Most patients with breast cancer have surgery not only to remove the cancer from the breast but the sentinel lymph node is removed under the arm. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor and in turn is the first lymph node the cancer is likely to spread to from the tumor.
In a National Cancer Institute funded randomized trial, women with sentinel lymph nodes with positive cancer cell findings were put into two groups – those who had all of their lymph nodes removed and those who had no further surgery to remove them. The final results, published in the February 9, 2011 edition of the Journal of the American Medical Association, found no difference in survival for those patients who had no further surgery versus those who had all of their lymph nodes removed.
(For more information, listen to this “Cancer Connection” podcast with Julie Margenthaler, MD.)
The reason is that with positive cancer cells in the lymph nodes, they would get chemotherapy and radiation treatment, which in turn would eliminate the cancer cells. Traditionally, a surgeon would remove all of the lymph nodes in what’s called an axillary dissection if the sentinel node came back positive to remove risk of the cancer spreading. Moving forward at the Siteman Cancer Center, such a procedure may not happen for early stage breast cancer patients.
“I do think a lot of women who in the past would have had all of their lymph nodes removed will be able to avoid that in the future,” says Julie Margenthaler, MD, breast surgeon at the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine. “At the Siteman Cancer Center, we have to critically look at this information and acknowledge there are patients who will not benefit having additional lymph nodes removed.”
Physicians have known about this data since the summer of 2010 when it was presented at a professional conference. Since then physicians like Dr. Margenthaler have had discussions with their patients that they may not need all of the lymph nodes removed.
“We have to look at this on a case by case basis and it’s a difficult conversation but if you individualize each patient you can make good treatment decisions and for a lot of these patients that’s going to mean no further axillary surgery,” she says.
Dr. Margenthaler says there will still be cases where it is appropriate to remove all of a patient’s lymph nodes, “It will continue to be performed in patients where obvious lymph node involvement is present.”