Management of the axilla in patients with breast cancer

This article reviews the changes in management of the axilla in patients with breast cancer in the last decade. It discusses the recent advances, existing controversies and provides evidence-based guidelines for use in clinical practice.Sentinel lymph node (SLN) biopsy has replaced the more morbid axillary lymph node dissection (ALND) and four node sampling for axillary nodal staging. Blue dye guided four node sampling is an acceptable alternative when radioisotope facilities are not available. ALND is reserved for patients with proven axillary lymph node involvement.Preoperative axillary ultrasound and fine-needle aspiration cytology or core biopsy of suspicious lymph nodes reliably identifies around 30% of node positive patients. Intraoperative assessment of the SLN using frozen section or real time molecular assays enables surgeons to perform one stage ALND in node positive patients. For those patients in whom intra-operative SLN assessment is negative, but whose final pathology reveals SLN metastasis, standard treatment has been to perform a completion ALND. Predictive models can be used to identify a lowrisk group of SLN-positive patients in whom routine ALND may not be necessary. In the future, completion ALND for microscopic disease will not be the standard of care but axillary radiotherapy may be an alternative with equal control and less morbidity.