Axillary hollow surgery

Axillary dissection

Lymph node involvement is an important prognostic factor (and will therefore have a major influence on the treatment decision). Before the sentinel node technique was validated, axillary dissection was the rule. It is still performed in cases where the nodes are clinically affected or there is a metastatic lymph node (although its usefulness in the latter case is currently being debated). The procedure is an infra- and retro-pectoral lymphadenectomy.

It is generally acknowledged that lymph node dissection of levels I and II is sufficient to provide useful information on systemic treatment. By foregoing the dissection of level III, the number and severity of lymphoedemas of the upper limbs (swollen arms) is decreased.

Complications of axillary dissection, such as swollen arms, pain or paraesthesias in different degrees, are reported in about 25% of cases.

Sentinel node

Since the 1990s, sentinel node biopsy has become the standard treatment for axilla staging, as it identifies the first filter of a possible metastasis.

A tracer element (Te99 and more rarely Blue Dye) is injected into the peritumoural and periareolar areas a few hours before surgery. From there, it migrates through the lymphatic vessels to the first sentinel lymph node draining the primary tumour region. The lymph nodes, which are now radioactive, are identified using a Geiger probe and are then excised and analysed intraoperatively by the pathologist.

If the sentinel node is not metastatic, it is assumed, with a false negative rate of 6 to 12%, that the other axillary nodes are also free of metastases.

Sentinel node prediction has been further improved through pathological analyses that are more detailed than the simple analysis of axillary nodes during dissection.

This method offers great benefits to patients, as complications such as paraesthesias and arm lymphoedemas are rarer (5% of cases versus 25% after axillary dissection).

This method has already proven its worth for both large and multifocal tumours and, in some cases, after primary (neo-adjuvant) chemotherapy. Its applicability is questioned in multicentric cancers and, in the case of a locally advanced neoplasia or if the axilla is clinically affected, the sentinel node approach cannot be attempted and axillary dissection must be performed.