Current Status of Axillary Management in Breast Cancer

摘要: The standard treatment for breast cancer was for long considered to be removal of the breast, underlying muscles and the draining lymph nodes based on the Halstedian concept, first proposed in the 1800s which stated that tumors spread systematically from the breast to the draining lymph nodes before distant metastases could develop. 1 The concept of Halsted’s classical radical mastectomy was extended further by other proponents who advocated removal of the internal mammary group of lymph nodes also based on the assumption that control of loco-regional disease would prevent distant metastases and death. 2: 3 The Halstedian concept was subsequently challenged by Fisher who noticed that many women developed distant metastases and died despite excellent locoregional control. This observation led him to propose that breast cancer is a systemic disease early in its course and hence loco-regional treatment is unlikely to affect long-term survival. 4 The ‘systemic’nature of breast cancer formed the basis for offering less radical surgery in the form of mastectomy or breast conserving surgery with radiation. Strong evidence in support of Fisher’s hypothesis came from the NSABP-04 trial that compared clinically node negative breast cancer patients treated by radical mastectomy, total mastectomy along with nodal irradiation and total mastectomy alone. After 25 years of follow-up, there was no significant difference in the disease free survival and the overall survival between the three groups. 5 Furthermore, the patients who were treated by total mastectomy alone underwent axillary dissection if they subsequently developed resectable …