Management of the clinically node-negative axilla in primary breast cancer

Axillary lymph node status is an important prognostic factor in patients with primary breast cancer. Yet, management of the axilla in these patients has been controversial. Sentinel lymph node biopsy (SLNB) is a less morbid procedure with similar survival and recurrence when compared to axillary lymph node dissection (ALND) and has emerged as the standard of care for staging patients with clinically node-negative disease. The results of three randomized trials seem to suggest that completion ALND may not be necessary in all women with T1/T2 tumors that have sentinel node-positive tumors and a low burden of axillary disease. However, while patients with isolated tumor cells or micrometastatic disease in the sentinel node may forego further axillary treatment, we believe that those with macrometastatic disease on SLNB should undergo additional axillary treatment (either ALND or radiotherapy) until further evidence defining which patients may benefit from observation alone emerges.