What is the treatment for involved axillary lymph nodes?

From the Guidelines

The treatment for involved axillary lymph nodes in breast cancer patients typically involves surgical removal through axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB), followed by adjuvant therapy, with consideration of omitting further axillary surgery in patients with 1-2 positive sentinel nodes who undergo lumpectomy and whole-breast radiation, as supported by the ACOSOG Z0011 trial 1.

Key Considerations

• For patients with clinically positive nodes at the time of diagnosis, confirmed by FNA or core biopsy, or when sentinel nodes are not identified, a level I and II axillary dissection is recommended 1.
• The decision to perform axillary dissection or sentinel lymph node biopsy should be based on the patient's individual risk factors, tumor characteristics, and the potential impact on adjuvant systemic therapy 1.
• Radiation therapy to the axilla may be recommended, typically delivered at doses of 45-50 Gy over 5 weeks, and systemic therapy may include chemotherapy regimens, endocrine therapy, or targeted therapy, depending on the patient's disease characteristics 1.

Surgical Management

• A level I and II axillary dissection involves removing 10-40 lymph nodes, and may be performed in patients with positive sentinel nodes or clinically positive axillary nodes 1.
• Sentinel lymph node biopsy is the standard approach in patients presenting with a clinically negative axilla, and may be sufficient for patients with 1-2 positive sentinel nodes who undergo lumpectomy and whole-breast radiation 1.

Adjuvant Therapy

• Systemic therapy is essential in the treatment of breast cancer with involved axillary lymph nodes, and may include chemotherapy regimens such as dose-dense AC-T, TC, or TAC, as well as endocrine therapy or targeted therapy 1.
• The choice of adjuvant therapy should be based on the patient's individual risk factors, tumor characteristics, and the potential impact on recurrence risk and overall survival 1.

From the Research

Treatment for Involved Axillary Lymph Nodes

The treatment for involved axillary lymph nodes in breast cancer patients typically involves a combination of surgical and non-surgical approaches.

• Axillary lymph node dissection (ALND) is a common surgical procedure used to remove cancerous lymph nodes in the axilla 2, 3, 4.
• However, ALND can be associated with significant complications, such as numbness, seroma, lymphedema, and infection 2.
• Sentinel lymph node biopsy (SLNB) is a less invasive alternative to ALND, which involves removing only the first lymph node to which cancer cells are likely to spread 5.
• For node-positive patients treated with neoadjuvant chemotherapy, restaging of the axilla with ultrasound (US) and MRI, and targeted axillary dissection in addition to SLNB, is highly recommended to minimize the false-negative rate of SLNB 5.
• The number of lymph nodes retrieved during axillary dissection can impact overall survival, with retrieval of approximately 20 lymph nodes associated with improved survival 4.

Diagnostic Approaches

Diagnostic approaches, such as axillary ultrasound (US), MRI, and US-guided biopsy, play a critical role in assessing nodal disease burden and guiding treatment decisions 5, 6.

• Axillary US has been shown to be highly sensitive and specific in detecting level II and III axillary lymph node metastasis after axillary lymph node dissection for invasive breast cancer 6.
• US features, such as an increase in lymph node diameter, a low Solbiati index value, and the presence of new suspicious lesions, can be predictive of lymph node metastasis 6.

Multidisciplinary Treatment Decision Making

Multidisciplinary treatment decision making is critical in the management of involved axillary lymph nodes, involving close collaboration between breast radiologists, surgeons, and other healthcare professionals 5.

• Accurate assessment of axillary lymph node involvement is essential in staging breast cancer and guiding treatment decisions 5, 3.
• Emerging evidence suggests that axillary lymph node dissection may be avoided in selected patients with node-positive as well as node-negative cancer, highlighting the need for individualized treatment approaches 5.