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Discussion

INVITED DISCUSSANT: DR AMY WAER (Tucson, AZ): I justhave a couple of questions for you.

1. Who performed the axillary ultrasonographic procedures at

your institution?2. How many of the patients undergoing axillary ultrasonography

had a fine needle aspiration (FNA), and how many axillarylymph nodes were biopsied?

3. How many total lymph nodes were positive in the 1 patientwith more than 3 lymph nodes?

DR CLIVE S GRANT: Thank you, Dr Waer, for your questions.First, at Mayo Rochester, the practice is that radiologists do themammography, the mammographic and ultrasound-directed nee-dle biopsies, and they also do the ultrasound. The frequency of

FNA is 29%. I think that gets to be a bit arbitrary, however,because 1 radiologist might say, “Okay, the criteria are these, andI’m a little suspicious,” so if they are much more suspicious, they

will use ultrasound-directed FNA. And there are a fair numberof those patients whose FNA turns out to be negative. So I thinkthey have set criteria, cortical thickness, etc, but it may vary from

1 radiologist to another. And the number of lymph nodes in that1 patient who had 3 or more was 3 lymph nodes.

DR NORA HANSEN (Chicago, IL): I congratulate the authors onan excellent presentation. I am concerned that your approach will

subject more patients to a potentially unnecessary axillary lymphnode dissection (ALND). In your study, for the patients whohad a positive FNA based on an axillary ultrasound, how many

patients had more than 2 positive nodes on an axillary dissection?As you know, in the American College of Surgeons OncologyGroup (ACOSOG) Z0011 study, only patients with more than2 positive sentinel nodes were required to undergo an axillary

16 Ibrahim-Zada et al Discussion J Am Coll Surg

lymph node dissection. By proceeding directly to ALND for a posi-tive FNA axillary node on axillary ultrasound, you may be subject-

ing more patients to an ALND than needed. At our institution, wehave been trying to avoid axillary ultrasound unless we are clinicallysuspicious of positive axillary nodes on physical examination or if

patients are undergoing a mastectomy. We no longer do frozensection on sentinel nodes for clinically negative lymph nodes andawait the final pathology to decide whether or not the patient

requires further axillary surgery. Your approach may be subjectingmore patients to unnecessary ALND.

DR CLIVE S GRANT: I certainly understand what you are saying.And there are many institutions that used to do axillary ultrasoundto facilitate avoiding the sentinel node biopsy when the axillary

ultrasound, needle biopsy was positive. And then they wouldskip the sentinel node step and do an axillary dissection. Your pointis, are we, in fact, committing patients to have an axillary dissection

when, in fact, they might be eligible and well treated with radiationto the breast that spills over into the axilla. We have taken the tackthat axillary ultrasound has become part of our clinical preoperative

examination. We are balancing those patients who may have posi-tive nodes that we sort of overtreat with axillary dissection,compared with patients about whom, if we do only examination,

we would be very nervous that we might, in fact, undertreatsome who might be premenopausal, estrogen receptor negative,and have bigger metastases that we didn’t detect with just palpa-tion. And we feel more comfortable using the ultrasound. So it’s

a balance between those two.

DR JOHN RUSSELL (Albuquerque, NM): In the presentation, yousaid that these were breast conservation surgery-eligible patients, butit wasn’t clear whether you included anymastectomy patients in your

study. If you did, and those patients had positive sentinel nodes, howdid you subsequently manage the axilla in those patients?

DR CLIVE S GRANT: That was, obviously, the retrospective part.And the intent was, if you are facing patients who are going to

consider breast conservation vs mastectomy, if they were breastconserving surgery-eligible based on size and extent, even if theyhad a mastectomy, which was a bit arbitrary in some of the criteria,

we included them because we wanted to use a wider populationthan if we narrowed it to maybe just those breast-conserving

therapy patients. So we did include mastectomy patients, but theirassessment would have allowed them potentially to be breastconserving surgery-possibility patients. And back then, we were

doing completion axillary dissection for anything that was positive.It’s from this point forward that we are really talking aboutavoiding axillary dissection for potentially sentinel node-positive

patients, but only in the breast-conserving surgery group rightnow. There are no prospective data, randomized data that allowyou to avoid an axillary dissection if you have a positive sentinelnode and you are already planning a mastectomy. That can be

an awkward discussion at times.

DR DAVID WINCHESTER (Evanston, IL): I just wanted to echosome of Dr Hansen’s comments. If you look at the reports thatwere in some of your opening slides, the SEER data, the National

Cancer Data Base data, the Z0011, they all point to a 1% recur-rence rate and no difference in survival. As you look at thesereports, there’s no difference in survival for patients who do and

do not have axillary dissections. We are moving away from doingmore aggressive lymph node surgery. How do you incorporatethis algorithm into practice if we are seeing that there is no differ-

ence in survival or regional recurrence with axillary dissection, espe-cially in an era of increased use of adjuvant therapy?

DR CLIVE S GRANT: What we have done is used axillary ultra-sound as one of our preoperative clinically relevant decision-

makers about doing a completion axillary dissection at this point.There is a study proposed, which I think is very interesting, whichwould look at patients who meet the Z0011 criteria, that is, tumorsize 2 cm or smaller, who by axillary ultrasound, have negative

nodes. Those patients would be randomized to doing sentinelnode vs doing no axillary investigation, that is, no axillary sentinelnode, because if it doesn’t change their outcome, if the recurrence

is low, and, in fact, if the adjuvant therapy is not being changed bythe nodes being positive or a number of nodes being positive, theimportance of axillary nodes is diminished. Right now, we do use

ultrasound to help us decide about who needs a completion axillarydissection for breast conservation patients.