Axillary dissection over the years: Where to from here?

Management of the axilla in breast cancer patients has been a subject of in tense debate and controversy. Axillary lymph node status is still considere d to be the single most important prognostic indicator in breast cancer pat ients, Despite a tendency toward a conservative approach for the surgery of primary breast carcinoma, axillary lymph node dissection (ALND) has remain ed an integral part of breast cancer management for more than a century. Am ong patients with T1/T2 tumors, up to 70% have a negative axillary dissecti on, and more than 50% of these node-negative patients develop morbidity rel ated to ALND. It is ironic that the extent, morbidity, and cost of a stagin g procedure (ALND) is more than that of the surgical treatment of the prima ry tumor, We must readdress the question of axillary management in breast c arcinoma in the light of information gained from the sentinel node biopsy t rials around the world. We review the historical milestones and various mod alities used for axillary management, discuss the concept of sentinel node biopsy for breast carcinoma, and propose a management plan.