Axillary surgery: is it necessary?

Surgery to the axilla serves two purposes in the management of breast cancer. Firstly, it provides accurate information about the involvement of the axillary lymph nodes which stage the disease and guide selection of adjuvant therapy. Secondly, it facilitates removal of any lymph nodes infiltrated by metastatic deposits and reduces the risk of local recurrence. The risk of relapse and prognosis following surgical treatment are directly related to the number of axillary lymph nodes containing metastatic deposits which emphasises the need for accurate axillary node staging. Axillary node clearance is considered the most accurate and effective way to stage and treat the axilla. In the past, it was reported that as few as 27% of breast cancer patients underwent axillary staging. The morbidity of axillary node clearance includes the development of postoperative arm lymphoedema, but the arm lymphoedema rate should not exceed 5% in good hands. This rate is much higher if a level I at I and II axillary node disection is combined with radiotherapy. In the Edinburgh trial, radiotherapy to the axilla after an axillary node sampling procedure was associated with reduced shoulder movements but there was no excess of lymphedema in this group. Following radiotherapy, early detection of axillary recurrence can be difficult and if not adequately treated may lead to brachial plexopathy, pain and reduced quality of life. The results of long-term follow-up (25 years) of patients in the Guy’s Wide Excision Trials are published in The Breast this month. The provocative finding that failure of