Breast cancer patients treated without axillary surgery - Clinical implications and biologic analysis

Objective To evaluate the impact of breast carcinoma (T1-2NO) surgery witho ut axillary dissection on axillary and distant relapses, and to evaluate th e usefulness of a panel of pathobiologic parameters determined from the pri mary tumor, independent of axillary nodal status, in planning adjuvant trea tment. Methods In a prospective nonrandomized pilot study, 401 breast cancer patie nts who underwent breast surgery without axillary dissection were accrued f rom January 1986 to June 1994. At surgery, all patients were clinically nod e-negative and lacked evidence of distant metastases after clinical or radi ologic examination. A precise 4-month clinical and radiologic follow-up was performed to detect axillary or distant metastases. Patients with clinical evidence of axillary nodal relapse were considered for surgery as salvage treatment. Biologic characteristics of primary carcinomas were investigated by immunohistochemistry, and four pathologic and biologic parameters (size , grading, laminin receptor, and c-erbB-2 receptor) were analyzed to determ ine a prognostic score. Results The 5-year follow-up of these patients revealed a low rate of nodal relapses (6.7%), particularly for T1a and T1b patients (2% and 1.7%, respe ctively), whereas T1c and T2 patients showed a 10% and 18% relapse rate, re spectively. Surgery was a safe and feasible salvage treatment without techn ical problems in all 19 cases of progressive disease at the axillary level. The low rate of distant metastases in T1a and T1b groups (<6%) increased t o 15% in T1c and 34% in T2 patients. Analyzing the primary tumor with respe ct to the panel of pathologic and biologic parameters was predictive of met astatic spread and therefore can replace nodal status information for plann ing adjuvant treatment. Conclusions Middle-term follow-up shows that the rate of axillary relapse i n this patient population is lower than expected, suggesting that only a mi nimal number of microembolic nodal metastases become clinically evident. Av oidance of axillary dissection has a negligible effect on the outcome of T1 patients, particularly in T1a and T1b tumors with no palpable nodes, becau se the rate of axillary node relapse is very low for both, in T1 breast car cinoma, postsurgical therapy should be considered on the basis of biologic characteristics rather than nodal involvement. The authors' prognostic scor e based on the primary tumor identified patients who required postsurgical treatment, providing a practical alternative to axillary status for decidin g on adjuvant treatment. Conversely, in the T2 group, the high rate of salv age surgery for axillary relapses, which is expected in tumors larger than 2.5 cm or 3.0 cm, represents a limit for avoiding axillary dissection. Preo perative evaluation of axillary nodes for modification of surgical dissecti on in this subgroup would be more useful more than in T1 breast cancer beca use of the high risk. Complete dissection is feasible without technical pro blems if precise follow-up detects progressive axillary disease.