Surgical Management of the Axilla in Breast Cancer

Abstract

The management of the axilla in breast cancer has shifted from axillary dissection in all patients to sentinel lymph node biopsy (SLNB) alone for most patients, including patients with sentinel lymph node metastases. Although important to clinical staging, physical examination alone does not accurately predict axillary metastasis. There are some circumstances where SLNB is contraindicated or should be used with caution. The impact of SLNB after neoadjuvant chemotherapy remains unproven, but its use is reasonable for some patients. Patients with tumor-free sentinel lymph nodes or nodes with micrometastatic disease require no further axillary surgery. Most patients with one to three lymph nodes positive for macrometastatic disease who undergo segmental mastectomy and radiation do not require an axillary lymph node dissection (ALND). There has not been a dramatic increase in axillary recurrence or a decrease in survival with the decreased use of ALND. In the future, with improvements in genomic analysis, ALND and even SLNB may be even less important in local control and prognosis. This review contains 9 figures, 7 tables and 52 references. Key words: ACOSOG Z0011, axilla, axillary dissection, axillary radiation, breast cancer, macrometastasis, micrometastasis, sentinel lymph node biopsy