How Many Nodes Are Enough? The Breast Surgeon’s Dilemma

Excerpt

For most of the 20th century, surgeons believed axillary lymph node dissection (ALND) to be a therapeutic procedure for breast cancer, according to Halsted’s notion that breast cancer metastasizes in series from the breast to the nodes and then from the nodes to distant organs.1 The ALND was thought to limit malignant spread by eliminating a critical pathway for cellular migration from the breast to distant sites. On the basis of the rationale that “bigger must be better,” surgeons considered the adequacy of their ALND to be measured by the degree to which the dissected axilla was left devoid of lymphatic and adipose tissue.2 Considered a necessary evil of proper surgical cancer care, lymphedema was largely ignored by the surgical community. This conceptual framework, while intellectually plausible, proved to be biologically flawed. …