Death of dissection.

The summer has already ushered in the possible death of completion lymph node dissection in melanoma with results of the MSLT-II trial failing to show improvement in overall survival. This week, JAMA rounds out the bad news for nodal dissection by bringing us the 10-year survival outcomes of ACOSOG Z0011. As a reminder, women receiving breast conservation for cT1-2N0 breast cancers with 1-2 pathologically involved nodes found on sentinel lymph node dissection (SLND) were randomized to +/- completion axillary dissection (ALND) with everyone receiving subsequent radiation to the breast alone (read: breast alone except for the 19% receiving prohibited nodal radiation and the 50% high tangents). Both overall and disease-free survivals continued to meet predefined non-inferiority thresholds, with SLND alone numerically winning out. Ok….but didn’t we know this 5-years ago? Well, yes, but this long term confirmatory data is an important step in squashing concerns over late recurrences among the majority (>75%) of women with more indolent hormone-receptor positive disease. And it remains a huge step in diminishing morbidity of combined axillary therapies. So for now SLND can stand proudly in its place as standard of care when performed with breast conservation therapy for cN0 breast cancer.