Axillary node dissection

[DrSwede]

I'm trying to find a good source for Complete Axillary Lymph Node Dissection. I'm interested in the indications, contraindications, how the procedure is performed, etc... (and if I'm lucky its use in treating metastatic melanoma)

Are there any good books on this that I can find in my med school library?

The reason I'm asking is d/t my lack of knowledge of what specialist actually performs this procedure. Is it a General Surgeon? Surgical Oncologist?
Do they do the Sentinel Node Biopsy too?

Thanks in advance!

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[Castro Viejo]

I'm trying to find a good source for Complete Axillary Lymph Node Dissection. I'm interested in the indications, contraindications, how the procedure is performed, etc... (and if I'm lucky its use in treating metastatic melanoma)

Chassin's or Zollinger's surgical atlases will often have indications, contraindications, and surgical pitfalls for a variety of operations, including an ALND.

The reason I'm asking is d/t my lack of knowledge of what specialist actually performs this procedure. Is it a General Surgeon? Surgical Oncologist?
Do they do the Sentinel Node Biopsy too?

This all falls under the realm of General Surgery, as do both Surgical Oncology and Breast Surgical Oncology, so any of these three types of surgeons should be qualified to perform an ALND if required. Whether or not they do this as opposed to a sentinel node biopsy is entirely dependent on what their take on the literature is regarding the utility of SLNB versus an ALND. I've met General Surgeons who feel that because SLNB isn't "standard of care," they won't do it and always resort to ALND. Others will never do ALND unless the sentinel node is positive. Oh well...

 

[heartsurgeon]

senitnel lymph node biopsy is a gray zone area.But rememeber that if you have clinically positive axilla(clinical palpation, noninvasive radiological investigation) you never do a SLN;one would go directly for a therapuetic axillary clearance.

 

[heartsurgeon]

A good source of information can be found in Devita's text book of oncology.I presonally found M.D Anderson hanbook of surgical oncology crisp and precise.

 

[surg]

I would disagree and say that sentinel node has become the standard of care whenever it is available. Elective lymph node dissection is still acceptable when sentinel node is not available.

In melanoma, you need to find someone who can do a complete (Levels I,II, AND III) axillary dissection and that means someone who sees melanoma a fair bit. Few general surgeons and breast surgeons do this level of dissection routinely since it is rarely necessary for breast surgery. Having now had 2 patients in the last month have inadequate clearance by their general surgeon requiring me to re-operate for left behind PALPABLE nodes, I'm a little miffed as you can imagine since the re-do takes probably 3 times as long.

If you can, try to find Balch's book Cutaneous Melanoma. That should have everything you are looking for. Surprisingly readable for a textbook. It also discusses technique although I also like's Chassin's take on it as well in his Operative strategy book.

 

[opr8n]

I've met General Surgeons who feel that because SLNB isn't "standard of care," they won't do it and always resort to ALND. Others will never do ALND unless the sentinel node is positive. Oh well...

i have seen this as well, and i dont agree
i think the literature has clearly shown that SLNB is an adequate way to ascess the presence/absence of tumor in the axilla
(assuming you can actually find the SLN or two)

 

[SocialistMD]

I would disagree and say that sentinel node has become the standard of care whenever it is available.

Who doesn't have methylene blue or lymphazurin?

 

[Winged Scapula]

Hell, its possible to do with methylene blue or any sort of dye (having done many during fellowship because of my dislike for the staining that occurs. No one seemed interested in my desire to use a fluroscein dye). I think what surg is referring to when stating "wherever possible" is that some hospitals may not have Nuc Med capability to inject the radiotracer or the pathology back-up needed. I doubt the dye is the problem. But I digress...

- there are numerous textbooks which will give the OP information on indications, contraindications etc. The MD Anderson Handbook of Surgical Oncology is an excellent text, very detailed given its size. It does not though, have detailed operative descriptions.

- most surgery atlases will have descriptions of this procedure; choose whichever one you like. I prefer Zollinger and Zollinger, although Chassins and Skandalakis, etc. are good as well.

The procedure is performed by general surgeons, breast surgeons, and surgical oncologists. Sentinel Node Biopsy, in many facilities, requires additional privileges; ie, I could not get privileges to do them unassisted and without approval until I showed that I had done so many during training (I think I had to have done 20).

I'm not sure who doesn't think it is standard of care because it certainly is for anyone without clinically positive nodes, with high grade or palpable DCIS and all cases of invasive breast cancer and melanoma.

A small percentage will not map and will require a full axillary node dissection. There is some controversy as to whether or not you have to clear Level III for breast disease. Surg is right, not many do, although my partner and I do.

 

[Hamilton Bailey]

In melanoma, you need to find someone who can do a complete (Levels I,II, AND III) axillary dissection....Few general surgeons and breast surgeons do this level of dissection routinely since it is rarely necessary for breast surgery.

That's if you are performing a staging ALND for breast CA with no palpable nodes..

If you are performing a therapeutic ALND for advanced breast CA (ie grossly involved nodes) it would have to include all 3 levels..

correct me if I am wrong..

 

[Winged Scapula]

That's if you are performing a staging ALND for breast CA with no palpable nodes..

If you are performing a therapeutic ALND for advanced breast CA (ie grossly involved nodes) it would have to include all 3 levels..

correct me if I am wrong..

Textbook true but semantic difference. Axillary Node Dissection = levels I and II. Axillary Node CLEARANCE = levels I, II and III.

The question is whether or not it is necessary, as there is not good evidence that removing Level III nodes changes a patient's prognosis. Therefore, some surgeons don't do it. And some only do it if Level II nodes are involved.

There are mutterings about abandoning the axillary node dissection as a therapeutic procedure and replacing it with RT.

 

[opr8n]

There are mutterings about abandoning the axillary node dissection as a therapeutic procedure and replacing it with RT.

i am assuming that chemo is invloved with that, not just XRT, right?

 

[Winged Scapula]

i am assuming that chemo is invloved with that, not just XRT, right?

Like most things in life, it depends on size of tumor, OncoTypeDx score, clinically palpable nodes, etc.

Some would get RT only, others the combo platter.

 

[DrSwede]

Thanks for all the great responses! Now I've got some reading to do for this case

 

[surg]

Just as a side note, since the original poster asked about melanoma specifically. Melanoma doesn't have a therapy that works really well for people with residual disease, (interferon, IL-2, DTIC all have low efficacy rates and RT is effective to some extent but not like breast CA), thus the more aggressive approach of virtually all melanoma surgeons. In breast surgery, with the number of good drugs and hormonal therapies for it as well as the better sensitivity to RT, you can get away with a slightly lesser dissection IMO.

Oh, and despite the rapid progression of SLNB to surgeons, a number of people never learned it, don't have the path backup to do the serial sectioning, don't have nuc med (absolutely mandatory for melanoma SLN, could be skipped in breast for those with good experience and not interested in int. mammary nodes), SLNB might not be "available" in their local area. This occurs outside of urban/big surburban areas more often than you think. Those patients would either have to travel, or decide to choose between elective dissection and close clinical observation (depending on their depth of melanoma and clinical node status).

BTW, WS, you do Levels I-III for everyone with a positive SLN? or just in some circumstances? just curious. I typically don't do a full III unless I have clearly positive nodes up high, although given that I also do melanoma, it's not uncommon for me to notice that I have pulled down some III's without really thinking about it since I can do that without a lot of work. If you always do it, does your RT avoid an axillary field or supraclav field then?

 

[Hamilton Bailey]

Textbook true but semantic difference. Axillary Node Dissection = levels I and II. Axillary Node CLEARANCE = levels I, II and III.

Excellent point!! therapeutic ALND sounds like an oxymoron..

The question is whether or not it is necessary, as there is not good evidence that removing Level III nodes changes a patient's prognosis. Therefore, some surgeons don't do it. And some only do it if Level II nodes are involved.

Well in T1/2 N0 breast tumors it may be ok to do a staging ALND upto level 2..(since skip mets to L3 are seen in only 5% of these pts)

But for clinically > T3/N1 breast tumors (where nodal involvement has been confirmed by FNAC) dont you think its wise to do a therapeutic ALNC upto L3..for Loco-Regional control..

There are mutterings about abandoning the axillary node dissection as a therapeutic procedure and replacing it with RT.

BAD...VERY BAD option..
esp if you are going to radiate AFTER you have staged the axilla with a L2 dissection..
But if its clinically N2 or 3.. I guess you could possibly do away with the ALNC..

 

[Hamilton Bailey]

Thanks for all the great responses! Now I've got some reading to do for this case

Try this link
http://www.edu.rcsed.ac.uk/HowIDoIt/Axillary clearance.htm

 

[Hamilton Bailey]

I've met General Surgeons who feel that because SLNB isn't "standard of care," they won't do it and always resort to ALND. Others will never do ALND unless the sentinel node is positive. Oh well...

For early breast cancer..the ALMANAC trial concludes: Sentinel lymph node biopsy is associated with reduced arm morbidity and better quality of life than standard (level 3) axillary treatment and should be the treatment of choice for patients who have early-stage breast cancer with clinically negative nodes.

http://jnci.oxfordjournals.org/cgi/content/full/98/9/599

 

[Hamilton Bailey]

The ALMANAC trial used...
"In the randomized phase of the trial, subsequent patients of the eligible surgeons were randomly assigned to undergo sentinel lymph node biopsy or standard axillary treatment, i.e., level I – III axillary lymph node dissection or four-node axillary sampling"
"Our study has several limitations. First, the inclusion of four node sampling techniques in the standard treatment arm may have led to an underestimate of the benefit of sentinel lymph node biopsy."

 

[Castro Viejo]

For early breast cancer..the ALMANAC trial concludes: Sentinel lymph node biopsy is associated with reduced arm morbidity and better quality of life than standard (level 3) axillary treatment and should be the treatment of choice for patients who have early-stage breast cancer with clinically negative nodes.

http://jnci.oxfordjournals.org/cgi/content/full/98/9/599

Thanks. I realize that there are numerous studies that support the use of SLNB.