Chapter 45 Axillary Surgery
INTRODUCTION
Although breast cancer surgery can be traced back to AD 200, it was not until the early 18th century that French surgeon Jean Louis Petit first noted the significance of enlarged axillary nodes and that they should be removed along with the diseased breast tissue.1 Axillary metastasis has since been shown to be the most important prognostic indicator of both patient survival2 and breast cancer recurrence.3 Therefore, axillary surgery is a crucial step in the proper management of patients with carcinoma of the breast.
William Halsted’s4 revolutionary radical mastectomy excised all three levels of axillary nodes as well as the breast and pectoralis major. This effectively eliminated all regional diseased tissue, but at the cost of great deformity to the patient. Subsequent management of both the breast and the axilla has trended toward conservation of as much nondiseased tissue as possible. Today, an axillary dissection removes most of the level I and II nodes. The extent of this dissection has been shown to be sufficient enough to reduce local recurrence, stage the patient’s level of disease, and determine the most effective treatment.5 Level III nodes are removed only if palpable or otherwise suspected of containing malignancy.
Seventy percent of patients with a clinically negative axilla will also prove to be microscopically free of axillary metastases.6 Axillary dissection carries significant long-term morbidity for these patients. The advent of the sentinel lymph node biopsy (SLNB), first successfully applied by Morton and colleagues7 for use in melanoma surgery, has allowed node-negative patients to be spared complete axillary dissection. When compared with axillary dissection, SLNB results in less postoperative morbidity (arm numbness and swelling) and allows for faster recovery.8 The sentinel lymph node is defined as the first lymph node to which a primary tumor will drain. In breast cancer, this is typically a level I node.
SLNB can reliably predict the status of a regional lymph node basin. Giuliano and coworkers9 and Krag and associates10 applied this technique to breast cancer. Giuliano and coworkers used isosulfan blue dye to localize the sentinel node in 65.5% of patients. The rate improved to 78% with accumulated experience, accurately predicting axillary status in 95.6% of patients. Krag and associates used unfiltered technetium sulfur colloid to identify the sentinel node in 82% of patients, accurately predicting each case. Albertini and colleagues11 utilized both isosulfan blue dye and technetium sulfur colloid, identifying a sentinel node in 92% of patients.
Axillary Dissection
INDICATIONS
OPERATIVE PROCEDURE
Incision
Inappropriate Placement of Incision
• Prevention
Axillary Dissection and Identification of Pertinent Nerves and Blood Vessels (Fig. 45-1)
Nerve Damage
• Consequence
• Repair
Recovery is less likely with damage to the motor nerves. On long-term follow-up of patients with injury to the long thoracic nerve, 81% cannot lift or pull heavy objects, 58% cannot play sports (such as tennis or golf), and 54% are unable to work with their hands above shoulder level.13 Attempts have been made to surgically restore normal scapulohumeral dynamics in cases of serratus anterior paralysis by transferring the pectoralis major tendon14 or fixing the inferior angle of the scapula.15 These therapies are still experimental and, if they prove successful, may be applied more readily in the future.
• Prevention
Lymphedema
• Consequence
It is difficult to precisely define the incidence of lymphedema. In a review of the literature, lymphedema occurred in 6% to 30% of patients.16 It should be noted that these studies varied in length of follow-up from 14 months to 11 years and that the incidence of lymphedema clearly increased with longer patient follow-up. Petrek and associates17 studied a cohort of breast cancer survivors at 20 years after surgery and found that 49% reported the sensation of lymphedema. Although most of these patients (77%) developed this complication within the first 3 years, additional patients developed lymphedema at a rate of approximately 1% per year.
• Prevention
Drain Placement
Inadequate or Failure of Drain Placement
• Consequence
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