New standards of care in the management of the axilla

Purpose of Review: The management of the axilla in early breast cancer remains controversial. This review describes the current literature focussing on the management of the clinically negative axilla. Recent Findings: For women with isolated tumour cells or micrometastases [nodal deposit(s) > 2 mm] in one or more axillary nodes, disease-free survival may be reduced, without a significant impact on overall survival. For macrometastases (node deposits >2mm), the convention of axillary clearance has been challenged. Axillary clearance compared with no surgery in patients undergoing breast conservation in women with predominantly small, estrogen receptor-positive, low-grade cancers receiving systemic therapy demonstrated no difference in disease-free survival or overall survival. However, the confounding treatment by axillary radiotherapy (alongside breast radiotherapy) is in keeping with improved disease-free survival in conservation patients treated with breast and axillary radiotherapy compared with those treated with breast radiotherapy alone. Direct prospective comparison of axillary clearance and radiotherapy is eagerly awaited. Summary: Further information is still required to define which patients with low-volume macrometastatic axillary disease may not require further local treatment and whether surgery or radiotherapy is equally effective in treating the node-positive axilla.