Axillary radiotherapy appears to be a safe and less morbid alternative to axillary node dissection in clinically noted negative breast-cancer patients who have a positive sentinel lymph node, Dr. Michele A. Gadd said at a breast-cancer symposium sponsored by the Cancer Therapy and Research Center. Dr. Gadd is a surgical oncologist at the Dana-Farber Cancer Institute and Harford Medical School, Boston.

      Her study showed that axillary radiation plus systemic therapy provided adequate local control in such patients--and with a substantial reduction in morbidity, compared to completion axillary dissection. The impetus for this study was the recognition that axillary dissection beyond the sentinel lymph node biopsy may no longer be essential in an era when the number of positive lymph nodes is not a major consideration in decisions regarding systemic therapy, as reflected by the latest practice guidelines. The average breast tumor size has decreased, with a simultaneous reduction in nodal involvement.

      Dissection of the axillary node basin entails significant morbidity. Studies have routinely documented a reduction in standardized quality of life measures, along with an average 20% incidence of lymphedema, 35% chance of arm numbness, 10% chance of chronic pain, and 10% incidence of reduced arm motion.

      Dr. Gadd reported on 560 patients with clinically node negative stage T1-2 invasive breast cancer who underwent sentinel lymph node biopsy, which proved positive in 21%. A subgroup of 77 sentinel node biopsy-positive patients underwent whole breast and nodal radiotherapy. In 34 months, there has been just one axillary recurrence, for a 1.3% rate. It occurred 23 months after initial breast cancer diagnosis. There were three distant recurrences.

      Patients returned to work and physical activities earlier following radiotherapy, compared with axillary dissection. No drainage tube was required and less pain was associated with radiotherapy than with axillary clearance. Arm circumference measurements showed no evidence of lymphedema at two years. The vast majority of patients indicated that there daily activities were not affected at all by shoulder stiffness, arm numbness, pain, or arm swelling.

      Doctor Walker adds: More studies need to be carried out to confirm this data. It should be noted that these patients required total breast (and axillary) radiation, eliminating the possibility of having 5-day partial breast irradiation. Since, in our hands, the morbidities listed above occur at a rate significantly less than those reported in their study, most of our patients would thus far prefer to have a completion axillary dissection and partial breast radiation.