HOLLY MASON, MD
Section Chief, Breast Surgery, Baystate Health

In a continued effort to provide specialized breast surgical care to the Pioneer Valley, the Baystate Health breast surgery team has incorporated a procedure called Target Axillary Dissection into our standard of care.  To provide background, the standard surgical treatment for women with breast cancer that has spread to their axillary lymph nodes has been the axillary node dissection.  This involves the removal of 10-20 lymph nodes from the armpit area, to see if the cancer has spread beyond the breast itself. The problem with an axillary node dissection is the long-term risks.  The procedure often causes long-term swelling of the arm, which is called lymphedema, as well as numbness and loss of range of motion.  The risk of lymphedema for such an axillary node dissection can be 15-20% or greater. 

Breast cancer for patients with larger tumors or positive nodes is treated using medical therapy, whether chemotherapy or anti-hormone/endocrine therapy, which can be given before surgery.  This is called neoadjuvant therapy.  Recent research has shown that in women who present with a positive lymph node, neoadjuvant therapy can be given in hopes of destroying all the cancer in this lymph node, converting it from “positive” to “negative”. This process of conversion is known as “down-staging”.  Thus, if at the time of surgery, the previously biopsied and positive node is removed with multiple other surrounding sentinel nodes. The sentinel nodes are the first lymph nodes in the path of fluid drainage from the breast. The lymph nodes are examined by the pathologist during the surgery, and if no cancer remains in those nodes at the time and no additional cancer is found in the sentinel nodes, surgical treatment of the lymph nodes is complete and axillary node dissection can be avoided.

The ability to safely avoid an axillary node dissection in many patients allows for lower risk of lymphedema and subsequently a higher quality of life long-term but still adequately treats the cancer.  We have come a long way from the days when all patients with breast cancer had all axillary lymph nodes removed with very high rates of debilitating lymphedema.  The theme of de-escalation of care, which has been discussed previously in this newsletter, continues as we try to individualize treatment for each patient, optimizing survival from breast cancer while minimizing the impact of our treatments.