br After AS was performed the axillary
After AS was performed, the axillary vein, long thoracic nerve and thoraco-dorsal nerve were not exposed even if a few suspicious LNs were removed, including targeted LNs and SLNs. Conventional ALND is defined as gross removal of most of the ALNs, with exposure of the axillary vein, long thoracic nerve and thoracodorsal nerve18 (Fig. 3). Clinically, we defined AS as removal of a bunch of ALNs located around SLNs and targeted LNs, but without full exposure of the axillary vein, long thoracic nerve and thoracodorsal nerve. Pathologically, we defined AS as the removal of 5e10 ALNs.
Axillary sampling in breast cancer 683
Figure 1 Flow chart showing management of breast cancer with axillary Meropenem node metastasis and follow-up protocol.
The mean SD age of the ALND group was 48.5 8.8 years compared with 52.7 12.1 years in the targeted AS group (Table 1). In both groups, body mass index was similar and the most common tumor type was invasive ductal carci-noma. In the ALND group, the mean clinical and patholog-ical tumor sizes were 2.1 0.8 and 1.9 0.7 cm, respectively. In the targeted AS group, the corresponding sizes were 2.2 1.5 and 2.1 1.2 cm, respectively. The mean hospital stay was significantly longer in the ALND group (p Z 0.046). Although the mean number of meta-static ALNs was similar in both groups, the mean number of LNs removed was significantly higher in the ALND group (p < 0.001). Overall stage and tumor characteristics did not differ significantly between the groups. There was one case of local recurrence in the ipsilateral breast in both groups. During 5-years follow-up, the oncological results did not differ significantly between the groups.
Mean age, body mass index, and tumor types did not differ significantly between the targeted AS only and tar-geted AS with radiotherapy groups (Table 2). The mean clinical and pathological tumor sizes were 2.5 1.3 and 2.1 0.9 cm, respectively, in the targeted AS only group and 2.3 1.6 and 2.2 1.4 cm, respectively, in the tar-geted AS with radiotherapy group. T stages were all included in pT1-2 and the overall stage, tumor character-istics did not differ significantly between the groups.
The disease-free interval was 62.3 21.2 months in the targeted AS only group and 59.7 27.7 months in the targeted AS with radiotherapy group. There was one case (2.6%) of local recurrence and two deaths (5.1%) in the targeted AS with radiotherapy group. Distant metastasis occurred in one case (3.8%) in the targeted AS only group and in three cases (7.7%) in the targeted AS with radio-therapy group, although this difference was not significant.
For many years, ALND was the only management option to evaluate breast cancer metastasis and treat ALNs.4,19 However, ALND is associated with high morbidity, including postoperative seroma, shoulder movement re-striction, axillary paresthesia, and lymphedema.20e23
A new concept of axillary management, SLNB, replaced ALND for axillary staging and management in the late 1990s.24e26 This method was an innovative procedure to reduce postoperative morbidity, including pain, numbness and lymphedema. However, ALND was still performed when metastasis was diagnosed in SLNs and patients frequently had several complications. Recently, the question arose as to whether ALND should be performed in breast cancer with only 1e3 metastatic LNs, and changes in axillary manage-
ment were recommended by the American College of Sur-geons Oncology Group (ACOSOG) Z0011 trial.27,28 Since
Figure 2 Targeted AS procedure. (A) Before surgery, a radiologist injected 1.5 ml-charcoal tracer under sonographic guidance at the side of the suspicious LN. (B) During surgery, an incision was made on the skin overlying the suspicious LN and the surgeon followed the tract of the injected dye. AS was performed, including the tattooed and sentinel LNs. (C) LNs removed by targeted AS. The stained LN was removed with part of the surrounding tissue. (D) Five fat-trimmed axillary LNs. The first LN was stained by tattoo ink and blue dye. A small amount of ink was found at the cortical side of the LN (arrow). The second and third LNs were sentinel LNs and stained with blue dye. The fourth and fifth LNs were not stained with charcoal or blue dye and were classed as non-sentinel LNs. AS, axillary sampling; LN, lymph node.