Is elimination of sentinel lymph node (SLN) biopsies justified in patients with low-risk breast cancer?

From the Guidelines

Sentinel lymph node biopsies should not be entirely eliminated for low-risk breast cancer patients, but their use can be selectively reduced based on specific patient characteristics and treatment plans. For patients with early-stage breast cancer (T1-T2) and clinically negative lymph nodes, sentinel lymph node biopsy (SLNB) remains the standard of care, as supported by the NCCN Guidelines for Breast Cancer 1. However, for certain low-risk subgroups, omitting SLNB may be considered:

• Women aged 70 or older with hormone receptor-positive, HER2-negative, T1 tumors
• Patients undergoing breast-conserving surgery with planned whole-breast radiation therapy The rationale for potentially omitting SLNB in these cases is:

1. Low likelihood of nodal involvement in these subgroups
2. Limited impact on overall survival and treatment decisions
3. Reduced risk of lymphedema and other surgical complications A randomized trial (ACOSOG Z0011) compared SLN resection alone with ALN dissection in women 18 years of age or older with T1/T2 tumors, fewer than 3 positive SLNs, and undergoing breast-conserving surgery and whole breast irradiation, and found no difference in local recurrence, disease-free survival (DFS), or OS between the treatment groups 1. However, the decision to omit SLNB should be made on a case-by-case basis, considering:

• Patient preferences
• Comorbidities
• Tumor characteristics
• Potential impact on adjuvant therapy decisions Patients should be informed that omitting SLNB may result in less precise staging information but can reduce surgical morbidity, and close follow-up with clinical exams and imaging is essential if SLNB is omitted.

From the Research

Sentinel Lymph Node Biopsy in Low-Risk Breast Cancer

• The elimination of sentinel lymph node (SLN) biopsies in patients with low-risk breast cancer is a topic of ongoing debate 2.
• Some studies suggest that SLN biopsies may not be necessary in patients with low-risk disease, as the risk of lymph node metastases is low 2, 3.
• However, other studies emphasize the importance of axillary staging in breast cancer, including SLN biopsies, for prognostic information and guiding treatment decisions 4, 5, 6.

Benefits and Limitations of SLN Biopsies

• SLN biopsies have been shown to be a sensitive and accurate technique for nodal evaluation, providing prognostic information with less surgical morbidity than axillary lymph node dissection (ALND) 5.
• The use of SLN biopsies has been associated with improved quality of life for patients with early breast cancer, due to reduced risk of lymphedema and other complications 4.
• However, SLN biopsies may not be necessary in all cases, particularly in patients with low-risk disease or those who have undergone neoadjuvant chemotherapy 2, 3.

Clinical Implications

• The decision to perform an SLN biopsy should be individualized, taking into account the patient's overall health, tumor characteristics, and personal preferences 2.
• Clinicians must balance the potential benefits of SLN biopsies, including improved prognostic information and guiding treatment decisions, against the potential risks and complications 2, 5.
• Further research is needed to determine the optimal approach to axillary staging in breast cancer, including the role of SLN biopsies in low-risk patients 2, 6.