Surgery to Remove Sentinel Lymph Nodes With or Without Removing Lymph Nodes in the Armpit in Treating Women With Breast Cancer
Surgery to Remove Sentinel Lymph Nodes With or Without Removing Lymph Nodes in the Armpit in Treating Women With Breast Cancer
RATIONALE: Removing the sentinel lymph nodes and examining them under a microscope may help
 plan more effective surgery for breast cancer. It is not yet known if surgery to remove the
 sentinel lymph nodes is more effective with or without removal of the lymph nodes in the
 armpit in treating breast cancer.

 PURPOSE: Randomized phase III trial to compare the effectiveness of surgery to remove the
 sentinel lymph nodes with or without removal of lymph nodes in the armpit in treating women
 who have breast cancer.
OBJECTIVES:

 -  Compare the long term control of regional disease by sentinel node resection vs sentinel
 node resection followed by conventional axillary dissection in women with breast cancer
 who are clinically node negative and pathologically sentinel node negative.

 -  Compare the effect of these two regimens on the overall and disease-free survival of
 these patients.

 -  Compare the morbidity associated with these two regimens in these patients.

 -  Compare the prognostic value of these two regimens in patients who are sentinel node
 negative or positive by pathology.

 -  Determine whether a more detailed pathology investigation can identify a group of
 patients with a potentially increased risk of systemic recurrence who are node negative
 by pathology.

 -  Determine the technical success rate of sentinel node dissection and the variability of
 technical success rate in a broad population of surgeons.

 -  Determine the sensitivity of the sentinel node to determine the presence of nodal
 metastases in these patients.

 Objectives of quality of life questionnaire in sentinel node-negative patients:

 -  Compare the severity of self-assessed symptoms and activity limitations of patients
 treated with these two regimens.

 -  Compare the severity of self-assessed symptoms and activity limitations after breast
 cancer surgery in patients whose surgery was on the dominant side vs patients whose
 surgery was on the non-dominant side.

 -  Compare the impact of arm edema, range of motion, and sensory neuropathy on
 self-assessed measures of daily functioning, symptoms, and overall quality of life of
 patients treated with these regimens.

 OUTLINE: This is a randomized study. Patients are stratified according to the surgical
 treatment plan (lumpectomy vs mastectomy), age (49 and under vs 50 and over), and clinical
 tumor size (no greater than 2.0 cm vs 2.1-4.0 cm vs at least 4.1 cm). Patients are randomized
 to one of two surgery arms.

 All patients receive technetium (Tc 99m) sulfur colloid injected into normal breast tissue
 within 1 cm of the primary tumor or biopsy cavity and an intradermal injection of technetium
 (Tc 99m) sulfur colloid, approximately 0.5-8 hours before surgery. Patients also receive an
 injection of isosulfan blue dye around the tumor or biopsy cavity after a hot spot is
 identified with a gamma detector. If a hot spot is not identified, the blue dye is injected
 after a saline bolus injection.

 -  Arm I: Patients undergo sentinel node resection immediately followed by conventional
 axillary dissection.

 -  Arm II: Patients undergo sentinel node resection and an intraoperative examination of
 sentinel nodes.

 Patients with positive sentinel nodes undergo axillary dissection after sentinel node
 resection.

 Patients with cytologically negative sentinel nodes do not undergo axillary dissection.

 Patients with cytologically negative but histologically positive sentinel nodes return to
 surgery for axillary dissection.

 Patients with histologically positive sentinel nodes and those in whom the sentinel node is
 not identified undergo axillary dissection after sentinel node resection.

 Patients with pathologically positive, nonaxillary sentinel nodes undergo axillary dissection
 after sentinel node resection.

 Patients with evidence of tumor remaining after surgery undergo a total mastectomy.

 Quality of life is assessed at baseline, at weeks 1-3, and then every 6 months for 3 years or
 until recurrence.

 Patients are followed at 1 and 3 weeks, every 6 months for 3 years, and then annually
 thereafter.

 PROJECTED ACCRUAL: Approximately 5,400 patients will be accrued for this study within 4
 years.
DISEASE CHARACTERISTICS:

 -  Resectable invasive adenocarcinoma of the breast, confirmed by 1 of the following:

 -  Histologically confirmed by core or open biopsy

 -  Confirmed by fine needle aspiration cytology AND positive clinical breast
 examination and ultrasound or mammography

 -  Clinically negative lymph nodes

 -  No positive ipsilateral axillary lymph nodes

 -  No prior removal of ipsilateral axillary lymph nodes

 -  No suspicious palpable nodes in the contralateral axilla or palpable
 supraclavicular or infraclavicular nodes, unless proven nonmalignant by biopsy

 -  No ulceration, erythema, infiltration of the skin or underlying chest wall (complete
 fixation), peau d'orange, or skin edema of any magnitude

 -  Tethering or dimpling of the skin or nipple inversion allowed

 -  No bilateral malignancy or mass in the opposite breast that is suspicious for
 malignancy, unless proven nonmalignant by biopsy

 -  No diffuse tumors or multiple malignant tumors in different quadrants of the breast

 -  No other prior breast malignancy except lobular carcinoma in situ

 -  No prior or concurrent breast implants

 -  Hormone receptor status:

 -  Not specified

 PATIENT CHARACTERISTICS:

 Age:

 -  18 years and older

 Sex:

 -  Female

 Menopausal status:

 -  Not specified

 Performance status:

 -  Not specified

 Life expectancy:

 -  At least 10 years (excluding diagnosis of cancer)

 Hematopoietic:

 -  Not specified

 Hepatic:

 -  No hepatic systemic disease

 Renal:

 -  No renal systemic disease

 Cardiovascular:

 -  No cardiovascular systemic disease

 Other:

 -  No prior malignancy within past 5 years except:

 -  Effectively treated squamous cell or basal cell skin cancer

 -  Surgically treated carcinoma in situ of the cervix

 -  Surgically treated lobular carcinoma in situ of the ipsilateral or contralateral
 breast

 -  No concurrent psychiatric or addictive disorder

 PRIOR CONCURRENT THERAPY:

 Biologic therapy:

 -  No prior immunotherapy for this cancer

 Chemotherapy:

 -  No prior chemotherapy for this cancer, including neoadjuvant chemotherapy

 Endocrine therapy:

 -  No prior hormonal therapy for this cancer

 Radiotherapy:

 -  No prior radiotherapy for this cancer

 Surgery:

 -  See Disease Characteristics

 -  No prior breast reduction surgery

 -  Prior excisional biopsy or lumpectomy allowed