Chapter 63

The status of the axillary lymph nodes is the most significant factor predictive of long-term survival in patients with breast cancer. Axillary lymph node dissection (ALND) is an effective staging procedure and provides durable local control with a low rate of recurrence (NSABP B-4).1 Furthermore, although ALND has never been associated with an improvement in overall survival in individual randomized controlled trials (RCT), a meta-analysis of trials comparing ALND with observation suggests that a benefit exists.2

ALND has been the traditional means of staging the axilla in patients with breast cancer. However, since the advent of sentinel lymph node mapping, ALND is no longer the preferred staging procedure in patients with small, clinically node-negative breast cancer.3,4 The role of ALND in current practice is limited to women with locally advanced breast cancer and a subset of women with early breast cancer: in patients with clinically or radiologically apparent nodal disease at the time of presentation, in patients in whom a sentinel lymph node cannot be identified at the time of mapping, and in patients who have undergone a sentinel lymph node biopsy and were found to have an involved lymph node. The ACOSOG Z0011 trial was designed to study whether ALND after identification of a positive sentinel lymph node is associated with a survival benefit compared with observation alone.5 Its recent closure due to slow accrual ensures that ALND will continue to play a significant role in the management of patients with breast cancer.

Few absolute contraindications to ALND exist. Relative contraindications include comorbidities prohibiting general anesthesia or operative procedures (ie, coagulopathy), preexisting lymphedema, or shoulder immobility.

### Boundaries

The axilla is a pyramidal-shaped space existing between the upper arm and thoracic chest wall and is bounded by the following structures: superiorly by the axillary vein; anteriorly by the pectoralis major and minor (encased within the clavipectoral fascia); posteriorly by the subscapularis, teres major, and scapular insert of the latissimus dorsi muscle; laterally by the latissimus dorsi muscle; and medially by the serratus anterior muscle and chest wall (Fig. 63-1). The apex of the triangle (the highest point of the axillary dissection) is the costoclavicular ligament or Halsted ligament.

###### Figure 63-1

The boundaries of the left axilla on cross-section. m, Muscle. (Reproduced, with permission, from Petrek JA, Blackwood MM. Axillary dissection: current practice and technique. Curr Prob Surg. 1995;32:285.)

### Axillary Contents: Pertinent Neurovascular Structures (Fig. 63-2)

###### Figure 63-2

Axillary contents—pertinent neurovascular structures.

The long thoracic nerve arises from C5-7 and passes inferiorly on the lateral surface of the serratus anterior muscle, which it innervates. It is most commonly found within 1 cm of ...

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