Annals of Oncology 11: 1079-1080.. 2000
Editorial
Breast cancer and the axilla: Not entirely out of the labyrinth
The elegant and timely study of Greco et al. [1] from the is probably yes if we agree with the authors' statement
Istituto Nazionale Tumori in Milan makes a provocative that "modern treatment protocols assign adjuvant checontribution to the general debate on the management motherapy to most node negative patients, as well as
of axillary lymph nodes in breast cancer. Using a very those with involved nodes" and if we adopt the guidepragmatic approach the authors have shown that in lines of the sixth International Conference on Adjuvant
clinically node-negative breast cancer patients the final Therapy of Primary Breast Cancer [3].
decision on adjuvant treatment can be taken regardless
In other words, if we all agree that the percentage of
of the information on the histological status of the very small tumours is constantly increasing, that these
tumours are almost all clinically node negative, and that
lymph nodes.
The authors undertook a retrospective examination almost all clinically node negative tumours are found to
of 260 cases of early breast cancer patients after breast be also histologically negative at the axillary dissection,
surgery with axillary dissection and radiotherapy and then we should focus our attention more and more on
then assigned them to different types of adjuvant therapy the biological prognostic factors of the tumour itself and
according to a given set of guidelines, with and without abandon every kind of surgery of the axilla since sysconsideration of pathological node status. The patients temic medical treatments will be extensively prescribed
were also arbitrarily divided into two age groups (<65 anyway. So can we conclude on the basis of this arguyears and 65 years) since the chosen medical treatment ment that adjuvant chemotherapy will allow clinically
node negative breast cancer patients to avoid every sort
protocols differ between younger and elderly patients.
By comparing the two sets of adjuvant treatment of unnecessary surgery of the axilla?
The long process of dismantling the Halstedian dogindications - the first drawn up without considering the
pathological node status and the second redefined after mas conducted by surgeons over the last 20 years has
introducing this information - there was no change in already protected hundred of thousands of women from
the 44 cases over 65 years. The change in indication in the destructive mutilation of mastectomy, so rightly
the remaining 216 cases ranged from 6% to 18.5% as defined by B. Fisher in the columns of this journal as a
a consequence of a re-assignment to chemotherapy for biologically obsolete operation. Greco et al. have further
patients previously assigned to the low and intermediate contributed to this process of constantly re-evaluating
traditional and routine approaches in breast cancer
risk groups.
The first author of this paper has already shown a few treatment and as such their conclusions deserve strong
years ago that axillary dissection can be avoided in consideration, if not endorsement.
Others are also re-evaluating routine approaches in
selected cases [2] but now he goes further and together
with his medical oncologist colleagues he suggests that breast cancer treatment. For example, radiotherapy after
patient's age, pathological tumour size, grading and hor- conservative surgery is also being re-analysed in its scope
monal receptor status may be sufficient to determine the and outcome, especially in older women where the overall
risk of recurrence of clinically node negative breast balance of benefits and risks might turn out to be rather
cancer patients. They conclude that "axillary dissection unfavourable [4]. A multicentric randomised trial comis probably not necessary // guidelines recommending paring the classical Veronesi quadrantectomy followed
wide application of systemic adjuvant chemotherapy are by radiotherapy versus the same surgical procedure
without radiotherapy in early breast cancer patients of
applied".
At first sight the benefit of this approach for the more than 55 years of age is ready to start accrual in the
patient is clear: not only will she avoid a complete coming weeks with the aim of identifying another subset
axillary dissection of the three levels of lymph nodes, of patients who could avoid some unnecessary treatbut also other alternative surgical procedures such as ment.
The decision to delete all sort of axillary lymph node
the sentinel node biopsy, the random biopsy of nodes,
the so called lymph node sampling or the removal of the surgery and pathological analysis by taking for granted
first level. Some patients will also avoid radiotherapy to that most of the patients will have to receive anyway
the axilla - which is proposed by some groups when the some adjuvant medical treatment may help bring us out
axilla is not cleared - and its sequelae since this treat- of the labyrinth. However, the definition of clinically nodenegative patient will need a further and more in-depth
ment option is not considered by the chosen guidelines.
Can we consider the Milan group's suggestion as an description, taking into account the great variability in
acceptable way out of the labyrinth of endless discussions the clinical experience of the examiners and the possible
and debates on the role of axillary dissection? The answer additional use of imaging techniques. Research in this
1080
field should also be encouraged with new support, and
not only on PET, as suggested by this paper, but also on
other techniques, such as a new generation of ultrasound
probes and NMR.
Some sort of lymph node pathological examination
might also need to be proposed again for certain
anatomical situations, e.g., the internal mammary chain
involvement, and/or for specific subset of patients, i.e.,
clinically node negative subjects with very negative biological prognostic factors.
Thus, a lot remains to be understood and more efforts
have to be made to further refine our capability to tailor
our therapeutic programmes on the characteristics of
each individual patient.
No doubt one of the next difficulties we will confront
in the labyrinth of breast cancer treatment is finding
what can allow clinically node negative breast cancer
patients to avoid unnecessary chemotherapy.
A. Costa
Head of Surgery
The Maugeri Foundation, Pavia
Director, European School of Oncology
Milan, Italy
References
1. Greco M, Gennaro M,Valagussa Pet al. Impact of nodal status on
indication for adjuvant treatment in clinically node negative breast
cancer. Ann Oncol 2000; 11: 1137-40 (this issue).
2 Greco M, Agresti R, Raselli R et al. Axillary dissection can be
avoided in selected breast cancer patients: Analysis of 401 cases.
Anticancer Res 1996; 16: 3913-8.
3. Goldhirsch A, Glick JK., Gelber RD, Senn HJ. Meeting highlights:
International consensus panel on the treatment of primary breast
cancer. J Natl Cancer Inst 1998; 90: 1601-8.
4. Early Breast Cancer Tnalists' Collaborative group. Favourable and
unfavourable effects on long term survival of radiotherapy for early
breast cancer: An overview of the randomised trials. Lancet 20 ;
355:1757-70.