الفهرس 
Anatomy of the AxillaOnly 14 pages are availabe for public view
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Abstract
Axillary status is the most important prognostic factor in breast cancer treatment providing staging information and therefore largely defining treatment strategy.
This article reviews the current management of the axilla in women with breast cancer, reviews the changes that have evolved in clinical practice and provides a comprehensive critique of a new selective targeted approach (sentinel lymph node biopsy [SLNB]) in patient management.
Axillary dissection has remained for years the standard technique for the majority of cases, and it is still useful in a significant number of patients affected by this disease. Axillary lymph node status is a significant prognostic pathologic variable in patients with operable primary breast cancer: it remains the most powerful predictor of recurrence and survival. The number of lymph nodes with metastasis also has prognostic importance.
Indications of ALND include multi-centric tumors, prior to breast or axillary surgery, inflammatory breast cancer, pregnancy, patients with clinically positive axilla and SLN-positive (macrometastasis).
ALND level I and level II clearance provides not only prognostic information to predict outcomes but also excellent locoregional control of the disease. A mathematical model has suggested that a minimum of 10 nodes needs to be removed to attain a 93% predictive value that the remaining nodes are clear. The incidence of axillary recurrence with ALND is low, approximately 0% to 2%. It is, however, associated with clinically important morbidity, including impairment of infection, hematoma, seroma, lymphedema of the arm, pain, sensory disturbances, impairment of arm mobility and shoulder stiffness.
Lymphedema is the most important complication and leads to functional impairment, psychological morbidity, and decreased quality of life (QOL). The incidence of lymphedema after ALND ranges from 6% to 30%, with a greatly increased risk if radiotherapy has also been used.
ANS (four-node sampling) was introduced in the United Kingdom more than 30 years ago. This technique was based on the concept that the potentially involved ALNs should be palpated intraoperatively. At least four palpable lymph nodes need to be removed from the axillary tail and lower axillary fat to obtain 95% accuracy in staging the axilla with the same effectiveness as ALND in staging the axilla.
SLNB is a minimally invasive procedure that is an alternative to ALND or ANS in staging the axilla in patients with clinically node-negative breast cancers. It has the potential to improve the accuracy of axillary staging while reducing the number of unnecessary ALNDs and decreasing morbidity. The technique of SLNB is based on the premise that cancer cells that detach from the primary tumor are likely to arrive at, and be sequestered in, the first or sentinel node(s) to receive lymph from the tumor area. A tumor-free SLN therefore indicates the absence of lymph node metastasis in the rest of the lymphatic system, and thus further ALND or radiotherapy is thus not required in such cases.
SLNB has become the standard technique in the management of the axilla in patients with early breast cancer as it give surgeons a good idea about the axillary status with fewer complications as compared with the ALND. There are many methods used in identifying the SLN such as dyes, radioisotope Tc, Sentinella and magnetic field detectable dye.
SLNB is indicated in early cancer with small (T1 and T2) tumors, patients with clinically negative axilla, old and obese patients. It is also very important before neoadjuevant treatment.
The most important topic discussed in this assay is the management of the axilla. All panels up until 2012 have recommended that the SLNB is the standard technique for the management of the axilla in breast cancer cases. We still need to perform axillary dissection if the SLNB is positive with macrometastases. However, there is no need for completion of axillary dissection after SLNB if the SLNB is positive with micrometastases or ITCs as it is considered negative. It has recently been suggested that there may be no need to perform SLNB in the staging of the axilla; and that instead a professional U/S can be used to decide whether axillary dissection is necessary. It is hoped that this will be the technique in the future.
The management of uncontrolled local disease needs to be individualized and will usually involve a combination of treatments. A team approach is therefore very important and will include nurses, surgeons, oncologists and psychological support.
Optimal management of the axilla as a part of locally advanced breast cancer is a combined approach that uses chemotherapy, radiotherapy, surgery and/or endocrine therapy if applicable.