Axillary Lymphadenectomy Versus Axillary Lymph Node Sampling With Conservative Mastectomy

Abstract

I n the last three decades, the management of breast cancer has changed dramatically. Gradually, the extent of breast surgery has evolved from radical mastectomy to modified radical mastectomy to more conservative approaches as lumpectomy followed by radiotherapy that is now known as breast conservative therapy. Meanwhile, the same transformation is taking place in the management of the axilla in breast cancer patient, where the operations have evolved from complete ALND to a SLNB. One might refer to it as "axillary conservation". In this new era of SLNB, it has been shown to be highly accurate in determining when the remainder of the axilla is negative. Many parameters have been demonstrated to predict prognosis in breast cancer, but multivariate analysis has shown that the most useful, independent factors are tumor grade, tumor size and lymph node metastasis. Of these, the most powerful is lymph node metastasis. Axillary lymph node status continues to be the single most important prognostic variable in patients with breast cancer. Thus, the evaluation of the axilla has been a major focus of interest in the treatment and staging of patients with breast cancer. The sentinel lymph node is defined as any lymph node receiving lymphatic drainage directly from the primary tumour. Thus, it is the node most likely to be the site of initial lymphatic metastasis. The rationale is that, if the SLN is free from metastatic disease, the rest of the higher echelon lymph nodes in the axillary lymphatic drainage will also be negative and may therefore be left in situ. SNB was started with peritumoral injection in the mid-nineties. Around the year 2000, many departments changed to subareolar injection, making SNB in nonpalpable breast lesions much easier. The simplicity and reliability of this method requires less expertise than other techniques. It avoids the necessity for image-guided injections for nonpalpable lesions. Moreover, subareolar injection reduces the shine-through effect from tumours located in the upper outer quadrant of the breast. It is also recommend that SLNB be considered in patients with multicentric at least in institutes with considerable experience in SLNB.