gms | German Medical Science

Background: In the last century, the amount of surgery has gradually decreased. Breast conserving therapy is widely used but sentinel technique and axillary lymph node dissection (ALND) – at least after a positive sentinel lymph node - is still common.

Methods: We have assembled convincing arguments against ALND (and therefore also against sentinel technique) based on the probability that positive lymph nodes are unlikely to metastasize and that removing them is redundant. The hypothesis is based on evidence from clinical trials and observations from molecular biology.

Results: Clinical trials that suggest that leaving positive lymph nodes in the axilla may not be harmful: - Studies of pre operative adjuvant therapy show similar survival for patients with negative lymph nodes which have been reversed by chemotherapy and those that remain positive. - Randomised control trials with 25-30 years follow up indicate that clearing the internal mammary or axillary lymph nodes does not impact long term survival. - Lymph node irradiation is no more effective than removal. If treating lymph nodes is effective, then presumably more would be better. Irradiating lymph nodes in levels I-III, however, results in similar survival times as lymph node dissection in levels I-II only. - Internal mammary node irradiation does not improve survival. - Clearing more levels of lymph nodes by ALND does not affect survival. - Tumour site (medial or lateral) affects frequency of lymph node metastases but not survival. - Survival after sentinel technique is not better than after conventional ALND, even positive lymph nodes outside level I-II are now detected by sentinel technique and removed. - Population based studies from different countries show that disease stage is a more important predictor of mortality than differences in treatments. - ALND severely affects patient’s quality of life.

Conclusion: The hypothesis is that distant metastases develop over time from disseminated tumour cells that originate from the primary and not from the lymph nodes. Therefore we suggest that ALND and sentinel lymph node biopsies are redundant and that lymph nodes should only be removed if they are locally disruptive. Such a paradigm shift is not easy to implement, even though it would benefit breast cancer patients greatly.