The need for axillary lymph node dissection in T1/T2 breast cancer surgery--counterpoint

For breast cancer patients, the role of the axillary lymph node dissection (ALND) in the management of clinically node negative breast cancer patient has shifted from routine, to selective, to increasingly rare. With the publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial results, some are ready to announce the time of death of this procedure. However, many questions remain regarding the design and statistical interpretation of the study, the treatments the patients actually received, and its applicability in clinical practice in light of other studies concerning regional management. Thus, the reports of the ALND's death may be greatly exaggerated. Careful acknowledgement of the study's strengths and shortcomings, and more recent trial data, suggest that although ALND may be safely avoided in a subset of sentinel lymph node positive, Z0011-eligible patients, others may require multidisciplinary review and consensus, and a careful conversation with the patient, before deciding it is not necessary.