Breast Cancer

, Volume 20, Issue 1, pp 41–46 | Cite as

The changing role of axillary lymph node dissection for breast cancer

  • Masakuni NoguchiEmail author
  • Emi Morioka
  • Yukako Ohno
  • Miki Noguchi
  • Yasuharu Nakano
  • Takeo Kosaka
Review Article


Currently, it is standard practice that patients with negative sentinel lymph nodes (SLNs) do not undergo axillary lymph node dissection (ALND), whereas ALND is mandated in those with positive SLNs. However, the Z0011 trial showed that ALND could be safely omitted in selected patients with positive SLNs. This article presents a review and discussion of the current role and practice of ALND in the surgical management of breast cancer. A review of the English-language medical literature was performed using the MEDLINE database and cross-referencing major articles on the subject. It may be concluded that ALND can be avoided not only in patients with negative SLNs but also in those with positive SLNs who undergo breast-conserving therapy with whole-breast irradiation and appropriate systemic therapy. However, the omission of ALND would be indicated only in patients with a low axillary tumor burden. On the other hand, ALND remains a standard method of treating regional disease not only in patients with clinically positive nodes but also in other SLN-positive patients who do not meet the above criteria. Although the role of ALND has been limited to the prevention of axillary recurrence, SLN biopsy with whole-breast irradiation and systemic therapy can replace ALND in patients with a low axillary tumor burden.


Breast cancer Axillary lymph node dissection Sentinel lymph node biopsy ACOSOG Z0011 



American College of Surgeons Oncology Group


American Joint Committee on Cancer


Axillary lymph node dissection




Isolated tumor cells


Memorial Sloan-Kettering Cancer Center


National Surgical Adjuvant Breast and Bowel Project


Sentinel lymph node


Conflict of interest

The author indicated no potential conflicts of interest.


  1. 1.
    Fisher B, Redmond C, Fisher ER, Bauer M, Wolmark N, Wickerham DL, et al. Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med. 1985;312:674–81.PubMedCrossRefGoogle Scholar
  2. 2.
    Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567–75.PubMedCrossRefGoogle Scholar
  3. 3.
    Noguchi M, Miwa K, Michigishi T, Yokoyama K, Nishijima H, Takanaka T, et al. The role of axillary lymph node dissection in breast cancer management. Breast Cancer. 1997;4:143–53.PubMedCrossRefGoogle Scholar
  4. 4.
    Giuliano AE, Dale PS, Turner RR, Morton DL, Evans SW, Krasne DL. Improved axillary staging of breast cancer with sentinel lymphadenectomy. Ann Surg. 1995;222:394–401.PubMedCrossRefGoogle Scholar
  5. 5.
    Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11:927–33.PubMedCrossRefGoogle Scholar
  6. 6.
    Veronesi U, Viale G, Paganelli G, Zurrida S, Luini A, Galimberti V, et al. Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study. Ann Surg. 2010;251:595–600.PubMedCrossRefGoogle Scholar
  7. 7.
    Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569–75.PubMedCrossRefGoogle Scholar
  8. 8.
    Giuliano AE, McCall L, Beitsch P, Whitworth PW, Blumencranz P, Leitch AM, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg. 2011;252:426–32.Google Scholar
  9. 9.
    Morrow M, Giuliano AE. To cut is to cure: can we really apply Z11 in practice? Ann Surg Oncol. 2011;18:2413–5.PubMedCrossRefGoogle Scholar
  10. 10.
    Gnant M, Harbeck N, Thomssen C. St. Gallen 2011: summary of the consensus conference. Breast Care. 2011;2011(6):136–41.CrossRefGoogle Scholar
  11. 11.
    Halsted W. The results of operations for cure of cancer of the breast performed at Johns Hopkins Hospital. Johns Hopkins Hosp Bull. 1895;4:497.Google Scholar
  12. 12.
    Halsted W. The results of radical operations for the cure of carcinoma of the breast. Ann Surg. 1907;46:1019.Google Scholar
  13. 13.
    Noguchi M. Does regional treatment improve the survival in patients with operable breast cancer? Breast Cancer Res Treat. 2002;76:269–82.PubMedCrossRefGoogle Scholar
  14. 14.
    Orr RK. The impact of prophylactic axillary node dissection on breast cancer survival: a Bayesian meta-analysis. Ann Surg Oncol. 1999;6:109–66.PubMedCrossRefGoogle Scholar
  15. 15.
    Hayward JL. The Guy’s Hospital trials on breast conservation. In: Harris JR, Hellman S, Silen W, editors. Conservative management of breast cancer. Philadelphia: J.B. Lippincott; 1983. p. 77–90.Google Scholar
  16. 16.
    Hayward J, Caleffi M. The significance of local control in the primary treatment of breast cancer. Arch Surg. 1987;122:1244–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Hayward JL. The Guy’s trial of treatment of “early” breast cancer. World J Surg. 1977;1:314–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Cady B, Stone MD, Schuler JG, Thakur R, Wanner MA, Lavin PT. The new era in breast cancer. Invasion, size, and nodal status involvement dramatically decreasing as result of mammographic screening. Arch Surg. 1996;131:301–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Morrow M. Axillary dissection: when and how radical? Semin Surg Oncol. 1996;12:321–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Noguchi M, Katev N, Miyazaki I. Diagnosis of axillary lymph node metastases in patients with breast cancer. Breast Cancer Res Treat. 1996;40:283–93.PubMedCrossRefGoogle Scholar
  21. 21.
    Rubio IT. Positive sentinel lymph node: new controversies regarding axillary node dissection. J Surg Oncol. 2006;93:517–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Reynolds C, Mick R, Donohue JH, Grant CS, Farley DR, Callans LS, et al. Sentinel lymph node biopsy with metastasis: can axillary dissection be avoided in some patients with breast cancer. J Clin Oncol. 1999;17:1720–6.PubMedGoogle Scholar
  23. 23.
    Noguchi M. Avoidance of axillary lymph node dissection in selected patients with node-positive breast cancer. Eur J Surg Oncol. 2008;34:129–34.PubMedCrossRefGoogle Scholar
  24. 24.
    Singletary SE, Greene FL. Revision of breast cancer staging: the 6th edition of the TNM classification. Semi Surg Oncol. 2003;21:53–9.CrossRefGoogle Scholar
  25. 25.
    Noguchi M. Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes. Br J Surg. 2002;89:1505–15.PubMedCrossRefGoogle Scholar
  26. 26.
    Cserni G, Gregori D, Merletti F, Sapino A, Mano MP, Ponti A, et al. Meta-analysis of non-sentinel node metastases associated with micrometastatic sentinel nodes in breast cancer. Br J Surg. 2004;91:1245–52.PubMedCrossRefGoogle Scholar
  27. 27.
    Bilimoria KY, Bentrem DJ, Hansen NM, Bethke KP, Rademaker AW, Ko CY, et al. Comparison of sentinel lymph node biopsy alone and completion axillary lymph node dissection of node-positive breast cancer. J Clin Oncol. 2009;27:2946–53.PubMedCrossRefGoogle Scholar
  28. 28.
    Hansen NM, Grube B, Ye X, Turner RR, Brenner RJ, Sim MS, et al. Impact of micrometastases in the sentinel node of patients with invasive breast cancer. J Clin Oncol. 2009;27:4679–84.PubMedCrossRefGoogle Scholar
  29. 29.
    Hwang RF, Krishnamurthy S, Hunt KK, Mirza N, Ames FC, Feig B, et al. Clinicopathologic factors predicting involvement of nonsentinel axillary nodes in women with breast cancer. Ann Surg Oncol. 2003;10:248–54.PubMedCrossRefGoogle Scholar
  30. 30.
    Degnim AC, Kriffith KA, Newman L. Clinicopathologic features of metastasis in non sentinel lymph nodes of breast carcinoma patients: a metaanalysis. Cancer. 2003;98:2307–15.PubMedCrossRefGoogle Scholar
  31. 31.
    Van Zee KJ, Manasseh DM, Bevilacqua JL, Boolbol SK, Fey JV, Tan LK, et al. A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003;10:1140–51.PubMedCrossRefGoogle Scholar
  32. 32.
    Coutant C, Olivier C, Lambaudie E, Fondrinier E, Marchal F, Guillemin F, et al. Comparison of models to predict nonsentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: a prospective multicenter study. J Clin Oncol. 2009;27:2800–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Park J, Fey JV, Naik AM, Borgen PI, Van Zee KJ, Cody HS. A declining rate of completion axillary dissection in sentinel lymph node-positive breast cancer patients is associated with the use of a multivariate nomogram. Ann Surg. 2007;245:462–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Naik AM, Fey J, Gemignani M, Heerdt A, Montgomery L, Petrek J, et al. The risk of axillary relapse after sentinel lymph node biopsy for breast cancer is comparable with that of axillary lymph node dissection: a follow-up study of 4008 procedures. Ann Surg. 2004;240:462–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Hwang RF, Gonzalez-Angulo AM, Yi M, Buchholz TA, Meric-Bernstan F, Kuerer HM, et al. Low locoregional failure rates in selected breast cancer patients with tumor-positive sentinel lymph nodes who do not undergo completion axillary dissection. Cancer. 2007;110:723–30.PubMedCrossRefGoogle Scholar
  36. 36.
    Galimberti V, Botteri E, Chifu C, Gentilini O, Luini A, Intra M, et al. Can we avoid axillary dissection in the micrometastatic sentinel node in breast cancer? Breast Cancer Res Treat. 2012;131:819–25.PubMedCrossRefGoogle Scholar
  37. 37.
    Straver ME, Meijnen P, van Tienhoven G, van de Velde CJH, Mansel RE, Bogaerts J, et al. Sentinel node identification rate and nodal involvement in the EORTC 10981–22023 AMAROS trial. Ann Surg Oncol. 2010;17:1854–61.PubMedCrossRefGoogle Scholar
  38. 38.
    Cody HS III, Houssami N. Axillary management in breast cancer: what’s new for 2012? Breast. 2012;21:411–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Pazaiti A, Fentiman IS. Which patients need an axillary clearance after sentinel node biopsy? Int J Breast Cancer. 2011. doi: 10.4061/2011/195892.PubMedGoogle Scholar
  40. 40.
    McGhan LJ, Dueck AC, Gray RI, Wasif N, McCullough AE, Pockaj BA. The changing landscape of axillary surgery: which breast cancer patients may still benefit from complete axillary lymph node dissection? J Surg Oncol. 2011. doi: 10.1002/jso.22131.PubMedGoogle Scholar
  41. 41.
    Turner RR, Giuliano AE. Intraoperative pathologic examination of the sentinel lymph node. Ann Surg Oncol. 1999;5:670–2.CrossRefGoogle Scholar
  42. 42.
    Chao C, Wong SL, Ackermann D, Simpson D, Carter MB, Brown CM, et al. Utility of intraoperative frozen section analysis of sentinel lymph nodes in breast cancer. Am J Surg. 2001;182:609–15.PubMedCrossRefGoogle Scholar
  43. 43.
    Noguchi M. Is axillary dissection unnecessary in patients with a positive sentinel lymph node? Breast Cancer. 2012. doi: 10.1007/s12282-012-0351-4.Google Scholar

Copyright information

© The Japanese Breast Cancer Society 2012

Authors and Affiliations

  • Masakuni Noguchi
    • 1
    Email author
  • Emi Morioka
    • 1
  • Yukako Ohno
    • 1
  • Miki Noguchi
    • 1
  • Yasuharu Nakano
    • 1
  • Takeo Kosaka
    • 1
  1. 1.Department of Breast and Endocrine SurgeryKanazawa Medical University HospitalUchinadaJapan

Personalised recommendations