highlights the need for and ability of primary tumor characteristics to predict the incidence of regional lymph node metastases. To develop reliable criteria for patients who do not require axillary lymph node dissection and to gauge the usefulness of axillary lymph node dissection, primary tumor characteristics are critical. The article by Barth et al. is particularly valuable because it represents results from a small number of surgeons and pathologists working closely together in a well organized breast cancer clinic with extensive prospective data collection and analysis of consecutive axillary lymph node dissections in 918 patients with lesions of T1 size (Β°2 cm). It provides particularly fertile ground for the exploration of primary tumor features to make judgments regarding the likelihood of axillary lymph node metastases and the need for axillary lymph node dissection, because these smaller carcinomas are being observed with much greater frequency as a result of widespread mammographic screening. 2 Because the impact of mammographic screening has increased greatly in the 1990s, it would be even more useful if the authors analyzed their data by consecutive time periods, e.g., comparing 1979 through 1987 with 1988 through 1995. This would display truly contemporary data in the latter group and might accentuate their conclusions.
The greatest morbidity of current breast carcinoma management is that resulting from axillary lymph node dissection. This surgery requires general anesthesia, a brief hospitalization, short lived but significant postoperative morbidity, and a long term risk of Β’15% of arm edema and breast edema that, on occasion, can be disabling, as well as considerable expense (estimated at approximately $10,000). There is no more important goal in the near future for the manage-See reply to counterpoint on pages 1862-4 and ment of breast carcinoma patients than to find ways to eliminate referenced original article on pages 1918-22, this issue.
axillary lymph node dissection so that primary breast carcinoma management can consist of largely outpatient procedures with negligible Address for reprints: Blake Cady, M.D., Departshort and long term surgical morbidity. The only reason currently for ment of Surgical Oncology, New England Deaaxillary lymph node dissection is to provide prognostic information coness Hospital, 110 Francis Street, Suite 2H, based on the presence and number of lymph node metastases and Boston, MA 02215.
their size (micrometastases vs. macrometastases), which in turn leads to judgments regarding the need to utilize adjuvant systemic therapy