Recommendation for axillary lymph node dissection in women with early breast cancer and sentinel node metastasis: A systematic review and meta-analysis of randomized controlled trials using the GRADE system

Int J Surg. 2016 Oct:34:73-80. doi: 10.1016/j.ijsu.2016.08.022. Epub 2016 Aug 22.


Background: In 2014, the American Society of Clinical Oncology published an updated clinical practice guideline on axillary lymph node dissection (ALND) for early-stage breast cancer patients. However, these recommendations have been challenged because they were based on data from only one randomized controlled trial (RCT). We evaluated the rationale of these recommendations by systematically reviewing RCTs using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system.

Methods: We searched articles in the PubMed, EMBASE, CINAHL, Scopus, and Cochrane databases. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were recurrence rate and surgical complications of axillary dissection. The quality of evidence was assessed using the GRADE profiler.

Results: Five eligible studies were retrieved and analyzed. We divided sentinel lymph node (SLN) metastasis into two categories: SLN micrometastasis and SLN macrometastasis. In patients with 1 or 2 SLN micrometastasis, no significant difference was observed in OS, DFS, or recurrence rate between the ALND and non-ALND groups. For patients with 1 or 2 SLN marcometastasis, only one trial with a moderate risk of bias was included, and non-ALND was the preferred management overall. However, ALND might be appropriate for patients who placed a greater emphasis on longer-term survival at any cost.

Conclusion: We recommend non-ALND management for early breast cancer patients with 1 or 2 SLN micrometastasis or macrometastasis on the basis of a systematic review of the current evidence conducted using the GRADE system. However, the optimal practice of evidence-based medicine should incorporate patient preferences, particularly when evidence is limited.

Keywords: Axillary lymph node dissection; Breast cancer; Clinical practice guideline; GRADE; Meta-analysis; Recommendation; Sentinel lymph node metastases.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Axilla / pathology
  • Axilla / surgery
  • Breast Neoplasms / pathology
  • Breast Neoplasms / surgery*
  • Disease-Free Survival
  • Female
  • Humans
  • Lymph Node Excision / standards*
  • Lymph Nodes / pathology
  • Lymph Nodes / surgery*
  • Lymphatic Metastasis
  • Middle Aged
  • Neoplasm Micrometastasis
  • Neoplasm Recurrence, Local
  • Neoplasm Staging
  • Practice Guidelines as Topic*
  • Randomized Controlled Trials as Topic
  • Sentinel Lymph Node / pathology
  • Sentinel Lymph Node / surgery
  • Sentinel Lymph Node Biopsy