الفهرس 
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Abstract
SUMMARY
A major milestone in the management of breast cancer over the past decade has been the
transition from axillary lymph node dissection (ALND) to sentinel node biopsy (SNB) for
the detection of axillary lymph node metastases. This shift has triggered a reassessment
of the goals, outcomes, morbidity, and alternatives to ALND. ALND has historically
performed two important roles: (a) staging of the axilla by detection of nodal metastases;
(b) tumor control in the axilla. The tumor control achieved by axillary node dissection
can be an important element in patient prognosis. Meta-analyses have supported that the
local control achieved by ALND can impact disease-free survival, and salvage treatment
of an axillary recurrence results in at best a 40% to 50% overall survival. (Clarkeet al.,
2005) (Konkin et al.,2006) In addition, axillary node dissection has been considered an
important step in patient management by determining the type and extent of systemic
therapy necessary. Despite these roles, axillary node dissection can significantly
compromise patients’ quality of life by the occurrence of lymphedema, pain, restriction of
shoulder movement, or anesthesia. (Langer et al., 2007)
The emergence of SNB has permitted reliable identification of axillary nodal metastases
in a clinically negative axilla, therefore sparing 60% to 75% of patients the excess
morbidity of ALND. Still, 25% to 40% of patients require completion ALND following
positive SNB. (Kim et al., 2006)
Axillary irradiation is a rational alternative to ALND. In a clinically negative axilla,
irradiation achieves comparable local tumor control with less morbidity. In addition,
there is now less reliance on the number of axillary lymph nodes with metastases as the
primary indicator for systemic therapy. Other factors have emerged that may indicate the
need for and the type of systemic therapy to be delivered including HER 2 neu
overexpression, other gene expression, negative hormone receptors, and so forth.The
combination of sentinel node biopsy to detect axillary metastases, other prognosticators
Summary
as indicators for systemic therapy, andaxillary irradiation for regional tumor control
potentially fulfills the three primary goals of ALND. (Jay et al., 2010)
Several studies have demonstrated that the axillary reverse mapping nodes are involved
with metastatic foci in some patients with extensive axillary lymph node metastasis.
Therefore, patients with suspected extensive nodal disease at clinical examination,
ultrasonography of the axilla, or intraoperative pathologic assessment should not be
candidates for preservation of axillary reverse mapping nodes and lymphatics. On the
other hand, the SLN draining the breast is the same node as the axillary reverse mapping
node draining the upper extremity in some patients, It is impossible to preserve
converged sentinel lymph node – axillary reverse mapping node, although the excision of
one converged node does not always translate into lymphedema, because multiple
lymphatic channels drain the arm. Thus, there is no reliable separation of arm and breast
lymphatic pathways, because there are lymphatic interconnections between lymph nodes
draining the upper extremity and nodes draining the breast. However, it has been
suggested that patients with clinically uninvolved nodes might derive the most benefit
from the axillary reverse mapping procedure.(Jay et al., 2010)