Information on breast cancer metastases due to minor armpit surgery

In breast cancer patients with metastases in the armpit, all lymph nodes in the armpit are often removed after treatment with chemotherapy

In women with breast cancer and armpit lymph node metastases, not all axillary lymph nodes should be removed as standard. A minor operation provides a good prediction of the disappearance of metastases in the armpit after chemotherapy. This is demonstrated by research coordinated by the Erasmus MC Cancer Institute.

In breast cancer patients with metastases in the armpit, all lymph nodes in the armpit are often removed after treatment with chemotherapy. In retrospect, such an axillary gland toilet – as the procedure is called – is probably not needed for 1 in 3 women. It turns out that they no longer have metastases in the armpit after chemotherapy. However, due to major armpit surgery, they are often left with ailments, such as a thick arm because lymphatic fluid isn’t draining properly, arm pain, or difficulty moving it. In the Netherlands, approximately 3,000 women are diagnosed with breast cancer with metastases to the armpit lymph nodes each year.

iodine marker
A smaller operation that selectively removes a number of glands in the armpit is a good alternative to the axillary gland toilet. This is evident from the so-called RISAS study, in which 227 patients with breast cancer participated. All had metastases in the armpit before the start of chemotherapy.

Fourteen Dutch hospitals took part in the study, led, among others, by cancer surgeon Linetta Koppert and trainee radiotherapist Janine Simons of the Erasmus MC Cancer Institute. The results were published in the scientific journal JAMA surgeryafter being previously presented at a major breast cancer conference in the United States.

All patients in the study underwent the RISAS procedure. Before chemotherapy, a radioactive iodine marker is placed in the axillary node with metastases. After chemotherapy, this gland is removed, along with the gatekeeper gland. This is the gland that first collects lymph fluid from the tumor. In addition, the patients underwent a complete toilet of the axillary glands. This allowed the researchers to verify whether the metastases had been lost with the RISAS procedure.

Missing metastases
In 3.47% of the patients there were no metastases in the nodes of the RISAS procedure, but in the remaining toilet nodes of the axillary glands there were. The chance of losing metastases if only the iodine-labeled gland or gatekeeper gland is removed is about 1 in 6. This chance appears to be much lower with the RISAS procedure, or 1 in 14.

The researchers are pleased with their results. “The goal is to remove as few glands as possible to prevent side effects. But the right glands, to reliably determine whether or not there are more metastases. Our study shows that this can be done well with the RISAS procedure. . The chance of missing metastases is very low, ‘says Simons.

Not just in cancer centers
Many Dutch hospitals have already switched to minor combined axillary surgery, pending the results of the RISAS study. ‘But the participating hospitals, where it was not yet a routine, have now opted for this approach. We have shown that the RISAS approach works not only in specialized cancer centers, but also in regional hospitals. Many hospitals abroad, where the axillary gland toilet is often still the standard, have also eagerly awaited our results, ‘says Simons.

It remains important to adequately inform patients about the various armpit surgeries and the associated advantages and disadvantages, the researchers point out.

Follow-up research
The study team is currently investigating whether information from imaging and pathology can predict whether metastases disappeared prior to axillary surgery (REFINE study). The long-term effect of the RISAS procedure on survival and eventual disease recurrence is also the subject of further research. The national MINIMAX study investigates the effect of various axillary surgeries on survival and quality of life.

End of the RISAS study
The RISAS study was made possible in part by KWF Kankerbestrijding and, in addition to Linetta Koppert and Janine Simons, was led by:

• Prof. dr. Marjolein Smidt, cancer surgeon, MUMC +
• dr. Ernest Luiten, cancer surgeon, Tawam Hospital (United Arab Emirates)
• dr. Thiemo van Nijnatten, specializing in radiology and nuclear medicine, MUMC +
• dr. Carmen van der Pol, cancer surgeon, Alrijne Hospital

Participating Centers: Erasmus MC, Amphia Hospital, Albert Schweitzer Hospital, Bravis Hospital, Ikazia Hospital, Maasstad Hospital, Franciscus Gasthuis & Vlietland, MUMC +, UMCU, Wilhelmina Hospital, Martini Hospital, Zuyderland Medical Center, Hospital Group Twente, Treant Hoogeveen.

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