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LETTER TO THE EDITOR
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 66-69

Micrometastases in axillary nodes: Out of the reckoning?


Department of Surgical Oncology, Breast Services, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India

Date of Web Publication3-May-2016

Correspondence Address:
Vani Parmar
Department of Surgical Oncology, Breast Services, Tata Memorial Centre, Parel, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-330X.181642

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How to cite this article:
Singh A, Parmar V. Micrometastases in axillary nodes: Out of the reckoning?. South Asian J Cancer 2016;5:66-9

How to cite this URL:
Singh A, Parmar V. Micrometastases in axillary nodes: Out of the reckoning?. South Asian J Cancer [serial online] 2016 [cited 2019 Aug 21];5:66-9. Available from: http://journal.sajc.org/text.asp?2016/5/2/66/181642

Dear Editor,

The treatment of breast cancer has seen a paradigm shift towards minimally invasive surgery with large randomized trials [1],[2] conclusively establishing sentinel lymph node biopsy (SLNB) in node negative patients as the standard of care. SLNB has in turn led to an increase in the detection of micrometastasis and isolated tumor cells as a result of more thorough and exhaustive evaluation of a smaller number of nodes. The study looking at immunohistochemistry (IHC) detection of micrometastases in node-negative patients by Choudhury et al. [3] brings to the fore yet another debate in the surgical management of breast cancer.

Of 178 patients who underwent a mastectomy at the author's institute, 32 (17.9%) were negative for axillary lymph node metastasis. On further IHC evaluation of these 32 cases, 6 (18.75%), and 4 (13%) cases were positive for axillary lymph node metastases by cytokeratin (CK) and epithelial membrane antigen (EMA) staining respectively. A statistically significant correlation is also established between the sentinel nodes identified by the surgeon and the detection of these micrometastases by CK and EMA IHC. All the patients detected with micrometastases received adjuvant chemotherapy and barring two who were lost to follow-up, the rest were disease-free at a median follow-up of 56 months. The numbers are very small, but it definitely opens up the Pandora's Box again.

Clinical significance of detection and treatment of micrometastatic disease in the axilla has been widely studied and debated with controversial results. In the NSABP B-32 trial [4] despite a statistically significant detriment in overall survival (OS) of 1.2% in the group with occult metastases, the investigators ruled out the routine use of IHC for the detection of micrometastatic disease.

Similarly in the MIRROR study, [5],[6] the group with micrometastases had worse disease-free survival (DFS) outcomes and axillary recurrence rates, but these reached statistical significance only in the group that did not receive adjuvant therapy. In one of the landmarks trials on nodal micrometastases, ACOSOG Z0010 occult metastases were detected in 349 (11%) of 3326 cases. [7] However, no significant association was noted between IHC detected occult metastases and DFS or OS at a median follow-up of 6.3 years and the 5 year OS and DFS rates were comparable between IHC positive and negative sentinel node groups. Another important trial, the International Breast Cancer Study Group 23-01 randomized women with micrometastatic disease in the sentinel node to SLNB alone versus completion axillary lymph node dissection. [8] Even though the trial closed early due to low accrual and failure to attain the projected event rates, both groups at a median follow-up of 5 years had similar axillary recurrence, DFS and OS rates indicating no clinical significance of micrometastases on outcome. Furthermore, in a meta-analysis [9] by de Boer et al. despite a poorer DFS and OS associated with micrometastases and isolated tumor cells, this significance was lost on multivariate analysis.

The data on micrometastatic disease must also be viewed in the light of trials such as ACOSOG Z11, wherein macrometastatic positive nodes left behind in the axilla did not impact survival in breast cancer patients [10] and AMAROS [11] where axillary clearance and axillary radiotherapy after a positive SLNB yielded comparable axillary control rates. Even as lymph node examination becomes more and more thorough with the advent of a host of investigations like imprint cytology, IHC staining, and even reverse transcription polymerase chain reaction, we are yet to fully define the actual prognostic implication of micrometastases. National Comprehensive Cancer Network guidelines [12] do not recommend the routine use of IHC for detection of axillary nodal disease and till we are confident of the way ahead, it might be best to let sleeping dogs lie!!!

 
  References Top

1.
Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Constantino JP, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: Overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol 2010;11:927-33.  Back to cited text no. 1
    
2.
Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med 2003;349:546-53.  Back to cited text no. 2
    
3.
Chaudhury M, Agrawal S, Pujani M, Thomas S, Pujani M. Immunohistochemical detection of axillary lymph node micrometastases in node negative breast cancer patients using cytokeratin and epithelial membrane antigen. South Asian J Cancer 2015;4:28-31.  Back to cited text no. 3
    
4.
Weaver DL, Ashikaga T, Krag DN, Skelly JM, Anderson SJ, Harlow SP, et al. Effect of occult metastases on survival in node-negative breast cancer. N Engl J Med 2011;364:412-21.  Back to cited text no. 4
    
5.
de Boer M, van Deurzen CH, van Dijck JA, Borm GF, van Diest PJ, Adang EM, et al. Micrometastases or isolated tumor cells and the outcome of breast cancer. N Engl J Med 2009;361:653-63.  Back to cited text no. 5
    
6.
Pepels MJ, de Boer M, Bult P, van Dijck JA, van Deurzen CH, Menke-Pluymers MB, et al. Regional recurrence in breast cancer patients with sentinel node micrometastases and isolated tumor cells. Ann Surg 2012;255:116-21.  Back to cited text no. 6
    
7.
Giuliano AE, Hawes D, Ballman KV, Whitworth PW, Blumencranz PW, Reintgen DS, et al. Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage invasive breast cancer. JAMA 2011;306:385-93.  Back to cited text no. 7
    
8.
Galimberti V, Cole BF, Zurrida S, Viale G, Luini A, Veronesi P, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): A phase 3 randomised controlled trial. Lancet Oncol 2013;14:297-305.  Back to cited text no. 8
    
9.
de Boer M, van Dijck JA, Bult P, Borm GF, Tjan-Heijnen VC. Breast cancer prognosis and occult lymph node metastases, isolated tumor cells, and micrometastases. J Natl Cancer Inst 2010;102:410-25.  Back to cited text no. 9
    
10.
Giuliano AE, McCall L, Beitsch P, Whitworth PW, Blumencranz P, Leitch AM, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: The American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg 2010;252:426-32.  Back to cited text no. 10
    
11.
Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJ, Mansel RE, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): A randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 2014;15:1303-10.  Back to cited text no. 11
    
12.
National Comprehensive Cancer Network (NCCN). NCCN Clinical practice Guidelines in Oncology Breast Cancer. Version 1.2014; 2014. Available from: http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf [Last accessed on 2014 Apr 11].  Back to cited text no. 12
    




 

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