Axillary dissection





Definition

Axillary dissection is a surgical procedure that incises (opens) the armpit (axilla or axillary) to identify, examine, or remove lymph nodes (small glands, part of the lymphatic system, which filters cellular fluids).


Purpose

Axillary dissection is utilized to stage breast cancer in order to determine the necessity of further treatment based on cancer cell spread. Additionally, axillary dissection includes removal and pathological examination of axillary lymph nodes for persons having operable

To determine the advancement of breast cancer, lymph nodes in the armpit are removed. An incision is made (A), and lymph nodes are removed and tested (B), leaving a small scar (C). (Illustration by GGS Inc.)
To determine the advancement of breast cancer, lymph nodes in the armpit are removed. An incision is made (A), and lymph nodes are removed and tested (B), leaving a small scar (C). (
Illustration by GGS Inc.
)
breast cancer. The anatomy of the axilla is complex and composed of several critical nerves, arteries, and muscles. Because of this complex anatomy and connection with the breast, the axilla is a common route for possible metastatic (cancer cell spread to distant areas within the body) involvement from breast cancer. The absence or presence of cancer cells in axillary lymph nodes is the most power prognostic (outcome) indicator for breast cancer. Axillary dissection is an accurate procedure for axillary node assessment (removal and pathological examination). Clinical examination of the breast (more specifically palpation, or feeling the affected area for lumps) for the axillary region is inaccurate and unreliable. The only method to identify whether or not a lymph node has cancer cells, is to surgically remove the node and perform examination with a microscope to detect abnormal cancer cells.


Demographics

If axillary dissection is not performed, recurrence of cancer in the armpit is common even after breast surgery. Recent evidence suggests that persons who underwent lumpectomy alone without axillary dissection had a 10-year average recurrence rate of 28% in the axilla. Generally, recent evidence also suggests that the more nodes and tissues removed in the axilla, the lower the risk of recurrence of cancer. Research also indicates that 10-year axillary cancer recurrence rates are low (10% for node negative and 3% for node positive) for women who have mastectomy and axillary node removal. The recurrence rate for breast cancer is approximately 17% for women who did not have axillary node removal.


Description

Lymph nodes (or lymph glands) are filtering centers for the lymphatic system (a system of vessels that collects fluids from cells for filtration and reentry into the blood). Additionally, there is a complex arrangement of muscles, tissues, nerves and blood vessels. Axillary dissection is surgically explained in terms of three levels. Level I axillary dissection is also called lower axillary dissection because it is the removal of all tissue below the axillary vein and extending to the side where the axillary vein crosses the tendon of a muscle called the latissimus dorsi. Level II dissection is continuous—it includes the removal of level tissues and further extensive removal of cancerous tissues. Level II dissection removes diseased tissues deeper in the middle (medial) area of another muscle called the pectoralis minor. Level III dissection is the most aggressive breast cancer axillary surgery, and it entails the removal of all nodal tissue (tissues related to the lymphatic system) from the axilla.

Diagnosis/Preparation

Operable breast cancer is the primary indication for axillary dissection. Persons receiving this surgery have been diagnosed with breast cancer and are undergoing surgical removal of the breast. Diagnosis of breast cancer typically involves palpation of a lump (mass), and other tests such as mammography (special type of x ray used to visualize deep into breast tissues) and biopsy. The specific diagnosis to estimate the extent of axillary (cancerous) involvement can be made by performing a sentinel node biopsy. The sentinel node is the first lymph node that drains fluid from the primary tumor site. If there is no presence of cancerous cells in the sentinel node, the likelihood that higher echelon lymph nodes have cancer is very small. Conversely, if cancerous cells are detected in the sentinel node, then axillary dissection is recommended.

Preparation for axillary dissection is the same as that for modified radical mastectomy . This includes but is not limited to preoperative assessments (special tests and blood analysis), patient education, postoperative care , and follow-up consultations with surgeon and cancer specialist (medical hematologist/oncologist). Psychotherapy and/or community-centered support group meetings may also be beneficial to treatment.


Aftercare

One of the major problems that can result from axillary lymph node removal is lymphedema (fluid accumulation in the arm). Postoperative aftercare should include the use of compression garments, pneumatic compression pumps, and massage to combat fluid retention. Additionally, persons may have pain and should discuss this with the attending surgeon. Other surgical measures for aftercare should be followed similar to persons receiving a modified radical mastectomy. Skin care is important and caution should be exercised to avoid cuts, bites, and skin infections in the affected area. Further measures to control lymphedema can include arm exercises and maintenance of normal weight.


Risks

There are several direct risks associated with axillary surgery. A recent study indicated that approximately 31% of persons may have numbness and tingling of the hand and 10% develop carpal tunnel syndrome. In females who have had a previous breast surgery before the axillary surgery, recurrent wound infections and progression of lymphedema can occur. Additionally, persons may also feel tightness and heaviness in the arm as a result of lymphedema.

Normal results

Normal results can include limited but controlled lymphedema and adequate wound healing. Persons receiving axillary dissection due to breast cancer require several weeks of postoperative recovery to regain full strength.


Morbidity and mortality rates

Sickness and/or death are not necessarily related to axillary surgery per se. Rather, breast cancer outcome is related to breast cancer staging. Staging determined by axillary surgery can yield valuable information concerning disease progression. Early stage (stage I) breast cancer usually has a better outcome, whereas advance stage cancer (stage 4) is correlated with a 10-year survival rate.


Alternatives

Currently research does not support other therapies. Further study is required but other therapies are currently not recommended. There are no adequate alternatives to axillary surgery in breast cancer persons. The most recent evidence suggests that removal of lymph nodes and tissues in the armpit is correlated with elevated survival rates.


Resources

BOOKS

Noble, John. Textbook of Primary Care Medicine. 3rd ed. St. Louis, MO: Mosby, Inc., 2001.

Townsend, Courtney. Sabiston Textbook of Surgery. 16th ed. St. Louis: W. B. Saunders Company, 2001.

PERIODICALS

Cantin, J., H. Scarth, M. Levine, and M. Hugi. "Clinical practice guidelines for the care and treatment of breast cancer." Canadian Medical Association Journal 165 (July 24, 2001).

Fiorica, James. "Prevention and Treatment of Breast Cancer." Obstetrics and Gynecology Clinics 28 (December 2001).

Hugi,M. R., I. A. Olivotto, and S. R. Harris. "Clinical practice guidelines for the care and treatment of breat cancer:11.Lymphedema." Canadian Medical Association Journal 164 (January 23,2001).

ORGANIZATIONS

American Cancer Society. (800) ACS-2345. http://www.cancer.org .

Y-ME National Breast Cancer Organization. 212 W. Van Buren, Suite 500 Chicago, IL 60607. (312) 986-8338. Fax: (312) 294-8597. (800) 221-2141 (English). (800) 986-9505 (Español). http://www.y-me.org .

OTHER

Cancernews. [cited May 15, 2003]. http://www.cancernews.com .


Laith Farid Gulli, MD, MS

Nicole Mallory, MS, PA-C

Bilal Nasser, MD, MS

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


The procedure is performed in a hospital equipped to perform major surgery. A general surgeon usually performs the operation with specialized formal training in surgical oncology (the specialty of surgery that provides surgical treatment for operable cancers).

QUESTIONS TO ASK THE DOCTOR


  • How do I prepare for the procedure?
  • How long does it take to know the results?
  • What postoperative care will be needed?
  • What are the possible risks involved in this procedure?

User Contributions:

Ann Connolly
Report this comment as inappropriate
Aug 13, 2009 @ 11:11 am
What do I do about the numb fingers. Can I get the feeling back right hand middle index inside of ring finger. had 2 lumpechtomies on right breast. It has been almost 2 years
Report this comment as inappropriate
Aug 20, 2010 @ 1:01 am
I have this problem after my delieveries. Iwant them to be removed .Please help and advise.It is painful when i press them hard otherwise its OK .it is pieces of loose skin hanging down from axilla.From where should i get it done .How much it will cost. Thanks.
carole
Report this comment as inappropriate
Aug 29, 2010 @ 12:00 am
i Had a total removal of the lymhnodes on the right and partial removal on the left after a bilateral mastectomy the drains are still leaking but have increased in volume instead of decreasing it is now 11 days after surgery what should i be expecting to happen.
Pauline
Report this comment as inappropriate
Nov 5, 2010 @ 1:13 pm
I have got to have carpel tunnel surgery on the side of my Lympph node removal, what are the risks to my arm following surgery is it safe to have the op.?
Report this comment as inappropriate
Nov 16, 2010 @ 10:22 pm
I had a history of boils and they would grow under my left and right Axilla. They would form everytime I used deodorant. My Primary Doctor referred me to a surgeon and they removed the grand under both armpits. My left arm came out fine, but the right became full of edema. I was diagnosed with, "Lymphadema, " in my right arm. Now I suffer from constant pain, my joint cracks and snaps often. I must keep a pillow under it for support because of pain. It hurts when I rest it on hard surfaces or arm of a chair. The pain was so severe it woke me up in tremors! The pain is unbearable.
Report this comment as inappropriate
Jan 8, 2011 @ 3:15 pm
I had all my lymph nodes removed after stage 2 right breast cancer surgery in 1983 . I've never had any swelling on my right lower arm & hand until 2 weeks ago. Is it likely that a complication could ensue even after all of this time?
Report this comment as inappropriate
Apr 22, 2011 @ 11:11 am
I am a male having radical lymph node surgery real soon. What are the chances of lymphoedema?

How bad will it look after healing?

Any pictures on the web?

Thank you
Report this comment as inappropriate
Jul 5, 2011 @ 4:16 pm
For your information to keep you informed of what to expect for recovery time in the armpit area. Please address during your next appointment to ensure recovery is going according to expectations of surgeon. Keep the faith and everything will be fine. It's been a long journey and you are almost there. Stay the course for yourself, family love ones and friends. God Bless. Live Laugh Love
LM
Report this comment as inappropriate
Aug 22, 2011 @ 2:02 am
Thank you very much for your clear article.
After a axillar disection form a carcinom in situ, I have a paiful axilla, because I suspect the rib was broken and placed surgically in a specific way.
1. How can I see where the rib was broken?
2. I have a normal position x ray examination, but I don't have the comment of it. Who is able to interpret it?
3. Which is the difference between pleural callus and the callus of the rib? When I did the Pet Ct examination I didn't know about the broken rib.
4. All the tumoral markers are OK.

In my case after a pet CT I discovered "On the scans, at the level of the 5th rib small focal FDG uptake is represented, in the surgical area.".
The conclusion :
" The FDG uptake observed, on the left-sided mastectomy area, raises the suspicion of local recidivation. Control of the region if necessary aspiration can be recommended. In the right shoulder joint degenerative etiology is probable. Otherwise pathological accumulation was not represented. In the left axilla, stadium after operation. In the lung pastiradiation residuum. Pleural callus 1s.."
Report this comment as inappropriate
Sep 25, 2011 @ 4:04 am
Iam a male and had my glands under my right arm ,right side of the neck and muscle .removed.
This was after discoivering melonomia.The operation was some 9 years ago and I have had continual massage to control the discomfort.
However it has got considerable worse with pain starting under both armpits even at rest and when I do any exercise I immediately get a heaviness in my upper right arm which spreads over my chest. The pain is severe and affects my breathing etc.My limbs are sore especially my joints. I still do treatment(masage) but it is not helping
Report this comment as inappropriate
Oct 8, 2011 @ 3:15 pm
I HAD A MASECTAMY & 10 LYMPHNOIDS REMOVED ON MY LEFT SIDE... 3 WEEKS AGO I STARTED SWELLING ON MY LEFT HAND, ARM & IN BETWEEN MY SHOULDER & NECK (INFLAMATION) ... I AM ALSO WEEZING... WHAT IS THAT AND WHAT DO I DO?
Margaret
Report this comment as inappropriate
Apr 16, 2012 @ 10:10 am
Help, I am having this done tomorrow and wonderful what I should wear after the removal of the lymph nodes. I am a Type I diabteic and have had a kidney transpant. I have asked lots of questions but am not sure how long recovery is or what I should even wear home from the hospital. This lump was foiund jsut three days ago and every day sionce has been a whilrwind.
Pat
Report this comment as inappropriate
Sep 25, 2012 @ 6:18 pm
I had some lymph nodes removed 5 months ago with a lumpectomy breast cancer stage 1 surgery... My arm was swelling a minimal amount and it did give me pain... I discovered the trampoline or jumping up and down in the swimming pool just where the buoyancy is greatest as it starts to get deep. this decreased the swelling and made the lymph work harder to circulate since the lymph has no pump jumping up and down or skipping is good exercise for this... If I do it often enough it prevents the swelling.
CAS
Report this comment as inappropriate
Feb 6, 2013 @ 3:15 pm
I had an axillary lymphadenectomy/ biospy to Rule out Lymph invovlement, which was negative. However, 18 months later I have developed upper arm fluid-like fullness, is there something to eliminate it?
mary richter
Report this comment as inappropriate
Apr 5, 2013 @ 1:01 am
September 2012 I had a desection of my left axillary lymph nodes. Twenty-five that were removed, 5 were positive for cancer. I then underwent 30 treatments of radiation. Before the surgery I also had 6 sessions of chemo. Eleven years prior to this I was Dx. with left CA and had the 1.5 centimeter lump removed with 4 sessions of chemo and 32 rounds of radiation. I also took 5 years of tamoxifan. Now with my latest Dx. and treatment I am taking letrozole for 5-10 years, but have developed pain in my L leg in the joints and muscle. I have stopped taking it for 4 days now and the pain has lessened. Also with this last cancer I was Dx. with not only estrogen receptor but also her2plus. I am taking Herceptin every 3 weeks for 1 year. What are my chances of recovery? Should I be doing something else? I definitely do not have the energy level that I once had, will this return? I need a definite answer to give me some ideas on what my future will be. Is her2plus a more advanced cancer? I would appreciate any information you can give me.

Comment about this article, ask questions, or add new information about this topic:

CAPTCHA


Axillary Dissection forum