In this procedure numerous nodes are removed and submitted to the pathologist for diagnostic study.
While the procedure is very accurate, it exposes patients to high risk of lymphedema. With the advent of sentinel node dissection, PET scans, PET/CT combination scans and lymphoscintigraphy, this procedure is a used to the extent that it was previously.
There are three levels of axillary lymph nodes (the nodes in the underarm or “axilla” area): 1. Level I is the bottom level, below the lower edge of the pectoralis minor muscle.
2. Level II is lying underneath the pectoralis minor muscle.
3. Level III is above the pectoralis minor muscle.
A traditional axillary lymph node dissection usually removes nodes in levels I and II. For women with invasive breast cancer, this procedure accompanies a mastectomy. It may be done at the same time as, or after, a lumpectomy (through a separate incision).
Based on the doctor's physical exam and other indicators about the likelihood that cancer has spread to your lymph nodes, the surgeon will generally remove between five and thirty nodes during a traditional axillary dissection. The total number of lymph nodes “involved” (showing evidence of cancer) is more important than the extent of cancer in any one node.(1)
The most common side effect of a lymph node dissection is lymphedema (swelling of the arm). Since, after surgery, you have fewer lymph nodes under your arm to process lymphatic fluid, the fluid may build up and cause swelling along your arm and sometimes your hand. If just a few nodes are removed, lymphedema may be a temporary condition, but if most of your lymph nodes were removed, it may be a long lasting problem.
Therapeutic massage and pressure garments can help with lymphedema. Your axillary skin may be numb or less sensitive to touch after surgery, because nerves may have been damaged during the procedure. Arm and shoulder range of motion may be affected, so be sure to ask for physical therapy to help regain your motion and strength.
Axillary lymph node dissection is an important part of your complete diagnosis and staging. Clear nodes and a small tumor will require less treatment because the chances of metastasis are low. However, it's important to know how many nodes are involved with cancer, so more tests can be done to determine if and where the cancer may have spread. This information impacts your treatment options and helps you and your doctor choose the most effective treatment plan for you.
The axillary lymph nodes are located under the arm. Axillary node dissection is performed to determine if cancer has spread beyond the breast. Cancer cells found in the lymph nodes suggest that it may have spread to other parts of the body and the patient may need more aggressive treatment. The results of this test help the patient and physician plan the best course of therapy.
Axillary node dissection is performed under general anesthesia (agent that renders the patient unconscious) at a hospital. The surgeon makes an incision under the arm and removes a pad of fat in which 10 to 20 lymph nodes are embedded. The incision is sutured and a drain may be put in to remove excess fluid. The procedure takes between 1 and 2 hours.
A few days before surgery, tests are usually performed to assess the patient's health. Preoperative tests ordered vary according to the patient's age and health, but generally include a blood test, a chest x-ray, and possibly an electrocardiogram (EKG). If these tests have been performed recently, such as for breast biopsy, they do not need to be repeated.
If the patient is taking medication that “thins” the blood, including aspirin, they should speak to their physician about it as soon as the decision to do the biopsy has been made. Patients usually stop taking blood thinners several days prior to a scheduled operation to avoid excessive bleeding during the procedure.
Because axillary dissections are usually performed under general anesthesia, the patient must refrain from eating or drinking at least 8 hours prior to surgery. This may include oral medications, and this must be discussed with the physician. On admission to the hospital, the patient must sign an informed consent form acknowledging that they understand the procedure and its risks, and that they will be receiving anesthesia and certain medications.
The anesthesiologist (the doctor who administers the anesthesia) performs a brief physical examination and takes the patient’s medical history. The anesthesiologist asks about medications that are currently being taken, about a history of allergies, and about previous adverse reactions to anesthesia. This information is essential to assess possible conditions or problems that may influence the choice of anesthesia and to take any special precautions if necessary.
An intravenous line (IV) will be started to administer fluids and medication during the procedure. This may be done in the patient's room or in the preoperative holding area. It is necessary to stay in bed from this point on, except to use the bathroom. Sedation may be given in the holding area or in the hospital room, and the anesthesia is administered in the operating room.
Immediately following surgery, the patient is taken to the postanesthesia care unit (PACU) and is closely monitored by the nursing staff until the anesthesia wears off. When the patient fully awakens from the anesthesia and the vital signs are stable, they are transferred to their room.
The IV remains in until clear liquids taken orally are tolerated. Most patients are able to eat and drink soon after they wake up from anesthesia. Unless an intravenous medication (e.g., antibiotic) has been ordered, the IV is removed at this time.
Once the anesthesia wears off, pain is felt in and around the incision site and pain medication is prescribed. There may be a tube draining fluid, which usually stays in until the first postoperative doctor's appointment. Most patients remain in the hospital overnight and the stay may be extended if complications develop. The incision under the arm fades over time. Patients may notice an indentation in their armpit where the fat was removed, sore muscles, tightness in the arm, and difficulty moving the arm. Stretching and range of motion exercises help and should be started as soon as permitted. A physical therapist or other practitioner can set up an exercise program to increase arm movement.
The drain and stitches are removed during the first follow-up visit. The area must be kept dry and sponge baths may be recommended. Deodorant should not be applied to the incision until healing is well underway.
The recovery period lasts about 6 weeks and heavy lifting and strenuous activity should be avoided. Some patients experience a loss of sensation under the arm caused by nerves being cut during the procedure. This loss of sensation may be permanent. It may take longer for the affected arm to regain its strength and full range of motion. Postoperative Complications The most common complications are: •Permanent numbness under the arm
• Infection of incision site
An axillary dissection removes many of the lymph nodes that protect against infection, and the hand and arm on the affected side may become more susceptible. Blood should not be drawn from this arm, and minor injuries should be reported to the physician. The hand and arm should be checked regularly for inflammation or cuts.
Wojcinski S, Nuengsri S, Hillemanns P, Schmidt W, Deryal M, Ertan K, Degenhardt F.
Franziskus Hospital, Department of Obstetrics/Gynecology, Bielefeld, Germany.
Lymphedema of the arm is the most common and impairing complication after breast cancer surgery with axillary lymph node dissection (ALND). Our prospective study evaluated the effect of two different surgical techniques for ALND on postoperative morbidity. Patients were scheduled to undergo ALND. Patients in group 1 (n = 17) underwent the most common and standard technique of ALND, which uses sharp dissection of the tissue and subsequent electro-coagulation of bleedings. Patients in group 2 (n = 17) underwent a modified standard technique of ALND with clamping and ligatures of all resection margins. Postoperative wound secretion was quantified and patients were followed up for 6 months to assess long-term morbidity. The variations in surgical technique had no significant influence on the outcome variables. However, patients in group 2 showed a tendency to less wound secretion (713 versus 802 mL; P = nonsignificant), a decreased rate of immediate postoperative seromas (11.8 versus 23.5%; P = nonsignificant) and less lymphedema after 3 months (29.4 versus 41.2%; P = nonsignificant). Moreover, the number of resected lymph nodes correlated with the total amount of drained fluid (P = 0.006), the duration of the drain (P = 0.015), and the risk for the development of lymphedema after 3 months (P = 0.016). The described variations in surgical technique had no influence on the outcomes of the patients. The number of resected axillary lymph nodes remains the most important risk factor for treatment-related morbidity. Therefore, a well-balanced choice of the extent of the axillary dissection should be the surgeon's main concern.
Verry H, Lord SJ, Martin A, Gill G, Lee CK, Howard K, Wetzig N, Simes J.
NHMRC Clinical Trials Centre, University of Sydney, Locked Bag 77, Camperdown, New South Wales 2050, Australia.
Background: Sentinel lymph node biopsy (SLNB) is less invasive than axillary lymph node dissection (ALND) for staging early breast cancer, and has a lower risk of arm lymphoedema and similar rates of locoregional recurrence up to 8 years. This study estimates the longer-term effectiveness and cost-effectiveness of SLNB.
Methods: A Markov decision model was developed to estimate the incremental quality-adjusted life years (QALYs) and costs of an SLNB-based staging and management strategy compared with ALND over 20 years' follow-up. The probability and quality-of-life weighting (utility) of outcomes were estimated from published data and population statistics. Costs were estimated from the perspective of the Australian health care system. The model was used to identify key factors affecting treatment decisions.
Results: The SLNB was more effective and less costly than the ALND over 20 years, with 8 QALYs gained and $883 000 saved per 1000 patients. The SLNB was less effective when: SLNB false negative (FN) rate >13%; 5-year incidence of axillary recurrence after an SLNB FN>19%; risk of an SLNB-positive result >48%; lymphoedema prevalence after ALND <14%; or lymphoedema utility decrement <0.012.
Conclusion: The long-term advantage of SLNB over ALND was modest and sensitive to variations in key assumptions, indicating a need for reliable information on lymphoedema incidence and disutility following SLNB. In addition to awaiting longer-term trial data, risk models to better identify patients at high risk of axillary metastasis will be valuable to inform decision-making.
Kuwajerwala NK, Feczko C, Dekhne N, Pettinga J, Lucia VC, Riutta J, Vicini F.
*Departments of Surgery, William Beaumont Hospital, Troy and Royal Oak †Cancer Clinical Trials §Physical Medicine and Rehabilitation ‡Research Institute, William Beaumont Hospital ∥Department of Radiation Oncology, Royal Oak, MI.
PURPOSE: The purpose of the study was to show that delayed axillary lymph node dissection (ALND) has higher rates of lymphedema compared with immediate ALND, using data from NSABP-B32 at Beaumont Hospital.
METHOD: NSABP B-32 at Beaumont had 207 patients with follow-up data on 199 patients, randomizing clinically negative axilla to sentinel lymph node biopsy (SLNB)+ALND (GrA N=98), and SLNB+cytology±ALND (GrB N=101). All patients had preoperative volumetric arm measurements and only node negatives had routine postoperative measurements assessing lymphedema for 36 months. We contacted node-positive patients for postoperative measurements for this study. Twenty-four and 15 cytology-positive patients had SLNB+ALND in GrA and GrB, respectively (SubGrA1 N=24; SubGrB1 N=15). Fourteen hematoxylin and eosin-positive patients had delayed ALND (SubGrB2a N=14). RESULTS: Lymphedema rate for node-positive SLNB+ALND was 10.3% [SubGrA1 (3/24)+SubGrB1 (1/15)=4/39] and node-negative SLNB+ALND was 6.8% (SubGrA2=5/74). Lymphedema was 14.3% for delayed ALND in SubGrB2a (2 of 14) and 0% for 72 SLNBs in SubGrB2b. Our study comparing immediate and delayed ALND lymphedema was not statistically significant (10.3% vs. 14.3%, P=0.65). Comparing node-negative ALND (SubGrA2= 5/74=6.8%) to node-positive ALND (A1+B1+B2a=6/53=11.3%) was not statistically significant (P=0.52). Comparing lymphedema for node-negative ALND (SubGrA2) to SLNB (SubGrB2b) only approached significance (6.8% vs. 0%, P=0.058).
CONCLUSIONS: The rate of lymphedema was higher in delayed ALND but not statistically significant. Comparison, however, is difficult, given the limited sample size. We urge the other centers of NSABP-B32 to validate this, by contacting the node-positive patients for measurements. The lymphedema rate for SLNB alone was 0% and approached statistical significance when compared with node-negative ALND.
Clin Transl Oncol. 2007 Aug
Millet A, Fuster CA, Lluch A, Dirbas F. Division of Breast Diseases. Department of Obstetrics and Gynecology. Valencia School of Medicine. Valencia, Spain.
Surgeons have routinely removed ipsilateral axillary lymph nodes from women with breast cancer for over 100 years. The procedure provides important staging information, enhances regional control of the malignancy and may improve survival. As screening of breast cancer has increased, the mean size of newly diagnosed primary invasive breast cancers has steadily decreased and so has the number of women with lymph node metastases. Recognising that the therapeutic benefit of removing normal nodes may be low, alternatives to the routine level I/II axillary lymph node dissection have been sought. A decade ago sentinel lymph node biopsy (SLNB) was introduced. Because of its high accuracy and relatively low morbidity, this technique is now widely used to identify women with histologically involved nodes prior to the formal axillary node dissection.
Specifically, SLNB has allowed surgeons to avoid a formal axillary lymph node biopsy in women with histologically uninvolved sentinel nodes, while identifying women with involved sentinel nodes who derive the most benefit from a completion axillary node dissection. Despite the increasing use of SLNB for initial management of the axilla in women with breast cancer, important questions remain regarding patient selection criteria and optimal surgical methods for performing the biopsy. This article discusses the evolution of axillary node surgery for women with breast cancer.
PMID: 17720654 [PubMed - in process]
J. L. Hinson1, P. McGrath1, A. Moore1, J. T. Davis1, Y. M. Brill1, E. Samoilova1, M. Cibull1, M. Hester1, E. Romond1, K. Weisinger1 and L. M. Samayoa1, 2, 3 (1) Multidisciplinary Breast Cancer Center, University of Kentucky, Lexington, Kentucky, United States (2) Veteran Administration Medical Center, Lexington, Kentucky, United States (3) Department of Pathology and Laboratory Medicine, UKMC, 800 Rose street MS # 157, Lexington, Kentucky, 40536, United States
Received: 30 April 2007 Revised: 18 June 2007 Accepted: 20 June 2007 Published online: 7 August 2007
Background Sonographic evaluation of the axilla can predict node status in a significant proportion of clinically node-negative patients. This review focuses on the value of ultrasound followed by ultrasound-guided cytology in assessing the need for sentinel node mapping and conservative versus complete axillary dissections.
Design Breast primaries from 168 sentinel node candidates were prospectively assessed for clinicopathologic variables associated with increased incidence of axillary metastases. Patients were classified accordingly, and those at a higher risk underwent ultrasound of their axillae, followed by aspiration biopsy if needed. Sentinel node mapping was performed in all low-risk patients, and in high-risk patients with normal axillary ultrasounds or negative cytology. Final axillary status was compared in terms of nodal stage, number of positive nodes, and size of metastasis.
Results 112 patients were at high risk for nodal disease (67%), with a statistically significant lower probability for remaining node-negative and a statistical significantly higher risk for having more than one positive node. All patients with more than three positive nodes were detected by ultrasound-guided cytology. High-risk patients with final positive axillae missed by ultrasound or ultrasound guided cytology had tumor deposits measuring ≤5 mm.
Conclusion Extent of axillary dissections can be decided based on the risk for axillary metastases: sentinel node mapping for low-risk patients; less-aggressive axillary dissections for high-risk patients with negative ultrasound and/or negative cytology; and a standard dissection for high-risk patients with positive cytology. Keywords Extent of axillary dissections - Risk of axillary metastases - Ultrasound guided cytology - Sentinel Node
also includes (1) Retroperitoneal Lymph Node Dissection and (2) Laparoscopic Retroperitoneal Lymph Node Dissection
Lymphedema After Breast Cancer Studies on Risk Assessment and Prevention
Updated May 10,2012