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 "Sentinel lymph node dissection for breast cancer: Indications and outcomes" 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 "Sentinel lymph node dissection for breast cancer: Indications and outcomes", section on 'Management of SLN metastases'.)
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 "Sentinel lymph node dissection for breast cancer: Indications and outcomes", section on 'Completion axillary dissection with BCT'.)
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- 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