Breast surgeon Melissa Camp’s primary focus is the complete removal of cancer—but she also wants to prevent lymphedema. To achieve these goals, she finds a less-is-more surgical approach can be preferable for managing the axilla in breast cancer.
In the past, surgeons routinely performed an axillary dissection for breast cancer, removing the majority of lymph nodes for both local control of disease and staging purposes. A full axillary dissection, however, increases the risk of developing lymphedema, arm pain or impaired arm mobility. These days, Camp says, “we’re doing fewer and fewer axillary dissections for breast cancer thanks to the improvements in systemic therapy and radiation.”
Even for patients with lymph node involvement at diagnosis, Camp says systemic therapy can be provided before surgery. If patients have a good response, they may not need a full axillary dissection.
Camp consults with the medical oncologists at The Johns Hopkins Hospital to decide whether patients should begin with systemic treatment. When patients are good candidates, the medical oncologists will proceed with chemotherapy plus HER2-targeted therapy when indicated.
“There are more effective systemic treatments available today than we’ve ever had in the past, especially for HER2-positive cancers,” says Camp.
When systemic therapy has a good response, Camp operates to remove any residual cancer in the breast and perform a sentinel lymph node biopsy, sampling the first few lymph nodes in the pathway that drain the breast. Johns Hopkins Hospital pathologists then examine the nodes intraoperatively.
If no cancer cells are found in the sentinel lymph nodes, no other lymph nodes are removed. If the sentinel lymph nodes still contain evidence of cancer cells, Camp will perform an axillary dissection.
“For patients who have had an excellent response to systemic treatment prior to surgery,” she says, “I don’t think there’s a real benefit to removing more lymph nodes if the sentinel lymph nodes have turned from positive to negative. If there’s still residual disease present, then the patient should have additional nodes removed.”
After surgery, the final pathology results help Camp decide if the patient will need additional treatment with radiation. If so, she consults with radiation oncologists to create a plan. In select patients, radiation to the axilla can be as effective for local control as axillary dissection but with less risk of lymphedema.
“Management of the axilla in breast cancer is moving away from a surgery-focused approach of axillary dissection in all patients with lymph node involvement and toward a multidisciplinary approach involving a combination of systemic therapy, surgery and radiation,” she says. “In appropriately selected patients, this approach does not compromise local control and results in a lower risk of lymphedema.”
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