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Original Investigation
September 12, 2017

Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node MetastasisThe ACOSOG Z0011 (Alliance) Randomized Clinical Trial

Author Affiliations
  • 1Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
  • 2Alliance Statistics and Data Center, Weill Cornell Medicine/New York–Presbyterian Hospital, New York, New York
  • 3Alliance Statistics and Data Center, Duke University, Durham, North Carolina
  • 4Dallas Surgical Group, Dallas, Texas
  • 5Clinical Research Unit/TRIO-US Network, Jonsson Comprehensive Cancer Center, University of California, Los Angeles
  • 6Ashikari Breast Center, Dobbs Ferry, New York
  • 7Department of Surgery, University of North Carolina, Chapel Hill
  • 8Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 9Nashville Breast Center, Nashville, Tenessee
  • 10Morton Plant Hospital, Clearwater, Florida
  • 11Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
  • 12MacLaren Regional Medical Center, Michigan State University, Flint
  • 13Department of Breast Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston
  • 14Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
JAMA. 2017;318(10):918-926. doi:10.1001/jama.2017.11470
Key Points

Question  Is there any diminution in 10-year overall survival for women with cT1-2N0 breast cancer and metastases to 1 or 2 sentinel lymph nodes undergoing breast-conserving surgery, whole-breast irradiation, and adjuvant systemic therapy treated with sentinel node dissection alone compared with that of patients treated with axillary dissection?

Findings  In this randomized clinical trial including 856 women, after median follow-up of 9.3 years, overall survival for patients treated with sentinel lymph node dissection alone was not inferior to those treated with completion axillary lymph node dissection (86.3% vs 83.6%, respectively; noninferiority hazard ratio margin of 1.3).

Meaning  These findings do not support the use of axillary lymph node dissection when metastases are found with sentinel lymph node sampling in women with cT1-2M0 breast cancer.

Abstract

Importance  The results of the American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial were first reported in 2005 with a median follow-up of 6.3 years. Longer follow-up was necessary because the majority of the patients had estrogen receptor–positive tumors that may recur later in the disease course (the ACOSOG is now part of the Alliance for Clinical Trials in Oncology).

Objective  To determine whether the 10-year overall survival of patients with sentinel lymph node metastases treated with breast-conserving therapy and sentinel lymph node dissection (SLND) alone without axillary lymph node dissection (ALND) is noninferior to that of women treated with axillary dissection.

Design, Setting, and Participants  The ACOSOG Z0011 phase 3 randomized clinical trial enrolled patients from May 1999 to December 2004 at 115 sites (both academic and community medical centers). The last date of follow-up was September 29, 2015, in the ACOSOG Z0011 (Alliance) trial. Eligible patients were women with clinical T1 or T2 invasive breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases.

Interventions  All patients had planned lumpectomy, planned tangential whole-breast irradiation, and adjuvant systemic therapy. Third-field radiation was prohibited.

Main Outcomes and Measures  The primary outcome was overall survival with a noninferiority hazard ratio (HR) margin of 1.3. The secondary outcome was disease-free survival.

Results  Among 891 women who were randomized (median age, 55 years), 856 (96%) completed the trial (446 in the SLND alone group and 445 in the ALND group). At a median follow-up of 9.3 years (interquartile range, 6.93-10.34 years), the 10-year overall survival was 86.3% in the SLND alone group and 83.6% in the ALND group (HR, 0.85 [1-sided 95% CI, 0-1.16]; noninferiority P = .02). The 10-year disease-free survival was 80.2% in the SLND alone group and 78.2% in the ALND group (HR, 0.85 [95% CI, 0.62-1.17]; P = .32). Between year 5 and year 10, 1 regional recurrence was seen in the SLND alone group vs none in the ALND group. Ten-year regional recurrence did not differ significantly between the 2 groups.

Conclusions and Relevance  Among women with T1 or T2 invasive primary breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases, 10-year overall survival for patients treated with sentinel lymph node dissection alone was noninferior to overall survival for those treated with axillary lymph node dissection. These findings do not support routine use of axillary lymph node dissection in this patient population based on 10-year outcomes.

Trial Registration  clinicaltrials.gov Identifier: NCT00003855

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