Additional Lymph Node Removal May Not Improve Survival in Breast Cancer Patients with Small Amounts of Cancer in Sentinel Node

Among women with early-stage breast cancer and small amounts of cancer (micrometastases) in the sentinel lymph node, removal of additional lymph nodes (completion axillary lymph node dissection) does not appear to improve overall survival. The results of this study were presented at the 2010 annual meeting of the American Society of Clinical Oncology.

For women with early breast cancer, determining whether the cancer has spread to the axillary (under the arm) lymph nodes is an important part of cancer staging. Evaluation of the axillary nodes may involve either an axillary lymph node dissection (ALND), in which many lymph nodes are surgically removed and evaluated or a less extensive procedure known as a sentinel lymph node biopsy.

The sentinel nodes are the first lymph nodes to which cancer is likely to spread. If the sentinel nodes are free of cancer, no further lymph node evaluation is performed. If the sentinel nodes contain cancer, however, most women then undergo ALND to remove additional nodes. This additional lymph node surgery has been shown to help control cancer locally, but the effect on survival has been controversial. Establishing the benefits of completion ALND is important because it can cause significant side effects such as pain, discomfort, and swelling (lymphedema).

To evaluate the effects of ALND in breast cancer patients with micrometastases in the sentinel node, researchers conducted a Phase III study among 991 women. Half the women underwent completion ALND, and half did not.

Five-year overall survival was 91.9% among women who underwent ALND and 92.5% among women who did not undergo ALND.Disease-free survival was 82.2% among women who underwent ALND and 83.8% among women who did not undergo ALND.The rate of local/regional recurrence (recurrence in or near the breast) was 4.3% among women who underwent ALND and 3.4% among women who did not undergo ALND.

In a prepared statement, the lead author of the study explained, “Our findings suggest that there may not be a benefit to removing more lymph nodes than the sentinel node only, and that women can avoid the risk of additional side effects that come with more extensive lymph node removal. Axillary lymph node dissection will still be needed in some cases, but these findings show it may be necessary for far fewer women.”

Reference: Giuliano AE, McCall LM, Beitsch PD et al. ACOSOG Z0011: A randomized trial of axillary node dissection in women with clinical T1-2 N0 M0 breast cancer who have a positive sentinel node. Presented at the 2010 annual meeting of the American Society of Clinical Oncology. June 4-8, 2010. Chicago, IL. Abstract CRA 506.

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Study Evaluates Impact of Lymph Node Removal in Early-stage Breast Cancer

Early-stage breast cancer patients without evidence of cancer in their sentinel lymph node who did not have additional lymph nodes removed report fewer side effects to the arm and breast than patients who undergo additional lymph node removal. These findings were recently published in the Journal of Clinical Oncology.[1]

For women with early breast cancer, determining whether the cancer has spread to the axillary (under the arm) lymph nodes is an important part of cancer staging. Evaluation of the axillary nodes may involve either an axillary lymph node dissection (ALND), in which many lymph nodes are surgically removed and evaluated, or a less extensive procedure known as a sentinel lymph node biopsy.

The sentinel nodes are the first lymph nodes to which cancer is likely to spread. A sentinel lymph node biopsy involves the removal of only these nodes. If cancer is found in the sentinel nodes, most women undergo additional lymph node removal. If the sentinel nodes are free of cancer, however, women may not require any additional lymph node removal. Avoidance of extensive lymph node removal reduces the risk of side effects such as lymphedema (swelling).

Several studies have been conducted to determine the efficacy of sentinel lymph node biopsy versus more extensive lymph node surgery. In a recent study presented at the 2010 annual meeting of the American Society of Clinical Oncology, researchers reported that among women with early breast cancer and no evidence of cancer in the sentinel lymph nodes, sentinel lymph node biopsy alone is as effective as more extensive lymph node surgery.[2] In addition to efficacy data, researchers are interested in quantifying how these procedures impact a patient’s quality of life both immediately following surgery as well as months and years later.

In the current substudy of a Phase III trial, researchers evaluated patient-reported data to determine the impact of sentinel node biopsy alone versus sentinel node biopsy plus ALND. The 749 patients in this study had operable, early-stage breast cancer with no clinical evidence of cancer in the lymph nodes. In addition, the patients in this substudy did not have evidence of cancer in the sentinel lymph node. Three-hundred fifty-six had been randomized to undergo sentinel lymph node biopsy plus ALND, and 391 underwent sentinel lymph node biopsy alone. Patients completed a questionnaire before surgery, immediately after surgery, and every six months for approximately three years to assess quality of life, breast symptoms, as well as arm function and symptoms.

During the postoperative period, sentinel node biopsy plus ALND was associated with an elevated likelihood of arm and/or breast symptoms, worse quality of life, and more limitations in work and social activity compared with sentinel node biopsy alone.In as little as a year after the procedure, a relatively small percentage of patients in either group reported moderate or severe side effects.?

The researchers concluded that among patients with no evidence of cancer in their sentinel nodes, sentinel node biopsy alone was associated with fewer arm and breast side effects and better quality of life. Over time, however, some of the differences between the groups diminished.?

Reference:

[1] Land SR, Kopec JA, Julian TB, et al. Patient-reported outcomes in sentinel-node negative adjuvant breast cancer patients receiving sentinel-node biopsy or axillary dissection: National Surgical Adjuvant Breast and Bowel Project Phase III Protocol B-32. Journal of Clinical Oncology. [early online publication]. August 2, 2010.

[2] Krag DN, Anderson SJ, Julian TB et al. Primary outcome results of NSABP B-32, a randomized phase III clinical trial to compare sentinel node resection (SNR) to conventional axillary dissection (AD) in clinically node-negative breast cancer patients. Presented at the 2010 annual meeting of the American Society of Clinical Oncology. June 4-8, 2010. Chicago, IL. Abstract LBA 505.

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Bladder Cancer Could Reoccur Despite Bladder Removal

Main Category: Urology / Nephrology
Also Included In: Cancer / Oncology
Article Date: 10 May 2013 - 0:00 PDT Current ratings for:
Bladder Cancer Could Reoccur Despite Bladder Removal

Patients with advanced bladder cancers that are surgically removed might need additional therapy to prevent recurrence in certain situations, a new UT Southwestern Medical Center study suggests.

The five-year international study led by researchers at UT Southwestern validates the use of a marker panel to predict which patients are more likely to have a recurrence of cancer after bladder removal, thereby identifying those patients as good candidates for follow-up chemotherapy.

The findings, published in the most recent edition of European Urology, are important because additional molecular information could help bladder-cancer patients and their physicians decide whether administering further toxic chemotherapy is worth the risk, said Dr. Yair Lotan, professor of urology at UT Southwestern and the study's primary investigator and first author.

Bladder cancer is the fourth most common cancer diagnosed in men, according to the American Cancer Society. The ACS estimates that more than 72,500 cases will be diagnosed in the United States this year, and that more than 15,200 people will die from the disease in 2013.

Patients with muscle-invasive bladder cancer typically are treated by removing all or part of the bladder (a cystectomy procedure) but are infrequently given additional chemotherapy, despite an overall relapse rate of one in every three cases.

Using five commercially available markers and the tissues of patients who had their bladders removed, UT Southwestern researchers in the departments of urology and pathology and the Harold C. Simmons Cancer Center monitored a group of 216 patients to track if their cancers recurred.

When controlled for pathologic factors such as stage, grade, lymphovascular invasion, lymph node status, surgical margin status, and whether the patients had already received chemotherapy, the number of altered biomarkers were found to be an independent predictor of recurrence and cancer-specific mortality, the researchers found.

"It is well known that bladder cancer tumors have certain molecular alterations, but the problem is that there has been little data regarding which patients should get additional therapy, especially if there is no radiologic or pathologic evidence that the cancer has spread beyond the bladder," Dr. Lotan said. "This situation exists despite the fact that approximately 35 percent of patients treated by cystectomy develop metastatic disease and many of these individuals die of their disease."

The investigation's goal was to establish whether molecular markers that are involved in cell cycle regulation and proliferation could help identify those patients at higher risk for recurrence or metastasis following bladder-cancer surgery, Dr. Lotan said.

The next steps will be to try to incorporate the molecular marker panel into clinical practice. Dr. Lotan is also a member of the Simmons Cancer Center.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our urology / nephrology section for the latest news on this subject. Other UT Southwestern researchers involved in the study are Dr. Arthur Sagalowsky, professor of urology and surgery; Dr. Ganesh Raj, associate professor of urology; Dr. Payal Kapur, associate professor of pathology; Dr. Vitaly Margulis, assistant professor of urology; Dr. Yull Arriaga, assistant professor of internal medicine; Dr. Aditya Bagrodia, urology resident; and medical student Varun Rachakonda. Medical oncologists and urologists from NewYork-Presbyterian/Weill Cornell Medical Center; the University Vita-Salute San Raffaele in Milan, Italy; and the University of Heidelberg’s Mannheim Medical Center in Germany also contributed to the research.
Please visit the Harold C. Simmons Cancer Center to learn more about clinical services for oncology at UT Southwestern, including highly individualized treatments for cancer at the region’s only National Cancer Institute-designated center.
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Hormone Replacement Therapy after Ovary Removal May be Safe for BRCA1/BRCA2 Carriers

For women with BRCA1 or BRCA2 gene mutations, use of hormone replacement therapy after preventive removal of the ovaries and fallopian tubes does not appear to increase the risk of breast cancer. These results were presented at the 2011 annual meeting of the American Society of Clinical Oncology.???

Inherited mutations in two genes—BRCA1 and BRCA2—have been found to greatly increase the lifetime risk of developing breast and ovarian cancer. Mutations in these genes can be passed down through either the mother’s or the father’s side of the family.??

Options to manage this increased cancer risk include regular cancer screening, chemoprevention (use of medications to reduce risk), or preventive surgery (surgery to remove the breasts and/or ovaries before cancer is diagnosed).?

When performed by the time a woman is in her mid-30s or early 40s, preventive removal of the ovaries can substantially reduce the risk of both ovarian cancer and breast cancer. This reduction in cancer risk, however, comes at the cost of an early menopause and symptoms such as hot flashes, sleep disturbances, and vaginal dryness.??

Hormone replacement therapy (HRT) can effectively manage these symptoms, but it’s been uncertain whether this is safe for women with BRCA1/BRCA2 mutations. Studies in women without these mutations have indicated the combined (estrogen plus progestin) hormone therapy increases the risk of breast cancer.?

To evaluate the risk of breast cancer among BRCA1/BRCA2 carriers who have undergone preventive removal of their ovaries and fallopian tubes, researchers collected information from 795 women with a BRCA1 mutation and 504 women with a BRCA2 mutation. ?

????After ovary removal, breast cancer was diagnosed in 14% of the women who took HRT and 12% of the women who did not take HRT. This difference between groups was not statistically significant, suggesting that it could have occurred by chance alone. By comparison, risk of breast cancer was 22% among women who did not have their ovaries removed and did not take HRT.??

These results suggest that short-term use of HRT to manage menopausal symptoms may be an option for BRCA1/BRCA2 carriers who have had their ovaries removed. HRT did not significantly increase the risk of breast cancer in this population.????

Reference: Domchek SM, Friebl T, Neuhausen SL et al. Is hormone replacement therapy (HRT) following risk-reducing salpingo-oophorectomy (RRSO) in BRCA1 (B1) and BRCA2 (B2)-mutation carriers associated with an increased risk of breast cancer? Paper presented at: 2011 Annual Meeting of the American Society of Clinical Oncology; June 3-7, 2011; Chicago, IL. Abstract 1501.?

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