Armpit Lymph Node Surgery for Breast Cancer

Breast cancer surgery including mastectomy or breast conservative surgery (lumpectomy) often also involves armpit lymph node surgery as this is often the first site that breast cancer cells spread outside the breast. There has been a huge move in the recent years to limit the extent of surgery performed on the axillary (armpit) lymph nodes to reduce the likelihood of the complications associated with these surgeries. Unfortunately, most currently available patient information materials fail to cover these recent changes. We hope this blog will help breast cancer patients better understand the currently available strategies and prepare them for a more informed discussion with their surgeons.

Surgical Procedures

Broadly speaking armpit lymph node surgery for breast cancer can be divided into three procedures:

• Sentinel lymph node biopsy (SLNB)

• Axillary lymph node dissection (ALND)

• Targeted axillary dissection (TAD)

It is important to understand that the type of surgery performed in the axilla is independent of the type of surgery performed in the breast, i.e. you may have mastectomy or lumpectomy with any of the above procedures. The choice of axillary surgery performed is based on a combination of clinical, radiological, and pathological findings as discussed below.

Sentinel Lymph Node Biopsy (SLNB)

SLNB is the most common operation to assess the axillary lymph nodes. It involves removal of typically the first 1-3 nodes that drain the breast (sentinel nodes, SNs). The idea is that if these nodes are negative (harbor no breast cancer cells) then the remaining lymph nodes in the axilla are also negative therefore saving the patient from higher morbidities of a complete ALND.

The most common way of identifying the SNs is a combination of radiotracer and blue dye injection around the areola. The radioactive tracer is injected on the day or day before surgery in the radiology department followed by a radionuclide scan to confirm radioactivity in the SN(s). The blue dye is injected by your surgeon in the operating theatre after induction of general anaesthesia. These tracers travel along the lymphatic channels and are picked up by the first armpit lymph nodes draining the breast. During SLNB, your surgeon will use a special probe to identify radioactive nodes complemented by visual identification of the blue nodes.

 Recently other tracers have been introduced to replace blue dye and/or radiotracer for SLNB. These include fluorescent dye indocyanine green (ICG) and paramagnetic particles Magtrace®. The choice of tracer is often based on the logistics and surgeons’ preference and with adequate experience they are thought to yield equivalent results.

Importantly SLNB can only be offered to patients that are clinically lymph node negative. This means that after thorough evaluation with physical examination and imaging there is no indication that the cancer has already spread to the lymph nodes. These patients are thought to have early breast cancer, and the definitive assessment of their axillary lymph nodes is performed by SLNB at the time of their breast surgery. On the other hand, if an abnormal lymph node is identified by palpation and/or radiology, a needle biopsy through the skin is done to determine if the lymph node is indeed positive (harbors cancer cells). If a positive lymph node is confirmed on percutaneous needle biopsy, the patient should proceed with an ALND or a planned TAD as discussed below. 

Axillary Lymph Node Dissection

ALND involves anatomical dissection of arm pit lymph nodes as a whole packet. It aims to remove the majority of lymph nodes that drain the breast which in many instances overlap with the nodes draining the upper limb.  With the advent of SLNB in the late 1990s, ALND is reserved only for patients who present with clinically positive lymph nodes (confirmed with needle biopsy) or have positive SNs. However as pointed above there has been a huge move in the recent decades to omit ALND even in these patients. For instance, in cases with only 1 to 2 positive SNs, it has been shown that omission of ALND is oncologically safe. Similarly in patients with 1-3 positive SNs, axillary radiotherapy has been shown to have equivalent oncological outcome to ALND but reduces lymphoedema rate by a half.

Targeted Axillary Dissection

This is the most recent advancement in de-escalation of axillary surgery. By definition TAD involves SLNB + removal of the clipped node(s). As mentioned above in patients who present with clinically positive lymph nodes, SLNB cannot be performed and traditionally these patients have been subject to ALND. The only way to avoid ALND in these patients is through a TAD which often follows 4-6 months of preoperative (neoadjuvant) systematic (chemo)therapy. Patients with 1-3 clinically positive nodes may be eligible for TAD.  In this procedure the most abnormal lymph node is marked with a metal clip placed though the skin in the office or in the radiology department. Following completion of neoadjuvant systemic therapy, a standard SLNB is performed along with removal of the clipped node. Patients in whom no residual cancer is demonstrated in the SNs and the clipped node may safely avoid ALND. 

Complications of Armpit Lymph Node Surgery

The complications of SLNB are far less than a complete ALND and include general complications such as infection, bleeding, and wound healing issues as well as specific complications listed below. It is expected that the rate of complications associated with TAD are somewhat similar or slightly more than SLNB.

• Anaphylactic reaction: Severe life-threatening allergic reaction to the blue dye has been reported in 0.15% of the cases. Your anaesthetist is well-equipped to treat this condition in the unlikely event this occurs.

• Numbness: A patch of permanent numbness in the medial aspect of the upper arm may occur following axillary lymph node surgery due to division of cutaneous nerves that travel through the armpit. The reported rate of this complication following SLNB is 10% whereas it occurs in almost all cases of ALND. Fortunately, the functional consequence of this complication is almost none.

• Seroma: Fluid accumulation in the armpit is common after ALND. Hence a drain tube is often placed at the time of surgery for continuous drainage of seroma fluid. The patient is often discharged with Hospital In The Home (HITH) support. A nurse will visit the patient daily and the drain is generally removed a few days after surgery once the drainage is reduced to below 30-50ml/day. It is possible that further needle aspirations may be required during follow up visits with your surgeon which is easily done in the office with no pain. Seroma is very rare following SLNB and therefore a drainage tube is not required. 

• Shoulder stiffness: Pain and limitation of range of motion in the shoulder joint is often reported after axillary surgery. Patients are encouraged to actively use their shoulder following surgery to prevent frozen shoulder. Following ALND patients are often seen by a physiotherapist and/or their breast care nurse before discharge and are educated for a gentle progressive shoulder exercise regimen during their recovery.

• Lymphoedema: This is by far the most feared long-term complication of axillary surgery. Breast cancer related lymphoedema has been reported in about 20% of patients following ALND and up to 2-4% following SLNB. The true rate is hard to know as it may happen years after the surgery and its definition has not been consistent in the reports. Chronic lymphoedema is a debilitating swelling of the arm due to accumulation of protein rich fluid following transection of arm lymphatic channels that drain into the axillary nodes. Unfortunately, there is no cure for this condition and conservative management offered by lymphoedema therapists has been the mainstay of support for these patients. These conservative measures include skin care, manual massage, compression garments, and physiotherapy exercises. Therefore, our best chance is to prevent it in the first place!

Immediate lymphatic reconstruction

We have seen significant evolution in breast cancer care from the days of radical mastectomies to our current state of active screening followed by multidisciplinary, individualised organ preserving therapies. Despite this, we still see patients presenting with advanced, aggressive disease that will require a full gamut of invasive surgeries and harsh systemic and radiation therapies to survive!

When it comes to lymphoedema, as mentioned above, our best chance is to prevent it in the first place. Once lymphoedema is established, there will be no cure, and all the subsequent therapies will be palliative in nature. Breast cancer surgeons have come a long way to replace ALND with SLNB or TAD, however as pointed before, there are still a subset of patients that will require a full ALND ± radiation with much higher chance of chronic lymphoedema.  

We know that arm lymphoedema following ALND results from disruption of the lymphatic channels draining the upper limb. These channels pass through the armpit and join with the channels draining the breast and the upper back to eventually drain into a large vein at the base of the neck. Therefore at least theoretically we may be able to prevent upper limb lymphoedema if we identify these channels and hook up their cut ends in the armpit to a nearby vein! This is the basis of a procedure called Immediate Lymphatic Reconstruction (ILR), or immediate lymphovenous bypass. Initially reported by a group of Italian surgeons in the early 2000, it has finally gained some momentum and it’s currently offered by a limited number of centres around the globe.

Immediate lymphatic reconstruction: The cut ends of arm lymphatic channels are joined with a recipient vein in the armpit at the time of ALND. 

Although it may sound simple, it is technically a very challenging procedure requiring meticulous dissection during ALND to preserve a suitable vein and microsurgical skills to identify and join lymphatic channels of maximum 1mm in diameter to the recipient vein (so called Lymphovenous Anastomosis, LVA).

Although the preliminary results show a promising reduction in lymphoedema rate by about a third, the level of evidence is still low and, at this stage, it should be considered an experimental procedure. For the same reason there is currently no Medicare Rebate in Australia for this operation and it can only be offered in the private sector with out-of-pocket costs.

The fact that more than 75 procedures have been described in the literature to treat lymphoedema is a testimony to surgeons’ frustration in dealing with this difficult problem! Dr Saam Tourani devoted his PhD research at The University of Melbourne to Microsurgical Treatment of Lymphoedema. He has extensively published on this topic in the highest-ranking plastic surgery journals and has given multiple speeches across the globe to like-minded surgeons with passion in lymphatic surgery. Saam spent a great deal of his research to show why surgeons have failed to cure chronic lymphoedema over the years including with the most recent microsurgical procedures such as LVA and Vascularised Lymph Node Transfer (VLNT). Dr Tourani has been advocating for a proactive approach to prevent lymphoedema in the first place and is very happy to see that Immediate Lymphatic Reconstruction is finally being taken up by more and more centres around the globe. Saam is passionate about minimally invasive, and organ/function preserving surgery and encourages breast cancer patients to explore these options with their treating surgeons. He has been an early adopter of Targeted Axillary Dissection and the use of neoadjuvant systemic therapy to limit the number of ALNDs and is happy to discuss ILR with patients who must undergo ALND due to oncological reasons.