The word “dissection” may conjure images of a high school biology lab full of frogs or sheep’s eyeballs in various stages of deconstruction. But an axillary node dissection is a decidedly different type of procedure and not one you should fear, even though some doctors are now trying to avoid performing this type of surgery as a matter of routine.
In 1894, when William Halsted published his findings on the radical mastectomy as a breakthrough means of treating breast cancer, he performed surgeries that attempted to take all the breast tissue and all tissue from the axilla region — the area under the armpit where the axillary lymph nodes reside. The idea was that by removing all the tissue and the lymph nodes that might potentially be cancerous — and leaving little more than just skin to cover the ribs — the cancer could be effectively “cured.”
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For a long while, breast cancer surgeons followed this precedent. But times have changed. By the late 1970s, breast conserving surgery — a combination of lumpectomy and radiation and/or chemotherapy that attempts to preserve as much of the breast tissue as possible — began to take hold as the preferred standard of care in many breast cancer cases. By the mid-1990s, sentinel node biopsies were being performed regularly. This procedure typically removes one to three of the lymph nodes closest to the tumor, which are the ones most likely to receive cancerous cells first when they began to metastasize. Studies have shown that bigger (i.e. radical mastectomy) is not necessarily better than the less invasive breast-conserving approaches such as lumpectomy and sentinel node biopsies typically preferred today. In some cases, survival rates are actually better with breast conserving surgery than they are with more aggressive surgeries, and the rate of side effects is usually lower, too.
Dr. Terry Mamounas, medical director of the comprehensive breast program at UF Health Cancer Center at Orlando Health, says, “the trend nowadays is to minimize the extent of surgery. So we do less surgery and achieve the same outcome and improve the patient’s quality of life while improving their functionality.”
These days, axillary lymph node dissection is typically only recommended for patients who have already had a lumpectomy and sentinel node biopsy that have returned positive results. The American Cancer Society reports that “although traditionally cancer in sentinel lymph nodes was an indication for additional axillary lymph node surgery, new guidelines state that axillary lymph node dissection may be unnecessary if cancer cells are found only in one or two sentinel lymph nodes in patients who undergo breast conserving surgery followed by whole breast radiotherapy. Sentinel lymph node biopsy is not typically an option if one or more axillary lymph nodes are found to contain cancer prior to surgery. In that case, a full axillary lymph node dissection is often indicated.”
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Mamounas says that most surgeons “start with the sentinel node biopsy, and if that’s negative, we feel comfortable not taking any more. If the sentinel nodes are involved, then you do an axillary dissection.”
If your surgeon has recommended an axillary lymph node dissection, expect to have major surgery. ALND is typically performed under general anesthesia and involves a large incision under the arm. Mamounas explains that surgeons performing this procedure will take the lymph nodes and fatty tissue “between anatomic boundaries — the pectoral muscle up front, the latissimus muscle in the back and the axillary vein at the top.”
He says that although it’s possible that other lymph nodes under the collar bone and around the breast bone could also be cancerous, a surgeon will be unable to reach these nodes because of the configuration of bones. That’s where radiation treatments come into play. “When we have significant nodal involvement, or any nodal involvement really, we consider giving radiotherapy,” Mamounas says. “So even if some nodes have been left behind, then we try to cover them with radiotherapy.” Although it’s difficult to be certain if all the affected lymph nodes have been removed, the idea is that targeted and systemic therapies like radiation and chemotherapy can help reduce the chances of recurrence if any cancerous cells are left behind.
In some cases, you may begin chemotherapy, radiation treatments or other systemic drug therapies prior to surgery in order to shrink the tumor and kill cancer cells in the lymph nodes before any are even removed. And in certain instances, Mamounas says, your doctor may decide not to remove any additional lymph nodes at all. “We also have found out that instead of removing additional nodes in patients with positive sentinel nodes, if you give radiation to the axilla, then you can control it equally well and cause less lymphedema.”
Lymphedema, or a swelling of the region that can be painful and disfiguring, is a common problem that can also result from an axillary lymph node dissection. The National Cancer Institute reports that across various studies, the rate at which patients who’ve had an axillary lymph node dissection develop lymphedema can range from 20 to 53 percent. This is significantly higher than the rate at which patients who’ve had a sentinel node biopsy develop lymphedema, which the NCI reports is 5 to 17 percent.
Once the axillary lymph nodes are removed, they will be sent to a pathologist for additional testing to help your doctor determine more precisely the stage of your breast cancer. “More often than not, axillary lymph node dissection is a staging procedure,” Mamounas says. But in some cases, it’s used as a treatment “because you want to take the disease out and also to find out how many are involved.”
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Either way, Mamounas says that for most surgeons, the goal these days is to preserve as many lymph nodes as possible, as they serve a vital role in helping your body fight infection. Removing lymph nodes can lead to painful side effects, including scarring resulting in decreased range of motion of the arm, numbness and nerve pain, lymphedema and infection.
Therefore, less is usually more when it comes to lymph nodes and breast cancer. Keeping more lymph nodes intact reduces the chances of all of these side effects becoming a problem and in most cases, it doesn’t negatively impact survival rates.
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What’s an Axillary Node Dissection for Breast Cancer? originally appeared on usnews.com
