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International Experts Publish Advice on Avoiding Unnecessary Lymph Node Removal for Breast Cancer

Human breast cancer cells implanted in an experimental animal with two different tracers (red and blue) to investigate the interaction of tumor cells.
Human breast cancer cells implanted in an experimental animal with two different tracers (red and blue) to investigate the interaction of tumor cells. Credit: Min Yu/National Cancer Institute/USC Norris Comprehensive Cancer Center
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Researchers from the Heidelberg University Hospital and the University of Lucerne as well as international scientists, patient representatives and European cancer societies have bundled scientific data and their expert knowledge on the surgical management of the lymph nodes in breast cancer. Recommendations are intended to avoid unnecessary removal of the lymph nodes and spare patients chronic lymphedema. Publication in Open Access Journal eClinicalMedicine by The Lancet.

Preoperative chemotherapy for breast cancer can significantly shrink the size of the tumor and metastatic lymph nodes before surgery. Breast surgery thus has the possibility of avoiding the complete evacuation of the lymph nodes in the armpit and reducing the risk of stressful side effects such as lymphedema of the arm. A multidisciplinary consortium of European cancer societies, international medical institutions with Heidelberg participation, and patient representatives addressed the challenges of clinical axillary lymph node management in early-stage breast cancer. Leading experts voted on all essential questions and formulated recommendations for clinical application.

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A total of five work packages were developed that follow the patient's path from diagnosis to local therapy in the axilla and deal with specific clinical scenarios. “The benefits of preoperative chemotherapy for breast cancer are not always fully realised. Published data describe that mastectomies and complete lymph node removal are still too common. A reduced surgical removal of the lymph nodes is only partially implemented even with good preoperative results," reports Professor Dr. Peter Dubsky, head of the breast center at the Hirslanden Klinik St. Anna in Lucerne, adjunct professor at the University of Lucerne and leader of the consortium. “If you remove fewer lymph nodes in the armpit, you reduce the risk of damaging the lymphatic drainage from the arm. In addition to existing guidelines, the international working group has therefore created a new medical concept with practical recommendations that is intended to prevent unnecessary surgical removal of the lymph nodes and can be quickly integrated into clinical use," says Dr. André Pfob from Heidelberg University Hospital (UKHD) and joint first author of the publication with Dr. Orit Kaidar person from Tel Aviv, Israel.

At a conference in September 2022 in Lucerne, it was possible to reach agreement in a previously controversial debate and to develop a far-reaching, practical guide. The participating subject matter experts voted on 72 statements and reached 52.8 percent consensus (agreement of 75 percent or more), 43.1 percent a majority (51 percent to 74 percent agreement), and 4.2 percent no decision. "According to the voting results, imaging and a standardized pathology of the lymph nodes should be a prerequisite for planning local and systemic therapy in breast cancer patients. In the majority of the scenarios discussed in the consortium, the removal of all axillary lymph nodes could be achieved by the targeted removal of a few lymph nodes, for example the sentinel lymph nodes, be replaced,” summarizes Dr. Put the results together. “The result of the lymph node operation has complex effects on the subsequent radiation and chemotherapy or hormone therapy. These should be adapted to the individual patient.” In order to check the success of the recommendations for the individual women, the risk of the cancer recurring and the side effects are recorded and evaluated.

The summary of the recommendations is called "The Lucerne Toolbox". The project was funded by the Hirslanden Klinik St. Anna in Lucerne. The first edition of the Lucerne Toolbox, which dealt with the issue of mastectomy, was published in 2021.

Reference: Kaidar-Person O, Pfob A, Gentilini OD, et al. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus. eClinicalMedicine. 2023;0(0). doi: 10.1016/j.eclinm.2023.102085

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