Surgical Considerations in the Management of Primary Invasive Breast Cancer

  • Carissia Calvo
  • Ismail JatoiEmail author


Patients with primary breast cancer might consider three surgical options: modified radical mastectomy (MT), MT with contralateral prophylactic mastectomy (CPM), and breast-conserving surgery (BCS). Following BCS, radiation therapy (RT) is often required to reduce the risk of ipsilateral breast tumor recurrence, although older patients with indolent tumors may not require radiotherapy after BCS. Moreover, radiotherapy is required for selected high-risk patients who undergo mastectomy. Relative contraindications to BCS include pregnancy, previous breast RT, active collagen vascular diseases, large tumor size in relation to breast size, multicentric disease, and mutation carriers (who are generally treated with bilateral mastectomy for unilateral breast cancer). Preoperative chemotherapy can be utilized to decrease the size of large tumors, allowing BCS to be feasible. Most women with primary breast cancer prefer the option of BCS with adjuvant RT. Paradoxically, there has been a trend in recent years toward the increased utilization of bilateral mastectomy (MT + CPM) for the treatment of unilateral breast cancer, despite a decreased risk for the development of contralateral breast cancer due to improved adjuvant systemic therapies. Sentinel lymph node biopsy (SLNB) is useful in determining the status of the regional lymph nodes while avoiding the morbidity associated with a more extensive axillary lymph node dissection (ALND). Multiple published randomized controlled studies have demonstrated the safety of omitting ALND in women with negative SLNB. Recently published randomized studies have provided evidence that SLNB alone is safe, even in instances where patients have a low burden of axillary disease in the sentinel nodes, particularly if these patients receive adjuvant radiotherapy and adjuvant systemic therapy.


Breast Surgery Mastectomy Breast-conserving surgery Lumpectomy Axilla Sentinel node 


  1. 1.
    Virchow R. Cellular pathology. Philadelphia: JB Lippincott; 1863.Google Scholar
  2. 2.
    Halsted WS. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins hospital from June 1889 to January 1894. Ann Surg. 1894;20:55–497.CrossRefGoogle Scholar
  3. 3.
    Margoles RG. Surgical considerations for invasive breast cancer. Surg Clin North Am. 1999;79:1031–46.CrossRefGoogle Scholar
  4. 4.
    Bonnadonna G, Valagussa P. The contribution of medicine to the primary treatment of breast cancer. Cancer Res. 1988;48:2314–24.Google Scholar
  5. 5.
    Urban JA, Marjoni MA. Significance of internal mammary lymph node metastases in breast cancer. AJR Am J Roentgenol. 1971;111:130–6.CrossRefGoogle Scholar
  6. 6.
    Wagensteen OH. Another look at supraradical operation for breast cancer. Surgery. 1957;41:857–61.Google Scholar
  7. 7.
    Andreassen M, Dahl-Iversen E, Sorensen B. Extended exeresis of regional lymph nodes at operation for carcinoma of breast and the result of a 5-year follow-up of the first 98 cases with removal of the axillary as well as the supraclavicular glands. Acta Chir Scan. 1954;107:206–13.Google Scholar
  8. 8.
    Lacour J, Bucalossi P, Cacers E, et al. Radical mastectomy versus radical mastectomy plus internal mammary dissection. Cancer. 1976;37:206–14.PubMedCrossRefGoogle Scholar
  9. 9.
    McWhirter R. Simple mastectomy and radiotherapy in treatment of breast cancer. Br J Radiol. 1955;28:128–39.PubMedCrossRefGoogle Scholar
  10. 10.
    Mustakalio S. Conservative treatment of breast carcinoma—review of 25-year follow-up. Clin Radiol. 1972;23:110–6.CrossRefGoogle Scholar
  11. 11.
    Margolese R. Surgical considerations in selecting local therapy. J Natl Cancer Inst Monogr. 1992;11:41–8.Google Scholar
  12. 12.
    Bloom HJG, Richardson WW, Harries EJ. Natural history of untreated breast cancer (1805–1933). BMJ. 1962;2:213–21.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Fisher B, Redmond C, Fisher ER, et al. Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Eng J Med. 1985;312:674–81.CrossRefGoogle Scholar
  14. 14.
    Cancer Research Campaign Working Party. Cancer research campaign (King’s/Cambridge) trial for early breast cancer. Lancet. 1980;2:55–60.Google Scholar
  15. 15.
    Veronesi U, Cascinelli N, Mariani L, et al. Twentyyear follow-up of a randomized study comparing breastconserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347:1227–32.PubMedCrossRefGoogle Scholar
  16. 16.
    Arriagada R, Le MG, Rochard F, et al. Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. J Clin Oncol. 1996;14:1558–64.PubMedCrossRefGoogle Scholar
  17. 17.
    Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233–41.PubMedCrossRefGoogle Scholar
  18. 18.
    Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast-conservation therapy. Cancer. 2003;98:696–702.CrossRefGoogle Scholar
  19. 19.
    van Dongen JA, Voogd AC, Fentiman IS, et al. Longterm results of a randomized trial comparing breastconserving therapy with mastectomy: European organization for research and treatment of cancer 10801 trial. J Natl Cancer Inst. 2000;92:1143–50.PubMedCrossRefGoogle Scholar
  20. 20.
    Bilchert-Toft M, Rose C, Anderson JA, et al. Danish randomized trial comparing breast-conservation therapy with mastectomy. J Natl Cancer Inst Monogr. 1992;11:19–25.Google Scholar
  21. 21.
    Lonning PE. Treatment of early breast cancer with conservation of the breast: a review. Acta Oncol. 1991;30:779–92.PubMedCrossRefGoogle Scholar
  22. 22.
    Fowble B. Ipsilateral breast tumor recurrence following breast-conserving surgery for early stage invasive breast cancer. Acta Oncol. 1999;13(Suppl):9–17.CrossRefGoogle Scholar
  23. 23.
    Fisher B. Personal contributions to progress in breast cancer research and treatment. Semin Oncol. 1996;23:414–27.PubMedGoogle Scholar
  24. 24.
    Fisher B, Anderson S, Fisher ER, et al. Significance of ipsilateral breast tumor recurrence after lumpectomy. Lancet. 1991;338:327–31.PubMedCrossRefGoogle Scholar
  25. 25.
    Kurtz JM, Spitalier JM, Amalric R, et al. The prognostic significance of late local recurrence after breastconserving therapy. Int J Radiat Oncol Biol Phys. 1990;18:87–93.PubMedCrossRefGoogle Scholar
  26. 26.
    Donegan WL, Perez-Mesa CM, Watson FR. A biostatistical study of locally recurrent breast carcinoma. Surg Gynecol Obstet. 1966;122:529–40.PubMedGoogle Scholar
  27. 27.
    Borger J, Kemperman H, Hart A, et al. Risk factors in breast-conservation therapy. J Clin Oncol. 1994;12:653–60.PubMedCrossRefGoogle Scholar
  28. 28.
    Jatoi I, Proschan MA. Randomized trials of breastconserving therapy versus mastectomy for primary breast cancer: a pooled analysis of updated results. Am J Clin Oncol. 2005;28(3):289–94.PubMedCrossRefGoogle Scholar
  29. 29.
    Ving-Hung V, Verschraegen C. Breast-conserving surgery with or without radiotherapy: pooled analysis for risks of ipsilateral breast tumor recurrence and mortality. J Natl Cancer Inst. 2004;96:114–21.Google Scholar
  30. 30.
    Early Breast Cancer Trialists’ Collaborative Group. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomized trials. Lancet. 2005;366:2087–106.CrossRefGoogle Scholar
  31. 31.
    Turner BC, Harrold E, Matloff E, et al. BRCA1/BRCA2 germline mutations in locally recurrent breast cancer patients after lumpectomy and radiation therapy: implications for breast-conserving management in patients with BRCA1/BRCA2 mutations. J Clin Oncol. 1999;17:3017–24.PubMedCrossRefGoogle Scholar
  32. 32.
    Kinzler KW, Vogelstein B. Gatekeepers and caretakers. Nature. 1997;386:761–3.PubMedCrossRefGoogle Scholar
  33. 33.
    Pierce LJ, Strawderman M, Narod SA, et al. Effect of radiotherapy after breast-conservig treatment in women with breast cancer and germline BRCA ½ mutations. J Clin Oncol. 2000;18(19):3360–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Metcalfe KA, Lubinski J, Ghadirian P, et al. Prediction of contralateral prophylactic mastectomy in women with a BRCA 1 or BRCA 2 mutation: the hereditary breast cancer clinical study group. J Clin Oncol. 2008;26(7):1093–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Benson J, Jatoi I. Management options breast cancer: case histories, best practice, and clinical decision-making. London: Informa Healthcare; 2009.CrossRefGoogle Scholar
  36. 36.
    Hughes KS, Schnaper LA, Berry D, et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med. 2004;351(10):971–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Atkins H, Hayward JL, Klugman OJ, et al. Treatment of early breast cancer: a report after ten years of a clinical trial. BMJ. 1972;2(5811):423–9.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Winchester O, Cox J. Standards for breast-conservation treatment. CA Cancer J Clin. 1992;42:134–62.PubMedCrossRefGoogle Scholar
  39. 39.
    Foster RS, Wood WC. Alternative strategies in the management of primary breast cancer. Arch Surg. 1998;133:1182–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Veronesi D, Bonadonna G, Zurrida S, et al. Conservation surgery after primary chemotherapy in large carcinomas of the breast. Ann Surg. 1995;222:609–11.CrossRefGoogle Scholar
  41. 41.
    Lehman CD, Gatsonis C, Kuhl CK, et al. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 2007;356:1295–303.PubMedCrossRefGoogle Scholar
  42. 42.
    Solin LJ, Orel SG, Hwang SG, et al. Relationship of breast magnetic resonance imaging to outcome after breastconservation treatment with radiation for women with early stage invasive breast carcinoma or ductal carcinoma in situ. J Clin Oncol. 2008;26:386–91.PubMedCrossRefGoogle Scholar
  43. 43.
    Nattinger AB, Hoffmann RG, Kneusel RT, et al. Relation between appropriateness of primary therapy for early stage breast carcinoma and increased use of breast conserving surgery. Lancet. 2000;356:1148–53.PubMedCrossRefGoogle Scholar
  44. 44.
    Nattinger AB, Gottlieb MS, Veum J, et al. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med. 1992;326:1147–9.CrossRefGoogle Scholar
  45. 45.
    Kelemen JJ, Poulton T, Swartz MT, et al. Surgical treatment of early stage breast cancer in the department of defense healthcare system. J Am Coll Surg. 2001;192:293–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Freedman RA, He Y, Winer EP, Keating NL. Trends in racial and age disparities in definitive local therapy of early stage breast cancer. J Clin Oncol. 2009;27(5):713–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Tuttle TM, Haberman EB, Grund EH, et al. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25(33):5203–309.PubMedCrossRefGoogle Scholar
  48. 48.
    Nattinger AB, Hoffmann RG, Shapiro R, et al. The effect of legislative requirements on the use of breastconserving surgery. N Engl J Med. 1996;335:1035–40.PubMedCrossRefGoogle Scholar
  49. 49.
    Dolan J, Granchi TS, Miller CC, et al. Low use of breast-conservation surgery in medically indigent populations. Am J Surg. 1999;178:470–4.PubMedCrossRefGoogle Scholar
  50. 50.
    Collins ED, Moore CP, Clay KF, et al. Can women with early stage breast cancer make an informed decision for mastectomy? J Clin Oncol. 2009;27(4):519–25.PubMedCrossRefGoogle Scholar
  51. 51.
    Jatoi I, Benson JR, Liau SS, Chen Y, Cisco RM, Norton JA, et al. The role of surgery in cancer prevention. Curr Probl Surg. 2010;47(10):750–830.PubMedCrossRefGoogle Scholar
  52. 52.
    Jatoi I, Benson JR. The case against routine preoperative breast MRI. Future Oncol. 2013;9(3):347–53.PubMedCrossRefGoogle Scholar
  53. 53.
    Sorbero ME, Dick AW, Beckjord EB, Ahrendt G. Diagnostic breast magnetic resonance imaging and contralateral prophylactic mastectomy. Ann Surg Oncol. 2009;16(6):1597–605.PubMedCrossRefGoogle Scholar
  54. 54.
    Murphy JA, Milner TD, O’Donoghue JM. Contralateral risk-reducing mastectomy in sporadic breast cancer. Lancet Oncol. 2013;14(7):e262–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Institute nc. surveillance epidemiology and end results program (2014) Available from:
  56. 56.
    Jatoi I, Parsons HM. Contralateral prophylactic mastectomy and its association with reduced mortality: evidence for selection bias. Breast Cancer Res Treat. 2014;148(2):389–96.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Dowden RV, Rosato FE, McGraw JB. Reconstruction of the breast after mastectomy for cancer. Surg Gynecol Obstet. 1979;149:109–15.PubMedGoogle Scholar
  58. 58.
    Johnson CH, van Heerden JA, Donohue JH, et al. Oncological aspects of immediate breast reconstruction following mastectomy for malignancy. Arch Surg. 1989;124:819–23.PubMedCrossRefGoogle Scholar
  59. 59.
    Vinton AL, Traverso W, Zehring RD. Immediate breast reconstruction following mastectomy is as safe as mastectomy alone. Arch Surg. 1990;125:1303–8.PubMedCrossRefGoogle Scholar
  60. 60.
    Dean C, Chetty D, Forrest APM. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet. 1983;1:459–62.PubMedCrossRefGoogle Scholar
  61. 61.
    Damen TH, Mureau MA, Timman R, et al. The pleasing end result after DIEP flap breast reconstruction: a review of additional operations. J Plast Reconstr Aesthet Surg. 2009;62(1):71–6.PubMedCrossRefGoogle Scholar
  62. 62.
    Jatoi I, Kaufmann M, Petit JY. Atlas of breast surgery. Heidelberg: Springer; 2006.Google Scholar
  63. 63.
    Corral CJ, Mustoe TA. Special problems in breast cancer therapy: controversy in breast reconstruction. Surg Clin North Am. 1996;76:309–26.PubMedCrossRefGoogle Scholar
  64. 64.
    Hulka BS, Kerkvliet NL, Tugwell P. Experience of a scientific panel formed to advise the federal judiciary on silicone breast implants. N Engl J Med. 2000;342:812–5.PubMedCrossRefGoogle Scholar
  65. 65.
    Nyren O, Yin L, Josefsson S, et al. Risk of connective tissue disease and related disorders among women with breast implants: a nation-wide retrospective cohort study in Sweden. BMJ. 1998;316:417–22.PubMedPubMedCentralCrossRefGoogle Scholar
  66. 66.
    Janowsky EC, Kupper LL, Hulka BS. Meta-analyses of the relation between silicone breast implants and the risk of connective tissue diseases. N Engl J Med. 2000;342:781–90.PubMedCrossRefGoogle Scholar
  67. 67.
    Schneider WJ, Hill HL Jr, Brown RG. Latissimus dorsi myocutaneous flap for breast reconstruction. Br J Plast Surg. 1977;30:277–81.PubMedCrossRefGoogle Scholar
  68. 68.
    Amez Z, Smith R, Eder R. Breast reconstruction by the free lower transverse rectus abdominis muscular cutaneous flap. Br J Plast Surg. 1988;41:500–7.CrossRefGoogle Scholar
  69. 69.
    Alderman AK, McMahon L, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the impact of sociodemographic factors. Plast Reconstr Surg. 2003;111:695–703.PubMedCrossRefGoogle Scholar
  70. 70.
    Alderman AK, Wei Y, Birkmeyer JD. Use of breast reconstruction after mastectomy following the Women’s Health and Cancer Rights Act. JAMA. 2006;295(4):387–8.PubMedGoogle Scholar
  71. 71.
    Jatoi I. Management of the axilla in primary breast cancer. Surg Clin North Am. 1999;79:1061–73.PubMedCrossRefGoogle Scholar
  72. 72.
    Veronesi U, Rilke R, Luini A, et al. Distribution of axillary node metastases by level of invasion. Cancer. 1987;59:682–7.PubMedCrossRefGoogle Scholar
  73. 73.
    Morrow M. Axillary dissection: when and how radical? Semin Surg Oncol. 1996;12:321–7.PubMedCrossRefGoogle Scholar
  74. 74.
    Harris JR, Osteen RT. Patients with early breast cancer benefit from effective axillary treatment. Breast Cancer Res Treat. 1985;5:17–21.PubMedCrossRefGoogle Scholar
  75. 75.
    Samphao S, Eremin JM, El-Sheemy M, Eremin O. Management of the axilla in women with breast cancer: current clinical practice and a new selective targeted approach. Ann Surg Oncol. 2009;15(5):1282–96.CrossRefGoogle Scholar
  76. 76.
    Epstein RI. Routine or delayed axillary dissection for primary breast cancer? Eur J Cancer. 1995;31A:1570–3.PubMedCrossRefGoogle Scholar
  77. 77.
    Sacks NPM, Baum M. Primary management of carcinoma of the breast. Lancet. 1993;342:1402–8.PubMedCrossRefGoogle Scholar
  78. 78.
    Baxter N, McCready DR, Chapman JA, et al. Clinical behavior of untreated axillary nodes after local treatment for primary breast cancer. Ann Surg Oncol. 1996;3:235–40.PubMedCrossRefGoogle Scholar
  79. 79.
    Graverson HP, Bilchert-Toft M, Andersen J, et al. Danish breast cancer cooperative group. Breast cancer: risk of axillary recurrence in node-negative patients following partial dissection of the axilla. Eur J Surg Oncol. 1988;14:407–12.Google Scholar
  80. 80.
    Jatoi I, Hilsenbeck SG, Clark GM, et al. The significance of axillary lymph node metastasis in primary breast cancer. J Clin Oncol. 1999;17:2334–40.PubMedCrossRefGoogle Scholar
  81. 81.
    Jatoi I, Anderson WF, Rosenberg PS. Qualitative age interactions in breast cancer: a tale of two diseases? Am J Clin Oncol. 2008;31:504–6.PubMedCrossRefGoogle Scholar
  82. 82.
    Cabanes PA, Salmon RI, Vilcoq JP, et al. Value of axillary dissection in addition to lumpectomy and radiotherapy in early breast cancer. Lancet. 1992;339:1245–8.PubMedCrossRefGoogle Scholar
  83. 83.
    Gelber RD, Goldhirsch A, Coates AS. Adjuvant therapy for breast cancer: understanding the overview. J Clin Oncol. 1993;11:580–5.PubMedCrossRefGoogle Scholar
  84. 84.
    Lonning PE. Breast cancer prognostication and prediction: are we making progress? Ann Oncol. 2007;18(Suppl 8):viii 3–7.Google Scholar
  85. 85.
    Bold RI, Mansfield PF, Berger DH, et al. Prospective, randomized, double-blind study of prophylactic antibiotics in axillary lymph node dissection. Am J Surg. 1998;176:239–43.PubMedCrossRefGoogle Scholar
  86. 86.
    Coit DG, Peters M, Brennan MF. A prospective randomized trial of perioperative cefazolin treatment in axillary and groin dissection. Arch Surg. 1991;126:1366–72.PubMedCrossRefGoogle Scholar
  87. 87.
    Rotstein C, Ferguson R, Cummings KM, et al. Determinants of clean surgical wound infections for breast procedures at an oncology center. Infect Control Hosp Epidemiol. 1992;13:207–14.PubMedCrossRefGoogle Scholar
  88. 88.
    Ivens D, Hoe AL, Podd TJ, et al. Assessment of morbidity from complete axillary dissection. Br J Cancer. 1992;66:136–8.PubMedPubMedCentralCrossRefGoogle Scholar
  89. 89.
    Lyman GH, Giuliano AE, Somerfield MR, et al. American society of clinical oncology guideline recommendations for sentinel lymph node biopsy in early stage breast cancer. J Clin Oncol. 2005;23:7703–20.PubMedCrossRefGoogle Scholar
  90. 90.
    Cabanas RM. An approach for the treatment of penile carcinoma. Cancer. 1977;39:456–66.PubMedCrossRefGoogle Scholar
  91. 91.
    Morton DL, Wen DR, Wong JR, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg. 1992;127:392–9.PubMedCrossRefGoogle Scholar
  92. 92.
    Chen AY, Halpern MT, Schrag MM, et al. Disparities and trends in sentinel lymph node biopsy among early stage breast cancer patients (1998–2005). J Natl Cancer Inst. 2008;100(7):462–74.PubMedCrossRefGoogle Scholar
  93. 93.
    Giuliano AE, Jones RC, Brennan M. Sentinel lymphadenectomy in breast cancer. J Clin Oncol. 1997;15:2345–50.PubMedCrossRefGoogle Scholar
  94. 94.
    Veronesi D, Paganelli G, Galimberti V. Sentinel node biopsy to avoid dissection in breast cancer with clinically negative lymph nodes. Lancet. 1997;349:1864–7.PubMedCrossRefGoogle Scholar
  95. 95.
    Smith LF, Cross MJ, Klimberg VS. Subareolar injection is a better technique for sentinel node biopsy. Am J Surg. 2000;180:434–7.PubMedCrossRefGoogle Scholar
  96. 96.
    Morrow M, Rademaker AW, Bethke KP, et al. Learning sentinel node biopsy: results of a prospective trial of two techniques. Surgery. 1999;126:714–20.PubMedCrossRefGoogle Scholar
  97. 97.
    Giuliano AE, Dale PS, Turner RR, et al. Improved axillary staging of breast cancer with sentinel node lymphadectomy. Ann Surg. 1995;222:394–9.PubMedPubMedCentralCrossRefGoogle Scholar
  98. 98.
    McMasters KM, Giuliano AE, Ross MI, et al. Sentinel lymph node biopsy for breast cancer—not yet standard of care. N Engl J Med. 1998;339:990–5.PubMedCrossRefGoogle Scholar
  99. 99.
    Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003;349(6):546–53.PubMedCrossRefGoogle Scholar
  100. 100.
    Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology group trial Z0011. J Clin Oncol. 2007;25:3657–63.PubMedCrossRefGoogle Scholar
  101. 101.
    Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC trial. J Natl Cancer Inst. 2006;98(9):599–609.PubMedCrossRefGoogle Scholar
  102. 102.
    Albertini JJ, Lyman GH, Cox C, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA. 1996;276:1818–22.Google Scholar
  103. 103.
    Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg. 2010;252:426–32.PubMedGoogle Scholar
  104. 104.
    American Joint Committee on Cancer Breast Cancer Staging 7th edition. Available from: Accessed 28 May 2016.
  105. 105.
    Galimberti VV. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013;14:297.PubMedPubMedCentralCrossRefGoogle Scholar
  106. 106.
    Solá MM. Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastasis: final results from the multicenter clinical trial AATRM 048/13/2000. Ann Surg Oncol. 2013;20:120.PubMedCrossRefGoogle Scholar
  107. 107.
    Goyal AA, Dodwell D. POSNOC: a randomised trial looking at axillary treatment in women with one or two sentinel nodes with macrometastases. J Clin Oncol (Royal College of Radiologists (Great Britain)). 2015;27:692.Google Scholar
  108. 108.
    Donker MM. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014;15:1303.PubMedPubMedCentralCrossRefGoogle Scholar
  109. 109.
    Kuehn TT. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013;14:609.PubMedCrossRefGoogle Scholar
  110. 110.
    Boughey JCJ. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455.PubMedPubMedCentralCrossRefGoogle Scholar
  111. 111.
    Boileau JJ. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015;33:258.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Texas Health Science CenterSan AntonioUSA
  2. 2.Division of Surgical Oncology and Endocrine SurgeryUniversity of Texas Health Science CenterSan AntonioUSA

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