Management of the Axilla



Axillary surgery is undertaken to determine if any cancer has spread to the lymph nodes (staging) and secondly, to ensure removal of any such affected nodes and thus reduce the chance of local disease recurrence.


Surgical Options



  1. A complete clearance of the axilla. This involves removing all the lymph nodes and may necessitate dividing small pectoralis minor muscle, although this does not result in any demonstrable weakness. The dissection is continued internally to the root of the neck and usually 20 or more nodes are removed.
  2. A level I/II dissection. This involves removing the majority of the nodes, including those behind the pectoralis muscle without dividing pectoral minor and removes 10-20 nodes.
  3. A level I dissection. The lower axilla is dissected and about half the total nodes are removed up to the edge of pectoralis minor.
  4. An axillary sample. Six or more nodes 'cherry picked' from the level I area.
  5. Sentinel Node Biopsy.
  6. No axillary dissection


Recommendations



Current best practice suggests either a sentinel node biopsy or a level I/II axillary dissection should be performed on all patients with invasive cancers. There is no clear evidence that more extensive surgery is of benefit and this full clearance is associated with a higher rate of post surgical side effects, especially arm swelling (lymphoedema) and shoulder stiffness. However if there are clinically involved nodes in level II a complete clearance should be performed to minimise the risks of local recurrence. With the exception of sentinel node biopsy (see separate information sheet) lesser dissections increase the risk of missing an involved node and possible sub-optimal treatment as a consequence.

Patients with ductal carcinoma-in-situ (DCIS) alone should not undergo an axillary node dissection; although in some circumstances a sentinel node biopsy is indicated. This is assessed on an individual basis and should be discussed with you.