Clinical Procedures
Axillary Dissection
Updated: Oct 18, 2024
Author: Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC; Chief Editor: Erik D
Schraga
Sections
Overview
Background
Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or
remove lymph nodes. Axillary dissection has been the standard technique used in the
staging and treatment of the axilla in breast cancer. Patients presenting with symptomatic
early breast cancer have a 30-40% chance of having positive axillary nodes and 20-25%
chance if presenting through a screening program.
Staging of the axilla is an important step in the treatment of breast carcinoma. Axillary
lymph node status is a significant prognostic pathologic variable in patients with operable
primary breast cancer, and it remains the most powerful predictor of recurrence and
survival. The number of lymph nodes with metastasis also has prognostic importance. [1,
2]
Axillary dissection was first advocated as part of the treatment of invasive breast cancer in
the 18th century by Lorenz Heister, a German surgeon. [3, 4, 5] In modern practice, the role
and benefits of axillary dissection have been influenced by the National Surgical Adjuvant
Breast Project B-04 trial, [6] which concluded that axillary dissection has no effect on
survival. However, other studies provided substantial evidence that axillary dissection
provides excellent local control of disease in the axilla, with a local recurrence rate of 2% or
less, [7, 8] which may lead to improved overall survival. [9, 10]
Indications
, Axillary dissection should be reserved for patients with proven axillary disease
preoperatively or with a positive sentinel node biopsy.
Axillary dissection is only therapeutic in patients who are node positive. Therefore,
performing axillary dissection in all patients would lead to an overtreatment of at least 60%
of patients who are all node negative. The introduction of sentinel-node biopsy has
changed the approach to the axilla, as the status of the axilla can be established with less
morbidity for patients when compared with complete axillary dissection.
In a retrospective study (2014-2022) cmprising data from 90 patients with stage cT1-2N0
breast cancer to evalute how often axillary lymph node dissection is necessary with upfront
surgery and which factors are associated with at least three positive sentinel lymph nodes
(SLNs) following preoperative lymph node biopsy, investigators found that over 70% of the
women with cT1-2 breast cancer and image-detected nodal metastases had fewer than
three positive SLNs and didn’t need axillary lymph node dissection. [11] Factors associated
with having three or more positive SLNs were more than one abnormal lymph node on
preoperative imaging, SLN microscopic extracapsular extension, and an increased median
number of SLN removal.
There may be a gradual shift away from carrying out an axillary clearance in patients with
positive sentinel nodes. A trial (AMAROS), presented at the Annual Meeting of American
Society of Clinical Oncology, compared the use of axillary radiotherapy with axillary
clearance in patients who had a positive sentinel node and found no significant difference
in disease-free or overall survival, but reduced lymphedema rates in the radiation group.
Results from the American College of Surgeons Oncology Group (ACOSOG) Trial (Z0011)
reported patients without clinical or radiological evidence of axillary metastases
undergoing breast-conserving surgery having whole-breast radiotherapy, with positive
sentinel nodes, did not achieve any further oncological benefit by having axillary clearance.
There is an increasing use of neoadjuvant chemotherapy in breast cancer, and the optimal
timing of sentinel node biopsy can be controversial. Axillary dissection is advocated for all
Axillary Dissection
Updated: Oct 18, 2024
Author: Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC; Chief Editor: Erik D
Schraga
Sections
Overview
Background
Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or
remove lymph nodes. Axillary dissection has been the standard technique used in the
staging and treatment of the axilla in breast cancer. Patients presenting with symptomatic
early breast cancer have a 30-40% chance of having positive axillary nodes and 20-25%
chance if presenting through a screening program.
Staging of the axilla is an important step in the treatment of breast carcinoma. Axillary
lymph node status is a significant prognostic pathologic variable in patients with operable
primary breast cancer, and it remains the most powerful predictor of recurrence and
survival. The number of lymph nodes with metastasis also has prognostic importance. [1,
2]
Axillary dissection was first advocated as part of the treatment of invasive breast cancer in
the 18th century by Lorenz Heister, a German surgeon. [3, 4, 5] In modern practice, the role
and benefits of axillary dissection have been influenced by the National Surgical Adjuvant
Breast Project B-04 trial, [6] which concluded that axillary dissection has no effect on
survival. However, other studies provided substantial evidence that axillary dissection
provides excellent local control of disease in the axilla, with a local recurrence rate of 2% or
less, [7, 8] which may lead to improved overall survival. [9, 10]
Indications
, Axillary dissection should be reserved for patients with proven axillary disease
preoperatively or with a positive sentinel node biopsy.
Axillary dissection is only therapeutic in patients who are node positive. Therefore,
performing axillary dissection in all patients would lead to an overtreatment of at least 60%
of patients who are all node negative. The introduction of sentinel-node biopsy has
changed the approach to the axilla, as the status of the axilla can be established with less
morbidity for patients when compared with complete axillary dissection.
In a retrospective study (2014-2022) cmprising data from 90 patients with stage cT1-2N0
breast cancer to evalute how often axillary lymph node dissection is necessary with upfront
surgery and which factors are associated with at least three positive sentinel lymph nodes
(SLNs) following preoperative lymph node biopsy, investigators found that over 70% of the
women with cT1-2 breast cancer and image-detected nodal metastases had fewer than
three positive SLNs and didn’t need axillary lymph node dissection. [11] Factors associated
with having three or more positive SLNs were more than one abnormal lymph node on
preoperative imaging, SLN microscopic extracapsular extension, and an increased median
number of SLN removal.
There may be a gradual shift away from carrying out an axillary clearance in patients with
positive sentinel nodes. A trial (AMAROS), presented at the Annual Meeting of American
Society of Clinical Oncology, compared the use of axillary radiotherapy with axillary
clearance in patients who had a positive sentinel node and found no significant difference
in disease-free or overall survival, but reduced lymphedema rates in the radiation group.
Results from the American College of Surgeons Oncology Group (ACOSOG) Trial (Z0011)
reported patients without clinical or radiological evidence of axillary metastases
undergoing breast-conserving surgery having whole-breast radiotherapy, with positive
sentinel nodes, did not achieve any further oncological benefit by having axillary clearance.
There is an increasing use of neoadjuvant chemotherapy in breast cancer, and the optimal
timing of sentinel node biopsy can be controversial. Axillary dissection is advocated for all
