A 52-year-old postmenopausal woman presents with a 2 cm hard, irregular, non-tender lump in the upper outer quadrant of the right breast with skin tethering. Axillary lymph nodes are clinically enlarged. Triple assessment (clinical, mammography, and core biopsy) confirms invasive ductal carcinoma, ER-positive, HER2-negative. Sentinel lymph node biopsy shows 2 of 3 nodes positive for micrometastases. Which of the following best represents the standard surgical approach for the axilla in this patient?
- A No further axillary surgery; proceed to adjuvant radiotherapy to the axilla
- B Axillary lymph node dissection (level I–III) ✓
- C Repeat sentinel lymph node biopsy after neoadjuvant chemotherapy
- D Observation alone with axillary ultrasound surveillance
Explanation
In a patient with clinically node-positive disease confirmed preoperatively or with more than 2 positive sentinel nodes, axillary lymph node dissection (ALND) of levels I–III remains the standard of care to achieve locoregional control and accurate staging. The Z0011 trial supports omission of ALND in patients with 1–2 positive sentinel nodes undergoing breast-conserving surgery with whole-breast radiotherapy, but this patient has clinically palpable nodal disease and 2 positive nodes — making ALND appropriate. Observation alone is insufficient for confirmed nodal disease. Adjuvant axillary radiotherapy may substitute for ALND in specific clinical scenarios but not as the primary approach here.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.