Axillary lymph node dissection for Breast Cancer

Overview
Axillary lymph node dissection is the surgical removal of several lymph nodes, usually between five and 30, from the underarm area. It is both a diagnostic procedure performed in order to determine whether breast cancer has developed the ability to spread through the body, and a way of treating breast cancer that is spreading. Negative test results for the lymph nodes removed in the procedure indicate that the cancer is still localized in the breast, whereas positive results suggest that the cancer is metastasizing, or spreading. Axillary lymph node dissection helps doctors determine the stage of the cancer and decide what the best treatment options are.

Lymph nodes are part of the lymphatic system. The lymphatic system drains the fluid that bathes your tissues, nourishes your cells, and carries away waste products. Lymph nodes are important to the immune system because they contain white blood cells that fight infection such as T lymphocytes and B lymphocytes.

In breast cancer, the lymph nodes in the axillary area, or underarm, are usually the first lymph nodes cancer might spread to from the original tumor. There are three levels of axillary lymph nodes, classified by their relative position to the pectoralis minor muscle. Level I nodes are the lowest, located below the lower edge of the muscle. Level II nodes are located underneath the muscle. Level III are the highest nodes, located above the muscle. In axillary lymph node dissection, the surgeon commonly removes nodes in Levels I and II. One or two nodes from Level III may also be removed as an extra precaution.

Axillary lymph node dissection may be performed as an independent surgery, during a mastectomy in cases of invasive breast cancer, or before or after lumpectomy. Axillary lymph node dissection is a more extensive surgery than sentinel node biopsy. Positive results from a sentinel node biopsy may require follow-up with axillary lymph node dissection or axillary radiation therapy.

What does it involve?
Axillary lymph node dissection may be an outpatient procedure or necessitate one or two days of hospital stay for monitoring.

On the day scheduled for the axillary lymph node dissection, you may need to stop eating and drinking eight to 12 hours before the procedure starts. You will arrive at the hospital and change into a gown. You will likely receive a relaxing medication followed by a general anesthetic.

Surgery for axillary lymph node dissection takes about one hour. During the surgery, the surgeon will make a small incision, approximately two to three inches long, under your arm. They will remove tissue containing lymph nodes and fat. At the end of the surgery, the surgeon may insert a rubber drainage tube into the spot where the tissue was in order to help drain excess fluid. The drainage tube may be removed before you leave the hospital, or within one to two weeks after your surgery.

After sentinel node biopsy surgery, you will be sent to a recovery room. Depending on the extent of your surgery, you will spend either a few hours or a night or two. During this time, your blood pressure, heart rate and temperature will be monitored. You will be discharged when your condition is stable. Your surgeon will provide instructions on how to care for your wound and drain, how to exercise your arm so it does not become stiff, and how to recognize signs of infection. You will be given prescriptions for medication to help manage your pain. Make sure you understand the instructions, and do not be afraid to ask questions.

While you finish your recovery at home, get plenty of rest. Take pain medications as needed. Carefully monitor for signs of complications. Call your doctor immediately if you experience swelling or redness in the arm or hand on the side you had the axillary lymph node dissection.

The tissue removed during the axillary lymph node dissection will be sent to the lab for testing. It may take one or two weeks to receive results.

Intended Outcomes
Axillary lymph node dissection can diagnose the stage of the breast cancer, help treat cancer that has spread, and help determine appropriate treatment plans.

Results
A clinical study completed in 2013 compared the effectiveness of axillary lymph node dissection versus axillary radiation therapy on patients with positive sentinel node biopsy results. The study followed 474 women for 40 months after the treatments. The two treatments were found to have no significant difference between rates of recurrence and survival.

Constraints
After axillary lymph node dissection, you can expect some pain during recovery and some numbness in your underarm or the back of your arm. The numbness may be temporary or permanent. There will be one or more small scars. Ice and over-the-counter painkillers can help with the pain.

You may experience lymphedema (swelling) or seroma (build-up of lymph fluid) around the surgical site. The swelling may affect the hand or arm on that side. If you experience seroma, your doctor may need to remove the fluid with a needle.

It is important to exercise your arm and shoulder the way you will be taught after surgery in order to maintain function and avoid stiffness and weakness.

There may also be increased likelihood of infection in the affected area. Carefully monitor for signs of infection including redness, pain or heat.

Rarely, nerve damage after axillary lymph node dissection can cause a condition called winged scapula wherein your shoulder blade sticks out at an angle. It is not usually painful or debilitating.

Any type of surgery carries risks including blood clots, blood loss, infection, breathing problems, reactions to medication, and heart attack or stroke during the surgery.