Breast: Lymph Node Management

Lymph Node Management

Specific Lymph Node Concerns

Suspicious Lymph Node Found on Physical Exam: US & FNA Prior to Surgery
Supraclavicular Lymph Node: Chemotherapy, Radiation Therapy & Resect the Primary Breast Lesion
- Resect Lymph Node Only if Not Fully Treated

Lymph Node Metastases

Isolated Tumor Cells (ITC): < 0.2 mm
Micrometastases: 0.2-2.0 mm
- Slightly Worse Prognosis
- May Predict Recurrence (Debated)
Micrometastases: ≥ 2.0 mm
- Significantly Effects Survival

Sentinel Lymph Node Biopsy (SLNB)

Definition: Surgical Removal of Axillary Sentinel Lymph Nodes
Indications:
- Invasive Carcinoma if Early (T1 or T2) with Clinically Negative Nodes
- DCIS if Mastectomy is Performed
Contraindications:
- Clinically Positive Nodes
- Inflammatory Breast Cancer
- Locally Advanced Disease (T3 or T4)
  - May Still Consider SLNB for T3 Disease (Debated)
Debated Contraindications
- Large Tumors (T3)
- After Neoadjuvant Chemotherapy
- Prior Axillary Surgery
False Negative Rate: 5-10%

Axillary Lymph Node Dissection (ALND)

Definition: Surgical Removal of Axillary Lymph Node Levels I & II
- Does Not Include Level III
Indications:
- If SLNB is Contraindicated
- After SLNB If:
  - No Radiotracer/Dye is Found (Rate < 5%)
  - ≥ 3 Positive Lymph Nodes are Pathologically Confirmed (ACOSOG Z0011 Trial)
    - *Specifically Referring to Lumpectomy
  - Any Positive Lymph Nodes After a Mastectomy – Debated

Complications

Decreased Arm Range-of-Motion (40%) – Most Common Complication After Axillary Surgery
Infection (7%)
Hematoma (2-10%)
Seroma
Nerve Injury (< 1%)
Arm Swelling
- Sudden/Early: Concern for Axillary Vein Thrombosis
- Slow/Late: Concern for Lymphatic Fibrosis
Lymphedema
- SLNB Risk: < 5%
- ALND Risk: 20%
Stewart-Treves Syndrome
- Lymphangiosarcoma Due to Chronic Lymphedema
- *See Vascular: Lymphatic Pathology

Axillary Lymph Nodes Levels ¹

Sentinel Lymph Node Biopsy (SLNB)

Injection

Agents:
- 1% Isosulfan Blue Dye
  - Inject 3-5 cc & Massage the Area for 5 Minutes to Dilate Lymphatics
  - Creates a Visible Blue Tint to the Node
  - Teratogenic & Contraindicated in Pregnancy
  - Can Cause a Severe Anaphylactic Reaction (0.7-1.1%)
- Radiotracer (Technetium-99)
  - 0.5 mCi Injected the Day of Surgery
  - Identified Using a Gamma Probe Intraoperatively
  - Safe in Pregnancy
- Using Both Dye & Radiotracer Results in Highest Success Rates
Injection Locations:
- Around the Tumor Periphery (Not into the Tumor Itself – Lymphatics May Be Occluded)
- Palpable Edge of the Biopsy Cavity
- Sappey Plexus

Retrieval Indications

Dye: Retrieve All Nodes That Have Taken Up Dye
Radiotracer: Retrieve All Nodes with > 10% the Highest Ex-Vivo Count
- Ex-Vivo Count – Count of the Highest Lymph Node Once Removed from the Body
Retrieve Any Firm Node (Regardless of Dye/Radiotracer)

Blue Node ²

Breast Lymphoscingigraphy; Injection Site (Red Arrow), One Sentinel Lymph Node (Yellow Arrow) ³

Axillary Lymph Node Dissection (ALND)

Borders Mn

Superior: Axillary Vein
Inferior: Tail of Breast
Medial: Serratus Anterior
Lateral: Latissimus Dorsi

Procedure

Positioning
- Supine
- Arms Abducted ≤ 90 Degrees (> 90 Degrees Increases Risk of Stretching Brachial Plexus)
Incision
- If Performed During a Lumpectomy or Only ALND:
  - Curvilinear Incision
  - 1-2 cm Below Axillary Hair Line
  - Extend from Anterior to Posterior Axillary Folds
- If Performed During a Modified Radical Mastectomy:
  - Attempt to Use Same Mastectomy Incision
  - Extend Laterally if Needed
  - Separate Incision if Not Able
Define Borders
- Define Pectoralis Major (Anterior)
  - Take Care to Preserve the Medial Pectoral Neurovascular Bundle (Found Through or Lateral to the Pectoralis Minor)
- Define Latissimus Dorsi (Lateral)
  - Extend Inferiorly Until It Pulls to the Chest Wall
  - Extend Superiorly to the Insertion
  - Take Care to Preserve the Intercostobrachial Nerve (Crosses 1-2 cm Below the Axillary Vein)
- Visualize Axillary Vein (Superior)
  - Divide Clavipectoral Fascia
  - Extend Posteriorly to Visualize the Vessel
  - Bifurcations are Frequent – Never Ligate Transverse Veins High in Axilla
  - Do Not Skeletonize or Open the Sheath Unless Indicated (Increases Lymphedema Risk)
Identify & Protect Nerves
- Intercostobrachial Nerve – Lateral by the Latissimus Dorsi 1-2 cm Below Axillary Vein
  - If Unable to Spare: Sharply Ligate
- Long Thoracic Nerve – Along the Lateral Chest Wall
  - Found Just Below Medial Axillary Vein & Extending Inferiorly
  - Do Not Incise Fascia of Serratus Anterior
- Thoracodorsal Nerve – Along the Mid-Axilla with the Associated Neurovascular Bundle
  - Found Just Below the Mid-Axillary Vein
Dissection
- Mobilize Fat Pad by Blunt Dissection
- Dissect to Defined Borders
  - Medial: Serratus Anterior
  - Lateral: Latissimus Dorsi
  - Superior: Axillary Vein
  - Inferior: Tail of Breast
- Include Level I & Level II Nodes
Closure
- Secure Hemostasis
- Place a JP Drain (Debated)

Axillary Lymph Node Dissection (ALND) ⁴

Mnemonics

Borders of an ALND

Medial (M): Think ‘M’ Shaped Serrations Over the Lateral Chest Wall (Serratus Anterior)
Lat-Lat: Latissimus Dorsi is Lateral

References

Lu Q, Hua J, Kassir MM, Delproposto Z, Dai Y, Sun J, Haacke M, Hu J. Imaging lymphatic system in breast cancer patients with magnetic resonance lymphangiography. PLoS One. 2013 Jul 5;8(7):e69701. (License: CC Not Specified)
Carson J, Bedrnicek J, Abdessalam S. Radiographically negative, asymptomatic, sentinel lymph node positive cutaneous T-cell lymphoma in a 3-year-old male: a case report. Case Rep Pediatr. 2012;2012:791602. (License: CC BY-3.0)
Mathelin C, Salvador S, Croce S, Andriamisandratsoa N, Huss D, Guyonnet JL. Optimization of sentinel lymph node biopsy in breast cancer using an operative gamma camera. World J Surg Oncol. 2007 Nov 17;5:132. (License: CC BY-2.0)
Soares EW. Anatomical variations of the axilla. Springerplus. 2014 Jun 24;3:306. (License: CC BY-4.0)