Axillary lymph node dissection for patients with invasive breast cancer at Charlotte Maxeke and Chris Hani Baragwanath Academic Hospitals

Abstract

Background: The extent of axillary surgery correlates with its morbidity and sentinel lymph node biopsy (SLNB) has become the standard of care in  clinically node-negative (cN0) patients.This study aims to evaluate the application of SLNB and axillary lymph node dissection (ALND) and the associated  risk factors for node-negative ALND in our units.

Methods: We included female patients with primary breast cancer who underwent axillary surgery in the  breast units at Charlotte Maxeke Johannesburg Academic Hospital and Chris Hani Baragwanath Academic Hospital from March 2013 to March 2015.  Univariate and multivariable logistic regression models were used to determine factors associated with pathological node-negative (pN0) ALND.

Results:  505 patients were included and 344 patients were staged clinically node-positive (68.1%), 161 (31.9%) were assessed as clinically node-negative and  deemed eligible for SLNB. Sensitivity of clinical nodal staging was 85.9% with a positive predictive value of 76.5%. The majority of patients (313, 61.9%)  underwent primary surgery while 192 (38.1%) underwent surgery after NACT. We performed 118 SLNBs and 387 ALNDs of which 97 were pathologically  node-negative. Risk was not increased after NACT (OR 1.06, p = 0.790). We identified a significant risk in patients with triple-negative and HER-2 enriched  subtypes compared to hormone receptor-positive patients (OR 3.05, 95% CI: 1.6-5.7, p = 0.001 and OR 2.25, 95% CI: 1.1-4.8, p = 0.035).

Conclusions: The  prevalence of pN0 ALND was 25.06%. In our cohort a significantly higher risk was found in hormone receptor-negative tumours. Preoperative nodal  assessment needs to be optimised and include pathological confirmation. SLNB needs to be extended to patients after NACT despite resource-  constraints.