Late in the nineteenth century, Halsted postulated that breast cancer spreads first to the regional lymph nodes and then to distant sites.30 Little importance was paid to blood-borne metastases. Halsted argued that extirpation of the axillary lymph nodes would improve survival, and he championed the radical mastectomy as the optimal treatment for primary breast cancer.31 This operation removes the tumor-containing breast, pectoralis muscle, and ipsilateral axillary lymph nodes en bloc. At the time, many surgeons assumed that resection of a node-negative breast cancer was curative, believing that such tumors were excised before distant spread occurred through the axillary lymphatics.18 Eventually, long-term follow-up studies of axillary nodenegative patients revealed that 30 die of metastatic breast cancer.8 In the early twentieth century, these deaths were often attributed to metastases through the internal mammary or supraclavicular lymph node chains.59,61 Extirpation of these nodal chains, however, failed to improve survival and greatly increased morbidity.2,42 Therefore, internal mammary and supraclavicular lymphadenectomies were abandoned. Today, the Halsted paradigm is no longer considered valid. Regional lymph node metastases are not considered a prerequisite for distant metastases. Nonetheless, axillary treatment remains an integral part of the management of primary breast cancer, indicated for invasive breast cancer but not for in situ lesions. For patients with invasive breast cancer, there are two treatment options for the axilla: radiotherapy and surgery. Surgery is the preferred option. It generally involves an axillary lymph node dissection (ALND), undertaken with either mastectomy or breast-sparing surgery. Radiotherapy, of course, has no value as a staging procedure and is an option only for the clinically node-negative axilla. In recent years, the management of the axilla has become a controversial issue. Of particular interest is the effect of axillary management on survival, local control, and staging. Moreover, some surgeons have recently championed the sentinel lymph node biopsy (SLNB) as an alternative to the ALND. This article addresses these issues and presents guidelines for the optimal management of the axilla in primary breast cancer (Table 1).

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