Axillary lymph node dissection: Purpose, Procedure, Benefits and Side Effects

The removal of the axillary (underarm) lymph nodes is the objective of the surgical procedure known as axillary lymph node dissection, abbreviated as ALND. This procedure is usually done as a part of breast cancer treatment, especially for larger tumours or those that have spread to the axillary lymph nodes.

There are several types of axillary lymph node dissection, depending on the specific need and procedure. The most common types are:-

• Sentinel lymph node biopsy (SLNB): In this procedure, only the sentinel node - the first few lymph nodes that receive lymph drainage from a tumour site - is removed and biopsied for metastatic cancer cells. This is usually done in cases when breast cancer is suspected or has been confirmed.
• Level I axillary dissection: This type of procedure involves removal of up to five lymph nodes from under the arm and can be used to check for metastatic cancer if a SLNB cannot be performed or if an axillary mass is present but not palpable.
• Level II/III axillary dissection: This type of procedure involves removal of up to 15-20 or more lymph nodes from under the arm and is typically reserved for patients with larger tumours that have fast-growing, aggressive features - such as inflammatory breast cancer - where there’s a higher risk of cervical or supraclavicular node involvement or distant spread of disease beyond the axilla via the deep venous plexus.

• Helps diagnose a variety of cancers: Axillary lymph node dissection helps doctors to detect or examine cancerous cells in the lymph nodes which can help determine the extent of cancer spread.
• Easy to access surgical site: The axillary lymph nodes are located inside the armpit, providing easy access for surgeons to perform this operation.
• Greater accuracy: Axillary lymph node dissection allows a higher degree of accuracy in detecting and assessing cancer cells in comparison to other surgical options such as sentinel node biopsy.
• Improved prognosis: A successful axillary node dissection drastically improves the chances of successful removal and treatment of diseased tissue while ensuring complete elimination of cancer cells with minimal damage to healthy tissues surrounding it.
• Reduced post-operative pain and discomfort: Axillary lymph node dissection ensures reduced post-surgical pain and recovery period as compared to open incision surgeries performed elsewhere in the body such as brain surgeries etc.

Axillary lymph node dissection (ALND) is typically done to remove any cancer cells that may have spread from the primary tumour. By removing cancerous lymph nodes, it helps reduce the risk of recurrence or spread of the cancer and can improve survival rates in certain cases. ALND is performed for the additional purpose of determining whether or not the cancer has spread to other parts of the body, such as organs located in other parts of the body.

Risks of ALND include:-

• Excessive bleeding or haemorrhaging: As with any surgery, there is a risk of excessive bleeding and haemorrhage during and following the ALND procedure.
• Infection: Just as with surgical procedures, there is a possibility of contracting an infection as a result of the introduction of bacteria into the body during the procedure.
• Damage to adjacent tissues: The tools used for ALND may damage adjacent tissues, such as nerves or blood vessels in rare cases.
• Lymphedema: Lymphedema is an accumulation of fluid that causes swelling in parts of the body because lymphatic drainage is blocked or impaired; this condition may result after having an ALND due to damage caused by removal or dissection of lymph nodes.

• Have a discussion with your physician about the possible benefits and drawbacks of the procedure.
• Ask questions and clear any doubts before the surgery.
• Prepare for pre-surgical tests such as chest X-ray, blood tests, urine tests, ECG etc.
• Ask your doctor or nurse which medicines to avoid before the procedure.
• Take your doctor's advice and stick to the diet plan he or she has given you.
• Arrange for transportation to and from the medical facility.

During axillary lymph node dissection, a surgeon will make an incision under your armpit and locate any swollen lymph nodes that might contain cancer cells. These nodes will then be removed and sent off for a pathology review by a pathologist who will analyse each node to determine if it has been affected by cancer cells and how far they have spread.

If cancer cells are present, further treatments such as chemotherapy or radiation therapy may be recommended depending on the results. Following removal of the affected nodes, stitches are placed in both sides of your armpit area in order to close up the incision area.

• The patient is provided with detailed information on the procedure and its risks.
• Consent is obtained from the patient.
• Appropriate preoperative testing and investigations are performed.
• The patient is prepped and anaesthetist.

• An incision is made over the axilla to access the lymph nodes.
• Lymph nodes are identified, dissected, and examined for metastatic cancer cells if present.
• Axillary arteries and veins may be identified and ligated if required.
• Specimen(s) of lymph nodes are collected for histological examination.

• The wound is closed using sutures or staples.
• A dressing may be applied over the wound depending on its size, location, and type of closure used.
• Postoperative orders are written including pain control medications as needed.

The cost of Axillary Lymph Node Dissection in India can vary based on the individual patient’s needs.

Generally, the cost ranges between Rs. 15,000 - Rs. 1,50,000 depending on where the surgery is performed and other factors such as the complexity of the procedure and diagnosis.

Some hospitals might also charge a fee for post-operative care and medicines related to this surgery, which will be added to the total cost.

• After having an axillary lymph node dissection, it is essential to adhere to a diet that is tailored to your specific needs.
• Generally, the doctor or nutritionist will recommend certain dietary restrictions for a few weeks after the surgery.
• Increasing the amount of fibre you consume, decreasing the amount of sodium you consume, eating smaller portions at regular intervals throughout the day, and avoiding foods that are high in fat are some common suggestions.
• Additionally, it is important to drink plenty of fluids and get plenty of rest to help with recovery.

Axillary lymph node dissection is generally considered to be a safe procedure. However, as with any surgical operation, there can be certain risks involved, including infection and potentially permanent nerve damage leading to weakened muscle control.

Recovery time for an axillary lymph node dissection can vary depending on the individual, but typically healing can take several weeks to a few months. During the first few days after surgery, light activities such as walking and light stretching can be done to help reduce swelling and pain. After several weeks, activities such as jogging, tennis and swimming may be resumed. However, it is important to listen to your body and not overexert yourself during the recovery process.

• Post-operative pain
• Swelling/inflammation
• Nerve damage/sensation loss
• Arm stiffness/restricted movement
• Lymphedema (swelling of arm)
• Infection or scarring
• Compartment Syndrome (rare)

• Aftercare for axillary lymph node dissections will vary depending on the individual's age, condition, and overall health. Some common aftercare steps include:
• Taking medications such as antibiotics to prevent infection.
• Applying cold compresses to the area for several days after surgery for pain relief.
• Keeping the incision site clean and dry when showering or bathing.
• Wearing an arm sling if needed to provide support and rest the arm during recovery.
• Continuing prescribed physical therapy exercises which help restore movement and strength in the shoulder and arm following surgery.
• Checking in with your surgeon at follow-up visits to monitor recovery.
• Limiting activities such as heavy lifting or sports activities until instructed by your doctor that it is safe to resume normal activities.

Axillary lymph node dissection is an effective treatment for several cancers, such as breast cancer, that spread to the lymph nodes, providing significant long-term survival rates and good overall results. Additionally, there is evidence that axillary lymph node dissection can be used as a stand-alone procedure or in combination with other therapies to improve outcomes. As such, this technique may offer options for patients previously considered to have limited options for treatment.