Two-step axillary operation increases risk of arm morbidity in breast cancer patients

doi:10.1016/j.breast.2006.01.006

The Breast

Volume 15, Issue 5, October 2006, Pages 620-628

https://doi.org/10.1016/j.breast.2006.01.006 Get rights and content

Summary

An investigation of the impact of axillary surgery on arm morbidity in patients who underwent sentinel lymph node biopsy (SLNB), axillary clearance in a one-step procedure, and axillary clearance in a two-step procedure, respectively, was performed. Over a period of 2 years 438 patients with invasive breast carcinoma or carcinoma in situ underwent SLNB at our clinic. Of these 393 were interviewed on symptoms of swelling, numbness, pain, reduced strength, reduced mobility and fatigue more than 1 year postoperatively. Using a standardised symptom score system postoperative morbidity was registered and differences between the patients were compared in a logistic regression analysis. Of the 393 patients who received the questionnaire 370 responded (94%). The mean follow-up was 23.5 months (range 12–37). SLNB resulted in significantly lower arm morbidity than axillary clearance. Doing stepwise logistic regression of the data the two-step axillary clearance represented the most important influential factor of the development of arm morbidity symptoms of swelling and numbness.

Introduction

Axillary lymph node dissection of level I & II (ALND) used to be the standard in the surgical treatment of patients with invasive breast cancer.1, 2 Apart from being a valid staging method the aim of this procedure was to improve local disease control and survival.³ ALND is, however, associated with considerable morbidity, such as lymphoedema, sensory disturbances, pain, and reduced arm-mobility.1, 4, 5

The observed frequency of lymphoedema and other morbidity symptoms following ALND varies from 2% to 70% with definitions of symptoms and study design.1, 2, 3, 4, 6, 7, 8

Sentinel node status has proved to be a precise indicator of the presence of metastases in the axillary lymph nodes.9, 10, 11 The sentinel lymph node procedure (SLNB) is at the same time associated with less invasive procedures and earlier discharge, which in itself has been shown to have positive psychosocial effects.¹² The risk of developing arm lymphoedema and other morbidity symptoms after SLNB has shown to be significantly lower than after a complete ALND.10, 13, 14, 15, 16, 17

The examination of the sentinel nodes excised during operation is often performed by means of frozen sectioning. This is an effective method for most patients, unfortunately a part of the sentinel nodes excised do not reveal malignancy and only when additional immunohistochemistry are performed the node presents with cancer cells. These patients have to undergo a second procedure with additional ALND. The impact on the development of morbidity of this two-step procedure has not yet been fully investigated.

The aim of this study was to investigate and evaluate whether there is a significant difference in arm morbidity between patients who have received a complete ALND in the first (and only) operation and the patients who undergo the two-step procedure. In addition a comparison of the experienced morbidity between patients who have received the sentinel node biopsy only and patients who have had a complete axillary dissection was made.

Section snippets

Subjects and methods

Over a 2-year period from November 1, 2001 through October 31, 2003, 438 patients underwent SLNB at our clinic. Out of these 393 were eligible to participate in the investigation (14 were dead, 11 had systemic recurrence of the disease and 20 were not eligible out of other reasons such as morbidity due to other disease or treatment of such). Out of the 370 patients who responded 362 had invasive breast carcinoma and 8 carcinoma in situ.

Results

Of the 393 who received the questionnaire 370 responded (94%). Postoperative morbidity between group B ( $n = 100$ ) and group C ( $n = 67$ ) were compared. Furthermore postoperative morbidity between patient group A ( $n = 203$ ) and patient groups B and C were compared to evaluate the difference in morbidity between patients undergoing SLNB only and patients undergoing a complete ALND. The mean follow-up was 23 months (range 12–36) for group A, 24 months (range 12–37) for group B, and 24 months (range 12–37)

Discussion

The data on arm morbidity was obtained in a retrospectively performed interview by means of a standardised questionnaire. This choice of design is susceptible to various types of bias all of which we sought to minimise in different ways. Since preoperative arm measurements were not obtained lymphoedema (and other arm morbidity symptoms) may have existed in patients preoperatively. The incidence in the general population is very rare, and since the number of patients in our study was high ( $n = 393$

Conclusions

This study has shown that for the patients who only receive a SLNB there is a minimal risk of developing arm morbidity symptoms and several different factors could have an influence on this risk. If the patients receive an ALND, however, there is a much higher risk of developing arm morbidity symptoms regardless of what other risk factors are present, and furthermore this risk is increased if the ALND is undertaken in a two-step operation rather than one. This finding emphasises the importance

Acknowledgement

M.Sc. Kare Engkilde, National Allergy Research Centre (Gentofte Hospital University of Copenhagen, Denmark) is gratefully acknowledged for statistical advise.

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The aim of this study is (1) to investigate the prevalence rate of arm lymphedema, pain, impaired shoulder range of motion, strength and shoulder function one year after a sentinel lymph node biopsy (SLNB) for breast cancer and (2) to determine predictive factors for these complications.
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One year after surgery 8% of sentinel node-negative breast cancer patients had developed arm lymphedema. Fifty percent of patients had pain, 30% had an impaired shoulder range of motion, 8% had a decreased handgrip strength and 49% had an impaired shoulder function. Pain, shoulder range of motion, strength and shoulder dysfunctions changed significantly over one year (p < 0.001). Higher Body Mass Index is a predictive variable for shoulder dysfunctions one year post-SLNB.
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Citation Excerpt :
This will make a two-stage procedure less precise and emphasize the importance of a high detection rate of metastases on frozen sections. The literature on the subject is limited and results are diverging.5–8 By using data from the Danish National Patient Register (NPR) and the Danish Breast Cancer Cooperative Group (DBCG) database we investigated the number of lymph nodes identified in a one-stage versus a two-stage axillary procedure in a large population of breast cancer patients.
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ORIGINAL ARTICLETwo-step axillary operation increases risk of arm morbidity in breast cancer patients

Summary

Introduction

Section snippets

Subjects and methods

Results

Discussion

Conclusions

Acknowledgement

Eur J Cancer

Breast

Breast

Eur J Surg Oncol

Eur J Surg Oncol

Am J Surg

Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis

Cancer

Treatment morbidity associated with the management of the axilla in breast-conserving surgery

Acta Oncol

Late treatment-related morbidity in breast cancer patients randomized to postmastectomy radiotherapy and systemic treatment versus systemic treatment alone

Acta Oncol

ORIGINAL ARTICLE
Two-step axillary operation increases risk of arm morbidity in breast cancer patients