Surgical management of the axilla

Abstract

In patients with breast cancer, the pathologic status of the axillary lymph nodes remains one of the most important factors predictive of long-term survival. The management of the axilla has changed dramatically since the results of several large randomized trials have shown that sentinel lymph node biopsy and selective use of axillary nodal dissection is preferential to routine full axillary dissection. The concept of the sentinel lymph node biopsy for breast cancer was first introduced in 1991. Various identification techniques, including blue dye, radiocolloid, or a combination of both, have been successful in identifying sentinel nodes. The technique has replaced full axillary nodal dissection as a highly accurate and less morbid axillary staging procedure in patients with clinically node-negative early-stage breast cancer. Surgeons can now choose amongst various options for managing the axilla, including sentinel node biopsy, full axillary dissection, and axillary irradiation. The management of the axilla in the elderly, during pregnancy, in the setting of DCIS, prior axillary surgery, prophylactic mastectomy, inflammatory breast cancer, or after neoadjuvant chemotherapy require special consideration. With the widespread use of sentinel node biopsy, more intensive examination of the sentinel node has led to the detection of micrometastases and isolated tumor cells in the axilla. Recent large randomized trials have helped determine the management of these findings in patients. As newer data becomes available, axillary management will continue to evolve.