Skip to main content
SpringerLink
Log in

Management of the Axilla in Breast Cancer

  • Chapter
  • First Online:
Changing Paradigms in the Management of Breast Cancer

Abstract

During the majority of the last century, management of the axilla in patients with breast cancer consisted of an axillary lymph node dissection (ALND) in most patients for the purpose of staging and locoregional control. Several landmark clinical trials in the past 30 years have challenged this dogma. Surgical staging of the axilla with sentinel lymph node (SLN) surgery, which is a less morbid procedure, has been shown to be equally effective in clinically node-negative patients, with ALND reserved for patients with positive nodes. More recent evidence from the ACOSOG Z0011 trial showed that omitting an ALND in patients with low-volume nodal disease is safe in patients receiving whole-breast radiation. This and other trials have contributed to the complexity and controversy in axillary management. As the use of more effective systemic and targeted local therapy has become available, the trend has shifted toward less aggressive surgery in the axilla. Patient selection in the modern era is paramount. Contemporary trials are directed toward optimizing the management of node-positive patients who have excellent response to neoadjuvant chemotherapy. Future trials may show that axillary staging in clinically node-negative patients may not even be necessary.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  1. Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer. 1989 Jan 1;63(1):181–7.

    Google Scholar 

  2. Beenken SW, Urist MM, Zhang Y, Desmond R, Krontiras H., Medina H, et al. Axillary lymph node status, but not tumor size, predicts locoregional recurrence and overall survival after mastectomy for breast cancer. Ann Surg. 2003 May;237(5):732–8; discussion 738–9.

    Google Scholar 

  3. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994 Sep;220(3):391–8; discussion 398–401.

    Google Scholar 

  4. Giuliano AE, Jones RC, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer. J Clin Oncol. 1997 Jun;15(6):2345–50.

    Google Scholar 

  5. Sappey MPC. Anatomie, Physiologie, Pathologie des vaisseaux Lymphatiques consideres chez L’homme at les Vertebres. Paris: A. Delahaye and E. Lecrosnier; 1874.

    Google Scholar 

  6. Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Ashikaga R, et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymphnode dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 2007 Oct;8(10):881–8.

    Google Scholar 

  7. Klimberg VS, Rubio IT, Henry R, Cowan C, Colvert M, Korourian S.  Subareolar versus peritumoral injection for location of the sentinel node. Ann Surg. 1999 Jun;229(6):860-4; discussion 864-5.

    Google Scholar 

  8. Kern KA. Sentinel lymph node mapping in breast cancer using subareolar injection of blue dye. J Am Coll Surg. 1999 Dec;189(6):539–45.

    Google Scholar 

  9. Al-Hilli Z, Hieken TJ, Boughey JC. Axillary ultrasound in the management of the newly diagnosed breast cancer patient. Breast J. 2015 Nov-Dec;21(6):634–41.

    Google Scholar 

  10. Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, et al. Sentinel-lymph node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010 Oct;11(10):927–33.

    Google Scholar 

  11. Giuliano AE, McCall L, Beitsch P, Whitworth PW, Blumencranz P, Leitch AM, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg. 2010 Sep;252(3):426–32; discussion 432–3.

    Google Scholar 

  12. Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011 Feb 9;305(6):569–75.

    Google Scholar 

  13. Giuliano AE, Ballman K, McCall L, Beitsch P, Whitworth PW, Blumencranz P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 randomized trial. Ann Surg. 2016 Sep;264(3):413–20.

    Google Scholar 

  14. Jagsi R, Chadha M, Moni J, Ballman K, Laurie F, Buchholz TA, et al. Radiation field design in the ACOSOG Z0011 (Alliance) trial. J Clin Oncol. 2014 Nov 10;32(32):3600–6.

    Google Scholar 

  15. Galimberti V, Cole BF, Zurrida S, Viale G, Luini A, Veronesi P, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013 Apr;14(4):297–305.

    Google Scholar 

  16. Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJ, Mansel RE, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014 Nov;15(12):1303–10.

    Google Scholar 

  17. Dominici L, Negron Gonzalez V, Buzdar A, Lucci A, Mittendorf EA, Le-Petross HT, et al. Cytologically proven axillary lymph node metastases are eradicated in patients receiving preoperative chemotherapy with concurrent trastuzumab for HER2-positive breast cancer. Cancer. 2010 Jun 15;116(12):2884–9.

    Google Scholar 

  18. Fisher B, Brown A, Mamounas E, Wieand S, Robidoux A, Margolese RG, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol. 1997 Jul;15(7):2483-93.

    Google Scholar 

  19. Kuerer H, Sahin A, Hunt K, Newman LA, Breslin TM, Ames FC, et al. Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy. Ann Surg. 1999 Jul;230(1):72–8.

    Google Scholar 

  20. Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013 Oct 9;310(14):1455–61.

    Google Scholar 

  21. Kuehn T, Bauerfeind I, Fehm T, Fleige B, Hausschild M, Helms G, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013 Jun;14(7):609–18.

    Google Scholar 

  22. Boileau JF, Poirier B, Basik M, Holloway CM, Gaboury L, Sideris L, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015 Jan;33(3):258–64.

    Google Scholar 

  23. Donker M, Straver ME, Wesseling J, Loo CE, Schot M, Drukker CA, et al. Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients: the MARI procedure. Ann Surg. 2015 Feb;261(2):378–82.

    Google Scholar 

  24. Caudle AS, Yang WT, Krishnamurthy S, Mittendorf EA, Black DM, Gilcrease MZ, et al. Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 2016 Apr 1;34(10):1072–8.

    Google Scholar 

  25. Clarke M, Collins R, Darby S, Davies C, Elphinstone P, Evans V, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005 Dec 17;366(9503):2087–106.

    Google Scholar 

  26. Danish Breast Cancer Cooperative Group, Nielsen HM, Overgaard M, Grau C, Jensen AR, Overgaard J. Study of failure pattern among high-risk breast cancer patients with or without postmastectomy radiotherapy in addition to adjuvant systemic therapy: long-term results from the Danish Breast Cancer Cooperative Group DBCG 82 b and c randomized studies. J Clin Oncol. 2006 May 20;24(15):2268–75.

    Google Scholar 

  27. Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Jackson SM, Wilson KS, et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst. 2005 Jan 19;97(2):116–26.

    Google Scholar 

  28. Truong PT, Olivotto IA, Whelan TJ, Levine M, Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 16. Locoregional post-mastectomy radiotherapy. CMAJ. 2004 Apr 13;170(18):1263–73.

    Google Scholar 

  29. Eifel P, Axelson JA, Costa J, Crowley J, Curran WJ Jr, Deshler A, et al. National Institutes of Health consensus development conference statement: adjuvant therapy for breast cancer, November 1–3, 2000. J Natl Cancer Inst. 2001 Jul 4;93(13):979–89.

    Google Scholar 

  30. Recht A, Edge SB, Solin LJ, Robinson DS, Estabrook A, Fine RE, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001 March 1;19(5):1539–69.

    Google Scholar 

  31. Overgaard M, Nielsen HM, Overgaard J. Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 b&c randomized trials. Radiother Oncol. 2007 Mar;82(3):247–53.

    Google Scholar 

  32. Ragaz J, Jackson SM, Le N, Plenderleith IH, Spinelli JJ, Basco VE, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med. 1997 Oct 2;337(14):956–62.

    Google Scholar 

  33. Moo TA, McMillan R, Lee M, Stempel M, Patil S, Ho A, et al. Selection criteria for postmastectomy radiotherapy in t1–t2 tumors with 1 to 3 positive lymph nodes. Ann Surg Oncol. 2013 Oct;20(10):3169–74.

    Google Scholar 

  34. McBride A, Allen P, Woodward W, Kim M, Kuerer HM, Drinka EK, et al. Locoregional recurrence risk for patients with T1,2 breast cancer with 1–3 positive lymph nodes treated with mastectomy and systemic treatment. Int J Radiat Oncol Biol Phys. 2014 Jun 1;89(2):392–8.

    Google Scholar 

  35. Whelan TJ, Olivotto IA, Parulekar WR, Ackerman I, Chua BH, Nabid A, et al. Regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015 Jul 23;373(4):307–16.

    Google Scholar 

  36. A randomized phase III clinical trial evaluation post-mastectomy chest wall and regional nodal XRT and post-lumpectomy regional nodal XRT in patients with positive axillary nodes before neoadjuvant chemotherapy who convert to pathologically negative axillary nodes after neoadjuvant chemotherapy. NSABP-51/RTOG 1304 Trial, NCT01872975 n.d.

    Google Scholar 

  37. Comparison of axillary lymph node dissection with axillary radiation for patients with node-positive breast cancer treated with chemotherapy. Alliance A11202 Trial, NCT01872975 n.d.

    Google Scholar 

  38. National Comprehensive Cancer Network (NCCN) guidelines version 2.2016. Ductal carcinoma in situ (DCIS). Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed 11 Sept 2016. n.d.

  39. Kaufmann M, Morrow M, von Minckwitz G, Harris JR, Biedenkopf Expert Panel Members. Locoregional treatment of primary breast cancer: consensus recommendations from an International Expert Panel. Cancer. 2010 Mar 1;116(5):1184–91.

    Google Scholar 

  40. Pandit-Taskar N, Dauer LT, Montgomery L, St. Germain J, Zanzonico PB, Divgi CR. Organ and fetal absorbed dose estimates from 99mTc-sulfur colloid lymphoscintigraphy and sentinel node localization in breast cancer patients. J Nucl Med. 2006 Jul;47(7):1202–8.

    Google Scholar 

  41. Intra M, Trifirò G, Viale G, Rotmensz N, Gentilini OD, Soteldo J. Second biopsy of axillary sentinel lymph node for reappearing breast cancer after previous sentinel lymph node biopsy. Ann Surg Oncol. 2005 Nov;12(11):895–9.

    Google Scholar 

  42. Taback B, Nguyen P, Hansen N, Edwards GK, Conway K, Giuliano AE. Sentinel lymph node biopsy for local recurrence of breast cancer after breast-conserving therapy. Ann Surg Oncol. 2006 Aug;13(8):1099–104.

    Google Scholar 

  43. Newman EA, Cimmino VM, Sabel MS, Diehl KM, Frey KA, Change AE, et al. Lymphatic mapping and sentinel lymph node biopsy for patients with local recurrence after breast-conservation therapy. Ann Surg Oncol. 2006 Jan;13(1):52–7.

    Google Scholar 

  44. Maaskant-Braat AJ, Voogd AC, Roumen RM, Nieuwenhuijzen GA. Repeat sentinel node biopsy in patients with locally recurrent breast cancer: a systematic review and meta-analysis of the literature. Breast Cancer Res Treat. 2013 Feb;138(1):13–20.

    Google Scholar 

  45. A randomized trial comparing sentinel lymph node biopsy vs. no axillary surgical staging in patients with small breast cancer and a negative preoperative axillary assessment (IEO S637/311), NCT02167490. n.d.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Toan T. Nguyen MD & Judy C. Boughey MD

Authors
  1. Toan T. Nguyen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Judy C. Boughey MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Judy C. Boughey MD .

Editor information

Editors and Affiliations

  1. Associate Professor of Surgery, Director Breast Care Center, Wake Forest School of Medicine, Winston-Salem, NC, USA

    Marissa Howard-McNatt

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Cite this chapter

Nguyen, T.T., Boughey, J.C. (2018). Management of the Axilla in Breast Cancer. In: Howard-McNatt, M. (eds) Changing Paradigms in the Management of Breast Cancer . Springer, Cham. https://doi.org/10.1007/978-3-319-60336-0_4

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-60336-0_4

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-60335-3

  • Online ISBN: 978-3-319-60336-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation