Overview of Axillary Lymphadenectomy
Axillary lymphadenectomy, or simply put, axillary dissection, is a surgery to remove all the lymphatic tissue—part of the immune system—from the armpit area. This operation was traditionally performed together with a type of breast cancer surgery known as a modified radical mastectomy. This procedure was a very important part of breast cancer treatment. But as we’ve learned more about how breast cancer works and improved our chemotherapy and radiotherapy methods, we’ve seen that less invasive procedures can be just as effective. This has led to a substantial decrease in the number of axillary lymphadenectomies performed.
There are still some situations where an axillary lymphadenectomy might be needed, though. These include cases where the lymph nodes in the armpit area are involved in breast cancer, when these lymph nodes show signs of cancer returning, and when these lymph nodes test positive for non-breast cancer types like melanoma (a type of skin cancer) and squamous cell carcinoma (a type of skin cancer).
It’s important to note that axillary lymphadenectomy comes with a significant risk of complications, especially a condition called lymphedema, where fluid builds up and causes swelling because the lymph nodes have been removed. So, understanding the anatomy of the armpit area and knowing when it’s appropriate to perform this type of surgery is extremely important to ensure the surgery is performed safely and works as intended.
Anatomy and Physiology of Axillary Lymphadenectomy
The axilla, or the armpit, is a key area in determining how a physician stages and treats breast cancer. This part of the body is responsible for draining 95% of the lymphatic fluid from the breast, making it an important area to understand and examine for doctors. The axilla is a pyramid-like space at the base of the neck, surrounded by various muscles at different angles: chest muscles, shoulder muscles, the clavicle (collar bone), and the upper arm bone.
The axilla holds various structures, like blood vessels, nerves, muscles, tendons, fatty tissue, and lymph nodes. The amount of fatty tissue can vary a lot from person to person. Two crucial blood vessels are the axillary artery and vein which change names into the brachial artery and vein when they reach the upper arm. Along with these, the axilla houses the brachial plexus, a network of nerves, all of which are encased within a sleeve-like structure called the axillary sheath.
There are many nerves in the axilla, but there are a couple of important ones to highlight. The first is the thoracodorsal nerve that goes along with the associated artery and vein to mainly help activate the large muscle in your back, the latissimus dorsi muscle. The second is the long thoracic nerve, which helps activate the serratus anterior muscle, a muscle along the side of your chest. There’s also the intercostobrachial nerve, which is a sensory nerve that helps you feel sensations on the inner part of your arm and the skin of the armpit. It’s important to know these nerves exist and where they’re located to avoid damaging them during surgeries.
The fatty tissue in the axilla also contains several groups of lymph nodes, which are small, bean-like structures that are part of the immune system, helping to fight off infections and diseases. These nodes are grouped and named based on where they’re located, such as the anterior or “pectoral” nodes which are near the side chest muscles and nodes on the back wall of the axilla, called the “posterior” or subscapular nodes. There are also lymph nodes on the side wall of the axilla, the central part of the axilla, and at the tip of the axilla, each receiving and draining lymph fluid from different areas.
Lymph nodes are usually classified based on their location regarding a muscle in the chest called the pectoralis minor muscle. The ones located lateral to or below the lower edge of this muscle are called Level I nodes, which are the most common sites for axillary metastases or the spread of cancer cells, representing 60%-70% of the cases. Level II nodes are located deep to the pectoralis minor muscle, and Level III nodes are above or medial to the upper edge of the muscle. Knowing this grouping helps physicians to develop a precise plan for cancer treatment, like removing lymph nodes from levels I and II for most cases or also including Level III nodes if the cancer is spread wide or in the case of malignant melanoma, a type of skin cancer.
Why do People Need Axillary Lymphadenectomy
If you have breast cancer, there are several reasons why the doctor might decide to perform a surgical procedure called axillary lymphadenectomy. This procedure removes some of your lymph nodes, specifically the ones located in your armpit, which is also known as the axilla.
These reasons include:
– The lymph nodes in your armpit show signs of containing cancer, which is determined through physical exams or imaging tests.
– You have inflammatory breast cancer, a rare and aggressive type of cancer that makes the breast red, swollen, and warm.
– More than three of your sentinel lymph nodes are positive. The sentinel lymph nodes are the first ones that breast cancer would spread to.
– The lymph nodes remain positive even after neoadjuvant therapy, treatment given before the main treatment to shrink the tumor.
– An attempt to biopsy (take a small tissue sample of) the sentinel lymph node was unsuccessful.
– You are not able to receive radiation therapy, which is a common treatment for cancer.
– The lymph nodes in your breast have shown recurrence of cancer after a previous treatment.
Apart from breast cancer, there are additional reasons why an axillary lymphadenectomy might be needed. These include:
– Having melanoma (a type of skin cancer) or squamous cell carcinoma (another type of skin cancer) in which your lymph nodes have visible signs of cancer.
Remember, your doctors make these decisions based on your particular situation, your overall health, and the specifics of the cancer you have. So, don’t hesitate to ask them about any concerns or questions you may have about these procedures.
When a Person Should Avoid Axillary Lymphadenectomy
There’s no strict rule that says you can’t have axillary lymph node dissection, a procedure to remove lymph nodes in the armpit, unless the cancer has spread to other distant parts of the body. However, in cases of localized breast cancer, which means the cancer is only in the breast, it’s always a good idea to think about treatments that are less invasive if they are available.
Equipment used for Axillary Lymphadenectomy
Performing the removal of lymph nodes from the armpit area doesn’t need particular tools. All a surgeon needs is a regular set of surgical tools which include retractors. Retractors are medical instruments used to hold back the edges of a wound to provide a clear view and access to the body area being operated on.
Who is needed to perform Axillary Lymphadenectomy?
In simpler terms, the team in the operating room usually includes a surgeon (a special type of doctor who performs surgery), an assistant to the surgeon, a surgical technician or nurse specially trained for the operating room, and a circulating nurse (a nurse who moves throughout the room, assisting where needed). The surgery might be done with you completely asleep (general anesthesia) or only numb in a certain region of your body (regional anesthesia).
Preparing for Axillary Lymphadenectomy
Before having a surgical procedure called an axillary lymphadenectomy, which involves removing lymph nodes from your armpit (or ‘axilla’), it’s recommended that your case be reviewed by a group of healthcare professionals who specialize in tumors. They will look at your medical condition and determine if you really need this surgery, or if there are other, less invasive options available.
It’s important to take a preventative antibiotic around 30 minutes before the surgeon makes the first cut. The antibiotic can help protect you against possible infections during the surgery.
When it’s time for the surgery, you’ll be made to lie flat on your back on the operating table. Your arm on the side where the surgery will occur will be stretched out, and your armpit will be positioned at the edge of the table to make it easier for the surgeon to perform the procedure. Just know that your arm will also be included in the area to be cleaned and draped for surgery.
For more complex cases, like when the surgery involves melanoma (a type of skin cancer) or noticeable level III lymph nodes (lymph nodes that are very deep in the armpit), a more extensive removal process may be required. The doctors might use a self-holding tool like an Omni-Tract™ or Thompson retractor to make the surgical procedure easier.
How is Axillary Lymphadenectomy performed
The axillary dissection procedure, or the process of removing lymph nodes in the armpit area, starts with getting the patient ready and into the right position. The area where the surgery will be performed is cleaned and covered by a sterile sheet, and the arm is placed in a way that allows the best access to the area of interest. Important body structures, such as the latissimus dorsi (a back muscle) and the pectoralis major (a chest muscle), are spotted and marked.
The initial cut is usually made along the lower edge of the armpit hair or behind and parallel to the edge of the pectoralis major muscles, measuring between 2 to 4 inches depending on the patient’s body size. A local anesthetic is used to numb the area, then a special tool that uses heat (electrocautery) is used to cut through the skin and fat layers. At this point, a layer of soft tissue known as the clavipectoral fascia is identified and cut open for better access to the armpit or axilla. Specific surgical instruments, such as Army-Navy or Richardson retractors, are used to keep the wound open and enhance visualization.
During this lymph node removal surgery, several key body structures are identified. To prevent any harm to them, careful dissection is performed using the electrocautery. The axillary vein, located on the upper side, marks the upper boundary of the surgery area. Any fatty tissue over this vein is removed and included in the tissue sample for any further tests. The thoracodorsal nerve which supplies signals to the latissimus dorsi muscle is kept safe if possible, however, in some cases, if the tumor has spread to it, it may need to be removed. The intercostobrachial nerve, which provides sensations to the inner part of the arm, is generally seen during dissection and is often removed.
The pectoralis major along its length is identified to facilitate the exposure of another muscle called pectoralis minor located underneath. The fat-filled tissue between these muscles is also included in the specimen. Another nerve called the long thoracic nerve is identified on the surface of the serratus anterior, it should also be carefully preserved during the procedure.
After removing the unnecessary fatty tissue and identifying important nerves, any remaining fatty tissue in the armpit area is also removed. If more superior lymph nodes need to be removed, which are located superior to the pectoralis minor, the muscle either needs to be pushed aside or cut at its origin. If everything was done correctly, the final view after this procedure should be the expanse of the pectoralis major, serratus anterior, and latissimus dorsi muscles as well as the axillary vein and any preserved nerves.
Typically, a closed suction drain is placed at this stage to drain away any accumulating fluids, and then the wound is closed layer by layer. Post-surgery, patients are usually kept under observation for a day, or, in some instances, are allowed to leave the same day. The amount of fluid being drained is kept under close watch. Taking rest and moving the arm regularly within 48 to 72 hours after the surgery can help reduce pain and prevent fluid accumulation. The drain can stay in place until the fluid output is less than about 2 tablespoons daily for 2 consecutive days. But keep in mind, keeping the drain for too long can produce an infection. To manage the discomfort after surgery, patients are usually given oral painkillers. Early detection of any signs of lymphedema (swelling in the arms), for example by measuring arm circumference, and prompt treatments are important for the best recovery.
Possible Complications of Axillary Lymphadenectomy
When your armpit lymph nodes are surgically removed, a common after-effect is the formation of a seroma—a pocket of clear fluid that sometimes collects in the body after surgery. Though most people experience seroma formation, it doesn’t always need to be treated; only between 10% and 80% of cases require medical intervention. One way to reduce this is by closed suction wound drainage, a process that removes the excess fluid. Temporary immobilization using slings or compressive bandages can also lower seroma rates, but this can increase the risk of lymphedema, which is the swelling in the arm due to a blockage in the lymphatic system. Other strategies include applying a special type of glue during surgery or carefully controlling bleeding.
Lymphedema is a common complication after these types of surgeries and is marked by the build-up of lymphatic fluid in the arm. About 20% of patients experience this, usually in the first two years following surgery. Factors like a larger-scale surgical operation, obesity, chemotherapy, radiation therapy, and having a mastectomy (breast removal surgery) together with a lymph node removal can increase the risk. Regular physical activity may increase this risk, but its benefits usually compensate for this. Doctors can detect lymphedema by routinely measuring the arm’s size and being alert to its symptoms.
Between 1% to 20% of patients can develop wound infections after lymph node removal in the armpit, usually mild infections of the surgical site. However, when deep infections occur, these might require another surgery to drain them.
Nerve injury is another potential risk of lymph node removal. Damage to certain nerves can weaken the muscles controlling the movement of the shoulder and shoulder blades or cause numbness in the inner arm. Any injury to the nerves controlling the major chest muscle is especially problematic for people who will undergo breast reconstruction with implants, as it can negatively affect the cosmetic result.
There’s also a risk, though rare, of developing a very aggressive form of cancer known as angiosarcoma in the limb where the lymph nodes were removed. This usually happens about 10 years after surgery in patients with severe, chronic lymphedema—that’s known as Stewart-Treves syndrome. The risk is higher for those who’ve also had radiation therapy. Though treatment involves both surgery and chemotherapy, the overall prognosis remains poor with a limited chance for a long-term cure.
Axillary web syndrome is another condition that could develop after the surgery, where fibrous bands form in the armpit, potentially causing pain and limiting shoulder movement. The condition usually appears within the first few weeks after surgery and resolves gradually over time. Remember that this syndrome resolves on its own, so don’t be alarmed if you experience it.
What Else Should I Know About Axillary Lymphadenectomy?
Axillary lymphadenectomy is a procedure where all lymphatic tissue is removed from the armpit, or ‘axilla’. In the past, this method was standard practice for treating cancers that involve the lymph nodes in the armpit area. However, it’s less commonly used today. Despite this, it remains a significant part of the surgeon’s toolbox, particularly for treating patients with breast cancer and other types of skin cancer such as melanoma and squamous cell carcinoma that have spread to the lymph nodes.
Understanding the layout of the armpit area, thorough surgical techniques, and appropriate care and monitoring after the surgery are all essential to reduce related complications, especially lymphedema – a condition where excess lymph fluid collects in tissues and causes swelling. In places where advanced radiotherapy and chemotherapy might be hard to get, removing lymph nodes in the armpit area is still a common way of treating patients suspected of having cancer spread to this area.