Article of the Month -- April 1997

THE ROLE OF AXILLARY DISSECTION IN MAMMOGRAPHICALLY DETECTED CARCINOMA

Steven M. Pandelidis, MD,* Kristi L. Peters, MS,† Mbaga S. Walusimbi, MD,* Roger L. Casady, MD,* Shelli V. Laux, RRA, CTR,‡ Sally H. Cavanaugh, PhD,† and Thomas L. Bauer, MD, FACS*

RESULTS
From January 1980 to May 1995, 4,543 needle localization biopsies were performed at York Hospital or its affiliated outpatient surgery facility. The mean age of patients undergoing the procedure was 62.3 years. Seven hundred three carcinomas were diagnosed by needle-localization biopsy of lesions detected on screening mammography. Four hundred eighty-one tumors were infiltrating ductal carcinoma; 184 were DCIS, and 38 were infiltrating lobular carcinoma. Most carcinomas (84.2 percent) were detected in patients 50 years of age or older. Of the 517 invasive tumors, only 31 were larger than 2 cm (Table I).

Medical records from the early years of the study showed that women with DCIS were often treated by axillary dissection in addition to wide excision and radiation or mastectomy. Of the 184 patients treated for DCIS, 109 underwent axillary lymph node dissection; no metastatic nodes were detected in these patients.

Of the 517 patients with invasive tumors, 476 had an axillary lymph node dissection. Most patients (65 percent) underwent total mastectomy and axillary lymph node dissection rather than wide excision, axillary lymph node dissection, and radiation therapy. All 21 patients with microscopic invasive tumors underwent axillary lymph node dissection; no metastatic nodes were detected in their axillary specimens. The association between size of the tumor and status of the axillary nodes is summarized in Table II.

Twenty-nine patients with well-differentiated T1b tumors (tumor [T], >0.5 to £1 cm) underwent axillary lymph node dissection. Metastatic axillary lymph nodes were found in only one of these patients, whose tumor was ER and PR negative.

Among the patients with well-differentiated T1b tumors, only 4 patients tested negative for ER and PR. The nodes were negative for metastases in the 16 patients with T1b, ER-, PR-positive well-differentiated tumors. The ER and PR status was not known in the remaining 9 patients with well-differentiated T1b tumors. No axillary recurrences have occurred among the 75 patients with DCIS and the 35 patients with infiltrating ductal carcinoma who did not undergo axillary lymph node dissection.

The anatomic distribution of the invasive carcinomas along with information about the status of the axillary lymph nodes is summarized in Table III. As expected, most carcinomas (57 percent) were in the upper outer quadrant. Lower inner quadrant lesions were the least likely to metastasize to axillary lymph nodes, but they still metastasized nearly 10 percent (3 of 32 patients) of the time. The difference in the rates of axillary lymph node metastases on the basis of tumor location was not statistically significant (chi-square test, p=.793).

Patients with microscopic invasive tumors did not receive adjuvant chemotherapy or tamoxifen citrate (Nolvadex, Zeneca Pharmaceuticals, Wilmington, Del). Usually, patients with positive nodes received adjuvant therapy. Some patients with negative axillary lymph nodes received chemotherapy or tamoxifen (Table IV).

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Journal of the American College of Surgeons

April 1997, Volume 184, Number 4

BACKGROUND, STUDY DESIGN, AND RESULTS

CONCLUSIONS

METHODS

DISCUSSION

REFERENCES

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