Overview
Definition:
Axillary lymph node dissection (ALND) is a surgical procedure involving the removal of lymph nodes from the axilla (armpit) region
It is a crucial component of staging and treating breast cancer, as well as other malignancies that metastasize to the axillary basin
Levels I and II refer to specific anatomical groupings of these lymph nodes.
Epidemiology:
The incidence of axillary lymph node involvement in breast cancer varies significantly with the stage of the disease, ranging from 10-20% in early-stage disease to over 70% in advanced stages
ALND is performed in a substantial proportion of breast cancer surgeries, particularly in those with clinically positive lymph nodes or after a positive sentinel lymph node biopsy.
Clinical Significance:
ALND is vital for accurate staging of breast cancer, which dictates subsequent treatment decisions, including adjuvant chemotherapy, radiation therapy, and endocrine therapy
It also serves a therapeutic role by removing potentially metastatic disease
Understanding the anatomical levels is critical for optimizing oncologic control while minimizing morbidity.
Indications
Primary Indications:
Clinically palpable axillary lymph nodes suspicious for metastasis on physical examination and imaging
Positive sentinel lymph node biopsy (SLNB) with a high tumor burden or specific tumor characteristics
Invasive breast cancer with no distant metastasis
Management of axillary lymphadenopathy from other malignancies like melanoma or lymphoma with axillary involvement.
Contraindications:
Gross extranodal extension of disease
Inflammatory breast cancer (often requires neoadjuvant therapy first)
Extensive nodal involvement making standard dissection technically challenging
Patients with severe comorbidities rendering them unfit for major surgery
Previous axillary radiation therapy to the same area.
Level Specific Considerations:
Level I nodes are lateral to the pectoralis minor muscle
Level II nodes are deep to or beneath the pectoralis minor muscle
Dissection of Level III nodes (medial to the pectoralis minor) is less common and reserved for extensive disease or specific indications, and is not typically included in standard Level I-II dissection.
Preoperative Preparation
Patient Evaluation:
Thorough history and physical examination focusing on breast and axillary findings
Review of mammography, ultrasound, MRI, and biopsy reports
Assessment of comorbidities and patient fitness for surgery
Discussion of surgical options, risks, and benefits, including potential for lymphedema.
Imaging And Biopsy:
Preoperative imaging is essential to assess the extent of primary tumor and axillary nodal status
Fine Needle Aspiration Cytology (FNAC) or core needle biopsy of suspicious axillary nodes is often performed
Sentinel Lymph Node Biopsy (SLNB) is standard for clinically negative axillae, and its results guide the decision for completion ALND.
Informed Consent:
Detailed discussion covering the procedure, expected outcomes, potential complications (e.g., lymphedema, seroma, infection, nerve injury), and the rationale for performing ALND at levels I and II
Alternative treatments or conservatism should be discussed if appropriate.
Procedure Steps
Patient Positioning And Anesthesia:
Patient positioned in the supine position with the ipsilateral arm abducted to 90 degrees and externally rotated
General anesthesia is typically used
A sterile prep and drape are performed.
Incision And Dissection:
An incision is made over the axillary region, typically following skin tension lines or an existing surgical scar
The dissection begins by identifying the pectoralis major and minor muscles
Level I nodes are dissected first, located inferior to the pectoralis minor
The dissection then proceeds superiorly and medially to address Level II nodes, deep to the pectoralis minor.
Identification And Preservation:
Key structures to identify and preserve include the long thoracic nerve (innervating the serratus anterior muscle), the thoracodorsal nerve (innervating the latissimus dorsi), and the medial pectoral nerve
Careful blunt and sharp dissection is employed to mobilize nodal-fatty tissue while protecting these vital structures
The axillary vein and artery are also important landmarks.
Excision And Drainage:
The entire lymphatic-bearing tissue from levels I and II is removed en bloc
Hemostasis is meticulously achieved
Drains (e.g., Jackson-Pratt drains) are typically placed in the axillary space to manage fluid collection (seroma).
Closure:
The wound is closed in layers, and dressings are applied
Drains are usually secured to the skin with a stitch and connected to suction.
Postoperative Care
Pain Management:
Adequate analgesia is provided, often with a multimodal approach including opioids, NSAIDs, and regional blocks
Patient-controlled analgesia (PCA) may be used.
Drain Management:
Drains are monitored for output volume and character
Removal is typically considered when daily output is less than 20-30 ml, though protocols vary
Early drain removal may increase seroma risk.
Mobilization And Physiotherapy:
Early arm mobilization is encouraged to prevent stiffness and promote lymphatic drainage
Specific physiotherapy exercises are initiated to improve range of motion and reduce lymphedema risk
Patients are advised to avoid heavy lifting and repetitive arm movements initially.
Wound Care And Monitoring:
Wound inspection for signs of infection, dehiscence, or hematoma
Monitoring for early signs of lymphedema, including arm swelling, heaviness, or discomfort
Patient education on self-care and signs of complications.
Complications
Early Complications:
Seroma formation (most common)
Hematoma
Wound infection
Skin necrosis
Temporary or permanent nerve injury (e.g., to the long thoracic nerve causing winged scapula, or to the thoracodorsal nerve).
Late Complications:
Chronic lymphedema (swelling of the arm, most significant long-term complication)
Chronic pain or discomfort in the axilla
Restricted shoulder range of motion
Recurrence of cancer in the axilla if dissection was incomplete or disease was extensive.
Prevention Strategies:
Meticulous surgical technique with preservation of nerves and vascularity
Careful hemostasis
Placement and early removal of drains (balanced approach)
Postoperative physiotherapy and patient education on arm care
Minimally invasive techniques and judicious use of ALND in select cases.
Prognosis
Factors Affecting Prognosis:
The number of positive lymph nodes removed
Extranodal extension of tumor
Size of the primary tumor
Histological subtype of cancer
Response to neoadjuvant or adjuvant therapy
Presence of lymphovascular invasion.
Outcomes:
For early-stage breast cancer, ALND significantly improves staging accuracy and can be curative if all metastatic nodes are removed
However, it is associated with a risk of morbidity, particularly lymphedema
Survival rates are strongly correlated with nodal status.
Follow Up:
Regular follow-up appointments are crucial to monitor for local recurrence, distant metastasis, and to manage potential long-term complications like lymphedema
Follow-up typically includes physical examinations and imaging as indicated
Patients are advised to practice lifelong vigilance for arm swelling and to report any changes promptly.
Key Points
Exam Focus:
Anatomical boundaries of Level I and Level II axillary lymph nodes
Identification and preservation of the long thoracic and thoracodorsal nerves
Primary indications for ALND versus SLNB
Common complications, especially seroma and lymphedema
Management of drains and physiotherapy recommendations.
Clinical Pearls:
Always consider nerve preservation during dissection
thorough knowledge of axillary anatomy is paramount
Seroma prevention and management is key to patient comfort and early rehabilitation
Patient education on arm care post-ALND is essential for long-term well-being
Consider oncologic outcomes alongside surgical morbidity.