Grossly involved nodes
Confirmed axillary nodal involvement
Some also favour ALND in patients who were down-staged to node
negative after neoadjuvant therapy.
Principles & Anatomy
Remove node bearing fat deep to axillary fascia
Area is between the pectoralis and lat dorsi muscles.
Dissection limited to level I is justified in most cases.
Level 1 nodes are inferior to the axillary vein and lateral to
the pectoralis minor muscle
Boundaries of level I
- anterior = clavipectoral fascia, posterior =
subscapularis muscle, inferior = axillary tail; superior
= just below axillary vein; medially = lateral edge of pec
- do not skeletonize the axillary vein; increases risk of
Diminishing returns on lymph nodes obtained and increased morbidity
when moving to level II and III
- particularly with level III, which substantially increases
Level II nodes are posterior to the pectoralis minor muscle.
Level III are medial to pec minor.
Primary axilla Ca
0.3-1% of breast cancer presents this way
Breast MRI will identify primary in 50%
--> manage with standard therapy.
Else consider other tumour origins and do a core or FNA.
If consistent with breast, axillary dissection .
--> then whole-breast irradiation without mastectomy
Carefully identify and preserve i) long thoracic; ii)
thoracodorsal; iii) medial pectoral motor nerves
- and intercostal nerves if possible.
Closed suction drain placed through a separate stab incision
- or be prepared to serially aspirate seromas if symptomatic
Wound closed primarily.
Long-acting LA in wound; clamp drain for 1-2h to allow LA to act
locally in cavity.
Complications, Alternatives and Controversies
1. Lymphoedema in 10-25%
3. Chronic arm pain
4. Reduced range of motion in shoulder.
25-50% of patients report some of 2-4; often decrease over time.
Radiation after dissection?
MDT setting decision
Used in patients with v. high risk of recurrence
Ie multiple positive nodes and extranodal deposits
Has a rate of brachial plexus compromise of 1%
And increases lymphoedema rate to up to 30% after level I and II
May appear many years later, e.g. 5-10y
May present with arm oedema, neuro impairment or pain.
Diagnose by FNA, core biopsy or surgical biopsy
Ipsilateral disease may be recurrence from a new primary; do a
--> completion resection and treatment of primary
Isolated axillary recurrence has an ok prognosis with 70% 5-yr
- worse if in supraclavicular, internal mammary or multiples sites.