How much is enough? The continuing debate on the axillary lymph node dissection in breast cancer.

The Permanente Journal/ Spring 2007/ Volume 11 No. 2 Since the Halsted radical mastectomy was introduced in 1894, breast cancer treatment has undergone major changes. More than a century later, breast conserving surgery is now accepted in the treatment armamentarium of early breast cancer. However, the role of axillary lymph node dissection (ALND) in breast cancer treatment continues to be controversial. The persistent question in this debate is whether we should abandon axillary lymph node evaluation in breast cancer management; I believe we cannot. Axillary lymph node disease status is considered the most significant prognostic factor for patients with earlystage breast cancer. Surgical resection and histopathologic examination of the lymph nodes are the gold standard for evaluating the disease status of the axillary lymph node. Unfortunately, ALND is associated with lymphedema, nerve injury, shoulder dysfunction, and other morbidities that compromise quality of life in about 20% of patients. To lessen morbidity associated with ALND, sentinel lymph node biopsy (SLNB) was developed in the 1990s. The definition of sentinel lymph node (SLN) is the first lymph node into which cancer cells would spread from the primary tumor before involving further lymph nodes within that basin. In theory, the result of the SLNB reflects the remainder of the nodal basin for metastases. SLNB is a less invasive procedure and more accurate since it allows a pathologist to study a lymph node in greater detail. Thus, SLNB has become the standard of care in clinically node-negative patients. SLNB has also been shown to be a reliable tool after patients receive preoperative systemic treatment in locally advanced breast cancer. Currently, it is accepted that ALND is indicated when a patient presents with clinically positive axillary lymph node disease. As stated above, there is also agreement that no further ALND is indicated when the SLNB shows no disease. The major point of debate now is what to do with positive SLN in patients with otherHow Much Is Enough? The Continuing Debate on the Axillary Lymph Node Dissection in Breast Cancer