Less Axillary Surgery for Early Breast Cancer

A groundbreaking retrospective study from Ankara Oncology Hospital has brought new clarity to the ongoing debate about the necessity of axillary lymph node dissection (ALND) in early-stage breast cancer patients. Focusing on those undergoing breast-conserving surgery with positive sentinel lymph node biopsy, the research evaluates the real-world applicability of the ACOSOG Z0011 trial criteria, which advocate omitting ALND under certain conditions. The findings underscore a paradigm shift, suggesting that sparing patients from extensive axillary surgery may not compromise survival or recurrence outcomes.

Early-stage breast cancer treatment has evolved drastically over the past decades, with increasing efforts to minimize surgical morbidity without sacrificing oncological safety. The ACOSOG Z0011 trial marked a milestone by demonstrating that in select patients with one or two positive sentinel lymph nodes, complete ALND might be unnecessary when combined with breast-conserving surgery, adjuvant systemic therapy, and radiation. However, its implementation in everyday clinical practice worldwide has been met with some hesitancy, largely due to concerns about long-term outcomes and recurrence risks.

This recent study retrospectively analyzed data from 1,218 patients treated between January 2018 and 2024, selecting 193 individuals who met the Z0011 criteria. Among them, 126 underwent ALND, while 67 did not, creating two cohorts for direct comparison. The study carefully excluded patients who had mastectomies, those with metastatic disease, cases where more than two positive nodes were detected, and patients receiving neoadjuvant chemotherapy, thereby ensuring the sample closely mirrored the original Z0011 conditions.

One of the key points of evaluation was overall survival (OS), examined over a five-year follow-up period, averaging more than 69 months. Remarkably, the group without ALND demonstrated a 5-year OS of 98.5%, slightly higher than the 95.2% observed in those who received ALND. While statistical confidence intervals overlapped, these results powerfully suggest that the omission of ALND does not translate into worse survival. This challenges traditional beliefs that more extensive surgery necessarily leads to better disease control.

Disease-free survival (DFS) further reinforced these conclusions. The study reported a 97.0% DFS rate in the group that followed the Z0011 approach without ALND versus 94.4% in the ALND group. This consistency indicates that avoiding ALND does not increase the risk of disease recurrence. Importantly, throughout the follow-up, no loco-regional recurrences were detected in the axillary lymph nodes or breast tissue, a critical reassurance for clinicians considering less aggressive surgical interventions.

The implications for patient quality of life cannot be overstated. ALND is known to carry risks such as lymphedema, nerve injury, and shoulder dysfunction, which significantly impact survivors’ daily activities. By validating the safety of omitting ALND in properly selected patients, the study supports a surgical de-escalation approach that minimizes morbidity while maintaining oncologic efficacy. This aligns with contemporary movements in oncology focused on precision medicine and tailored treatment strategies.

Moreover, the study’s real-world data bridge a crucial gap between controlled clinical trials and everyday clinical practice. While the original Z0011 trial provided robust evidence, its applicability was sometimes questioned due to variations in patient populations, healthcare settings, and adjuvant therapy protocols globally. Demonstrating consistent outcomes in a different geographic and healthcare context strengthens the generalizability of the findings.

Technically, the study utilized stringent inclusion criteria, ensuring that all participants had early-stage tumors classified as T1 or T2, clinically node-negative status preoperatively, and positive sentinel lymph node biopsy limited to one or two nodes. These parameters are essential to replicate the original trial conditions and provide clarity on the safety of omitting ALND exclusively in this subset of patients. Such precision underscores the importance of careful patient selection in surgical decision-making.

The integration of adjuvant systemic therapies, including chemotherapy and endocrine therapy, as well as comprehensive radiotherapy to the breast, likely played a pivotal role in controlling microscopic residual disease following sentinel node biopsy alone. This multimodal approach reaffirms the necessity of combining systemic and local therapies to optimize outcomes while allowing for surgical downscaling.

From a surgical oncology perspective, the research provokes a critical reassessment of long-standing dogma. It questions the rationale of performing complete axillary dissections in all node-positive cases and advocates for a more nuanced approach tailored to individual risk profiles. By doing so, it opens avenues for more conservative surgeries that do not compromise patient safety or disease control.

The study’s retrospective nature is a limitation, naturally introducing potential biases and confounding factors. Nevertheless, the large sample size and extended follow-up period add considerable strength to the conclusions. Further prospective studies and longer-term surveillance will be crucial to monitor for any late recurrences or unexpected adverse outcomes.

Clinicians worldwide can take encouragement from these findings, which bolster confidence in adopting the ACOSOG Z0011 criteria in routine clinical care. This transition promises not only to reduce surgical complications but also to streamline treatment pathways and allocate healthcare resources more efficiently without compromising outcomes.

Looking ahead, the advancement of molecular profiling and imaging may further refine patient selection for ALND omission. As personalized oncology continues to evolve, treatment de-escalation grounded in robust evidence will become increasingly important to balance oncological control with quality of life considerations.

In summary, this landmark study corroborates the safe de-escalation of axillary surgery in early breast cancer patients who meet the ACOSOG Z0011 criteria. By demonstrating no significant differences in overall survival, disease-free survival, or loco-regional recurrence between those undergoing ALND and those spared from the procedure, it firmly supports changing clinical practice paradigms in favor of less aggressive surgery.

Patients diagnosed with early-stage breast cancer can gain hope from these insights, knowing that less invasive surgical options are increasingly validated by rigorous research. For surgeons and oncologists, the findings offer a compelling reason to rethink standard protocols and embrace individualized care pathways that prioritize both efficacy and patient well-being.

This study sets a precedent for integrating landmark trial data into routine practice, highlighting the vital role of translational research in refining cancer treatment. Ultimately, it underscores the potential to improve survivor outcomes not just by curing disease but by enhancing quality of life through thoughtful, evidence-based care decisions.

Subject of Research: De-escalation of axillary surgery in early-stage breast cancer patients undergoing breast-conserving surgery with positive sentinel lymph node biopsy, evaluating outcomes of ALND omission based on ACOSOG Z0011 criteria.

Article Title: De-escalation of axillary surgery in early breast cancer: translating ACOSOG Z0011 study into clinical practice for breast-conserving surgery patients with positive sentinel lymph node biopsy.

Article References:
Sağdıç, M.F., Dinçer, B. & Özaslan, C. De-escalation of axillary surgery in early breast cancer: translating ACOSOG Z0011 study into clinical practice for breast-conserving surgery patients with positive sentinel lymph node biopsy. BMC Cancer 25, 706 (2025). https://doi.org/10.1186/s12885-025-14105-z

Image Credits: Scienmag.com

DOI: https://doi.org/10.1186/s12885-025-14105-z

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