Prospective evaluation of the morbidity of axillary clearance for breast cancer M. Duff, A. D. K. Hill, G. McGreal, S. Walsh, E. W. McDermott and N. J. O'Higgins St Vincent's University Hospital, Elm Park, Dublin 4, Ireland Correspondence to: Professor N. J. O'Higgins e-mail: niall.o'higgins@ucd.ie) Background: Axillary clearance, despite its morbidity, retains an essential role in the management of patients with breast cancer. The aim of this prospective study was to document the development of arm swelling and limitation of shoulder movement following complete axillary clearance. Methods: One hundred patients who had axillary clearance to level III, for treatment of breast cancer, were followed prospectively for over 1year. Arm volumes were measured using an optoelectronic volometer and shoulder movements with a goniometer. Results: Ten patients had signi®cant arm swelling at 1year. The swelling was mild in eight and moderate in two. No patient developed severe swelling. Reduced arm movements were noted in the ®rst week after operation but had returned to normal at 6 months. Conclusion: This study provided accurate documentation of the morbidity associated with axillary clearance, together with a reproducible method of arm volume measurement. Paper accepted 11 July 2000 British Journal of Surgery 2001, 88, 114±117 Introduction Axillary node involvement is recognized as the single most important factor in the staging of carcinoma of the breast 1 . Clinical assessment of the axilla is highly inaccurate 2 and axillary sampling can frequently underestimate the extent of nodal disease 1,3,4 . While recent reports on the intraopera- tive detection of sentinel lymph nodes 3±8 are promising, axillary clearance remains the most accurate means of determining lymph node status. Axillary clearance is associated with lower levels of local recurrence than other forms of management, but at the expense of signi®cant morbidity, in particular the limitation of shoulder function and arm swelling 9±11 . The measurement of changes in arm volume has been dif®cult to perform in an accurate and reproducible manner. Arm circumference, measured with a tape measure at set points from a bony prominence, is convenient and has been used frequently, but it is inaccurate 12,13 . The measurement of limb volume by water displacement is accurate if performed by experienced personnel on a mobile patient, but is dif®cult, time consuming and unsuitable for use immediately after surgery. The volometer is an ef®cient and accurate method of performing these measurements. The aim of this study was to document the development of arm swelling and limitation in shoulder movement in patients who had a mastectomy or breast-conserving surgery in association with axillary clearance for unilateral breast cancer. Patients and methods One hundred patients with unilateral breast cancer were followed prospectively from the time of surgery for 1±2 years. All patients had axillary clearance to level III, together with mastectomy or wide local excision. All surgery was performed in one surgical unit as described previously 14 and was continuously audited for quality control 15 . No intravenous access was acquired in the side undergoing axillary dissection. The need for adjuvant therapy was assessed individually but no patient received axillary radiotherapy. All patients were seen before and after operation by the physiotherapist and instructed in exercises to be performed after operation to maximize the range of shoulder movement. All arm volume measurements were carried out by a single operator using an optoelectronic volometer German Bo È sl Medizintechnik, Hamburg, Germany). Signi®cant Original article 114 ã 2001 Blackwell Science Ltd British Journal of Surgery 2001, 88, 114±117