Is axillary lymph node clearance required in node-positive breast cancer?

KEY POINTS * Axillary micrometastases require no further axillary treatment after SNB for patients with early stage breast cancer * After positive sentinel node biopsy, axillary irradiation

provides equivalent regional control to nodal clearance in early breast cancer * Less morbidity (especially lymphoedema) is seen after axillary radiotherapy * Axillary dissection can be

safely omitted in patients with more than two positive sentinel nodes after breast-conserving surgery, provided whole-breast radiation therapy is planned ABSTRACT Although the majority of

patients with breast cancer have clinically negative axillary nodes at preoperative assessment, around 15–20% of these women will have metastatic disease within the lymph nodes at operative

sentinel node biopsy, and additional selective treatment to the axilla might be required. Local treatment to the axilla can include axillary node clearance or axillary radiotherapy. The

recent results of the American College of Surgeons Oncology Group Z0011 trial suggested that some women would be safe from recurrence without further axillary treatment if they have less

than three involved sentinel nodes, with no extracapsular spread. We review the evidence base for management of the axilla after detection of a positive sentinel node, discuss the evidence

for why micrometastatic disease requires systemic but not axillary therapy, and present data suggesting that axillary irradiation for macrometastases gives equivalent control to axillary

node clearance, but causes less morbidity such as lymphoedema. Ongoing trials will confirm whether any further therapy can be omitted for all patients with low volume, sentinel-node

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AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Academic Surgery, University Hospital of South Manchester, Southmoor Road, Wythenshawe, M23 9LT, Manchester, UK Nigel J. Bundred 

& Nicola L. P. Barnes * Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 100CX, Netherlands Emiel Rutgers * Department of Radiotherapy, Netherlands Cancer

Institute, Plesmanlaan 121, Amsterdam, 100CX, Netherlands Mila Donker Authors * Nigel J. Bundred View author publications You can also search for this author inPubMed Google Scholar *

Nicola L. P. Barnes View author publications You can also search for this author inPubMed Google Scholar * Emiel Rutgers View author publications You can also search for this author inPubMed

 Google Scholar * Mila Donker View author publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS All authors made substantial contributions to all stages of

the preparation of the manuscript for submission. CORRESPONDING AUTHOR Correspondence to Nigel J. Bundred. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no competing financial

interests. POWERPOINT SLIDES POWERPOINT SLIDE FOR TABLE 1 POWERPOINT SLIDE FOR TABLE 2 RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Bundred, N.,

Barnes, N., Rutgers, E. _et al._ Is axillary lymph node clearance required in node-positive breast cancer?. _Nat Rev Clin Oncol_ 12, 55–61 (2015). https://doi.org/10.1038/nrclinonc.2014.188

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