Axillary lymph node dissection (ALND)

Axillary lymph node dissection (ALND) is a surgical procedure to remove the lymph nodes from under the arm (axilla). It is used to diagnose and stage breast cancer. This test may also be called axillary dissection or axillary node dissection.

ALND is still the standard way to check for cancer in the axillary lymph nodes in most treatment centres.

Why ALND is done

Cancer in the lymph nodes usually cannot be felt, so doctors need to remove the lymph nodes and examine them under a microscope to find out if they contain cancer. ALND is done to:

• see if cancer has spread from the breast to the lymph nodes
  • This information is used to determine the stage of the breast cancer.
• remove any cancer that may have spread to the lymph nodes and reduce the risk of cancer coming back (recurring) in the axilla
• help plan treatment

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When ALND is done

ALND is done:

• during a modified radical mastectomy or radical mastectomy
• with breast-conserving surgery
  • ALND may also be done as a separate procedure at a later date, after breast conserving surgery.
• when a sentinel lymph node biopsy (SLNB) is not suitable
• if the sentinel lymph node contains cancer (is positive)

ALND is not done:

• when there is no or very little chance that the lymph nodes contain cancer, such as in non-invasive cancer like ductal carcinoma in situ (DCIS)
• when a woman with a very strong family history of breast cancer has decided to have her breasts surgically removed to reduce her risk (prophylactic mastectomy)

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How ALND is done

ALND is done using general anesthesia in a hospital operating room.

• The surgeon makes an incision under the arm.
• The surgeon usually removes at least 10 lymph nodes from level I and level II.
  • Lymph nodes are not usually removed from all 3 levels because this does not improve survival and increases the chances of side effects.
  • Sometimes more than 10 lymph nodes are removed.
• After the lymph nodes are removed, a small tube (drain) is placed in the incision. A rubber bulb attached to the end of the tube collects fluid draining from the area, which reduces the chance of swelling from fluid building up in the tissue. The drain is left in place for a few days or until there is little drainage.

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Potential side effects

Side effects can happen any time during ALND. Some may happen during, immediately after, or a few days or weeks after the procedure. Most side effects go away after ALND. Late side effects can occur months or years after ALND. Some side effects may last a long time or be permanent.

It is important to report the following side effects to the healthcare team:

• pain, discomfort or tenderness under the arm or down the inside of the arm
• bruising
• infection
• seroma – a collection of lymph fluid under the skin in armpit, near the surgical incision
• swollen and tight-feeling arm
• stiffness or trouble moving the arm or shoulder
• changes in feeling or sensation down the inside of the upper arm or armpit – occurs because nerves running through the armpit often have been disturbed
  • numbness
  • coldness
  • weakness
  • heaviness
  • increased sensitivity to touch or pressure
  • burning or tingling sensation
• lymphedema
  • Lymphedema can occur anytime after lymph node removal.
  • The chance of developing lymphedema increases with the number of lymph nodes removed, especially after ALND and if radiation is given to the armpit.
  • A small percentage of women experience severe lymphedema. About 1 in 5 women have mild lymphedema.
• chronic pain caused by lymphedema or damage to the nerves in the armpit
• axillary web syndrome (AWS) – cords of scar tissue develop in the lymph vessels from the armpit to the elbow, also called lymphatic cording
  • pain
  • tightness in the arm
  • difficulty moving shoulder on the affected side

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What the results mean

The lymph nodes are sent to the laboratory to be examined by a pathologist. Each lymph node is examined to see if it contains cancer.

• A negative lymph node means that no cancer was found in the lymph node.
• A positive lymph node means that cancer was found in the lymph node.

The number of lymph nodes that have cancer is reported, along with the number of lymph nodes that were removed. For example:

• Four lymph nodes were removed and none have cancer. This would be reported as 0 out of 4 (0/4).
• Ten lymph nodes were removed and 3 have cancer. This would be reported as 3 out of 10 positive lymph nodes (3/10).

The pathologist may also report how much cancer is found in the lymph node(s):

• microscopic
  • Very few cancer cells have spread to the lymph node(s) and a microscope is needed to see them.
• gross
  • There is a lot of cancer in the lymph node(s). It can be felt in the lymph node(s) or seen with the naked eye (without a microscope).
• extracapsular extension
  • The cancer has grown outside the wall of the lymph node(s).

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What happens if a change or abnormality is found

The number of positive lymph nodes is used to stage breast cancer. The doctor uses the stage, along with other information about a woman's breast cancer, to make treatment decisions.

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