Download Management of the Axilla Nodal Basins and Beyond

2/15/2017
Management of
the Axilla
Nodal Basins
and Beyond
Axillary Lymph node Chain
– Is it a chain or not?
– Intramammary to the axilla
– Axilla to the infraclavicular
– Infraclavicular to supraclavicular
– Supraclavicular to neck
– Internal/intermammary by itself from the rest
Deborah Thames (R)(M)(QM)
Anatomy of the Breast
A – pectoralis major muscle
B – axillary lymph nodes: level I
C – axillary lymph nodes: level II
D – axillary lymph nodes: level III
E – supraclavicular lymph nodes
F – internal mammary lymph nodes
Important nodes are arbitrarily
divided into five groups
– 1. The lateral nodes lie behind the axillary vein and drain the upper limb.
– 2. The pectoral nodes, at the inferior border of the pectoralis minor, drain most of the breast.
– 3. The posterior, or subscapular, nodes, in the posterior axillary fold, drain the posterior shoulder.
– 4. The central nodes, near the base of the axilla, receive the lymph from the preceding three groups. They form the group most likely to be palpable (against the lateral thoracic wall).
– 5. The apical nodes lie medial to the axillary vein and superior to the pectoralis minor. The apical nodes receive the lymph from all the other groups and sometimes directly from the breast. They drain into two or three subclavian trunks, which enter the jugular‐subclavian venous confluence, or join a common lymphatic duct, or empty into lower, deep cervical nodes.
– Et al…. O’Rahilly
Extranodal Extension
Imaging the lymph nodes
– Extranodal extension (ENE) of sentinel lymph node metastasis is strongly associated with increased sentinel lymph node (SLN) disease burden, including increased breast cancer recurrence and decreased overall survival
– Mammogram
– Ultrasound
– ENE is known to be a strong predictor of non‐sentinel node tumor involvement and a marker of aggressive tumor biology, and patients with ENE were therefore excluded from the recent randomized controlled trial ACOSOG Z0011, which investigated the omission of axillary lymph node dissection in patients with SLN metastasis undergoing breast‐conserving therapy.
– MRI
– Pet
By Nancy A. Melville
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Pet Scanning in Breast Cancer
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Treatment Option
Surgical Options
– Axillary lymph node dissection (ALND): In this procedure, anywhere from about 10 to 40 (though usually less than 20) lymph nodes are removed from the area under the arm (axilla) and checked for cancer spread. ALND is usually done at the same time as the mastectomy or BCS, but it can be done in a second operation. This was once the most common way to check to see if breast cancer has spread to nearby lymph nodes, and it is still done in some patients. For example, an ALND may be done if a previous biopsy has shown one or more of the underarm lymph nodes have cancer cells. Level I receives the most lymphatic drainage from the breast.
Treatment Option
Surgical Options
– 3 Levels of lymph node dissection
– Level I is lower edge of pectoralis minor muscle – Level II is underneath the pectoralis minor muscle
– Level III is found above pectoralis minor muscle
– Typically is a patient is having a mastectomy, level I and II lymph nodes are removed. – Typically 5‐30 lymph nodes are removed during axillary dissection. – If there are positive nodes, radiation therapy is needed to help kill any remaining cancer cells if any.
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Treatment Option
Surgical Options
– Side effects: As with other operations, pain, swelling, bleeding, and infection are possible. The main possible long‐term effect of lymph node surgery is swelling in the arm or chest (lymphedema). This is less common after a sentinel lymph node biopsy than an axillary dissection. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling comes up later or lasts a long time. Ways to help prevent or reduce the effects of lymphedema. If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away. Treatment Option
Surgical Options
– The main possible long‐term effect of removing axillary lymph nodes is lymphedema (swelling) of the arm. Because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system, removing the lymph nodes sometimes blocks the drainage from the arm, causing this fluid to build up. This results in arm swelling.
– Up to 30% of women who have a full ALND develop lymphedema. It also occurs in up to 3% of women who have a sentinel lymph node biopsy. It may be more common if radiation is given after surgery. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling lasts a long time. If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away. Can be very chronic.
Treatment Option
Surgical Options
– Sentinel lymph node biopsy (SLNB): Although axillary lymph node dissection (ALND) is a safe operation and has low rates of most side effects, removing many lymph nodes increases the risk of lymphedema (this side effect is discussed further on). To lower this risk, doctors may use a sentinel lymph node biopsy (SLNB) procedure, which can check the axillary lymph nodes for cancer without removing as many of them. – In this procedure the surgeon finds and removes the first lymph node(s) to which a tumor is likely to spread (these are called the sentinel nodes). To do this, the surgeon injects a radioactive substance and/or a blue dye into the tumor, the area around it, or the area around the nipple. Lymphatic vessels will carry these substances into the sentinel node(s). 7
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Treatment Option
Surgical Options
Treatment Option
Surgical Options
– Then the sentinel node can be found either by using a special device to detect radioactivity in the nodes that the radioactive substance flows into, or by looking for lymph nodes that have turned blue. To double check, both methods are often used. The surgeon then cuts the skin over the area and removes the node(s) containing the dye or radiation. A pathologist then looks closely at these nodes (often 2 or 3). Because fewer nodes are removed than in an ALND, each one is looked at more closely for any cancer. – The lymph node can sometimes be checked for cancer during surgery. If cancer is found in the sentinel lymph node, the surgeon may go on to do a full axillary dissection. If no cancer cells are seen in the lymph node at the time of the surgery, or if the sentinel node is not checked at the time of the surgery, the lymph node(s) will be examined more closely over the next several days. If cancer is found in the lymph node, the surgeon may recommend a full ALND at a later time. Positive Lympnodes
– Pt must have chemotherapy and radiation therapy to keep the cancer from spreading and keep the cancer from coming back.
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Case study
Lets look at them
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