Management of the axilla in early breast cancer: is it time to change tack?

Abstract

The standard surgical treatment of the axilla in patients with early breast cancer is about to undergo a radical change. Although axillary dissection is an excellent procedure for both staging and local control, particularly in the clinically positive axilla, it has considerable morbidity and may understage a significant proportion of patients, because it will usually miss micrometastases that can occur in approximately 10% of 'node negative' patients. An increasing number of patients whose tumours are either non-invasive (ductal carcinoma in situ; DCIS), micro-invasive, tubular cancers or low-grade T1a tumours without lymphovascular invasion may be spared axillary surgery because the risk of axillary disease is 0-3%. Many studies, both prospective trials and large retrospective series, show that axillary radiotherapy alone provides similar local control rates to axillary dissection in patients with clinically negative axillas. Primary treatment of the axilla with radiotherapy alone, however, does not allow appropriate staging. Sentinel lymph node biopsy is being increasingly used in patients with breast cancer to provide this information. When a sentinel node is identified it is equal to or better than axillary dissection for staging the axilla and, if the node is positive, it will help select patients who should then proceed to further axillary surgery or axillary radiotherapy. Although sentinel lymph node biopsy is being rapidly adopted in many centres worldwide, the results of randomized controlled trials are needed before it can be recommended as the standard of care.

Women’s choice between sentinel lymph node biopsy and axillary clearance

“…Unfortunately, AC is associated with significant morbidity, including arm stiffness, arm swelling and increased risk of infection. While different series have reported various incidences of permanent problems, a clinically relevant rate of 10% is generally accepted 1,3,7 …”

“…The presence and extent of axillary metastatic disease is the most sensitive prognostic factor for breast cancer 1–3 . A study of over 20 000 patients showed that the 5‐year survival for a patient with breast cancer less than 2 cm in size is 98% in the absence of node involvement and 80% if metastases are found 4 .…”

Sentinel node biopsy: concepts and current status

“…Dissection of the node can be at times, technically more difficult since the position of the sentinel node is not always predictable. This could lead to creation of tissue flaps and risk of infection or necrosis (64). The node or nodes hence defined by the blue dye is then excised and evaluated by histopathology.…”