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
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
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
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
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
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
Caudle AS et al: Targeting and limiting surgery for patients with node-positive breast cancer. BMC Med. 13:149, 2015
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
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
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
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
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
Weaver DL et al: Effect of occult metastases on survival in node-negative breast cancer. N Engl J Med. 364(5):412-21, 2011
Yang WT: Staging of breast cancer with ultrasound. Semin Ultrasound CT MR. 32(4):331-41, 2011
Edge SB et al: AJCC Cancer Staging Manual. 7th ed. New York: Springer, 2010
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
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
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
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
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
Petrek JA et al: Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 92(6):1368-77, 2001
Newman LA et al: Presentation, management and outcome of axillary recurrence from breast cancer. Am J Surg. 180(4):252-6, 2000
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
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
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
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
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
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
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
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
Caudle AS et al: Targeting and limiting surgery for patients with node-positive breast cancer. BMC Med. 13:149, 2015
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
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
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
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
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
Weaver DL et al: Effect of occult metastases on survival in node-negative breast cancer. N Engl J Med. 364(5):412-21, 2011
Yang WT: Staging of breast cancer with ultrasound. Semin Ultrasound CT MR. 32(4):331-41, 2011
Edge SB et al: AJCC Cancer Staging Manual. 7th ed. New York: Springer, 2010
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
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
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
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
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
Petrek JA et al: Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 92(6):1368-77, 2001
Newman LA et al: Presentation, management and outcome of axillary recurrence from breast cancer. Am J Surg. 180(4):252-6, 2000
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
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
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
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