Technique of axillary lymph node dissection
- Julie Margenthaler, MD
Julie Margenthaler, MD
- Associate Professor, Division of General Surgery, Endocrine and Oncology Surgery
- Washington University School of Medicine
- Section Editor
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
Evaluation of the axilla provides information for treatment decisions in patients with invasive breast cancer. Axillary lymph node dissection is the standard initial approach for breast cancer patients who are clinically node positive. Sentinel node biopsy is the standard initial approach for patients with early stage breast cancer who are clinically node negative.
The technique of axillary lymph node dissection (ALND) will be reviewed here. The approach to management of the regional lymph nodes in breast cancer, sentinel node biopsy indications and outcomes, sentinel node biopsy techniques, and the effect of ALND on patient survival are discussed elsewhere. (See "Management of the regional lymph nodes in breast cancer", section on 'Axillary dissection' and "Diagnosis, staging and the role of sentinel lymph node biopsy in the nodal evaluation of breast cancer" and "Sentinel lymph node biopsy in breast cancer: Techniques" and "Management of the regional lymph nodes in breast cancer", section on 'Impact of ALND on survival'.).
Axillary lymph node dissection (ALND) is indicated for most patients with positive ipsilateral axillary lymph nodes, when diagnosed by sentinel lymph node dissection (SLND) or fine needle aspiration. However, the need for ALND in patients with a positive SLND showing micrometastases or macrometastases in less than three nodes has been questioned and remains controversial [1-3]. The management of a positive sentinel lymph node biopsy is discussed in detail elsewhere. (See "Management of the regional lymph nodes in breast cancer", section on 'Axillary dissection' and "Diagnosis, staging and the role of sentinel lymph node biopsy in the nodal evaluation of breast cancer".)
For patients with known nodal involvement, staging should be performed to assess the extent of disease. Patients found to have distant metastases usually do not need ALND. (See "Clinical features, diagnosis, and staging of newly diagnosed breast cancer".)
ALND is contraindicated as a first-line method of axillary staging for patients with early stage breast cancer who are clinically node negative and patients with ductal carcinoma in situ (DCIS). Completion ALND is not recommended in the setting of a negative sentinel lymph node dissection [4,5]. (See "Diagnosis, staging and the role of sentinel lymph node biopsy in the nodal evaluation of breast cancer".)
- Carlson GW, Wood WC. Management of axillary lymph node metastasis in breast cancer: making progress. JAMA 2011; 305:606.
- Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA 2011; 305:569.
- Ho AY, Cody HS. Which patients with sentinel node-positive breast cancer can avoid axillary dissection? Am Soc Clin Oncol Educ Book 2013; :61.
- Wang Z, Wu LC, Chen JQ. Sentinel lymph node biopsy compared with axillary lymph node dissection in early breast cancer: a meta-analysis. Breast Cancer Res Treat 2011; 129:675.
- Kell MR, Burke JP, Barry M, Morrow M. Outcome of axillary staging in early breast cancer: a meta-analysis. Breast Cancer Res Treat 2010; 120:441.
- Anson, BJ, McVay, CB. Thoracic walls: Breast or mammary region. In: Surgical Anatomy, 6th edition, Anson, BJ, McVay, CB (Eds), Saunders, Philadelphia 1984. p.357.
- Petrek JA, Blackwood MM. Axillary dissection: current practice and technique. Curr Probl Surg 1995; 32:257.
- Ung O, Tan M, Chua B, Barraclough B. Complete axillary dissection: a technique that still has relevance in contemporary management of breast cancer. ANZ J Surg 2006; 76:518.
- AJCC (American Joint Committee on Cancer) Cancer Staging Manual, 6th ed, Greene FL, Page DL, Fleming ID, et al (Eds), Springer-Verlag, New York 2002. p.223.
- Leaper DJ, Melling AG. Antibiotic prophylaxis in clean surgery: clean non-implant wounds. J Chemother 2001; 13 Spec No 1:96.
- Gagliardi AR, Fenech D, Eskicioglu C, et al. Factors influencing antibiotic prophylaxis for surgical site infection prevention in general surgery: a review of the literature. Can J Surg 2009; 52:481.
- Throckmorton AD, Boughey JC, Boostrom SY, et al. Postoperative prophylactic antibiotics and surgical site infection rates in breast surgery patients. Ann Surg Oncol 2009; 16:2464.
- Fry DE. Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures. Surg Infect (Larchmt) 2008; 9:579.
- Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.
- Braxton CC, Gerstenberger PA, Cox GG. Improving antibiotic stewardship: order set implementation to improve prophylactic antimicrobial prescribing in the outpatient surgical setting. J Ambul Care Manage 2010; 33:131.
- Tejirian T, DiFronzo LA, Haigh PI. Antibiotic prophylaxis for preventing wound infection after breast surgery: a systematic review and metaanalysis. J Am Coll Surg 2006; 203:729.
- NIH consensus conference. Treatment of early-stage breast cancer. JAMA 1991; 265:391.
- Veronesi U, Rilke F, Luini A, et al. Distribution of axillary node metastases by level of invasion. An analysis of 539 cases. Cancer 1987; 59:682.
- Pigott J, Nichols R, Maddox WA, Balch CM. Metastases to the upper levels of the axillary nodes in carcinoma of the breast and its implications for nodal sampling procedures. Surg Gynecol Obstet 1984; 158:255.
- Rosen PP, Lesser ML, Kinne DW, Beattie EJ. Discontinuous or "skip" metastases in breast carcinoma. Analysis of 1228 axillary dissections. Ann Surg 1983; 197:276.
- Danforth DN Jr, Findlay PA, McDonald HD, et al. Complete axillary lymph node dissection for stage I-II carcinoma of the breast. J Clin Oncol 1986; 4:655.
- Chevinsky AH, Ferrara J, James AG, et al. Prospective evaluation of clinical and pathologic detection of axillary metastases in patients with carcinoma of the breast. Surgery 1990; 108:612.
- Boova RS, Bonanni R, Rosato FE. Patterns of axillary nodal involvement in breast cancer. Predictability of level one dissection. Ann Surg 1982; 196:642.
- Axelsson CK, Mouridsen HT, Zedeler K. Axillary dissection of level I and II lymph nodes is important in breast cancer classification. The Danish Breast Cancer Cooperative Group (DBCG). Eur J Cancer 1992; 28A:1415.
- Fowble B, Solin LJ, Schultz DJ, Goodman RL. Frequency, sites of relapse, and outcome of regional node failures following conservative surgery and radiation for early breast cancer. Int J Radiat Oncol Biol Phys 1989; 17:703.
- Halverson KJ, Taylor ME, Perez CA, et al. Regional nodal management and patterns of failure following conservative surgery and radiation therapy for stage I and II breast cancer. Int J Radiat Oncol Biol Phys 1993; 26:593.
- Recht A, Pierce SM, Abner A, et al. Regional nodal failure after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol 1991; 9:988.
- Jeffrey SS, Goodson WH 3rd, Ikeda DM, et al. Axillary lymphadenectomy for breast cancer without axillary drainage. Arch Surg 1995; 130:909.
- Droeser RA, Frey DM, Oertli D, et al. Volume-controlled vs no/short-term drainage after axillary lymph node dissection in breast cancer surgery: a meta-analysis. Breast 2009; 18:109.
- He XD, Guo ZH, Tian JH, et al. Whether drainage should be used after surgery for breast cancer? A systematic review of randomized controlled trials. Med Oncol 2011; 28 Suppl 1:S22.
- Thomson DR, Sadideen H, Furniss D. Wound drainage after axillary dissection for carcinoma of the breast. Cochrane Database Syst Rev 2013; 10:CD006823.
- Nos C, Kaufmann G, Clough KB, et al. Combined axillary reverse mapping (ARM) technique for breast cancer patients requiring axillary dissection. Ann Surg Oncol 2008; 15:2550.
- Thompson M, Korourian S, Henry-Tillman R, et al. Axillary reverse mapping (ARM): a new concept to identify and enhance lymphatic preservation. Ann Surg Oncol 2007; 14:1890.
- Bedrosian I, Babiera GV, Mittendorf EA, et al. A phase I study to assess the feasibility and oncologic safety of axillary reverse mapping in breast cancer patients. Cancer 2010; 116:2543.
- Tausch C, Baege A, Dietrich D, et al. Can axillary reverse mapping avoid lymphedema in node positive breast cancer patients? Eur J Surg Oncol 2013; 39:880.
- Crane-Okada R, Wascher RA, Elashoff D, Giuliano AE. Long-term morbidity of sentinel node biopsy versus complete axillary dissection for unilateral breast cancer. Ann Surg Oncol 2008; 15:1996.
- Langer I, Guller U, Berclaz G, et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg 2007; 245:452.
- Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst 2006; 98:599.
- Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol 2007; 25:3657.
- Vitug AF, Newman LA. Complications in breast surgery. Surg Clin North Am 2007; 87:431.
- Pogson CJ, Adwani A, Ebbs SR. Seroma following breast cancer surgery. Eur J Surg Oncol 2003; 29:711.
- Tsai RJ, Dennis LK, Lynch CF, et al. The risk of developing arm lymphedema among breast cancer survivors: a meta-analysis of treatment factors. Ann Surg Oncol 2009; 16:1959.
- Kwan W, Jackson J, Weir LM, et al. Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life. J Clin Oncol 2002; 20:4242.
- Ivens D, Hoe AL, Podd TJ, et al. Assessment of morbidity from complete axillary dissection. Br J Cancer 1992; 66:136.
- Lin PP, Allison DC, Wainstock J, et al. Impact of axillary lymph node dissection on the therapy of breast cancer patients. J Clin Oncol 1993; 11:1536.
- Hladiuk M, Huchcroft S, Temple W, Schnurr BE. Arm function after axillary dissection for breast cancer: a pilot study to provide parameter estimates. J Surg Oncol 1992; 50:47.
- Keramopoulos A, Tsionou C, Minaretzis D, et al. Arm morbidity following treatment of breast cancer with total axillary dissection: a multivariated approach. Oncology 1993; 50:445.
- PREOPERATIVE AXILLARY ULTRASOUND
- SURGICAL ANATOMY
- Borders of the axilla
- Contents of the axilla
- - Motor nerves
- - Sensory nerves
- - Lymph nodes
- - Blood vessels
- PREOPERATIVE PREPARATION
- SURGICAL TECHNIQUE
- Critical steps of the dissection
- Axillary reverse mapping
- POSTOPERATIVE CARE
- SUMMARY AND RECOMMENDATIONS