Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer

SIMPLE SUMMARY: Axillary lymph node dissection (ALND) has traditionally been performed to assess nodal status, prevent axillary recurrence, and possibly improve survival. However, the procedure has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy was introduced as an alternative approach to assess axillary nodal status and potentially eliminate the need for ALND in patients with clinically node-negative (cN0) breast cancer. Despite this progress, eliminating ALND for all breast cancer patients still seems premature at this time. Recently, various forms of conservative axillary surgery have been developed to replace or supplement conventional ALND. Conservative axillary surgery may be promising in reducing the incidence of arm lymphedema without increasing the risk of axillary recurrence. ABSTRACT: Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.