The axilla: to clear or not to clear? That is the question!

The prime objectives for axillary dissection are staging and treatment to cure. No physical examination, no imaging techniques, and no tumor markers can replace axillary dissection for staging. Further, axillary node status in potentially curable breast carcinomas is still considered the single best predictor of outcome and the primary determinant of the use of systemic therapy. Finally, locoregional tumor control seems to improve survival, emphasizing meticulous axillary dissection. Today, the question to be asked is not whether or not to clear the axilla; rather, the question should go: How do we distinguish node-negative patients from those who are node-positive without clearing the axilla unnecessarily? No surgeon would advocate dissecting the axilla in node-negative patients if nodal status could be ascertained by a different technique. Ongoing trials addressing the reliability of the sentinel node technique seem promising, and this technique may perhaps in the near future solve the problem of distinguishing node-negative patients from those with axillary spread. For the time being, the necessity of determining axillary status and to treat for cure can hardly be questioned. Therefore, once axillary spread has been demonstrated in one way or another, an adequate and meticulous axillary dissection should be performed.