Management of the axilla in operable breast cancer treated by breast conservation: a randomized clinical trial

Background: In the treatment of operable breast cancer by breast conservati on, the extent of axillary dissection, the need for radiotherapy to the axi lla and the morbidity associated with these procedures have not been assess ed adequately. Methods: Patients with operable breast cancer were randomized to have level III axillary node clearance (232 patients) or axillary node sample (234 pa tients). Radiotherapy to the axilla was given selectively. Radiotherapy was not given to those who had an axillary clearance. In the early part of the study all patients who had node sample were treated by radiotherapy (54 pa tients); subsequently this was modified to include only those who were node positive. The morbidity to the shoulder and arm was assessed before and af ter operation by measuring upper limb volume and circumference, and combine d glenohumeral and scapular movement and muscle power. Results: Comparing the two surgical policies, no difference was found in lo cal (axillary clearance 14 versus sample 15), axillary (eight versus seven) or distant (29 versus 29) recurrence. There was no statistically significa nt difference in 5-year survival rate (clearance 82.1 versus sample 88.6 pe r cent). Morbidity was least in those who had a node sample and no radiothe rapy to the axilla. Radiotherapy to the axilla in patients who had a node s ample resulted in a significant reduction in range of movement of the shoul der, e.g. mean(s.e.) 2.2(0.6) cm reduction in lateral rotation at 3 years. Surgical axillary clearance was associated with significant lymphoedema of the upper limb, e.g. 4.1(0.7) per cent increase in arm volume at 3 years. Conclusion: A selective policy for the management of the axilla is associat ed with no increase in axillary recurrence or mortality rate compared with routine axillary node clearance. Patients who are node negative after axill ary sample can avoid radiotherapy or axillary clearance.