controversy currently gaining attention in breastA cancer management is whether to perform routine axillary lymph node dissection in invasive breast cancer. The use of this procedure has evolved over time.In the mid-1 SOOs, beginning with simple mastectomy without attention to axillary node removal, Halsted (1) developed the concept of radical axillary node dissection accompanying mastectomy, based on the presumed progressive, direct, and extensive lymphatic spread thought to be so pervasive, because of connecting lymphatic channels, that it even led to liver metastases. Halsted's operation (1) was a major advance in the regional control of breast cancer. This radical regional surgical philosophy lasted until shortly after World War 11, when the concept of a superradical mastectomy evolved: a number of surgeons began dissecting the internal mammary lymph nodes (2) and even the supraclavicular lymph nodes ( 3 ) along with the radical axillary node resection accompanying mastectomy. Controlled trials (3-5) demonstrated that these superradical lymph node resection procedures offered no more chance of cure than routine radical axillary node dissection.
fter decades of relatively static attitudes about sur-A gical treatment of breast cancer, since 1970 we have seen a rapid evolution of surgical approaches based on a newer understanding of the biology of breast cancer. Two decades of clinical trials made it apparent that the cure of breast cancer is unrelated to the details of the local surgical treatment of the primary cancer itself (1-5). Survival has been shown to be exactly equivalent following mastectomy, lumpeaomy with radiation therapy, and lumpectomy without radiation therapy; this established the fact that specific details of local tumor excision in the breast itself do not govern survival, although these details do indeed govern the risk of local recurrence in the breast. Considering all cases, total mastectomy has essentially no in-breast recurrence, a lumpectomy with radiation therapy is associated with a 10-15% risk of in-breast recurrence in most published series, and a lumpectomy without radiation therapy is associated with a very high in-breast recurrence rate of 30-40% or more (3). In-breast recurrence is a marker, therefore, for a poorer prognosis, and thus has an indicator function biologically and prognostically, but no controlling influence on survival ( 6 ) .These breast cancer trials also addressed the issue of the biologic implication of axillary lymph node metastases. Whether lymph node metastases in the axilla or internal mammary drainage basins are removed, radiated, or merely observed, survival is absolutely equivalent (1, 7 ) . Thus lymph node metastases are "indicators but not governors" of outcome in breast cancer (8). This assumption is based on many prospective trials in breast cancer, and is substantiated by similar trials in melanoma (9), colon cancer (lo), gastric cancer (ll), and other epithelial cancers. In all these cancers more radical lymph node dissections are no more successful in producing cure than modest lym-
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