[Management of axillary and internal mammary lymph nodes in primary breast cancer]

Axillary lymph node dissection (ALND) is an effective staging procedure and is essential for local control of breast cancer. The regimen of the adjuvant systemic therapy is largely based on the number of nodes involved. There is as yet no evidence of survival benefit from axillary treatment by either surgery or radiotherapy, but this issue remains controversial. In general, the standard treatment of the axilla is surgical clearance of nodes from level I and II (partial ALND). If these nodes are involved, the clearance of level III nodes (complete ALND) is indispensable from the viewpoint of local control. Because a high rate of adverse events is observed, the extent of ALND should be determined by considering the balance between side effects and therapeutic benefit on a case-by-case basis. For the management of internal mammary nodes, most reports on randomized trials indicate that neither surgical treatment nor radiotherapy influences survival. However, the prognostic significance of internal mammary node status is high and a selected biopsy of lymph nodes with adenopathy should be considered for staging purposes. The significance of local control in this region is still controversial at present. About 30% to 40% of all invasive breast cancers are node positive. Thus, in most cases, the potential morbidity of ALND could be avoided if the status of the axillary nodes was ascertained with a less invasive procedure. The technique of sentinel lymph node biopsy may eventually prove to decrease the need for standard ALND. The randomized trial NSABP-B32 is ongoing and the results should indicate the clinical need for ALND.