Abstract

The management of the axilla in patients with breast cancer undergoing surgery is a continually evolving field. Historically, axillary surgery has been both diagnostic and therapeutic, serving to determine nodal status and to remove clinically significant disease. However, recent trials of de-escalation or omission of axillary surgery altogether have consistently demonstrated noninferior oncologic outcomes in a wide variety of patient subsets, while also reducing associated morbidity. This article will briefly review landmark trials that have shaped the upfront management of the axilla, discuss recent advances, and highlight areas of ongoing investigation and future needs.

Introduction

Breast cancer is one of the most common cancers affecting women worldwide. The involvement of axillary lymph nodes is a significant prognostic factor in breast cancer, and the management of the axilla during surgery for breast cancer has been a subject of ongoing debate and research (Williams & Weiss, 2023). This article reflects on historical approaches and examines the changing landscape of axillary surgery in the light of landmark trials and recent advances. It also explores the direction of current research and potential future developments in the surgical treatment of the axilla.

Historical Perspective and Standard Approaches

Traditionally, axillary lymph node dissection (ALND) was a routine part of the surgical management of breast cancer. ALND involves the removal of numerous lymph nodes in the axilla to assess for cancer spread and to reduce the burden of disease. The nodal status obtained from ALND informs the prognosis and guides adjuvant therapy decisions. Sentinel lymph node biopsy (SLNB), a less invasive procedure where only the first few lymph nodes (sentinel nodes) are removed and examined, later became a standard of care for clinically node-negative patients following validation studies. While SLNB significantly reduced morbidity, such as lymphedema, compared to ALND, it nonetheless had associated risks and complications (Weiss & Williams, 2023).

Landmark Trials and Paradigm Shifts

Several pivotal clinical trials have greatly impacted the approach to the axillary surgery:

The ACOSOG Z0011 trial demonstrated that, for select patients with early-stage breast cancer and limited sentinel node involvement, omitting ALND did not impact survival or recurrence rates (Giuliano et al., 2010).
The AMAROS trial provided evidence that axillary radiotherapy could be an alternative to ALND in patients with positive sentinel nodes, offering similar control with fewer side effects (Donker et al., 2014).
The IBCSG 23-01 trial expanded upon these findings, showing that in patients with micrometastases in sentinel nodes, ALND could be avoided without compromising outcomes (Galimberti et al., 2013).
These trials marked a substantial shift towards de-escalation of axillary surgery, favoring less invasive approaches for appropriate patients while maintaining oncologic safety.

Recent Advances in Upfront Axillary Surgery

Recent studies have continued to refine the criteria and techniques for managing the axilla upfront in breast cancer surgery. A move towards personalized surgery, tailored to the individual patient’s cancer characteristics and risk profile, is evident. Innovations such as targeted axillary dissection (TAD), which combines SLNB with the removal of nodes marked by preoperative imaging or biopsy, have emerged. Advances in imaging techniques, such as the use of axillary ultrasound and MRI, further support this individualized approach by helping to identify patients who may indeed benefit from more or less extensive surgery (Williams & Weiss, 2023).

Ongoing Investigations and Future Directions

Current research is aimed at identifying subsets of patients who may safely avoid axillary surgery altogether, such as those with small tumors, low-grade disease, and those who respond well to neoadjuvant therapy. Genetic and molecular profiling also hold promise for further personalizing the approach to axillary management. Additionally, advances in intraoperative assessment tools and the potential use of axillary reverse mapping to preserve lymphatic integrity are under investigation (Weiss & Williams, 2023).

Implications and Considerations for Clinical Practice

The de-escalation of axillary surgery reflects a broader trend in oncology towards less invasive interventions that preserve the quality of life without compromising cancer control. This approach underscores the need for clinicians to stay abreast of the evolving evidence and integrate it into practice, offering patients the benefit of state-of-the-art care that is both effective and personalized.

Conclusion

The upfront surgical management of the axilla in breast cancer has seen substantial advancements over the past decade, moving away from routine extensive axillary clearance to more tailored and less invasive strategies. Continued research and innovation promise further improvements in care, with a focus on personalization and minimization of morbidity.

References

Giuliano, A. E., et al. (2010). Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA, 305(6), 569-575. doi:10.1001/jama.2010.90
Donker, M., et al. (2014). Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer patients: 5-year follow-up of the EORTC AMAROS trial. J Clin Oncol, 32(35), 3923-3930. doi:10.1200/JCO.2014.55.7756
Galimberti, V., et al. (2013). Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol, 14(4), 297-305. doi:10.1016/S1470-2045(13)70035-4
Williams, A. D., & Weiss, A. (2023). Recent Advances in the Upfront Surgical Management of the Axilla in Patients with Breast Cancer. Clinical Breast Cancer. doi:10.1016/j.clbc.2023.12.007
Weiss, A., & Williams, A. D. (2023). Avoiding axillary lymph node dissection in breast cancer surgery: evidence and strategies. Clinical Breast Cancer, DOI information pending.

Keywords

1. Breast Cancer Surgery
2. Axillary Surgery De-escalation
3. Sentinel Lymph Node Biopsy
4. Axillary Lymph Node Dissection
5. Personalized Surgical Management