الفهرس 
Anatomy of AxillaOnly 14 pages are availabe for public view
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Abstract
Breast cancer is a major global problem with nearly one million cases occurring each year over the past several decades.The incidence of the disease is rising worldwide, increasing in developing and developed countries. It comprises 17% of all cancers. (American Cancer Society,et al, 2012)
Female breast cancer is the most commonly diagnosed malignancy ,among women worldwide (23% of all new cancer cases), with an incidence rate more than twice that of colorectal cancer and cervical cancer, and about three times that of lung cancer. It is the second leading cause of cancer deaths in women today secondary to lung cancer. (Jemal , et al., 2011).
In Egypt, breast cancer represents the most common cancer among Egyptian females and constitutes 37% of all female cancers (Omar,et al, 2010) .
The diagnostic process of breast cancer is made by a combination of clinical assessment, radiological imaging and a tissue sample taken by either cytological or histological analysis that is called triple assessment. (Mack L., et al. 2009).
Clinical assessment of breast cancer begins with assessment of family history, personal history of breast problems and physical examination .Clinically breast cancer presents by irregular hard breast lumps, skin changes,bloody discharge, metastatic disease to a distant organ or to the axillary lymph nodes (ALNs) or breast cancer may be asymptomatic (Mack L., et al. 2009).
There are two clinical classifications for breast cancer.Manchester classification which classifies breast cancer into four stages from I to IV & T.N.M. classification which classifies breast cancer according to tumor size (T), presence or absence of LNs (N) and presence or absence of metastasis (M). (Carlson RW, et al., 2011).
Investigations for breast cancers include: mammography,complementary breast ultrasound (for women 30 years of age or less) and biopsy (fine needle aspiration FNAC, core needle
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biopsy, excisional biopsy or needle-guided biopsy for non-palpable mammographic abnormalities).CT and MRI are recently used for diagnosis of breast cancer. (Carlson RW, et al., 2011).
The gold standard treatment for early breast cancer is based on conservative breast surgery (CBS) which consists principally of complete primary breast tumor excision with accepted safety margin of
normal-appearing breast tissue and assessment of ALN status (axillary
lymphadenectomy) followed by postoperative adjuvant radiotherapy of
the remaining breast tissue. (Morrogh M.,et al, 2010).
Axillary lymph node dissection (ALND) also known as axillary
clearance) or (axillary lymphadenectomy) has been a part of the surgical
management of breast cancer since the era of Halsted. Initially, it was thought to be therapeutic,but came to be regarded as a staging procedure when it became evident that the majority of women with nodal metastases died of breast cancer after receiving local therapy alone. (Barry J., et al., 2011).
ALND is of value as it
(1) leads to a more effective adjuvant systemic therapy with improved patient survival,
(2) provides local control with a possible increase in survival;or
(3) provides prognostic information of value to the patient.
These benefits must be considered in light of the long-term complications associated with ALND, as well as the financial cost. (Carlson RW, et al., 2011)
Sentinel lymph node biopsy (SLNB) is one of the minimally invasive procedures that have been introduced in breast surgery to decrease morbidity following ALND. The SLN is the first lymph node or the first group of lymph nodes that drain the cancer. SLNB has become an accurate method and has been developed as an alternative to full ALND for staging the axilla in women with operable clinically node-negative breast cancer; being associated with less morbidity than ALND . It is possible to identify the SLN by injection of a tracer marker, such as a blue dye or a radionuclide (that can be used individually or in combination) into the breast around the site of the tumor .(Rovera F., et al, 2009).
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Recently, the axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during ALND and/or SLNB in an attempt to reduce the risk of postoperative lymphedema.(Bedrosian I., et al., 2010).
It is based on the hypothesis that the lymphatic pathway from the arm cannot be involved by metastasis of the primary breast cancer. (Nos, et al., 2008).
Standard ALND involves removal of level I & II ALNs. Level III ALNs were once routinely included in the dissection but no longer included because removal of these nodes increases the risk of lymph edema without providing significant additional prognostic information. (Neuman HB, et al., 2010).