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New ASCO Guidelines Say Not All Women Need Axillary Lymph Node Surgery

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When early-stage breast cancer is removed, the lymph node closest to the cancer – called the sentinel node – often is removed and sent to a pathologist for evaluation. Removing just this one node is called sentinel node biopsy or sentinel node dissection.

If cancer cells are in the sentinel node, it means the cancer has spread beyond the breast. Until recently, doctors thought that more treatment was needed to reduce the risk of the cancer coming back (recurrence), including removing other underarm lymph nodes (called axillary node dissection/surgery).

But research has shown that women diagnosed with early-stage breast cancer with one or two positive sentinel nodes who have lumpectomy and radiation do just as well as women who have axillary node surgery.

So the American Society of Clinical Oncology (ASCO) has put out new guidelines on sentinel lymph node biopsy for people diagnosed with early-stage breast cancer.

The new guidelines were published online on March 24, 2014 by the Journal of Clinical Oncology. Read the abstract of “Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update.”

ASCO is a national organization of oncologists and other cancer care providers. ASCO guidelines give doctors recommendations for treatments and testing that are supported by much credible research and experience.

The older ASCO guidelines on sentinel node biopsy published in 2005 recommended axillary node surgery for anyone diagnosed with early-stage breast cancer with one or more positive sentinel lymph nodes.

The new guidelines say:

  • Women with negative sentinel node biopsies shouldn’t have axillary node surgery.
  • Women with one or two positive sentinel nodes who plan to have lumpectomy plus radiation also don’t need axillary node surgery.
  • Women who have one or more positive sentinel nodes and plan to have mastectomy with no radiation should be offered axillary node surgery.

Women who have only sentinel node biopsy and not axillary node surgery have a much lower risk of lymphedema. Lymphedema is the build-up of lymph fluid in the soft tissues of the body, most often the arm and hand in people who’ve had breast cancer surgery, but also the breast, underarm, chest, trunk, and back. Besides swelling, lymphedema also can cause arm weakness and numbness, as well as shoulder pain.

The new guidelines also identify specific situations when sentinel lymph node biopsy should and shouldn’t be offered.

Sentinel node biopsy SHOULD be offered under these circumstances:

  • breast cancer in which there is more than one tumor, all of which have formed separately from one another (doctors call these multicentric tumors); these types of breast cancers are rare
  • DCIS treated with mastectomy
  • women who have previously had breast cancer surgery or axillary lymph node surgery
  • women who have been treated before surgery with chemotherapy or another systemic treatment (neoadjuvant treatment)

Sentinel node biopsy SHOULD NOT be offered under these circumstances:

  • the cancer is large or locally advanced (the cancer has spread extensively in the breast or to the nearby lymph nodes)
  • the cancer is inflammatory breast cancer
  • DCIS treated with lumpectomy
  • a woman is pregnant

If you’ve been diagnosed with early-stage breast cancer, sentinel node biopsy may be done as part of your surgery. If cancer cells are found in the sentinel node, you and your doctor will consider all the details of your situation, including your age, the characteristics of the cancer, and your preferences when deciding on a treatment plan.

You can learn more by visiting the Lymph Node Removal pages.

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