No Total Lymph Node Removal

Okay, get ready for some jargon:  lymphedema, axillary node dissection, sentinel node biopsy.  An appreciation of such terminology is necessary to understand the huge step forward in debrutalizing (I admit to wordsmithing here) the treatment of breast cancer for many women Rick and I talk about in this week's podcast, based on a study in JAMA.  So here goes:

Lymphedema is swelling that develops in the arms of women who've had most or all of their lymph nodes removed, or dissected, from their armpit, also  known as the axilla. So called axillary node dissection.  The swelling happens because lymph, one of the body's fluids that is normally transported through both lymphatic channels and lymph nodes, pools in the arm because the plumbing has been removed.  Lymphedema can be severe enough that movement can be quite difficult, and renders the limb susceptible to infection. 

Axillary node dissection was the standard of care for many women who had positive sentinel node biopsies, where a dye is injected in the area where a breast tumor is found and the lymph node draining that area was removed and found to contain cancer.  It was thought that a positive sentinel node meant the cancer had spread and it was prudent to remove all the nodes in the area. 

Now this study demonstrates that a positive sentinel node doesn't necessarily mean an axillary node dissection. Almost 1000 women with breast cancer and a positive sentinel lymph node biopsy were randomized to undergo axillary node dissection or not, with all women receiving other modalities deemed appropriate such as chemotherapy and radiation.  After five years of follow up, there was no significant difference in survival between the two groups.  Clearly, the take home message is that many women can be spared the potential development of lymphedema and the surgery to remove lymph nodes from the axilla.

Who can safely forgo axillary node dissection?  Women in this study had tumors less than 2 centimeters in size and no swollen or palpable lymph nodes in their armpit, which may have indicated the presence of cancer that had already spread and begun to grow.  As Ben Park, a breast cancer expert at Johns Hopkins, says, since most women in the US undergo fairly regular screening most of them found to have breast cancer will be in this category and can give axillary node dissection a miss.

What I love about this study is the clear effort to refine breast cancer treatment with quality of life issues very much in the fore.  I applaud the willingness of women with breast cancer and researchers to take this risk, and know that many women will benefit as a result.  Kudos!

Other topics this week include vaccination of infants whose moms were HIV positive, also in JAMA, a wireless monitoring device for people with congestive heart failure in the Lancet, and a gee whiz study Rick really loves in NEJM on in utero surgery for fetuses with one form of spina bifida, the most common birth defect.  Check out the way cool cartoons illustrating how such surgery is done.  Until next week, y'all live well.

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breast cancer lymph node removal
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