What is the role of axillary lymph node dissection (ALND) in the surgical treatment for breast cancer?

Updated: Feb 13, 2019
  • Author: Mary Jo Wright, MD; Chief Editor: James Neal Long, MD, FACS  more...
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Axillary lymph node dissection for breast cancer is a complete en bloc removal of the level I and level II lymph nodes. level I nodes are lateral to the pectoralis minor, level II nodes are beneath the pectoralis minor, and level III nodes are medial to the pectoralis minor.

The level III nodes are not removed surgically unless there is suspicious or palpable adenopathy present. Skip metastasis to the axillary apex of level III without lower axillary involvement is very rare.

Axillary lymph node dissection removes all nodal tissue defined by the borders of the axillary vein superiorly, the latissimus dorsi muscle laterally, the medial border of the pectoralis minor muscle medially, and the subscapularis muscle posteriorly.

Care is taken to preserve the long thoracic and thoracodorsal nerves along their course through the axilla. Injury to the long thoracic nerve results in a winged scapula, whereas injury to the thoracodorsal nerve compromises internal rotation and abduction of the arm beyond 90°.

The median and lateral pectoral nerves may also be injured during axillary lymph node dissection. The intercostobrachial nerves run directly through the resection specimen and are typically sacrificed, resulting in a predictable pattern of cutaneous numbness in the inner arm region for most patients after this procedure.

The American College of Surgeons Oncology Group Z0011 trial, a phase 3 randomized noninferiority trial, found that overall 5-year survival was similar for women with sentinel lymph node metastatic breast cancer who had undergone sentinel lymph node dissection alone versus axillary lymph node dissection, 92.5% and 91.8% survival rate, respectively. Five-year disease-free survival rate was also similar; 83.9% for sentinel lymph node dissection alone compared with 82.2% for axillary lymph node dissection. [26]

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