Axillary Lymph Node Dissection



Axillary lymph node dissection (ALND) has been a cornerstone of the management of breast cancer since the Halstedian era of radical mastectomy. ALND found its place due to the prevailing concepts of anatomic, sequential, breast cancer progression, as well as the somewhat predictable nature of the lymphatic drainage system of the breast. The removal of ipsilateral axillary nodes was employed to obtain maximum cure, regional control of lymph node metastases, and the most accurate breast cancer staging. This chapter reviews the indications and technique for an axillary node dissection.


Sentinel Node Biopsy Axillary Lymph Node Dissection Axillary Dissection Latissimus Dorsi Muscle Completion Axillary Lymph Node Dissection 
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  1. 1.
    Recht A, Houlihan MJ. Axillary lymph nodes and breast cancer: a review. Cancer. 1995;76(9):1491–512.PubMedCrossRefGoogle Scholar
  2. 2.
    Krag D, Weaver D, Ashikaga T, Moffat F, Klimberg VS, Shriver C, et al. The sentinel node in breast cancer – a multicenter validation study. N Engl J Med. 1998;339(14):941–6.PubMedCrossRefGoogle Scholar
  3. 3.
    McMasters KM, Tuttle TM, Carlson DJ, Brown CM, Noyes RD, Glaser RL, et al. Sentinel lymph node biopsy for breast cancer: a suitable alternative to routine axillary dissection in multi-institutional practice when optimal technique is used. J Clin Oncol. 2000;18(13):2560–6.PubMedGoogle Scholar
  4. 4.
    Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003;349(6):546–53.PubMedCrossRefGoogle Scholar
  5. 5.
    Quiet CA, Ferguson DJ, Weichselbaum RR, Hellman S. Natural history of node-positive breast cancer: the curability of small cancers with a limited number of positive nodes. J Clin Oncol. 1996;14(12):3105–2010.PubMedGoogle Scholar
  6. 6.
    Orr RK. The impact of prophylactic axillary node dissection on breast cancer survival – a Bayesian meta-analysis. Ann Surg Oncol. 1999;6(1):109–16.PubMedCrossRefGoogle Scholar
  7. 7.
    Mamounas EP, Brown A, Anderson S, Smith R, Julian T, Miller B, et al. Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2005;23:2694–702.PubMedCrossRefGoogle Scholar
  8. 8.
    Khan A, Sabel MS, Nees A, Diehl KM, Cimmino VM, Kleer CG, et al. Comprehensive axillary evaluation in neoadjuvant chemotherapy patients with ltrasonography and sentinel lymph node biopsy. Ann Surg Oncol. 2005;12(9):697–704.PubMedCrossRefGoogle Scholar
  9. 9.
    Schwartz GF, Meltzer AJ. Accuracy of axillary sentinel lymph node biopsy following neoadjuvant (induction) chemotherapy for carcinoma of the breast. Breast J. 2003;9(5):374–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Jones JL, Zabicki K, Christian RL, Gadd MA, Hughes KS, Lesnikoski BA, et al. A comparison of sentinel node biopsy before and after neoadjuvant chemotherapy: timing is important. Am J Surg. 2005;190(4):517–20.PubMedCrossRefGoogle Scholar
  11. 2010.
    Morrow M. Is axillary dissection necessary after positive sentinel node biopsy? Yes! Ann Surg Oncol. 2001;8(9 suppl):74S–6.PubMedGoogle Scholar
  12. 12.
    Krag DN. Is axillary dissection needed when the sentinal node is positive? Yes! J Surg Oncol. 2008;97(3):197–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Lucci A. Is axillary dissection needed when the sentinel node is positive? No: it is time to rethink axillary lymph node dissection when the sentinel node is positive. J Surg Oncol. 2008;97(3):201–2.PubMedCrossRefGoogle Scholar
  14. 14.
    Katz A, Niemierko A, Gage I, Evans S, Shaffer M, Fleury T, et al. Can axillary dissection be avoided in patients with sentinel lymph node metastasis? J Surg Oncol. 2006;93(7):550–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Kamath VJ, Giuliano R, Dauway EL, Cantor A, Berman C, Ku NN, et al. Characteristics of the sentinel lymph node in breast cancer predict further involvement of higher-echelon nodes in the axilla: a study to evaluate the need for complete axillary lymph node dissection. Arch Surg. 2001;136(6):688–92.PubMedCrossRefGoogle Scholar
  16. 16.
    Van Zee KJ, Manasseh DM, Bevilacqua JL, Boolbol SK, Fey JV, Tan LK, et al. Van Zee A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003;10(10):201040–51.CrossRefGoogle Scholar
  17. 17.
    Alran S, De Rycke Y, Fourchotte V, Charitansky H, Laki F, Falcou MC, Benamor M, Freneaux P, Salmon RJ; for the Institute Curie Breast Cancer Study Group, Sigal-Zafrani B. Validation and limitations of use of a breast cancer nomogram predicting the likelihood of non-sentinel node involvement after positive sentinel node biopsy. Ann Surg Oncol 2007;14(8):2195–201.Google Scholar
  18. 18.
    Chagpar A, Middleton LP, Sahin AA, Meric-Bernstam F, Kuerer HM, Feig BW, et al. Clinical outcome of patients with lymph node-negative breast carcinoma who have sentinel lymph node micrometastases detected by immunohistochemistry. Cancer. 2005;103(8):1581–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Cote RJ, Peterson HF, Chaiwun B, Gelber RD, Goldhirsch A, Castiglione-Gertsch M, et al. Role of immunohistochemical detection of lymph-node metastases in management of breast cancer. International Breast Cancer Study Group. Lancet. 1999;354(9182):896–900.PubMedCrossRefGoogle Scholar
  20. 20.
    Jeruss JS, Winchester DJ, Sener SF, Brinkmann EM, Bilimoria MM, Barrera Jr E, et al. Axillary recurrence after sentinel node biopsy. Ann Surg Oncol. 2005;12(1):34–40.PubMedCrossRefGoogle Scholar
  21. 21.
    Hwang RF, Gonzalez-Angulo AM, Yi M, Buchholz TA, Meric-Bernstam F, Kuerer HM, Babiera GV, Tereffe W, Liu DD, Hunt KK. Low locoregional failure rates in selected breast cancer patients with tumor-positive sentinel lymph nodes who do not undergo completion axillary dissection. Cancer. 2007;20100(4):723–30.Google Scholar
  22. 22.
    White RL Jr, Wilke LG. Update on the NSABP and ACOSOG breast cancer sentinel node trials. Am Surg 2004;70(5):420–4; Review.Google Scholar
  23. 23.
    Veronesi U, Orecchia R, Zurrida S, Galimberti V, Luini A, Veronesi P, et al. Avoiding axillary dissection in breast cancer surgery: a randomized trial to assess the role of axillary radiotherapy. Ann Oncol. 2005;16(3):383–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Louis-Sylvestre C, Clough K, Asselain B, Vilcoq JR, Salmon RJ, Campana F, et al. Axillary treatment in conservative management of operable breast cancer: dissection or radiotherapy? Results of a randomized study with 15 years of follow-up. J Clin Oncol. 2004;22(1):97–101.PubMedCrossRefGoogle Scholar
  25. 25.
    Petrek JA, Blackwood MM. Axillary dissection: current practice and technique. Curr Probl Surg. 1995;32(4):257–323.PubMedCrossRefGoogle Scholar
  26. 26.
    Zavotsky J, Jones RC, Brennan MB, Giuliano AE. Evaluation of axillary lymphadenectomy without axillary drainage for patients undergoing breast-conserving therapy. Ann Surg Oncol. 1998;5(3):227–31.PubMedCrossRefGoogle Scholar
  27. 27.
    Shamley DR, Barker K, Simonite V, Beardshaw A. Delayed versus immediate exercises following surgery for breast cancer: a systematic review. Breast Cancer Res Treat. 2005;90(3):263–71.PubMedCrossRefGoogle Scholar
  28. 28.
    Moore M, Burak WE, Nelson E, Kearney T, Simmons R, Mayers L, et al. Fibrin sealant reduces the duration and amount of fluid drainage after axillary dissection: a randomized prospective clinical trial. J Am Coll Surg. 2001;192(5):591–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Berger A, Tempfer C, Hartmann B, Kornprat P, Rossmann A, Neuwirth G, et al. Sealing of postoperative axillary leakage after axillary lymphadenectomy using a fibrin glue coated collagen patch: a prospective randomised study. Breast Cancer Res Treat. 2001;67(1):9–14.PubMedCrossRefGoogle Scholar
  30. 30.
    Tomaino MM. Neurophysiologic and clinical outcome following medial pectoral to long thoracic nerve transfer for scapular winging: a case report. Microsurgery. 2002;22(6):254–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in breast cancer patients. J Natl Cancer Inst 2001;93(2):96–20101; Review.Google Scholar
  32. 32.
    Paskett ED, Naughton MJ, McCoy TP, Case LD, Abbott JM. The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev. 2007;16(4):775–82.PubMedCrossRefGoogle Scholar
  33. 33.
    Roses DF, Brooks AD, Harris MN, Shapiro RL, Mitnick J. Complications of level I and II axillary dissection in the treatment of carcinoma of the breast. Ann Surg. 1999;230(2):194–201.PubMedCrossRefGoogle Scholar
  34. 34.
    Paik S, Shak S, Tang G, Kim C, Baker J, Cronin M, et al. A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med. 2004;351(27):2817–26.PubMedCrossRefGoogle Scholar
  35. 35.
    Stomper PC, Waddell BE, Edge SB, Klippenstein DL. Breast MRI in the evaluation of patients with occult primary breast carcinoma. Breast J. 1999;5(4):230–4.PubMedCrossRefGoogle Scholar
  36. 36.
    Varadhachary GR, Abbruzzese JL, Lenzi R. Diagnostic strategies for unknown primary cancer. Cancer. 2004;100(9):1776–85.PubMedCrossRefGoogle Scholar
  37. 37.
    Foroudi F, Tiver KW. Occult breast carcinoma presenting as axillary metastases. Int J Radiat Oncol Biol Phys. 2000;47(1):143–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Orel SG, Weinstein SP, Schnall MD, Reynolds CA, Schuchter LM, Fraker DL, et al. Breast MR imaging in patients with axillary node metastases and unknown primary malignancy. Radiology. 1999;212(2):543–9.PubMedGoogle Scholar
  39. 39.
    Buchanan CL, Morris EA, Dorn PL, Borgen PI, Van Zee KJ. Utility of breast magnetic resonance imaging in patients with occult primary breast cancer. Ann Surg Oncol. 2005;12(12):1045–53.PubMedCrossRefGoogle Scholar
  40. 40.
    Olson JA, Morris EA, Van Zee KJ, Linehan DC, Borgen PI. Magnetic resonance imaging facilitates breast conservation for occult breast cancer. Ann Surg Oncol. 2000;7(6):42010–5.CrossRefGoogle Scholar
  41. 41.
    Vlastos G, Jean ME, Mirza AN, Mirza NQ, Kuerer HM, Ames FC, et al. Feasibility of breast preservation in the treatment of occult primary carcinoma presenting with axillary metastases. Ann Surg Oncol. 2001;8(5):425–31.PubMedCrossRefGoogle Scholar
  42. 42.
    Shannon C, Walsh G, Sapunar F, A’Hern R, Smith I. Occult primary breast carcinoma presenting as axillary lymphadenopathy. Breast. 2002;2010(5):414–8.CrossRefGoogle Scholar
  43. 43.
    Chen C, Orel SG, Harris E, Schnall MD, Czerniecki BJ, Solin LJ. Outcome after treatment of patients with mammographically occult, magnetic resonance imaging-detected breast cancer presenting with axillary lymphadenopathy. Clin Breast Cancer. 2004;5(1):72–7.PubMedCrossRefGoogle Scholar
  44. 44.
    Brill KL, Brenin DR. Occult breast cancer and axillary mass. Curr Treat Options Oncol. 2001;2(2):149–55.PubMedCrossRefGoogle Scholar
  45. 45.
    Galimberti V, Bassani G, Monti S, Simsek S, Villa G, Renne G, et al. Clinical experience with axillary presentation breast cancer. Breast Cancer Res Treat. 2004;88(1):43–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Jatoi I, Kaufmann M, Petit JY.  Chapter 6: Surgery for breast carcinoma. In: Atlas of breast surgery. Berlin: Springer; 2006.Google Scholar
  47. 47.
    Giuliano AE, McCall LM, Beitsch PD, et al. J Clin Oncol. 2010;28:18S (suppl; abstra CRA 506).Google Scholar

Copyright information

© Springer New York 2010

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of VermontBurlingtonUSA

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