Trial Registration clinicaltrials.gov Identifier: NCT00003855 
 
 Axillary lymph node dissection (ALND) has been part of breast cancer surgery since the description of the radical mastectomy.1 ALND reliably identifies nodal metastases and maintains regional control,2,3 but the contribution of local therapy to breast cancer survival is controversial.4,5 The Early Breast Cancer Trialists' Collaborative Group synthesized findings from 78 randomized controlled trials, concluding that local control of breast cancer was associated with improved disease-specific survival.6 
 
 ALND, as a means for achieving local disease control, carries an indisputable and often unacceptable risk of complications such as seroma, infection, and lymphedema.7,8,9 Sentinel lymph node dissection (SLND) was therefore developed to accurately stage tumor-draining axillary nodes with less morbidity than ALND.10 SLND alone is the accepted management for patients whose sentinel lymph nodes (SLNs) are histologically free of tumor, while ALND remains the standard of care for patients whose SLNs contain metastases.11 
 
 Cancer biology is much better understood now than it was when ALND was introduced. Women were ineligible if they had 3 or more positive SLNs, matted nodes, or gross extranodal disease, or if they had received neoadjuvant hormonal therapy or chemotherapy. Patients were enrolled from 115 institutions, which included affiliates of the Cancer Trials Support Unit and the North Central Cancer Treatment Group. Removing the cancerous lymph nodes proved unnecessary because the women in the study had chemotherapy and radiation, which probably wiped out any disease in the nodes, the researchers said. Baseline Patient and Tumor Characteristics by Study Group Treatment Results There was an expected difference between ALND and SLND-alone treatment groups in total number of removed lymph nodes and total number of tumor-involved nodes; the median total number of nodes removed was 17 (interquartile range [IQR], 13-22) in the ALND group and 2 (IQR, 1-4) in the SLND-alone group.31 The median total number of nodes with histologically demonstrated tumor involvement (including SLNs) in the ALND group and SLND-alone group was equal (1 [IQR, 1-2] for both groups). In the ALND group, 97 of 355 patients (27.3%) had additional metastasis in lymph nodes removed by ALND, including 10% of patients with SLN micrometastasis who had macroscopically involved non-SLNs removed. Overall Survival At a median follow-up of 6.3 years (IQR, 5.2-7.7), there were 94 deaths (SLND-alone group, 42; ALND group, 52). These survival findings are consistent with those of the National Surgical Adjuvant Breast and Bowel Project B04 trial, in which women with clinically negative nodes were randomized to treatment by radical mastectomy, total mastectomy plus nodal irradiation, or total mastectomy with delayed ALND if nodal recurrence was observed.4 Initially and at each interim analysis for up to 25 years of follow-up, no statistically significant survival differences were observed between any of the groups. But over time, the two groups had no difference in survival: more than 90 percent survived at least five years. In those patients, ALND remains standard practice when SLND identifies a positive SLN. Previous Section Next Section Author Information Author Affiliations: John Wayne Cancer Institute at Saint John’s Health Center, Santa Monica, California (Dr Giuliano); M. D. Anderson Cancer Center, Houston, Texas (Dr Hunt); Mayo Clinic Rochester, Rochester, Minnesota (Dr Ballman); Dallas Surgical Group, Dallas, Texas (Dr Beitsch); Nashville Breast Center, Nashville, Tennessee (Dr Whitworth); Morton Plant Hospital, Clearwater, Florida (Dr Blumencranz); University of Texas Southwestern Medical Center, Dallas (Dr Leitch); McLaren Regional Medical Center, Michigan State University, Flint (Dr Saha); American College of Surgeons Oncology Group, Durham, North Carolina (Ms McCall); and Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Morrow). Dr. Armando E. Giuliano, the lead author of the study and the chief of surgical oncology at the John Wayne Cancer Institute at St. John’s Health Center in Santa Monica, Calif., said: “It shouldn’t come as a big surprise, but it will. Author Contributions: Dr Giuliano had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Wells Jr, MD (National Cancer Institute, Bethesda, Maryland).
– A new study has the potential to make breast cancer treatment easier for a sizable number of women, the New York Times reports. The study says the removal of lymph nodes from the armpit—a common, painful procedure that carries side effects of its own—isn't necessary for about 20% of patients in early stages of the disease. "The discovery turns standard medical practice on its head," declares the Times. “This is such a radical change in thought that it’s been hard for many people to get their heads around it,” says a doctor at Sloan-Kettering and an author of the study. The hospital has already changed its treatment procedures accordingly. The full study, published in the Journal of American Medicine, is here.