Breast Cancer ChoicesTM
|Scrutinizing the evidence for breast
cancer procedures and treatments
|What is the
regretted by breast
Link to medical
articles on lymph
|Can factors from
the tumor biology
(pathology report )
allow me to avoid
axillary lymph node
NY Times Feb 8, 2011
Lymph Node Study
Shakes Pillar of
No Benefit to
Some 82.2 percent of
the women who had the
dissection were alive
and disease free
compared with 83.8
percent of those who
did not. Cancer
recurred in the breast
or nearby in 4.3
percent of those who
had the operation and
3.4 percent in those
who did not.
Patients had more
distant recurrences with
excerpt from full text
To the surprise of most,
Fisher's study of 1700
patients failed to reveal any
survival advantage for
patients undergoing ELND.
Although the lymph node
recurrences in the treated
lymph node basin, this
improvement in local control
did not translate to a
benefit in overall survival. In
fact, when these patients
did have recurrences,
these were more likely to be
distant disease. Since
Fisher's landmark study,
five RCTs evaluating ELND
in breast cancer patients
have failed to reveal a
survival advantage for
patients treated with
ELND. The lack of
evidence supporting the
value of ELND for breast
cancer patients in these
five trials raised significant
questions regarding the
dogmatic but unproven
traditional approach to
surgical management in
patients with cancer.
|Lymph Node FAQ
From the Manual of
"Removal of the axillary
nodes does not affect
the frequency of
development of distant
metastasis or survival
The biopsy on my tumor was positive for cancer. My doctor has
recommended a sentinel lymph node biopsy (SLNB) or sentinel lymph
node dissection (SNLD) to see if the cancer has spread. How invasive
is this procedure?
the lymph nodes tested was one of the most important, life-altering decisions
they made. One of the major reasons for setting up the Breast Cancer Choices
website was the suffering of members who had some or all of their axillary
by nerve-severing, lymphedema, or phlebitis. The lymph node dissection
procedure has resulted in some women's inability to pick up children, trouble
carrying groceries, arm weakness and swelling as well as numbness and limited
range of motion. At least two of our members had nerves severed.
LYMPH NODE DISABILITIES ARE NOT CURABLE. The lymph node dissection is done
as a diagnostic, not a therapeutic procedure. However, many surgeons still believe
removing cancerous nodes is therapeutic despite the evidence.
Even though the sentinel lymph node biopsy is a more limited procedure than a full
axillary dissection of the nodes, you may nonetheless be required in advance to
grant your surgeon permission to remove other nodes if the sentinel node is
cancerous. The complication rate for sentinel node biopsy, including reactions to the
radioactive dye, must also be considered. See additional articles if you are
considering this procedure.
The decision to give permission to dissect the lymph nodes is a major one. Ask your
surgeon why you need your lymph nodes tested. The answer will probably be one of
the following: "It's standard procedure, "We need to stage you." "If there is cancer in
the nodes we will remove it."
All of the above statements are true. Most patients get this procedure done because
it is the standard package and they don't question whether it will improve their odds
of survival., But staging via the lymph node evaluation may have no value to the
patient if she is going to pursue conventional or alternative treatments aggressively
Are there any safety issues with a sentinel lymph node biopsy?
Dr. Robert Rosser recommends that the SLND should be done without massage or
any other attempt to hasten the flow of lymph to the lymph nodes. Dr. Rosser
contends that occult micrometastases (CK-IHC-positive micrometastases) in the
sentinel lymph nodes may be the result of the sentinel node procedure itself.
"Medical practioners routinely massage the breast, sometimes with heat, to increase
the flow of lymph, radiosotope, and blue dye to the axilla. Scrub nurses massage the
breast to prepare the skin for the surgical skin incisions. Surgeons grasp breast
tumors with clamps and forceps to retract them while completing the tumor's
excision. It should not be surprising that cellular fragments of less cohesive tumors
are disrupted and are caught in the flow of lymph. The danger to the patient comes
from those traumets that do not get trapped in the sentinel lymph node but enter the
systemic circulation." (See "Safety of Sentinel Lymph Node Dissection and
Signficance of Cytokeratin Micrometastases" on the Robert Rosser, MD page.)
Dr. Rosser recommends that the SLND should be done without massage or any other
attempt to hasten the flow of lymph to the lymph nodes.
But what if the cancer has spread to the lymph nodes? Won't removing them
improve my survival chances? That seems like common sense.
Yes, it does seem like common sense that the removal of cancerous lymph nodes
would improve the survival rate, but the evidence seems to show a different role
for the lymph nodes than was expected. That evidence hasn't yet impacted current
The Management of Regional Lymph Nodes in Cancer
D.B. Pharis; J.A. Zitelli
Br J Dermatol 149(5):919-925, 2003. © 2003 Blackwell Publishing [excerpts]
Management of the regional lymph nodes (RLNs) in potentially metastatic cancer is fraught with
controversies and misunderstandings. Early surgical oncologists observed many times that the
RLNs were enlarged in advanced cancers before distant disease appeared, leading to the theory
that the RLNs served as mechanical barriers temporarily preventing systemic dissemination of
tumour. Based on this theory, surgeons removed these enlarged lymph nodes along with the
primary tumour, an approach known as therapeutic lymph node dissection (TLND), in an attempt
at surgical cure of locally advanced disease. Unacceptable cure rates, believed to be a result of
unresected microscopic disease, led to the removal of clinically normal RLNs, a procedure
known as elective lymph node dissection (ELND), in an effort to remove these nonpalpable
tumour deposits. By the early twentieth century, routine dissections of the regional lymphatics in
an effort to remove all microscopic disease had become the dogma of surgical oncology based
exclusively on observation and theory rather than sound scientific evidence. This barrier theory
of lymph node biology continues to influence the management of the RLNs in cancer surgery
The theoretical benefit of ELND seemed unassailable when considered in the context of the
belief that the RLNs served as physical barriers to tumour dissemination. During a time when
little else could be offered to cancer patients, this seemingly rational theory and the chance of a
surgical cure for this dreaded disease captured the attention of surgeons around the world.
Numerous retrospective and single institutional studies were published that supported the
widespread use of ELND in nearly all forms of cancer with the potential for nodal metastasis
including cancer of the breast, uterus, cervix, vulva, prostate, head and neck, penis and, of
course, melanoma.[6-14] Advocates of ELND used the results of these uncontrolled studies to
validate the theory that the RLNs were in fact barriers to systemic tumour dissemination.
Consequently, the role of ELND in cancer surgery remained unchallenged in surgical oncology
until late in the twentieth century.
A turning point in this story began in 1960 when Bernard Fisher, then the director of the National
Surgical Adjuvant Breast and Bowel Program, began an ambitious study that was to be the first
randomized controlled trial (RCT) investigating the value of the ELND in breast cancer
patients. To the surprise of most, Fisher's study of 1700 patients failed to reveal any
statistically significant survival advantage for patients undergoing ELND. Although the lymph
node dissection group experienced fewer recurrences in the treated lymph node basin, this
improvement in local control did not translate to a benefit in overall survival. In fact, when these
patients did have recurrences, these were more likely to be distant disease. Since Fisher's
landmark study, five RCTs evaluating ELND in breast cancer patients have failed to reveal a
statistically significant survival advantage for patients treated with ELND. The lack of
evidence supporting the value of ELND for breast cancer patients in these five trials raised
significant questions regarding the dogmatic but unproven traditional approach to surgical
management in patients with cancer.
For more complete references and more studies see Medical Articles on Lymph Node
What about the risk of lymphedema after node surgery?
The risk of lympedema can depend on how many nodes were taken or if you have
radiation after surgery. Lymphedema can develop immediately or occur years later. A
2003 study showed that there is a significantly lower rate of lymphedema in patients
who have had SLND than full axillary dissection. (See Golshan, et al., Am Surg, ,
in the Medical Articles Lymph page.)
Society publishes an extensive list of activities patients should avoid
for the rest of their lives. See below:
Although there are no scientific studies to show that people can prevent lymphedema, most experts
recommend following these basic guidelines, which may lower your risk of developing lymphedema
or delay its onset:
Avoid Infections, Burns and Injuries. Try to avoid infections, burns, or injuries to the affected area.
Your body responds to these by making extra fluid. Burns and injuries canal so lead to infections.
Removal of or damage to lymph nodes and vessels makes it more difficult to transport this extra fluid,
and this can trigger lymphedema.
Keep the affected limb clean. Careful skin care may reduce the risk of lymphedema by helping you
to avoid infections. Dry creases between your toes after bathing. Keep your hands, feet, and cuticles
soft and moist by regularly applying moisturizing lotion or cream. Push cuticles back with a cuticle
stick rather than cutting them with scissors. Clean and protect any openings in the skin caused by
cuts, abrasions,insect bites, hangnails or torn cuticles by washing with soap and water. Use an over-
the-counter antibacterial cream on any opening once they are cleaned, and then cover with a
clean bandage. For burns, apply a cold pack or cold water for 15 minutes, then wash with
soap and water and apply a clean, dry dressing. Watch for early signs of infection: rash, red blotches,
swelling,increased heat, tenderness, or fever.
Call your doctor right away if you develop an infection. Use an electric shaver for removing underarm
and leg hair; these maybe less likely to cut or break the skin than straight razors or hair removal
creams. If necessary, use an insect repellent when outdoors to avoid bug bites. If a bee stings you in
the affected limb, clean and elevate the limb,apply ice, and contact your doctor if it becomes
infected. Avoid activities that irritate or chap the skin. Protect your limb from sunburn. Use sunscreen
that is labeled SPF15 or higher and try to stay out of the sun during the hottest part of the day. Avoid
oil splash burns from frying and steam burns from microwaved foods or boiling liquids. Your affected
limb may not detect temperatures as well as it did in the past. Test bath water temperatures with an
unaffected limb. Avoid excessive heat, such as from hot tubs and saunas, since heat can increase
fluid build-up. Copyright American Cancer Society, Inc.
the time patients, who had had full axillary dissection, reached the 20 year mark.
Cancer. 2001 Sep 15;92(6):1368-77.
Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis.
Petrek JA, Senie RT, Peters M, Rosen PP.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York
BACKGROUND: To the authors' knowledge, there are no long-term cohort studies of lymphedema,
despite the substantial morbidity of arm swelling. The goal of this study was to identify prevalence
of breast carcinoma-related lymphedema, time of onset, and associated predictive factors.
METHODS:A cohort of 923women consecutively treated with mastectomy and complete axillary
dissection at our center between 1976 and 1978 was observed intensively for 20 years. Two
hundred sixty-three study subjects (28.5%) who were alive and recurrence free constituted the
cohort for the current study. A subset of 52 women (20% of study population) with contralateral
mastectomy was analyzed separately. Subjects reported circumferential arm measurements
taken using a validated instrument.
In addition to providing analysis of clinical and treatment variables, this study is the first to the
authors' knowledge to analyze possible etiologic factors in the posttreatment years, such as
occupation, general physical activity, and sports/leisure activities. Univariate and multivariate
analytic methods were used.
RESULTS: At 20 years after treatment, 49% (128 of 263) reported the sensation of lymphedema.
Arm swelling measurements were severe (> or = 2.0 in [5.08 cm]; patients reported measurement
in inches) for 13% (33 of 263 women). Seventy-seven percent (98 of 128) noted onset within 3 years
after theoperation; the remaining percentage developed arm swelling at a rate of almost 1% per
year. Of the 15 potential predictive factors analyzed, only 2 were statistically significantly
associated with lymphedema: arm infection/injury and weight gain since operation (P < 0.001 and P
= 0.02, respectively). CONCLUSIONS: This defined cohort, treated by axillary dissection 20 years
ago, documents the high prevalence of lymphedema and its time course. Two significantly
associated factors, both potentially controllable, are identified. The current study provides further
support for treatments that limit lymph node dissection. The authors are prospectively evaluating
patients undergoing sentinel lymph node biopsy. Copyright 2001 American Cancer Society.
Can factors from the tumor biology --from the pathology report-- yield sufficient
information to allow me to avoid axillary lymph node dissection?
The Parmigiani study, cited below, suggests especially with respect to breast cancer patients who are
considering undergoing conventional treatments, that it may not be beneficial for those with early
stage breast cancer who are ER negative to have axillary node dissection. The rationale for this
suggestion is that the standard of care recommends chemotherapy whether or not cancer has spread
to the nodes. Women with early stage breast cancer who are ER positive may be the only ones who
might benefit from axillary node dissection, since they may not require any treatment. Considering the
axillary node procedure's potentially negative impact on the patient's quality of life, Parmigiani, et al., call
for a reevaluation of this procedure, but surgeons have been slow to question what they have done
routinely for so many years.
J Clin Oncol. 1999 May;17(5):1465-73.
Is axillary lymph node dissection indicated for early-stage breast cancer? A decision analysis.
Parmigiani G, Berry DA, Winer EP, Tebaldi C, Iglehart JD, Prosnitz LR.
Institute of Statistics and Decision Sciences and Center for Clinical Health Policy Research, Duke
University, Durham, NC.
PURPOSE: Axillary lymph node dissection (ALND) has been a standard procedure in the
management of breast cancer. In a patient with a clinically negative axilla, ALND is performed
primarily for staging purposes, to guide adjuvant treatment. Recently, the routine use of ALND has
been questioned because the results of the procedure may not change the choice of adjuvant
systemic therapy and/or the survival benefit of a change in adjuvant therapy would be small. We
constructed a decision model to quantify the benefits of ALND for patients eligible for
breast-conserving therapy. METHODS: Patients were grouped by age, tumor size, and
estrogen receptor (ER) status. The model uses the Oxford overviews and three combined Cancer
and Leukemia Group B studies. We assumed that patients who did not undergo ALND received
axillar yradiation therapy and that the two procedures are equally effective. All chemotherapy
combinations were assumed to be equally efficacious. RESULTS: The largest benefits from ALND
are seen in ER-positive women with small primary tumors who might not be candidates for adjuvant
chemotherapy if their lymph nodes test negative. Virtually no benefit results in ER-negative women,
almost all of whom would receive adjuvant chemotherapy. When adjusted for quality of life (QOL),
ALND may have an overall negative impact. In general, the benefits of ALND increase with the
expected severity of adjuvant therapy on QOL.
Our model quantifies the benefits of ALND and assists decision making by patients and
physicians. The results suggest that the routine use of ALND in breast cancer patients should be
reassessed and may not be necessary in many patients.
In a study sponsored by the American Cancer Society, Viale et al. agreed with
Parmigiani in their Feb 2005 conclusions, claiming tumor size and vascular invasion
around the tumor were the most reliable predictors of sentinel node spread.