Axillary Lymph Node Dissection Or Biopsy

The paper published in the Feb. 9th 2011 issue of JAMA by Giuliano et al, Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastases JAMA 2011; 305(6):569-575, is a landmark report that has resulted in a change of practice throughout the country.

The study was an American College of Surgeons Oncology Group trial, Z0011, in which patients with axillary nodal metastases found on sentinel lymph node (SLN) biopsy, were randomized to receive full axillary dissection or no additional axillary surgery.

Patients were women with clinical T1 or T2 invasive breast cancer, no palpable enlarged axillary nodes (i.e. a clinically negative axilla), and 1-2 SLNs containing metastases found by frozen section, touch preparation, or H and E staining on permanent section. Patients were matched according to clinical and tumor characteristics. All patients had lumpectomy. 445 patients were randomized to full axillary dissection and 446 to SLN biopsy alone. Median follow up was 6.3 years.

The results showed no difference in survival or disease-free survival between the two groups. The conclusion is, therefore, that full dissection can be omitted in patients undergoing breast conserving surgery with 1-2 involved nodes found at SLN biopsy. Thus fewer axillary dissections are being performed. I add these data and conclusions to my discussions with patients about their surgery.

Note that patients who had mastectomy, those with a clinically involved axilla, larger tumors and those receiving neoadjuvant chemotherapy were not included in the study, and therefore the results should not be extrapolated to apply to those patients.

The number of full dissections being performed has decreased as a consequence of this important work, however full dissection is still appropriate, and the standard of care, for selected patients. The paper published in the Feb. 9th 2011 issue of JAMA by Giuliano et al, Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastases JAMA 2011; 305(6):569-575, is a landmark report that has resulted in a change of practice throughout the country.

The study was an American College of Surgeons Oncology Group trial, Z0011, in which patients with axillary nodal metastases found on sentinel lymph node (SLN) biopsy, were randomized to receive full axillary dissection or no additional axillary surgery.

Patients were women with clinical T1 or T2 invasive breast cancer, no palpable enlarged axillary nodes (i.e. a clinically negative axilla), and 1-2 SLNs containing metastases found by frozen section, touch preparation, or H and E staining on permanent section. Patients were matched according to clinical and tumor characteristics. All patients had lumpectomy. 445 patients were randomized to full axillary dissection and 446 to SLN biopsy alone. Median follow up was 6.3 years.

The results showed no difference in survival or disease-free survival between the two groups. The conclusion is, therefore, that full dissection can be omitted in patients undergoing breast conserving surgery with 1-2 involved nodes found at SLN biopsy. Thus fewer axillary dissections are being performed. I add these data and conclusions to my discussions with patients about their surgery.

Note that patients who had mastectomy, those with a clinically involved axilla, larger tumors and those receiving neoadjuvant chemotherapy were not included in the study, and therefore the results should not be extrapolated to apply to those patients.

The number of full dissections being performed has decreased as a consequence of this important work, however full dissection is still appropriate, and the standard of care, for selected patients.

Sentinel node biopsy involves mapping the breast (or skin in the case of melanoma) to determine which 1-4 (average 2) lymph nodes drain the breast. This allows precise removal of the lymph nodes most likely to harbor metastases form the breast cancer. A standard axillary biopsy is a removal of 1 or more lymph nodes that are abnormal - usually by size criteria. A standard axillary lymph node dissection is the removal of all the lymph nodes in a certain anatomic area (the 3 dimensiaonl triangle between the lateral border of the pectoralis major muscle (anterior border), the axillary vein (superior border), and the lateral border of the lattisimus dorsi muscle (posterior border). There are typically 10-15 lymph nodes under each arm but like most things in biology the number is a bell shaped curve with some people having a few (6 or less) and some people having a lot (30 or more).
Sentinel node biopsy involves mapping the breast (or skin in the case of melanoma) to determine which 1-4 (average 2) lymph nodes drain the breast. This allows precise removal of the lymph nodes most likely to harbor metastases form the breast cancer. A standard axillary biopsy is a removal of 1 or more lymph nodes that are abnormal - usually by size criteria. A standard axillary lymph node dissection is the removal of all the lymph nodes in a certain anatomic area (the 3 dimensiaonl triangle between the lateral border of the pectoralis major muscle (anterior border), the axillary vein (superior border), and the lateral border of the lattisimus dorsi muscle (posterior border). There are typically 10-15 lymph nodes under each arm but like most things in biology the number is a bell shaped curve with some people having a few (6 or less) and some people having a lot (30 or more).

The vast majority of women with breast cancer should be getting no more than a sentinel lymph node biopsy. The exceptions are patients that have large (clinically positive) lymph nodes at the time of their diagnosis that have undergone a biopsy of their lymph node that shows cancer(fine needle aspiration or needle core biopsy typically). Women undergoing lumpectomy who have 1-2 sentinel nodes with cancer in them can now forego a completion dissection based on the recent ACOSOG study - Z0011 that was published in JAMA in February. The caveat is that they have to have whole breast irradiation (not partial breast irradiation). Also this does not apply to patients having a mastectomy (with or without reconstruction). If they have a positive sentinel node, they should have a completion dissection. The vast majority of women with breast cancer should be getting no more than a sentinel lymph node biopsy. The exceptions are patients that have large (clinically positive) lymph nodes at the time of their diagnosis that have undergone a biopsy of their lymph node that shows cancer(fine needle aspiration or needle core biopsy typically). Women undergoing lumpectomy who have 1-2 sentinel nodes with cancer in them can now forego a completion dissection based on the recent ACOSOG study - Z0011 that was published in JAMA in February. The caveat is that they have to have whole breast irradiation (not partial breast irradiation). Also this does not apply to patients having a mastectomy (with or without reconstruction). If they have a positive sentinel node, they should have a completion dissection.

I had drains put in on each side. Had to empty and measure daily. You do not want that fluid to back up, can get very uncomfortable and become infected as stated earlier by drbreastsurgery. It is uncomfortable some but I taped the bulbs to me loosely so they did not flop around. Made it much easier to deal with. Then I just wore a tube top. I had my drains in for a week. Everyone is different on how much will drain, just ask your doctor.
drains are often inserted for a mastectomy and for a complete axillary lymph node dissection.
for the mastectomy, this is because fluid may build up under the skin and on the muscle where the breast used to be, until the tissues heal. it is better that the fluid come out rather than build up and cause pain and even possibly get infected.
in the armpit, similarly, when the lymph nodes are removed, fluid may build up until the tissues have had a chance to heal.