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Recommendations for staging and managing the axilla

Clinical practice recommendations

Please see statements of evidence on which the following recommendations are based.

Recommendations to an individual should be based on their circumstances, the absolute benefits and harms of the treatment, and their personal preferences. These factors should be discussed with the woman.3

RECOMMENDATIONS

 

LEVEL OF EVIDENCE4

Note: Intervention studies unless otherwise indicated


REFERENCE
In women with early (operable) breast cancer:  
Management of the axilla should be determined by a multidisciplinary team in discussion with the woman III NBCC1 
NBCC5

The woman should be adequately prepared for the treatment or procedure. For staging and management of the axilla, this includes information on the benefits and risks of all aspects of axillary management including:

  • sentinel node biopsy
  • axillary dissection
  • axillary radiotherapy
  • observation

Refer to the NBOCC guidelines1-2 for information about the clinically significant morbidity associated with axillary dissection and guidelines on sentinel node biopsy

I NBCC & NCCI3
AXILLARY STAGING
Imaging alone (ultrasound, magnetic resonance spectroscopy, MRI, or PET) is not recommended for routine staging of the axilla II/III# Mobbs6
Bedrosian7
Damera8
Motomura9
Sato 10
van Rijk11
Podkrajsek12
Mathijssen 13
Kvistad 14
Yutani15
Barranger16
Lovrics17

For most patients, surgical staging of the axilla is required

Patients with clinically or pathologically positive axillary lymph nodes should be recommended for axillary dissection

Patients with unifocal tumours equal to or less than three centimetres in diameter and clinically negative axillary nodes should be offered sentinel node biopsy as an alternative to axillary dissection

Refer to the NBOCC Recommendations for use of sentinel node biopsy in early (operable)breast cancer2 for comprehensive guidelines on this procedure

Refer to statements of evidence and summary of trial or study results for information on positive sentinel node/s

II











II
NBOCC2











Guiliano18
AXILLARY TREATMENT
For women undergoing axillary dissection, level I or II dissection is recommended as appropriate care; however, if clinically indicated a level III dissection may be performed II NBCC1 
Tominaga19 
Kodama20
For women in whom axillary dissection is contraindicated, radiotherapy of the axilla is recommended where the risk of axillary relapse is considered clinically significant II Louis-Sylvestre21
NSABP0422
In selected women with a low risk of axillary involvement, observation may be an appropriate alternative to axillary dissection II NSABP04 22
IBCSG 23
Martelli24
Axillary radiotherapy is recommended for women at high risk of recurrence or suspected residual disease following axillary dissection II NBCC1
DBCG 82 b&c25

# Studies of diagnostic accuracy were assessed using NHMRC levels of evidence specific for diagnostic studies4

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