Lymph-node dissection in breast cancer

Background: Along with the ongoing modifications in treatment of primary br east cancer, the purpose and extent of lymph-node dissection has changed. T he following is an overview of the current knowledge and practice of lymphn ode dissection in breast cancer, with special regard to expected developmen ts in the near future. Axillary dissection is described as a ten-step proce dure, including dissection of level-I and -II and Rotter's nodes, without l evel-III nodes, providing at least ten lymph nodes for accurate staging inf ormation. Discussion: Axillary dissection still offers the most efficient local contr ol in node-positive patients, whereas, in primarily node-negative patients, irradiation seems to be equally effective. In general, lymph-node dissecti on does not alter overall survival but there is no doubt that surgical ther apy still contributes to cure in early-breast-cancer patients and seems to be curative for certain patients with stage-I carcinoma. The lymph node sta tus of the axilla is crucial for the indication of adjuvant therapy in earl y invasive breast cancer, but an increasing number of clinical node-negativ e patients could be managed with information based on features of the prima ry tumor, regardless of the nodal status. The most promising new concept fo r the selection of node-positive patients, while avoiding unnecessary morbi dity of axillary dissection in early-breast-cancer patients, is the sentine l-node concept. The principle is based on the identification of the first " sentinel" lymph node reached by lymphatic flow. Thus, only proven node-posi tive patients undergo axillary dissection. Local failure of internal mammar y lymph nodes is rarely recognized; however, internal mammary lymph nodes s eem to have an underestimated prognostic significance in about 10-20% of ax illary node-negative patients. This may lead to the withholding of systemic therapy for patients with early breast cancer. Nevertheless, there is no i ndication for a routine parasternal dissection today. The sentinel-node con cept may also support the selection of diagnostic internal lymphnode biopsy and subsequent adjuvant therapy in cases with no axillary lymph-node metas tases but with internal lymph-node metastases.