Back to Cancer Australia's website

Cancer Australia

Select a guideline

Recommendations for staging and managing the axilla

Statements of evidence

The following statements of evidence support the Clinical Practice Recommendations.

STATEMENTS

LEVEL OF EVIDENCE4

Note: Intervention studies unless otherwise indicated

REFERENCE
In women with early (operable) breast cancer:
Outcomes for women with breast cancer are better if they are treated by a clinician who has access to the full range of treatment options in a multidisciplinary care setting III NBCC5
AXILLARY STAGING
SURGICAL STAGING

Axillary dissection

Axillary dissection is the most accurate method for the axillary staging of breast cancer compared to axillary sampling, however it is associated with clinically significant morbidity, including lymphoedema

NBCC1
NBOCC2

The extent of axillary lymph node involvement is correlated with local and systemic recurrence rates

The proportion of positive nodes identified is a predictor for recurrence and survival

II^


III^
Truong26


van der Wal27
Voordeckers28
Ving-Hung29
Fortin30
Truong31
Kuru32

Sentinel node biopsy

Sentinel node biopsy is an accurate and suitable alternative to axillary dissection in women with tumours three centimetres or less in diameter to determine if cancer cells have spread to the axillary lymph nodes

Refer to the NBOCC Recommendations for use of sentinel node biopsy in early (operable) breast cancer, 2008 for comprehensive guidelines on this procedure2

Note new evidence published since 2008*

When the sentinel node is negative, there is no significant difference in overall survival, disease-free survival and regional control between sentinel node biopsy followed by axillary dissection and sentinel node biopsy alone in patients with clinically negative lymph nodes

II










II
NBOCC2












NSABP B-3233

Axillary sampling

Unguided axillary sampling (followed by radiotherapy, as indicated) provides inferior axillary tumour control, compared with axillary dissection

II Lambah34
NON-SURGICAL STAGING (IMAGING)
Imaging alone (without confirmatory pathology) is unreliable as a diagnostic test for axillary lymph node involvement, due to low sensitivity II/III# Mobbs6
Bedrosian7
Damera8
Motomura9
Sato10
van Rijk11
Podkrajsek12
Mathijssen 13
Kvistad14
Yutani15
Barranger16 Lovrics17

Ultrasound

Ultrasound confirmed by cytology (fine needle aspiration [FNA]) or histology core biopsy approaches 100% specificity and 93% accuracy, but ultrasound alone has a low (≤80%) negative predictive value

A preoperative finding of ultrasound-positive nodes confirmed by FNA or core biopsy might allow the patient to proceed to axillary clearance immediately, without initial sentinel node biopsy

A negative result on ultrasound plus FNA/core biopsy would not remove the need for surgical axillary staging

III# Mobbs6
Brancato35
Sapino36
Bedrosian7
Krishnamurthy37
Topal38
Damera8

Magnetic resonance imaging (MRI)

There are currently insufficient data available on the accuracy of MRI in axillary staging

Murray39
Kvistad14

Positron emission tomography (PET)

The available data on the accuracy of PET in axillary staging vary widely between studies

II# Greco40
Yutani15
Barranger16
Lovrics17
AXILLARY TREATMENT

AXILLARY DISSECTION

Similar clinical outcomes for survival, local recurrence and morbidity are achieved by either level II or III axillary dissection

II Tominaga19
Similar clinical outcomes for survival, local recurrence and morbidity are achieved by either level I or III axillary dissection II Kodama20
The number of nodes retrieved at axillary dissection varies between studies, and the estimated optimal number also differs between investigators III^ Axelsson41
Weir42
Mersin43
Truong31
Overall, axillary recurrence rates are low following axillary dissection II NSABP0422
IBCSG23
Martelli24
Patients with suspected residual disease following axillary dissection may need further treatment NBCC1

AXILLARY RADIOTHERAPY

Radiotherapy following axillary dissection is associated with increased rates of lymphoedema, compared with axillary dissection alone or axillary radiotherapy alone

Five-field radiotherapy gives benefit; however the role of targeting the axilla in this technique is unclear


Radiotherapy alone to the axilla may be indicated for selected patients at high risk of microscopic disease in the axilla and with contraindications to surgery, without a survival disadvantage

III Chang44
Grills45
Johansen46



Ragaz47
DBCG 82 b&c25

NSABP0422

* There is no significant difference in overall or disease-free survival, or in locoregional recurrence, between women undergoing axillary lymph node dissection, or sentinel lymph node dissection alone for women eligible for the Z0011 randomised trial. These women were treated with breast-conserving surgery, whole-breast irradiation and adjuvant systemic therapy. Refer to Summary of trial or study results for more information on the Z0011 trial and the patient characteristics of eligible women.

^ Prognostic studies were assessed using NHMRC levels of evidence specific for prognostic studies

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

Published using CeCC Docbook Manager