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Axillary Lymph Node Dissection
Dalliah M. Black, MD, FACS; Katherine McElroy, BA; Henry M. Kuerer, MD, PhD, FACS
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          • Outcomes

            TERMINOLOGY

            • Abbreviations

              • Axillary lymph node dissection (ALND)
              • Regional nodal irradiation (RNI)
            • Synonyms

              • Axillary lymphadenectomy
            • Definitions

              • ALND: Surgical removal of axillary contents (fat & nodes) for purposes of staging breast cancer & controlling local disease
              • Sentinel lymph node (SLN): Lymph node(s) that 1st drain breast, identified by Tc-99m sulfur colloid &/or isosulfan or methylene blue dye
              • Clinically node (-): No suspicious axillary nodes on clinical exam or imaging, including US
              • Pathologically node (-): No metastasis identified in SLN or ALND
              • Node (+): Micro- or macrometastasis identified in SLN or ALND
                • Isolated tumor cells (ITCs) not considered node (+)
              • Traditional ALND includes dissection of level I & level II axillary nodes
                • Level I: Nodes lateral to pectoralis minor muscle & inferior to axillary vein
                • Level II: Nodes posterior to pectoralis minor muscle
                • Level II includes Rotter nodes: Located between pectoralis major & minor muscles
                  • Not routinely excised unless suspicious on imaging or metastasis detected on fine-needle aspiration biopsy
                • Level III: Nodes medial to pectoralis minor muscle & below clavicle
              • Completion ALND: Performed if metastatic SLN excision (select patients)
              • Targeted axillary dissection (TAD): Excision of clipped, biopsy-proven metastatic node with preoperative localization & excision of SLNs

            PREPROCEDURE

            • Indications

              • Contraindications

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Findings and Reporting

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Expected Outcome

                          • Things to Do

                            OUTCOMES

                            • Complications

                              Selected References

                              1. Galimberti V et al: Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol. ePub, 2018
                              2. Giuliano AE et al: Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (alliance) randomized clinical trial. JAMA. 318(10):918-26, 2017
                              3. Nguyen TT et al: Breast cancer-related lymphedema risk is related to multidisciplinary treatment and not surgery alone: results from a large cohort study. Ann Surg Oncol. 24(10):2972-80, 2017
                              4. Ong CT et al: Patient Age and Tumor Subtype Predict the Extent of Axillary Surgery Among Breast Cancer Patients Eligible for the American College of Surgeons Oncology Group Trial Z0011. Ann Surg Oncol. 24(12):3559-3566, 2017
                              5. Caudle AS et al: Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 34(10):1072-8, 2016
                              6. Caudle AS et al: Targeting and limiting surgery for patients with node-positive breast cancer. BMC Med. 13:149, 2015
                              7. Caudle AS et al: Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg. 150(2):137-43, 2015
                              8. Agarwal S et al: Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer. JAMA Surg. 149(3):267-74, 2014
                              9. Donker M et al: Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 15(12):1303-10, 2014
                              10. Giuliano AE et al: Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage invasive breast cancer. JAMA. 306(4):385-93, 2011
                              11. Sanpaolo P et al: Prognostic value of breast cancer subtypes on breast cancer specific survival, distant metastases and local relapse rates in conservatively managed early stage breast cancer: a retrospective clinical study. Eur J Surg Oncol. 37(10):876-82, 2011
                              12. Weaver DL et al: Effect of occult metastases on survival in node-negative breast cancer. N Engl J Med. 364(5):412-21, 2011
                              13. Yang WT: Staging of breast cancer with ultrasound. Semin Ultrasound CT MR. 32(4):331-41, 2011
                              14. Edge SB et al: AJCC Cancer Staging Manual. 7th ed. New York: Springer, 2010
                              15. Krag DN et al: Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 11(10):927-33, 2010
                              16. Bedi DG et al: Cortical morphologic features of axillary lymph nodes as a predictor of metastasis in breast cancer: in vitro sonographic study. AJR Am J Roentgenol. 191(3):646-52, 2008
                              17. Shen J et al: Feasibility and accuracy of sentinel lymph node biopsy after preoperative chemotherapy in breast cancer patients with documented axillary metastases. Cancer. 109(7):1255-63, 2007
                              18. Fisher B et al: Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 347(8):567-75, 2002
                              19. Krishnamurthy S et al: Role of ultrasound-guided fine-needle aspiration of indeterminate and suspicious axillary lymph nodes in the initial staging of breast carcinoma. Cancer. 95(5):982-8, 2002
                              20. Petrek JA et al: Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 92(6):1368-77, 2001
                              21. Newman LA et al: Presentation, management and outcome of axillary recurrence from breast cancer. Am J Surg. 180(4):252-6, 2000
                              22. Kuerer HM et al: Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy. Ann Surg. 230(1):72-8, 1999
                              23. Bold RJ et al: Prospective, randomized, double-blind study of prophylactic antibiotics in axillary lymph node dissection. Am J Surg. 176(3):239-43, 1998
                              24. Zavotsky J et al: Evaluation of axillary lymphadenectomy without axillary drainage for patients undergoing breast-conserving therapy. Ann Surg Oncol. 5(3):227-31, 1998
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Post Procedure

                                      • Outcomes

                                        TERMINOLOGY

                                        • Abbreviations

                                          • Axillary lymph node dissection (ALND)
                                          • Regional nodal irradiation (RNI)
                                        • Synonyms

                                          • Axillary lymphadenectomy
                                        • Definitions

                                          • ALND: Surgical removal of axillary contents (fat & nodes) for purposes of staging breast cancer & controlling local disease
                                          • Sentinel lymph node (SLN): Lymph node(s) that 1st drain breast, identified by Tc-99m sulfur colloid &/or isosulfan or methylene blue dye
                                          • Clinically node (-): No suspicious axillary nodes on clinical exam or imaging, including US
                                          • Pathologically node (-): No metastasis identified in SLN or ALND
                                          • Node (+): Micro- or macrometastasis identified in SLN or ALND
                                            • Isolated tumor cells (ITCs) not considered node (+)
                                          • Traditional ALND includes dissection of level I & level II axillary nodes
                                            • Level I: Nodes lateral to pectoralis minor muscle & inferior to axillary vein
                                            • Level II: Nodes posterior to pectoralis minor muscle
                                            • Level II includes Rotter nodes: Located between pectoralis major & minor muscles
                                              • Not routinely excised unless suspicious on imaging or metastasis detected on fine-needle aspiration biopsy
                                            • Level III: Nodes medial to pectoralis minor muscle & below clavicle
                                          • Completion ALND: Performed if metastatic SLN excision (select patients)
                                          • Targeted axillary dissection (TAD): Excision of clipped, biopsy-proven metastatic node with preoperative localization & excision of SLNs

                                        PREPROCEDURE

                                        • Indications

                                          • Contraindications

                                            • Getting Started

                                              PROCEDURE

                                              • Patient Position/Location

                                                • Findings and Reporting

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Expected Outcome

                                                      • Things to Do

                                                        OUTCOMES

                                                        • Complications

                                                          Selected References

                                                          1. Galimberti V et al: Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol. ePub, 2018
                                                          2. Giuliano AE et al: Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (alliance) randomized clinical trial. JAMA. 318(10):918-26, 2017
                                                          3. Nguyen TT et al: Breast cancer-related lymphedema risk is related to multidisciplinary treatment and not surgery alone: results from a large cohort study. Ann Surg Oncol. 24(10):2972-80, 2017
                                                          4. Ong CT et al: Patient Age and Tumor Subtype Predict the Extent of Axillary Surgery Among Breast Cancer Patients Eligible for the American College of Surgeons Oncology Group Trial Z0011. Ann Surg Oncol. 24(12):3559-3566, 2017
                                                          5. Caudle AS et al: Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 34(10):1072-8, 2016
                                                          6. Caudle AS et al: Targeting and limiting surgery for patients with node-positive breast cancer. BMC Med. 13:149, 2015
                                                          7. Caudle AS et al: Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg. 150(2):137-43, 2015
                                                          8. Agarwal S et al: Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer. JAMA Surg. 149(3):267-74, 2014
                                                          9. Donker M et al: Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 15(12):1303-10, 2014
                                                          10. Giuliano AE et al: Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage invasive breast cancer. JAMA. 306(4):385-93, 2011
                                                          11. Sanpaolo P et al: Prognostic value of breast cancer subtypes on breast cancer specific survival, distant metastases and local relapse rates in conservatively managed early stage breast cancer: a retrospective clinical study. Eur J Surg Oncol. 37(10):876-82, 2011
                                                          12. Weaver DL et al: Effect of occult metastases on survival in node-negative breast cancer. N Engl J Med. 364(5):412-21, 2011
                                                          13. Yang WT: Staging of breast cancer with ultrasound. Semin Ultrasound CT MR. 32(4):331-41, 2011
                                                          14. Edge SB et al: AJCC Cancer Staging Manual. 7th ed. New York: Springer, 2010
                                                          15. Krag DN et al: Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 11(10):927-33, 2010
                                                          16. Bedi DG et al: Cortical morphologic features of axillary lymph nodes as a predictor of metastasis in breast cancer: in vitro sonographic study. AJR Am J Roentgenol. 191(3):646-52, 2008
                                                          17. Shen J et al: Feasibility and accuracy of sentinel lymph node biopsy after preoperative chemotherapy in breast cancer patients with documented axillary metastases. Cancer. 109(7):1255-63, 2007
                                                          18. Fisher B et al: Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 347(8):567-75, 2002
                                                          19. Krishnamurthy S et al: Role of ultrasound-guided fine-needle aspiration of indeterminate and suspicious axillary lymph nodes in the initial staging of breast carcinoma. Cancer. 95(5):982-8, 2002
                                                          20. Petrek JA et al: Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 92(6):1368-77, 2001
                                                          21. Newman LA et al: Presentation, management and outcome of axillary recurrence from breast cancer. Am J Surg. 180(4):252-6, 2000
                                                          22. Kuerer HM et al: Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy. Ann Surg. 230(1):72-8, 1999
                                                          23. Bold RJ et al: Prospective, randomized, double-blind study of prophylactic antibiotics in axillary lymph node dissection. Am J Surg. 176(3):239-43, 1998
                                                          24. Zavotsky J et al: Evaluation of axillary lymphadenectomy without axillary drainage for patients undergoing breast-conserving therapy. Ann Surg Oncol. 5(3):227-31, 1998