NCCN: Skip ALND in Some Early Breast Cancer

Axillary lymph node dissection can be skipped in some early-stage breast cancer patients with minimal sentinel node involvement, as well as in those with negative findings on sentinel node biopsy, according to revised clinical practice guidelines issued by the National Comprehensive Cancer Network.

The recommendation that no further axial surgery be considered for certain patients with only one or two involved sentinel lymph nodes reflects an upgrade of the National Comprehensive Cancer Network (NCCN) guideline on sentinel node biopsy to a category 1 recommendation.

The change is based on the findings of recent prospective studies. In particular, the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial, found no survival difference between early-stage breast cancer patients who underwent axillary lymph node dissection [ALND] and those who did not after one or two sentinel nodes were determined to be positive on biopsy (JAMA 2011;305:569-75).

The revised recommendation extends only to those patients with early-stage disease (tumor grades 1 or 2) who undergo breast-conserving surgery and whole-breast radiation and who have not received neoadjuvant chemotherapy, according to the guidelines. A primary objective is to reduce the risk of lymphedema associated with axillary lymph node dissection.

"In the absence of definitive data demonstrating superior survival from the performance of axillary lymph node dissection, patients who have particularly favorable tumors, patients for whom the selection of adjuvant systemic therapy is unlikely to be affected, for the elderly or those with serious comorbid conditions, the performance of axillary lymph node dissection may be considered optional," the guidelines advise.

The update was presented at the NCCN annual meeting in Hollywood, Fla. The Breast Cancer Panel lists potential conflict of interest disclosures on the NCCN website.