Value of Axillary Dissection in Early Breast Cancer

Abstract

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xillary lymph node dissection (ALND) has been an integral part of the surgical treatment of breast cancer since the popularization of the radical mastectomy by William Halsted in 1894. It was suggested that breast cancer first spreads locoregionally via lymphatics to the axillary lymph nodes and then metastasizes more distantly. Axillary lymph node staging is the single most important prognostic indicator for breast cancer. For many decades it has been routine practice to surgically remove axillary lymph nodes for histopathological assessment in all women with invasive disease to determine the most appropriate treatment options. To spare node-negative women with unnecessary axillary lymph node clearance and its significant associated morbidity, more limited surgery, in the form of sentinel lymph node biopsy (SLNB), has been developed and is now the operative technique of choice for surgical axillary staging. Current UK guidelines advise that sentinel node positive women should proceed to completion axillary lymph node clearance, while sentinel node-negative women need no further axillary treatmen. While sentinel node biopsy results in considerably less morbidity than axillary lymph node clearance, it does require radioisotope and/or blue dye injection, and usually general anaesthesia. Intra-operative assessment of the sentinel node is available in some centres but most currently rely on delayed histopathological assessment and carry out completion axillary lymph node clearance as a second operation . The American College of Surgeons Oncology Group Z0011 trial results provided convincing evidence that completion axillary lymph node dissection (CALND) was unnecessary in patients with 1 to 2 macrometastatic sentinel lymph nodes (SLNs). On a different note, Color Doppler ultrasound is a simple, minimally invasive, reliable, cost effective technique for the initial determination of axillary lymph node status in patients with breast cancer.