Surgical treatment and lymphedema

Lymphedema is a serious and disabling complication of the treatment of breast carcinoma. This is related directly to the removal of axillary lymph nodes. Because lymph node status is the single most important predictor of outcome, it is necessary to obtain accurate information. Whereas breast conservation has become the preferred approach for treating early breast carcinoma, the accompanying axillary dissection continues to cause morbidity.

The history of the operations for breast carcinoma is reviewed, and the anatomy, techniques, and complications of axillary lymphadenectomy are described. Data to support the necessity for accurate axillary staging is presented, and results of noninvasive axillary staging approaches are discussed. The technique and value of sentinel node biopsy are presented.

Axillary lymphadenectomy is required where lymph node metastases are present to accomplish local control, improve survival, and provide information for staging to plan adjunctive therapy. Noninvasive techniques do not yet provide high enough sensitivity to assess the status of the axilla. The sentinel lymph node biopsy is a technique that can identify those patients who require axillary lymphadenectomy.

Screening mammography has been responsible for down-staging the size of detected breast carcinomas, so that the axillary dissection may be omitted in small carcinomas of favorable histologic type. For carcinomas in which the probability of axillary metastases exists, by using the sentinel lymph node biopsy, axillary dissections can be avoided when results are negative, and the risk of lymphedema can be reduced.