During axillary lymph node dissection, an incision is made in the axilla from the anterior chest wall up to the axilla, as in radical or modified radical mastectomy, or as an additional incision, as in breast conserving surgery.
Axillary node dissection involves removal of all tissue between the anatomical landmarks of the axillary vein superiorly, the thoracicadorsal bundle laterally, and the long thoracic nerve medially.
Axillary node dissection removes 10-40 lymph nodes and this is ref2242ed to as level one and two node dissection.
Level one and two lymph node dissection surgery is associated with increased risk of adverse outcomes, including lymphedema, limited shoulder/arm motion, and neuropathic pain.
The above incision is cosmetically unattractive and can restrict range of motion of the shoulder joint.
Patients are placed in a supine position going breast-cancer surgery and this approach restricts axillary exposure.
Conventionally operations on the breast tumor with squeezing and pressing of the breast, is the initial procedure and axillary lymph node is then dissected.
With breast surgery, blood vessels and lymphatics of tumor drainage are patent and draining and can result in mechanical stimulation of metastases.
The patient is in the supine position which restricts surgical axillary exposure.
Median number of nodes examined in the U.S. ranges from 16-19.
Acute complications 20-30% and chronic lymphedema rates 7-37%.
Black women with breast cancer who undergo ancillary lymph node dissection are four times more likely to develop lymphedema than White women, regardless of other risk factors.
Can reliably identify lymph node metastases.
Results in a high rate of local cancer control, even in patients who initially presented with node positive disease.
In patients with clinically node negative disease, the procedure has been replaced by sentinel lymph node biopsy.
Risk of edema of the arm related to number of lymph nodes examined with greater than 10 nodes the risk is 28% and 9% with 1-10 lymph nodes examined.
At 3 months post-operatively 82% report at least one arm problem including swelling (24%), weakness (26%), limitation of arm movement (32%), stiffness (40%), pain (55%), and numbness (58%).
About 20% of patients have persistent arm pain.
At one year post-operatively 24% of patients had about 2-cm. arm swelling and 39% had about 15 degrees of restriction of shoulder motion.
Generally accepted that axillary dissection in a patient with clinically negative axilla does not impact disease free or overall survival.
Evidence exist to support omission of complete axillary lymph node dissection in patients undergoing breast conserving surgery with micrometastatic or macro metastatic disease in up to two sentinel lymph node.
The National Surgical Adjuvant Breast and Bowel Project B-04 trial randomly assigned patients to undergo axillary lymph node dissection or observation after total mastectomy for breast cancer and no survival benefit was noted.
The National Surgical Adjuvant Breast and Bowel Project B-04 trial randomly assigned patients to undergo simple mastectomy, a radical mastectomy with lymph node dissection or simple mastectomy with radiation to chest wall and axilla: 19% of patients assigned to no surgery or radiation developed positive axillary lymph nodes which was about half of the risk expected from the incidence of positive nodes in the radical mastectomy arm, suggesting the body can contain or eradicate persistent axillary tumor.
The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 randomized phase III trial in which breast cancer patients with clinically negative axillary nodes underwent sentinel node resection that was either always followed by axillary dissection we’ll followed by axillary dissection only when the sentinel node was found to be positive by H. and E. staining: 5611 patient’s: The most significant factor associated with poor outcomes with the presence of macro metastases (defined as greater than 2 mm in size) versus micrometastases, and that women with micrometastases present in the sentinel lymph node have the same prognosis as women with node negative breast cancer.
The NSABP B-32 study suggests that patients with evidence of micrometastatic disease and even a single lymph node have a prognosis more similar to patients with node-negative disease, and these patients may not benefit from axillary dissection.
In patients with treated with lumpectomy, breast radiation, and systemic therapy who had micrometastases or 1-2 macrometastases in SLNs had no survival advantage for axillary lymph node dissection and high rates of axillary cancer control after SLN biopsy alone (Giuliano AE et al ).
In patients with large volume, clinically involved axillary lymph nodes with breast cancer there is a beneficial role to axillary dissection.
Complications are increased by the extent of dissection.
False-negative rate of conventional level I/II axillary dissection is 1-3%.
Provides a 5.4% survival benefit with prophylactic axillary dissection for clinically node negative breast cancer patients.
Axillary recurrence after complete axillary dissection occurs in 1% of patients at a median interval of 2.6 years.
cN0 refers to clinically negative lymph nodes in breast cancer, but 26-38% of such patients have pathologically positive lymph nodes.
In cN0 patients 60-70% of patients receiving dissection may be receiving excessive treatment.
Is standard of care in breast cancer patients with positive sentinel lymph node biopsy.
No randomized trials have evaluated the need for completion axillary lymph node dissection following SLNB for patients with nodal metastases.
Most surgeons support completion of axillary lymph node dissection with a finding of a macrometastasis with a lesion greater than 2.0 mm found on sentinel lymph node evaluation.
Most surgeons also perform this procedure when a micrometastasis is present with a lesion larger than 0.2 mm and less than 2 mm.
The American College of Surgeons Oncology Group reviewing the National Cancer Data base from more than 450 hospitals and 1,144,397 women with breast cancer and found that patients with microscopic nodal metastases, a completion axillary lymph node dissection (ALND) did not improve outcomes compared with sentinel lymph node biopsy alone.
The American College of Surgeons Oncology Group reviewing the National Cancer Data base from more than 450 hospitals and 1,144,397 women with breast cancer and found that patients with macroscopic nodal metastases, a nonsignificant trend toward better outcomes was seen with completion ALND compared with sentinel lymph node biopsy alone.
The National Surgical Adjutant Breast and Bowel Project (NSABP) B-32 trial the largest ever conducted to determine whether sentinel node resection alone results in the same survival and regional tumor control as resection plus axillary node dissection and sentinel node negative patients: 5611 women with clinically negative invasive lymph node breast cancer randomized to actually know dissection and sentinel node biopsy or sentinel node biopsy alone, with axillary node dissection performed only if the sentinel nodes were positive.
B-32 with a median time of study of 95.3 months, estimates for five year overall survival were 96.4% in the axillary node dissection plus sentinel node biopsy group versus 95% in the sentinel node biopsy only group, and estimates for eight year overall survival were 91.8% versus 90.3%, respectively.
The American College of Surgeons Oncology Group Z0011 trial of patients with breast cancer and clinically negative axillary nodes underwent sentinel node dissection, and then randomized to axillary node surgery versus no axillary node surgery: after a median follow-up of more than six years there was no difference in outcome.
The American College of Surgeons Oncology Group Z0011 trial demonstrated equivalent survival in patients with breast cancer and 1-2 positive sentinel lymph nodes who were randomly assigned to sentinel lymph node biopsy alone or sentinel lymph node biopsy followed by axillary lymph node dissection.
In the above study regional recurrence with sentinel lymph node biopsy alone was less than 1%, despite an estimated 27% of patients had additional metastases in the undissected axillary nodes.
In The American College of Surgeons Oncology Group Z0011 trial all patients underwent breast conserving surgery and whole-breast radiation, while regional nodal irradiation was not allowed.
In patients with planned mastectomy axillary lymph node dissection is usually required if there are positive sentinel lymph node metastasis present, since knowing the fully quantified extent of nodal that is that disease enables physicians to determine whether radiation will be necessary following mastectomy.
AMAROS trial of women with early sentinel lymph node positive breast cancer comparing axillary radiation to axillary lymph node dissection: rates of axillary recurrence 1% vs 0.5% after 5 years, with no differences in 5 year disease free or overall survival (Rutgers EJ et al).
In the above study axillary resection associated with more lymphedema than axillary radiotherapy.
Axillary lymph node dissection remains the standard of care for breast cancer patients who present with clinically node positive disease.
In patients with clinically positive axillary node disease neoadjuvant therapy may make subsequent axillary dissection unnecessary.
Axillary lymph node dissection is not recommended for women with early stage breast cancer who do not have axillary nodal metastases.
Axillary lymph node dissection is not recommended for early stage breast cancer with 1-2 sentinel nodes positive for metastases and who received breast conserving surgery and conventional whole breast radiation.
Patients may be given axillary lymph node dissection with early stage breast cancer with nodal metastases found on sentinel node biopsy who will receive mastectomy.
In the era of sentinel lymph node biopsy approximately 50% of ALND are unnecessary.
In the phase 3 International Breast Cancer Study Group (IBSG) there was no difference between disease-free survival, overall survival or recurrence of disease in patients with one or more micrometastatic sentinel nodes when treated with axillary dissection or no axillary dissection.
In the SENOMAC trial the omission of completion of axillary lymph node dissection was noninferior to more extensive surgery in patients with clinically node negative breast cancer, who had sentinel node macro metastasis, most of whom received nodalradiation therapy.