BJS commission on the surgical management of the axilla in breast cancer

Introduction: The management of breast cancer has evolved dramatically over the past 25 years. In stark contrast to the radical mastectomy proposed by Halsted1 over 100 years ago, patients can benefit from individualized treatment programmes with less extensive surgery, possibly with oncoplastic techniques, complex and highly effective chemotherapeutic regimens (±immunotherapy and human epidermal growth factor receptor 2 (HER2) direct therapy), and focused radiation. Surgery has become more refined and offers the maximal benefit, whilst minimising morbidity. It is the surgical management of regional axillary lymph nodes that however has undergone the most significant changes over the last 25 years. Whilst all patients were previously subjected to an axillary lymph node dissection (ALND), this morbid procedure is now reserved for those with advanced lymph node involvement. The therapeutic value of axillary surgery is limited to specific cases and such surgery is now performed predominantly for staging and prognostic purposes as well as guiding, in selected cases, the provision of adjuvant therapy. Surgeons continue to investigate whether a more minimal approach to the axilla in patients with breast cancer could be employed. Conversely, there remains a group of patients who still require ALND and techniques to minimise associated complications, such as lymphoedema, have been increasingly investigated. As the rate of change within this area continues to increase, the purpose of this BJS Commission is to provide an overview, at this point, of all aspects of surgical management of the axilla including future considerations. To undertake this overview, the editorial board of the BJS selected experts within the different domains of axillary management of breast cancer. All those selected had a significant record of high-quality publications within their special interest. Once a list of expert authors was compiled, it was then approved by the BJS Editorial team and of those invited, all agreed to partake within this Commission. All authors were also asked to include ‘future experts’ at a senior trainee or early consultant level, to complement the authorship group. Authors were then split into five groups, each tasked with providing a detailed contemporary review of certain key aspects of axillary surgery. By selecting an international group of experts, the aim was to formulate a balanced and collaborative analysis that represents practice within this realm of breast surgery, globally. The overview was approved by the BJS Editors.