Axillary Surgery
Randomized clinical trials have brought about major changes in the surgical management of the axilla in patients with breast cancer. Sentinel lymph node biopsy is the standard of care for axillary staging in patients with invasive breast carcinoma with cl
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Axillary Surgery Farin Amersi and Armando E. Giuliano
19.1 Introduction Over the last 25 years, outcomes from randomized clinical trials have brought about major changes in the surgical management of the axilla in patients with breast cancer. Axillary sentinel node biopsy (SNB) has substantially changed management and has become accepted as a staging procedure in patients with early-stage breast cancer. The role of axillary lymph node dissection (ALND) has been an area of controversy for the last decade as it became accepted as a procedure for axillary staging and improving local control; however, there was no survival benefit [1, 2]. In addition, the decision to initiate either neoadjuvant or adjuvant chemotherapy is no longer limited to patients with nodal involvement but also depends upon characteristics of the primary tumor including tumor size, histologic grade, lymphovascular invasion, and receptor status. It is well known that SNB has less morbidity and fewer complications than traditional axillary lymph node dissection (ALND) [3–5]. The ability to perform a less invasive procedure with significantly less morbidity and complications, without compromising prognostic information, has always been appealing. Three prospective randomized clinical trials in patients with a clinically node-negative axilla comparing SNB to ALND have been published [6–8]. In NSABP-B32, which was the largest randomized sentinel node trial, 5611 patients with clinically T1 and T2 tumors who were clinically node-negative were randomized to either SNB followed by ALND or SNB alone with ALND only performed if the sentinel lymph node (SLN) contained metastases [6]. There were 80 participating F. Amersi · A. E. Giuliano (*) Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA e-mail: [email protected]; [email protected]
centers and 233 surgeons. This study used frozen section analysis of SLN and both radioisotope and isosulfan blue to identify the SLN. The technical success rate for identifying the sentinel nodes was reported at 96.9% and a false-negative rate of 9.5%. At mean follow-up of 8 years, the axillary recurrence rate for sentinel node-negative patients was 0.7%. Interestingly, the axillary recurrence is far less than the false-negative rate. The false-negative rate in the other two randomized trials of SLN-negative patients was also reported to be between 6.7% and 8.8% with an axillary recurrence rate between 0.2% and 0.8%, also far less than expected from the false- negative rate [7, 8].
19.2 A xillary Surgery with Sentinel Node Biopsy: Indications SNB has become the standard of care for axillary staging in clinically node-negative patients with breast cancer. As the indications for adjuvant therapy continue to involve, SNB provides a basis for identifying high-risk patients who may benefit from the use of adjuvant systemic therapy, hormonal therapy, or radiation. SNB also provides local control if metastasis is limited to the SLN. For patients with early- stage br
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