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If the node is involved, should the patient have an ALND at the time of definitive surgery or a second SLNB?
Routine application of this procedure along with completion ALND in carefully selected patients will provide an opportunity for both surgeon and pathologist to gain expertise and hence reduce the false negative rate to an acceptable minimum.
2) Surgically, it appears that more aggressive surgical techniques such as ALND increase the incidence rate of AWS.
Based on this practice-changing trial result, guidelines of the National Comprehensive Cancer Network no longer recommend completion ALND for patients who meet the ACOSOG ZOO 11 criteria.
3 years of follow-up showed that, compared with peers who had an ALND, the women who skipped this surgery did not have inferior 5-year rates of locoregional recurrence or overall survival (JAMA.
The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 randomized prospective clinical trial established SLN biopsy as a safe and effective method for staging the axilla, demonstrating that SLN biopsy is equivalent to ALND in patients with T1 to T2, cN0 invasive breast carcinoma (Table).
Pectoral skin flaps over breast were raised with diathermy while ALND was performed using sharp dissection.
A second surgery was also required in 2 other patients who had undergone mastectomy, both of whom underwent completion ALND after the SLN was found to be positive on final histology (the SLN had not been submitted for intraoperative analysis).
This is good news for some breast cancer patients, since the ALND procedure has been linked to numerous complications, including infection, abnormal sensation, and lymphedema (fluid collection and swelling under the armpit).
Knauer and colleagues in the Austrian Sentinel Node Study Group published data on a series of 125 patients with multicentric breast tumours who had SLNB followed by completion ALND in a large multi-institutional trial: the false-negative rate of SLNB was 4% [15].
Some authors suggest, however, that when axillary nodes are demonstrated to be positive on PET and PET-CT, the positive-predictive value is sufficiently high to obviate the need for sentinel lymph node biopsy in those patients who are ALND dissection candidates.