Axillary surgery in breast cancer: An updated historical perspective

Abstract

This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing effort s of researchers toward new challenges, as documented by extensive studies and trials. Axillary surgery has evolved, aiming to offer the best oncologic treatment and improve the quality of life of women. Axillary lymph-node dissection (ALND) has been replaced by sentinel lymphnode biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with minimal morbidity, and becoming the standard of care in the management of breast cancer. However, this is only the beginning. Strategies in defining systemic and radiotherapeutic treatments have gradually been optimized, offering increasingly refined and targeted breast cancer treatment tools. In recent years, the paradigm of completion ALND after a positive SLNB has been questioned, and several studies have led to revolutionary changes in clinical practice. Moreover, the increasingly pivotal role played by neoadjuvant chemotherapy (NAC) has had a profound effect on the extent of axillary surgery, paving the way to a more finite "targeted" procedure in women with node-positive breast cancer who convert to negative nodes clinically after NAC. The utility of SLNB itself and its subsequent omission in women with negative nodes clinically and breast conservative surgery is also under scientific evaluation. The changes over time in the surgical approach to breast cancer have been numerous and significant. The novel emerging perspective characterized by recent advances in biology and genetics, in dedicated axillary ultrasound imaging and chemotherapy regimens, is the present reality that points to the future of axillary node treatment in breast cancer.

Breast Cancer Surgery: New Issues

“…Over the past two decades, systemic therapy with neo-adjuvant intent has been playing a rapidly growing role. Indeed, it has been proven to be a valid tool in downstaging both breast and axillary disease [66], not only in case of locally advanced BC, but also in selected cases of early-stage BC with biologically aggressive subtypes, such as triplenegative breast cancer and HER2-positive disease, that would normally require adjuvant chemotherapy [67]. Novel treatment regimens showed pathological complete response (pCR) rates of up to 70% and 30-40% for HER2-positive and triple-negative breast cancers, respectively [68][69][70].…”

Staging of the Axilla in Breast Cancer and the Evolving Role of Axillary Ultrasound

“…In the 19th century, Rudolph Virchow postulated that axillary lymph node metastases facilitated the distant metastatic spread of breast cancer. 2 This led William Halsted to propose radical mastectomy (excision of the breast tissue, pectoralis muscle, and ipsilateral axillary lymph nodes) for the treatment of breast cancer. 3 In the century since Halsted pioneered the radical mastectomy, advances in diagnostic imaging, systemic therapy, radiation therapy and an improved understanding of breast cancer biology have led to a dramatic de-escalation of breast cancer surgery.…”

Axillary ultrasound and fine-needle aspiration cytology to predict clinically relevant nodal burden in breast cancer patients

“…Axillary lymph node dissection (ALND) was performed routinely by William Halsted [ 3 ] with great morbidity, especially lymphedema and loss of arm function. In the 1990s, the sentinel node biopsy (SLNB) emerged, leading to the same important prognostic information and minimal morbidity, becoming the standard of care in the management of the axilla in clinically node-negative breast cancer patients [ 4 ].…”