Survival of lymph node-negative breast cancer patients in relation to number of lymph nodes examined

Long-term survival after sentinel lymph node biopsy or axillary lymph node dissection in pN0 breast cancer patients: a population-based study

PURPOSE

Findings from randomized clinical trials have shown that survival in patients with sentinel lymph node (SLN)-negative breast cancer is noninferior with SLN biopsy (SLNB) alone versus further axillary lymph node dissection (ALND). However, the long-term outcome of these two surgical approaches in pN0 breast cancer patients in real-world setting remains uncertain.

METHODS

We included patients diagnosed with pathologically staged T1-2N0M0 breast cancer between 2000 and 2015 in surveillance, epidemiology, and end results 18-registry database. Patients were considered to have undergone SLNB alone if they had ≤ 5 examined lymph nodes (ELNs), and ALND if they had ≥ 10 ELNs. The outcomes included overall survival (OS) and breast cancer-specific survival. Propensity score analyses by weighting and matching and multivariable Cox regression analysis were performed to minimize treatment selection bias.

RESULTS

We included 309,430 patients (253,501 SLNB and 55,929 ALND). In the weighted cohort, ALND was associated with significantly lower OS (hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.10-1.16) and BCSS (HR 1.16; 95% CI 1.10-1.22) compared with SLNB alone. Both the propensity score-matching model and multivariable Cox model demonstrated a survival benefit for SLNB when compared with ALND. Subgroup analyses for key variables did not change these findings.

CONCLUSION

We found statistically significant differences in OS and BCSS between SLNB and ALND, though the magnitude of these differences was small. Our findings further support that SLNB alone should be the standard of care for patients who do not have metastatic lymph nodes identified during breast cancer surgery.

Less Axillary Lymphadenectomy is More Beneficial: 27-Year Follow-up of Patients with Breast Cancer

Background: One of the most important alterations in breast cancer treatment is the change of view in axillary lymph node management. At the moment, sentinel lymph node biopsy (SLNB) is the standard care in axillary lymph node management. However, in patients with clinically positive lymph nodes or in patients, who have no willingness to receive radioactive drugs, axillary lymph node dissection (ALND) must be done. To the best of our knowledge, there is no overall survival (OS) benefit in ALND, especially at the early stage of breast cancer, during which this procedure is not justified. Objectives: Herein, we have reported the results of 27 years of experiments in limited axillary lymph node dissection (LALND) in comparison to ALND as well as the relationship among the number of removed lymph nodes, OS, and disease-free survival (DFS) at the early stage of breast cancer. Methods: OS and DFS for 588 cases, who were at the early stage of breast cancer and treated by LALND between 1984 and 2019, were compared with 1026 patients, who were treated by ALND during the same interval in this study. Notably, SLNB cases were excluded. Results: The results revealed no significant difference among the groups in terms of DFS (P = 0.268, 0.123, and 0.333). Also, there was no difference in terms of OS between the LALND group (1 - 4 nodes, 5 - 6 nodes, and 7 - 8 nodes) and ALND group (≥ 9 nodes) in patients without lymph node involvement (AHR less than 2). However, in the patients with axillary lymph node metastasis (N1, N2), similar results were obtained. Correspondingly, in this group, the best results were observed in those patients, whose 7 - 8 lymph nodes were removed. Conclusions: Regarding the results of the current study; it can be concluded that performing the LALND in the defined anatomic range and removing 7 - 8 lymph nodes instead of removing 10 lymph nodes are not inferior when it is not possible to do SLNB (there is no access to it) and/or being a contraindication to do it for evaluating the status of axillary lymph nodes in the patients at the early stage of breast cancer.

Negative Lymph Node Count and Lymph Node Ratio Are Associated With Survival in Male Breast Cancer

BACKGROUND

Male breast cancer (MBC) is usually diagnosed at late stages and therefore has a worse prognosis than female breast cancer (FBC). MBC is also more likely to have lymph node (LN) involvement than FBC.

MATERIALS AND METHODS

We sought to determine the prognostic role of the examined lymph node (LN), negative LN (NLN), and positive LN counts and the LN ratio (LNR), defined as (positive LNs/ENLs), on the survival rate among MBC patients. We performed a large population-based study using the data from the Surveillance, Epidemiology, and End Results program.

RESULTS

Older age, black race, stage IV disease, ≤ 1 NLN, and a > 31.3% LNR were significantly associated with worse survival across all prediction models. Moreover, we demonstrated a decreased risk of mortality in MBC patients across the MBC-specific survival model (hazard ratio, 0.98; 95% confidence interval, 0.96-0.998; P = .03) and 10-year MBC-specific survival model (hazard ratio, 0.98; 95% confidence interval, 0.96-0.999; P = .04).

CONCLUSION

MBC has had an augmented incidence over the years. We found several independent predictors of MBC survival, including age, race, stage, NLNs, and the LNR. We strongly suggest adding the NLN count and/or LNR into the current staging system. Further studies are needed to provide information on the mechanisms underlying the association between the NLN count and MBC survival and the LNR and MBC survival.

Recent perspectives of breast cancer prognosis and predictive factors

Breast cancer is the most common type of cancer affecting women worldwide. Although there have been great improvements in treating the disease and at present between 80 and 90% of the women survive ≥5-years after their primary diagnosis. However, due to the high incidence of the disease >450,000 women succumb to breast cancer annually worldwide. The majority of improvements in breast cancer survival may be explained through better knowledge of the development and progression of the disease. Consequently, the treatments employed have become more effective. Furthermore, continuous efforts are being made for the identification of novel and efficient biomarkers for the timely prognosis of breast cancer. The present review aims to examine recent perspectives of breast cancer prognosis and the predictive factors involved.

The number of tumor-free axillary lymph nodes removed as a prognostic parameter for node-negative breast cancer

Recently, there has been controversy about the relationship between the number of lymph nodes removed and survival of patients diagnosed with lymph node-negative breast cancer. To assess this relationship, 603 cases of lymph node-negative breast cancer with a median of 126 months of follow-up data were studied. Patients were stratified into two groups (Group A, 10 or fewer tumor-free lymph nodes removed; Group B, more than 10 tumor-free lymph nodes removed). The number of tumor-free lymph nodes in ipsilateral axillary resections as well as 5 other disease parameters were analyzed for prognostic value. Our results revealed that the risk of death from breast cancer was significantly associated with patient age, marital status, histologic grade, tumor size, and adjuvant therapy. The 5- and 10-year survival rates for patients with 10 or fewer tumor-free lymph nodes removed was 88.0% and 66.4%, respectively, compared with 69.2% and 51.1%, respectively, for patients with more than 10 tumor-free lymph nodes removed. For patients with 10 or fewer tumor-free lymph nodes removed, the adjusted hazard ratio (HR) for risk of death from breast cancer was 0.579 (95% confidence interval, 0.492-0.687, P < 0.001), independent of patient age, marital status, histologic grade, tumor size, and adjuvant therapy. Our study suggests that the number of tumor-free lymph nodes removed is an independent predictor in cases of lymph node-negative breast cancer.

Neoadjuvant chemotherapy in breast cancer significantly reduces number of yielded lymph nodes by axillary dissection

Background

Neoadjuvant chemotherapy (NC) is an established therapy in breast cancer, able to downstage positive axillary lymph nodes, but might hamper their detectibility. Even if clinical observations suggest lower lymph node yield (LNY) after NC, data are inconclusive and it is unclear whether NC dependent parameters influence detection rates by axillary lymph node dissection (ALND).

Methods

We analyzed retrospectively the LNY in 182 patients with ALND after NC and 351 patients with primary ALND. Impact of surgery or pathological examination and specific histomorphological alterations were evaluated. Outcome analyses regarding recurrence rates, disease free (DFS) and overall survival (OS) were performed.

Results

Axillary LNY was significantly lower in the NC in comparison to the primary surgery group (median 13 vs. 16; p < 0.0001). The likelihood of incomplete axillary staging was four times higher in the NC group (14.8% vs. 3.4%, p < 0.0001). Multivariate analyses excluded any influence by surgeon or pathologist. However, the chemotherapy dependent histological feature lymphoid depletion was an independent predictive factor for a lower LNY. Outcome analyses revealed no significant impact of the LNY on local and regional recurrence rates as well as DFS and OS, respectively.

Conclusion

NC significantly reduces the LNY by ALND and has profound effects on the histomorphological appearance of lymph nodes. The current recommendations for a minimum removal of 10 lymph nodes by ALND are clearly compromised by the clinically already established concept of NC. The LNY of less than 10 by ALND after NC might not be indicative for an insufficient axillary staging.

Stage migration effect on survival in gastric cancer surgery with extended lymphadenectomy: the reappraisal of positive lymph node ratio as a proper N-staging

OBJECTIVE

The purpose of this study is to analyze the relationship between the number of examined lymph nodes (NexLN) and survival in gastric cancer and to determine whether the metastatic/examined lymph node ratio (LN ratio) system can compensate for the shortcomings of the UICC/AJCC staging.

METHODS

Prospective data of 8949 primary T1-T4a gastric cancer patients who underwent curative surgery were reviewed. The patients were stratified by T-stage and grouped according to NexLN; 1 to 14 exLN denoted the first group and every subsequent 10 LNs thereafter. Numbers of LN and 5-year survival rates were analyzed according to NexLN. "The NR-staging system" was generated using 0.2 and 0.5 as the cut-off values of LN ratio and then compared with UICC/AJCC stages.

RESULTS

The proportion of advanced N-stage increased with NexLN. Survival and the LN ratio were constant regardless of NexLN when combining all N0-N3b patients, however, T2/3 and T4a patients showed an increasing tendency toward survival in N1/2 and N3a as NexLN increased, mainly due to a stage migration effect. The LN ratio system showed better patterns of distribution of the LN stage and survival graph. The power of the differential staging of the LN ratio system was fortified with higher NexLN.

CONCLUSION

The relationship between NexLN and survival is probably affected by stage migration in a high-volume gastric cancer center. The LN ratio system could be a better option to compensate for this effect, and the value of the prognosis prediction in this system increases with a higher NexLN.

Extent of lymph node resection does not increase perioperative morbidity and mortality after surgery for stage I lung cancer in the elderly

BACKGROUND & OBJECTIVES

Pathologic evaluation of > 10 lymph nodes (LNs) is considered necessary for accurate lung cancer staging. However, physicians have concerns about increased risk in perioperative mortality (POM) and morbidity with more extensive LN sampling, particularly in the elderly. In this study, we compared the outcomes in elderly patients with stage I non-small cell lung cancer (NSCLC) undergoing extensive (> 10 nodes) and limited (≤ 10 nodes) LN resections.

METHODS

Using data from the Surveillance, Epidemiology and End Results registry linked to Medicare records, we identified 4975 patients ≥ 65 years of age with stage I NSCLC who underwent a lobectomy between 1992 and 2002. Risk of perioperative morbidity and POM after the evaluation of ≤ 10 vs. >10 LNs was compared among patients after adjusting for propensity scores.

RESULTS

Multiple regression analysis showed similar POM between the two groups (OR, 1,01; 95% CI, 0,71-1,44). Other postoperative complications were similar across groups except for thromboembolic events, which were more common among patients undergoing resection of > 10 LNs (OR, 1,72; 95% CI, 1,12-2,63).

CONCLUSIONS

These data suggest that evaluation of > 10 LNs, which allows for more accurate staging, appears to be safe in the elderly patients undergoing lobectomy for stage I NSCLC without compromising postoperative recovery.

Advances in local-regional treatment for patients with early-stage breast cancer: a review of the field

This review highlights advances in the field of the local-regional treatment for patients with early-stage breast cancer. Through the years, the surgical treatment for early-stage breast cancer has evolved into more conservative treatment, with breast-conserving measures replacing the mastectomy as the most common procedure performed to treat the primary tumor. Likewise, nodal staging has evolved so that the lymphatic mapping procedures have replaced axillary dissection, resulting in a less morbid procedure and better staging information. Advances in radiation treatment have resulted in increasingly tailored approaches to adding radiation treatment after breast-conserving surgery or mastectomy. These improvements in local-regional treatment have benefitted patients through increased breast conservation treatment, improved local control, increased survival, and improved quality of life.

Comparable Survival Between pN0 Breast Cancer Patients Undergoing Sentinel Node Biopsy and Extensive Axillary Dissection: A Report From the Korean Breast Cancer Society

Purpose

Recent studies showing survival benefit of extensive axillary lymph node dissection (ALND) in pN0 breast cancer have challenged the concept of sentinel node biopsy (SNB). In this study, the survival and recurrence after SNB alone and ALND in pN0 Korean breast cancer patients were investigated.

Patients and Methods

Using information from two large databases, including a Korean nationwide registry, we assessed survival relative to the extent of ALND in pN0 breast cancer patients. We also compared the survival of pN0 patients who underwent SNB alone with survival in those who underwent varying degrees of ALND.

Results

In an analysis of 1,607 pN0 patients from a single institution, less extensive ALND significantly increased the risks of breast cancer death and systemic recurrence but not of locoregional recurrence. These findings were validated by an analysis of nationwide registry data on 17,672 pN0 patients; patients with > 20 dissected lymph nodes had significantly better overall survival (OS) and breast cancer–specific survival (BCSS) than those with 10 to 20 or < 10 dissected lymph nodes. Patients who underwent SNB alone showed OS (hazard ratio [HR], 1.03; 9% CI, 0.08 to 1.56) and BCSS (HR, 1.15; 95% CI, 0.75 to 1.78) similar to those of patients who underwent extensive ALND (> 20 dissected lymph nodes), despite the small number of lymph nodes removed.

Conclusion

Extensive ALND is associated with better survival and less systemic recurrence than less extensive ALND in patients with pN0 breast cancer. However, SNB alone showed excellent survival results, similar to those of extensive ALND, supporting the long-term oncologic safety of SNB.

The number of negative pelvic lymph nodes removed does not affect the risk of biochemical failure after radical prostatectomy

OBJECTIVES

To assess patients who had radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for pT2-4 N0M0 prostate cancer, to determine if LN yield affects the risk of biochemical failure (BCF), as the extent of PLND at the time of RP has become increasingly uncertain with the decreasing trend in tumour stage.

PATIENTS AND METHODS

We reviewed the Columbia University Urologic Oncology Database for patients with pT2-4 N0M0 prostate cancer treated with RP from 1990 to 2005. Exclusion criteria included <12 months of follow-up, incomplete clinical and pathological data, and neoadjuvant androgen-deprivation therapy (ADT) or immediate adjuvant ADT or external beam radiotherapy. Unadjusted and adjusted models were used to determine the ability of clinical and pathological variables to predict BCF.

RESULTS

The final dataset included 964 patients, with a mean age of 60.5 years and median preoperative prostate-specific antigen (PSA) level of 6.2 ng/mL. The median (range) LN yield was 7 (1-42) and the median follow-up 59 (12-190) months. In the unadjusted and adjusted models, preoperative PSA, pathological Gleason score, pathological stage, surgical margin status and year of surgery were significant predictors of BCF. The LN group was not a significant predictor of BCF in both the unadjusted and adjusted model (P = 0.759 and 0.408, respectively). When patients were stratified into high- and low-risk groups, LN yield remained an insignificant predictor of BCF.

CONCLUSION

A higher LN yield at the time of RP does not increase the chance of cure for patients with pT2-4N0M0 prostate cancer. This lack of a survival advantage holds true for patients with high-risk disease.

Impact on regional recurrence and survival of axillary surgery in women with node-negative primary breast cancer

Background

This study examined whether axillary lymph node dissection (ALND) with removal of many normal lymph nodes resulted in a reduced rate of axillary recurrence and better survival, as reported in recent studies.

Methods

The follow-up analyses were based on 8657 patients with node-negative primary breast cancer treated solely by surgery. Median follow-up was 9 years.

Results

The number of lymph nodes removed correlated with a reduction in the rate of subsequent axillary recurrence (from 2·1 to 0·4 per cent; P = 0·037), local recurrence (from 7·4 to 3·8 per cent; P &lt; 0·001) distant metastases (from 15·0 to 10·3 per cent; P &lt; 0·001) and death as first event (from 7·5 to 5·5 per cent; P = 0·012).

Conclusion

When ALND is indicated, at least ten axillary lymph nodes should be retrieved. The role of ALND as primary treatment has decreased significantly during the past decade. The findings leave the concept of the sentinel node biopsy intact, as a highly specific procedure compared to ALND.

Prognostic significance of total number of nodes removed, negative nodes removed, and ratio of positive nodes to removed nodes in node positive breast carcinoma

BACKGROUND

This study was undertaken to investigate whether total number of nodes (pNtot) removed, negative nodes removed (pNneg), and ratio of positive nodes to total nodes removed (pNratio) are predictors of survival in node positive patients.

STUDY DESIGN

The records of 801 consecutive invasive breast cancer patients with T1-3 tumour and positive axillary lymph node who underwent modified radical mastectomy in our hospital were reviewed. pNtot and pNneg were categorized, and pNratio was computed. The influence of these probable prognostic factors on survival was investigated. Survival curves were generated by Kaplan-Meier method and log-rank test was used for comparisons. Multivariate analyses were performed by Cox proportional hazard model.

RESULTS

Median pNtot, and pNneg are 19 (range 5-54), and 13 (range 0-53), respectively. pNtot>15, and pNneg>15 were independently associated with reduced hazard ratios (HRs) of 0.62 (CI 0.48-0.79), and 0.68 (CI 0.52-0.89), respectively. The highest ratio (>0.25) of pNratio is associated with the highest hazard ratio for death (HR 3.8, CI 2.74-5.50) compared to the lowest ratio for death (<0.001).

CONCLUSIONS

pNtot, pNneg, and pNratio appear prognostic factors for survival in node positive breast cancers. Axillary lymph node dissection with more number of nodes removed (>15) or negative nodes (>15) are associated with increased survival.

Breast surgery: minimally invasive diagnosis and treatment

The increasingly large proportion of elderly women in the United States population carries a disproportionate burden of breast cancer. The advent of minimally invasive surgical techniques applicable to breast disease has brought new opportunities to diagnose and treat breast cancer in the older population. This article reviews issues important to the evolving field of breast cancer management in older women: cancer risk and screening considerations, diagnosis and biopsy approaches, and surgical treatment options based on current studies and recommendations.

Postoperative survival and the number of lymph nodes sampled during resection of node-negative non-small cell lung cancer

STUDY OBJECTIVE

To examine the association between postoperative survival and the number of lymph nodes (LNs) examined during surgery among persons who underwent definitive resection of node-negative (stage IA or stage IB) non-small cell lung cancer (NSCLC).

DESIGN AND SETTING

Information on postoperative survival and the number of LNs examined during surgery for stage I NSCLC treated with definitive surgical resection was retrieved from the population-based Surveillance, Epidemiology and End Results database for the period from 1990 to 2000. The association between survival and the number of LNs was examined using multivariate Cox proportional hazard models with adjustment for age, race, sex, type of surgery performed, and tumor size, grade, and histology.

RESULTS

A total of 16,800 patients were included in the study. The overall survival analysis for patients without radiation therapy (RT) demonstrated that in comparison to the reference group (one to four LNs), patients with five to eight LNs examined during surgery had a modest but statistically significant increase in survival, with a proportionate hazard ratio (HR) of 0.90 and a 95% confidence interval (CI) of 0.84 to 0.97. Similar results for 9 to 12 LNs and 13 to 16 LNs examined produced further increases in survival, with HRs of 0.86 (95% CI, 0.79 to 0.95) and 0.78 (95% CI, 0.68 to 0.90), respectively. There appeared to be no incremental improvement after evaluating > 16 LNs. The corresponding results for lung cancer-specific mortality and for patients receiving RT were not substantially different. The highest median survival (97 months) occurred in patients with 10 to 11 LNs evaluated.

CONCLUSIONS

Our results indicate that patient survival following resection for NSCLC is associated with the number of LNs evaluated during surgery. This is likely due to reduction of staging error: a decreased likelihood of missing positive LNs with an increasing number of LNs sampled. Although we are reluctant to recommend a definitive "optimal number," our data support the conclusion that an evaluation of nodal status should include somewhere from 11 to 16 LNs.

Australasian Experience and Trials in Sentinel Lymph Node Biopsy: The RACS SNAC Trial

PURPOSE

Sentinel lymph node biopsy (SLNB) has been rapidly adopted by surgical oncologists in the management of invasive breast cancer. This study reviews the Royal Australasian College of Surgeons (RACS) Sentinel Node versus Axillary Clearance (SNAC) trial and reports an interim analysis of the first 150 subjects. Other currently open multi-institutional randomized trials in SLNB are reviewed.

METHODS

The SNAC trial is a multicentre, centrally randomized, phase III clinical trial. Subjects are randomized to SLNB alone (with completion axillary clearance, AC, for sentinel node-positive patients) or AC plus SLNB, with stratification according to age (< 50 years, more than or equal to 50 years), primary tumour palpability (palpable vs impalpable), lymphatic mapping technique (blue dye plus scintigraphy vs blue dye alone) and centre.

RESULTS

The trial was launched in May 2001 in two centres. Randomization continues currently at the rate of approximately 30 subjects per month (total, 1,012 at the time of writing) from 32 participating centres in Australia and New Zealand. Data from the first 150 subjects have been analysed to assess: compliance with randomized treatment allocation; measures of test performance for SLNB (detection, removal, sensitivity, specificity and false-negative rates); measures of arm volume, function, symptoms and quality of life; and sample size estimates.

CONCLUSIONS

The SNAC trial is one of the fastest accruing clinical trials in Australasia. It is on track to determine whether differences in morbidity, with equivalent cancer-related outcomes, exist between SLNB and AC for women with early breast cancer.

Accurate Axillary Nodal Staging Can be Achieved after Neoadjuvant Therapy for Locally Advanced Breast Cancer

Lymph node status remains the most important prognostic indicator for breast cancer. Recent reports have established that the accuracy of assessing lymph node status is proportional to the number of nodes dissected. The accuracy of axillary staging following neoadjuvant chemotherapy has been cited as a technical concern due to limited node retrieval. The current study attempts to evaluate the ability to perform sentinel node biopsy (SNB) and formal axillary node dissection (AND) following neoadjuvant chemotherapy and to compare these results with non-neoadjuvant patients. One hundred sixteen consecutive patients undergoing SNB with simultaneous AND were retrospectively reviewed. Forty-two of these patients were treated with neoadjuvant chemotherapy prior to AND. Overall success rate in performing SNB in the neoadjuvant group was 95 per cent, and no false negatives have been noted to date. The overall SNB success rate in the non-neoadjuvant group was also 95 per cent with a false negative rate of 3 per cent. After AND in each group, a mean of 21 nodes were retrieved in the neoadjuvant group and 17.9 nodes in the non-neoadjuvant group ( P = 0.018). In the neoadjuvant group, there were 19 node positive patients (42%) and 21 patients (28%) in the non-neoadjuvant group ( P = 0.16). The mean number of positive nodes per patient was also similar between the two groups (2.9 in the neoadjuvant group vs 1.67 in the non-neoadjuvant group, P = 0.10). Following neoadjuvant therapy, accurate evaluation of the axilla is feasible. In this study, the mean number of nodes is significantly different in favor of the neoadjuvant group, but there is no significant difference in the number of node positive patients identified or in the mean number of positive nodes identified per patient. SNB is technically feasible with accuracy similar to that seen in patients with no history of neoadjuvant therapy. Neoadjuvant chemotherapy extends the use of breast-conserving therapy without sacrificing the ability to accurately stage the axilla either by use of standard axillary dissection or SNB.

Comparative morbidity of axillary lymph node dissection and the sentinel lymph node technique: implications for patients with breast cancer

OBJECTIVE

To assess our long-term complications from complete axillary lymph node dissection (AXLND) in patients with breast cancer.

SUMMARY BACKGROUND DATA

Complete AXLND as part of the surgical therapy for breast cancer has come under increased scrutiny due the use of the sentinel lymph node (SLN) biopsy technique to assess the status of the axillary nodes. As the enthusiasm for the SLN technique has increased, our impression has been that the perceived complication rate from AXLND has increased dramatically while the negative aspects of the SLN technique have been underemphasized.

METHODS

Female patients seen in routine follow-up over a 1-year period were eligible for our retrospective study of the long-term complications from AXLND if they were a minimum of 1 year out from all primary therapy; ie, surgery, radiation, and/or chemotherapy. All patients had previously undergone either a modified radical mastectomy (MRM) or a segmental mastectomy with axillary dissection and postoperative radiation (SegAx/XRT). All patients had a Level I-III dissection. Objective measurements, including upper and lower arm circumferences and body mass index (BMI), were obtained, and a subjective evaluation from the patients was conducted.

RESULTS

Ninety-four patients were eligible for our study; 44 had undergone MRM, and 50 had undergone SegAx/XRT. The average number of nodes removed was 25.6 (standard deviation, 8). Thirty-three percent of the patients had positive nodal disease, 95% of the patients had an upper arm circumference within 2 cm of the unaffected side, and 93.3% had a lower arm circumference within 2 cm of the unaffected side. Subjectively, 90.4% of the patients had either no or minimal arm swelling, and 96.8% of the patients had "good" or "excellent" overall arm function. The most common long-term symptom was numbness involving the upper, inner aspect of the affected arm (25.5%).

CONCLUSIONS

Our data indicate that a complete AXLND can be performed with minimal long-term morbidity. The lower the morbidity of AXLND, the less acceptable are the unique complications of the SLN technique.

Management of T1a Breast Cancer

Identification of early-stage breast cancers has increased over the past 2 decades primarily because of mammographic screening. The general guidelines to management of breast cancer may not apply to the smallest of these tumors, as their metastatic potential may be smaller than larger tumors. Tumors < 5 mm (T1a) carry an excellent prognosis, despite a variety of treatment approaches. However, some patients' cancer returns. There appear to be some histologic features that can predict a higher risk of axillary metastases, and therefore, a higher risk of distant metastases. Controversy exists over the extent of treatment, as to whether less than conventional treatment, such as mastectomy, axillary evaluation, and breast-conserving surgery and radiation, can be done. T1a lesions associated with extensive ductal carcinoma in situ and T1a lesions in young patients should be treated with caution if less than conventional breast treatment is to be considered. In older patients with good histologic features, axillary assessment may not be necessary. Very wide excision alone may be appropriate for some patients, but partial breast irradiation is under study and may provide a reasonable compromise. Systemic therapy for node-negative patients is not recommended. Recurrences within the breast occur later in early-stage breast cancers than with extensive-stage breast cancers, requiring annual imaging and evaluation for many years.

Novel agents for chemoprevention, screening methods, and sampling issues

An aggressive approach to breast cancer control based on preventing the disease must complement efforts at effective treatment. To date clinical trials testing new chemopreventative agents have not generally met with the kind of success expected. A wide range of new breast cancer chemopreventative agents are poised to be tested in clinical trials. We review these novel agents and approaches, including those for which clinical trials have been initiated and those that are promising in the preclinical arena. Further progress in this area requires not only new agents, but novel methods for screening for risk assessment, sampling and development of intermediate biomarkers. We review these novel potential surrogate endpoints, including new imaging-techniques, breast sampling approaches, and methods to assess biomarkers in breast epithelium. Factors that could contribute to a meaningful choice of the chemopreventive agents and the design of clinical trials are discussed.