast Cancer Patients Undergoing Mastectomy With Positive Sentinel Lymph Nodes
Chantal Reyna, *Michael Johnston, *Mackenzie Morris, *Tiffany Lee, *Dennis Hanseman, Jaime Lewis, Elizabeth Shaughnessy
University of Cincinnati College of Medicine, Cincinnati, OH

Objectives: Routine axillary lymph node dissection (ALND) declined following the ACOSOG Z0011 trial in women with T1/T2 tumors and 1-2 positive sentinel lymph nodes (SLN) who underwent breast conservation therapy (BCT). Previous studies have suggested ALND can be omitted in early breast cancer patients undergoing mastectomy with positive SLNs. The goal of this study was to assess the national utilization of ALND and survival outcomes for larger, locally advanced tumors in patients who underwent mastectomy with positive SLNs.
Methods: The National Cancer Database from 2004-2016 was queried for women with clinical T3/T4, N0 tumors who underwent mastectomy and otherwise fit Z0011 criteria. Neoadjuvant systemic therapy or clinical nodal disease were excluded. The periods before and after the publication of ACOSOG Z0011 were compared. Axillary management was compared: SLNB alone (1-5 lymph nodes examined) versus ALND (≥10 lymph nodes examined).
Results: 1257 women met inclusion criteria, of whom 61% underwent ALND. The proportion of ALND decreased from 72% in 2004-2011 to 53% in 2012-2016 (p<0.01). Patients undergoing ALND were slightly younger (59 vs 61 years, p <0.01) and had more poorly differentiated tumors (35% vs. 27%, p=0.03). On Kaplan-Meier analysis, there was a significantly better overall survival for ALND compared to SLNB alone, despite the higher proportion of poorly differentiated tumors in the ALND group.
Conclusions: While previous studies suggest omitting ALND in early breast cancer mastectomy patients, our analysis is the first large database study to show there is a national trend to forego ALND in women with larger tumors (T3 or T4) who undergo mastectomy with positive SLN(s). However, this study demonstrates a significant survival benefit for ALND in this population and omitting ALND may be detrimental to patient outcomes.


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