This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
StatPearls [Internet].
Show detailsContinuing Education Activity
Axillary lymphadenectomy is a procedure performed most commonly for breast cancer lymph node metastasis, and this activity focuses on breast cancer specifically. Once the standard of care for breast cancer axillary evaluation, it has decreased in frequency and has specific indications at present. This activity reviews the anatomy and indications for this procedure and highlights the role of the interprofessional team in forming a treatment plan for patients pre- and postoperatively.
Objectives:
- Identify the indications for axillary lymphadenectomy.
- Describe the technique of axillary lymphadenectomy.
- Review the appropriate evaluation of the potential complications of axillary lymphadenectomy.
- Explain interprofessional team strategies for improving care coordination and communication to advance axillary lymphadenectomy and improve outcomes.
Introduction
Axillary lymphadenectomy, or axillary dissection, is a procedure where a surgeon dissects out the lymph nodes within the axilla en bloc. This is done most commonly for cancer workups and treatment. This procedure used to be done widely, but it is done much more selectively in recent years with advances in early detection and treatment, as well as numerous studies showing no increased benefit to this procedure in certain circumstances. The most common disease process that this is done for is breast cancer. While the focus of this article will be on breast cancer, it is important to note that sentinel lymph node biopsy and axillary lymphadenectomy can be performed for lung cancer and melanoma as well.[1]
Anatomy and Physiology
Axillary anatomy is very important to know for performing axillary lymphadenectomy. There are three levels of axillary lymph nodes. Typically, level one and level two lymph nodes are taken during this dissection. Level three nodes are not sought after in current times. Level one nodes are lateral to the pectoralis minor muscle, level two lymph nodes are deep to the pectoralis minor muscle, and level three lymph nodes are medial to the pectoralis minor muscle. Rotter's nodes are lymph nodes between the pectoralis major and minor muscles. The axillary fat pad is deep to the subcutaneous fat and does have a different appearance so that it is usually distinguishable. The borders of the axilla are especially important as they act as a guide to orient the surgeon during the procedure and indicate where the dissection should be performed. The important borders of the axilla are the axillary vein superiorly, which can act as the first structure to identify during an especially difficulty dissection. The medial border is the chest wall. The pectoralis major and pectoralis minor make the anterior border. The axillary skin is the lateral border. The posterior border is the latissimus dorsi muscle. There are multiple nerves within this area that great care must be taken to avoid injuring. The most likely injured is the intercostobrachial nerve. When this is transected, it causes paresthesias to the medial upper arm. The long thoracic nerve, thoracodorsal neurovascular bundle, and lateral thoracic artery are also within the region and can be at risk for injury. The long thoracic nerve innervates the serratus anterior muscle. Injury to the long thoracic nerve results in winged scapula and patients may complain of upper extremity weakness or decreased range of motion of the shoulder. The thoracodorsal nerve innervates the latissimus dorsi muscle, and injury causes loss of function.
Indications
In most cases, axillary sentinel lymph node biopsy has taken the place of axillary dissection in clinically node-negative patients. Indications for axillary lymphadenectomy include[2]:
Clinically positive axillary lymph nodes that have been proven with biopsy in a patient that is not planning on undergoing neoadjuvant chemotherapy
Patients with inflammatory breast cancer
Patients who do not meet guidelines for the Z0011 criteria
Patients with three or more axillary sentinel nodes that are positive for cancer
Persistently positive lymph nodes after neoadjuvant therapy
Axillas with failed radiotracer and/or lymphazurin/methylene blue during sentinel lymph node biopsy
Axillary lymph node recurrence after prior breast cancer treatment[3][4][5][6][7][8]
Contraindications
There are typically not any absolute contraindications to axillary lymphadenectomy. If a patient has recurrent breast disease or a second primary with a history of an axillary dissection on the same side, an axillary dissection is not usually performed for new cancer. In current times, most patients will be able to have a sentinel lymph node biopsy in place of a formal axillary dissection, except, of course, for the indications listed above. If a patient has distant metastasis, an axillary dissection is not usually necessary with evidence of grossly metastatic disease.
Equipment
An operating suite is needed for this procedure, along with the necessary equipment for anesthesia, as well as standard surgical instrument sets. Typically a radiotracer probe is not needed for this procedure. It may be in the room if the initial procedure was a sentinel lymph node biopsy and was converted to an axillary lymphadenectomy, but is not used for this procedure.
Personnel
General surgeons, surgical oncologists, or breast surgeons typically perform this procedure. This procedure is done in the operating room, typically with general anesthesia. The usual operating room personnel are required, including anesthesiology, surgical technologist, and circulating nurses. Pathologists will then review the specimen after the procedure is completed. Once pathology is back, surgeons, in combination with radiation and medical oncologists, will decide on the necessary next steps in treatment.
Preparation
These patients are typically brought to breast tumor board prior to surgery so that a prospective plan is made before taking the patients for surgery. The surgeon then obtains informed consent before the operation. This includes the patients with possible axillary dissection during a sentinel lymph node biopsy procedure, in addition to patients who had a planned axillary lymphadenectomy. Radiotracer and/or lymphazurin/methylene blue are not necessary for this procedure but may have been used if the initial procedure was a sentinel lymph node biopsy that was converted to axillary dissection.[9]
Technique or Treatment
The patient's axilla is prepped and draped in the usual sterile fashion. The patient is supine with the arm of the affected side at 90 to 100 degrees of abduction on an arm board. The landmark used superficially for the axillary incision is the inferior axillary hair line. An oblique incision is made, and electrocautery is typically used to dissect through the subcutaneous tissue to access the axillary fat pad once the clavipectoral fascia is incised. Once this is identified, many surgeons will identify the axillary vein and begin dissection inferior to this. Retraction is used to elevate the pectoralis muscles to dissect out the level two lymph nodes. Typically, most of this dissection can be performed bluntly. The axillary specimen is usually removed en bloc. The cavity is examined, and hemostasis is achieved as necessary, taking care to not injure any of the surrounding nerves or major vessels. A small drain may be left in place, with the exit point at a site other than the incision. The drain is sutured in place. The axillary incision is closed based on surgeon preference. Some sort of compressive dressing can be used postoperatively to provide some support and decrease seroma formation in addition to the drain.[10]
Complications
Axillary lymphadenectomy does carry increased morbidity when compared to sentinel lymph node biopsy, which is, in part, why it is performed more selectively in recent years. Typical complications with any surgery include infection and bleeding. Complications specific to this procedure include temporarily decreased range of motion of the shoulder, hematoma, lymphedema, lymphocele, lymphatic fibrosis, lymphangiosarcoma, injury to vasculature, or nerves within the region, or axillary vein thrombosis. Drains are placed commonly after this procedure, and while not a complication in itself, prolonged need for the drain can be a complication. Typically after an axillary lymphadenectomy is performed, there is not a need for additional surgery in the same region, unless there is an axillary recurrence in the future.[11]
Clinical Significance
Axillary lymphadenectomy is done when there is already positive disease within the axilla. Typically this is done to ascertain the extent of the disease within the axilla, which is extremely important for staging. In turn, the status of the axillary nodes and stage of the patient plays a major part in the subsequent treatment that the patient will be receiving. This can include chemotherapy and radiation therapy. A ten lymph node minimum is considered an adequate axillary dissection, although if less are obtained, surgeons rarely go back to surgery for additional lymph nodes. Of note, once a patient has had an axillary dissection, care is taken to avoid IV or blood pressure recordings in that arm as there is an increased risk of lymphedema compared to sentinel lymph node biopsy. Postoperatively, patients are given arm exercises and can be referred to a lymphedema clinic if this does arise.[12][5]
Enhancing Healthcare Team Outcomes
Breast cancer care requires an interprofessional team approach, including surgeons, medical oncologists, radiation oncologists, radiologists, pathologists, nurse navigators, physical therapists, and more. These teams are crucial in formulating plans during breast tumor boards and in the aftercare of these patients for survivorship planning. Being up to date in all aspects of these specialties provides for the best patient care, improved patient outcomes, and overall enhances the team's performance when taking care of these patients.
References
- 1.
- Black DM, Mittendorf EA. Landmark trials affecting the surgical management of invasive breast cancer. Surg Clin North Am. 2013 Apr;93(2):501-18. [PMC free article: PMC3907110] [PubMed: 23464699]
- 2.
- Ling DC, Iarrobino NA, Champ CE, Soran A, Beriwal S. Regional Recurrence Rates With or Without Complete Axillary Dissection for Breast Cancer Patients with Node-Positive Disease on Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy. Adv Radiat Oncol. 2020 Mar-Apr;5(2):163-170. [PMC free article: PMC7136630] [PubMed: 32280815]
- 3.
- Wu D, Liu SY, Amina M, Fan ZM. [Normalization in axillary lymph node management after neoadjuvant therapy for breast cancer]. Zhonghua Wai Ke Za Zhi. 2019 Feb 01;57(2):97-101. [PubMed: 30704211]
- 4.
- de Barros ACSD, de Andrade DA. Extended Sentinel Node Biopsy in Breast Cancer Patients who Achieve Complete Nodal Response with Neoadjuvant Chemotherapy. Eur J Breast Health. 2020 Apr;16(2):99-105. [PMC free article: PMC7138363] [PubMed: 32285030]
- 5.
- Costaz H, Rouffiac M, Boulle D, Arnould L, Beltjens F, Desmoulins I, Peignaux K, Ladoire S, Vincent L, Jankowski C, Coutant C. [Strategies in case of metastatic sentinel lymph node in breast cancer]. Bull Cancer. 2020 Jun;107(6):672-685. [PubMed: 31699399]
- 6.
- Jung J, Kim BH, Kim J, Oh S, Kim SJ, Lim CS, Choi IS, Hwang KT. Validating the ACOSOG Z0011 Trial Result: A Population-Based Study Using the SEER Database. Cancers (Basel). 2020 Apr 11;12(4) [PMC free article: PMC7226449] [PubMed: 32290437]
- 7.
- Cipolla C, Valerio MR, Grassi N, Calamia S, Latteri S, Latteri M, Graceffa G, Vieni S. Axillary Nodal Burden in Breast Cancer Patients With Pre-operative Fine Needle Aspiration-proven Positive Lymph Nodes Compared to Those With Positive Sentinel Nodes. In Vivo. 2020 Mar-Apr;34(2):729-734. [PMC free article: PMC7157864] [PubMed: 32111777]
- 8.
- Dixon JM, Cartlidge CWJ. Twenty-five years of change in the management of the axilla in breast cancer. Breast J. 2020 Jan;26(1):22-26. [PubMed: 31854498]
- 9.
- Alvarado MD, Mittendorf EA, Teshome M, Thompson AM, Bold RJ, Gittleman MA, Beitsch PD, Blair SL, Kivilaid K, Harmer QJ, Hunt KK. SentimagIC: A Non-inferiority Trial Comparing Superparamagnetic Iron Oxide Versus Technetium-99m and Blue Dye in the Detection of Axillary Sentinel Nodes in Patients with Early-Stage Breast Cancer. Ann Surg Oncol. 2019 Oct;26(11):3510-3516. [PubMed: 31297674]
- 10.
- 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 Jun;76(6):518-21. [PubMed: 16768781]
- 11.
- Gupta S, Gupta N, Kadayaprath G, Neha S. Use of Sentinel Lymph Node Biopsy and Early Physiotherapy to Reduce Incidence of Lymphedema After Breast Cancer Surgery: an Institutional Experience. Indian J Surg Oncol. 2020 Mar;11(1):15-18. [PMC free article: PMC7064678] [PubMed: 32205962]
- 12.
- Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, Ashikaga T, Weaver DL, Mamounas EP, Jalovec LM, Frazier TG, Noyes RD, Robidoux A, Scarth HM, Wolmark N. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010 Oct;11(10):927-33. [PMC free article: PMC3041644] [PubMed: 20863759]
Disclosure: Ariel Toomey declares no relevant financial relationships with ineligible companies.
Disclosure: Catherine Lewis declares no relevant financial relationships with ineligible companies.
- Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes.[Lancet. 1997]Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes.Veronesi U, Paganelli G, Galimberti V, Viale G, Zurrida S, Bedoni M, Costa A, de Cicco C, Geraghty JG, Luini A, et al. Lancet. 1997 Jun 28; 349(9069):1864-7.
- [Optimal treatment of the axilla after positive sentinel lymph node biopsy in early invasive breast cancer. Early results of the OTOASOR trial].[Orv Hetil. 2013][Optimal treatment of the axilla after positive sentinel lymph node biopsy in early invasive breast cancer. Early results of the OTOASOR trial].Sávolt A, Musonda P, Mátrai Z, Polgár C, Rényi-Vámos F, Rubovszky G, Kovács E, Sinkovics I, Udvarhelyi N, Török K, et al. Orv Hetil. 2013 Dec 8; 154(49):1934-42.
- Review [Sentinel lymph node status and axillary lymph node dissection in the surgical treatment of breast cancer].[Orv Hetil. 2014]Review [Sentinel lymph node status and axillary lymph node dissection in the surgical treatment of breast cancer].Cserni G. Orv Hetil. 2014 Feb 9; 155(6):203-15.
- Validation of sentinel lymph node biopsy in breast cancer women N1-N2 with complete axillary response after neoadjuvant chemotherapy. Multicentre study in Tarragona.[Rev Esp Med Nucl Imagen Mol. 2...]Validation of sentinel lymph node biopsy in breast cancer women N1-N2 with complete axillary response after neoadjuvant chemotherapy. Multicentre study in Tarragona.Carrera D, de la Flor M, Galera J, Amillano K, Gomez M, Izquierdo V, Aguilar E, López S, Martínez M, Martínez S, et al. Rev Esp Med Nucl Imagen Mol. 2016 Jul-Aug; 35(4):221-5. Epub 2016 Feb 2.
- Review Management of the axilla in patients with breast cancer and positive sentinel lymph node biopsy: An evidence-based update in a European breast center.[Eur J Surg Oncol. 2020]Review Management of the axilla in patients with breast cancer and positive sentinel lymph node biopsy: An evidence-based update in a European breast center.Garcia-Etienne CA, Ferrari A, Della Valle A, Lucioni M, Ferraris E, Di Giulio G, Squillace L, Bonzano E, Lasagna A, Rizzo G, et al. Eur J Surg Oncol. 2020 Jan; 46(1):15-23. Epub 2019 Aug 13.
- Axillary Lymphadenectomy - StatPearlsAxillary Lymphadenectomy - StatPearls
- transcription initiation factor TFIID subunit 1 isoform X13 [Homo sapiens]transcription initiation factor TFIID subunit 1 isoform X13 [Homo sapiens]gi|2217393932|ref|XP_047298359.1|Protein
- Homo sapiens TATA-box binding protein associated factor 1 (TAF1), transcript var...Homo sapiens TATA-box binding protein associated factor 1 (TAF1), transcript variant 5, non-coding RNAgi|1714609554|ref|NR_104388.2|Nucleotide
- Intellectual disability, X-linked, syndromic 33Intellectual disability, X-linked, syndromic 33MedGen
- C4225418[conceptid] (1)MedGen
Your browsing activity is empty.
Activity recording is turned off.
See more...