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Axillary lymphadenectomy, or axillary dissection, is a surgical procedure to remove lymphatic tissue from the axilla. Although, historically, this procedure was routinely performed alongside mastectomy for breast cancer treatment, its use has declined with advancements in breast cancer biology, systemic therapies, and less invasive alternatives proven effective in clinical trials. Currently, axillary lymphadenectomy is primarily reserved for managing clinically involved axillary lymph nodes in breast cancer, melanoma, and squamous cell carcinoma. Axillary lymphadenectomy involves careful dissection to preserve vital anatomical structures, such as nerves and blood vessels, while removing fibrofatty tissue and lymph nodes. Postoperative care emphasizes managing complications, including lymphedema, seroma, nerve injury, and wound infections. Although axillary lymphadenectomy is performed less frequently nowadays, it remains crucial in specific clinical scenarios, particularly in regions with limited access to advanced treatments, highlighting the need for surgical expertise and attentive postoperative management. This activity for healthcare professionals is designed to enhance the learner's competence in recognizing the indications for axillary lymphadenectomy, performing surgical techniques effectively, and implementing interprofessional management strategies to treat patients, ultimately improving clinical outcomes. Objectives: Identify the clinical indications for axillary lymphadenectomy in patients with breast cancer, melanoma, and squamous cell carcinoma. Implement appropriate surgical techniques to preserve vital anatomical structures during axillary lymphadenectomy. Select the most appropriate postoperative care interventions to optimize recovery and reduce morbidity in axillary lymphadenectomy patients. Collaborate with an interprofessional healthcare team to ensure comprehensive patient care before, during, and after axillary lymphadenectomy. Access free multiple choice questions on this topic.

Axillary lymphadenectomy, or axillary dissection, is a surgical procedure involving the removal of all lymphatic tissue from the axilla. Traditionally, this procedure was performed alongside a modified radical mastectomy and was a critical component in breast cancer management. However, advancements in breast cancer biology, improvements in systemic chemotherapy and radiation techniques, and landmark trials demonstrating the effectiveness of less invasive procedures have significantly reduced the frequency of axillary lymphadenectomy.[1][2][3] The primary indications for axillary lymphadenectomy currently include clinically involved axillary lymph nodes in breast cancer, axillary node recurrences, and positive lymph nodes in nonmammary malignancies such as melanoma and squamous cell carcinoma.[4][5] Axillary lymphadenectomy is associated with significant morbidity, particularly lymphedema, making a comprehensive understanding of axillary anatomy surgical indications crucial for safe and effective surgical performance.[6][7]

Seroma formation is nearly universal following axillary lymphadenectomy, although clinically significant seromas requiring intervention are less common, with reported rates ranging from 10% to 80%. Closed suction wound drainage effectively reduces clinically significant seromas. Temporary immobilization with slings or compressive bandages may lower seroma rates; however, the increased risk of lymphedema outweighs this benefit. Additional strategies, such as applying fibrin sealant during surgery and minimizing electrocautery through meticulous surgical technique, can further reduce seroma formation.[20][21] Lymphedema, the accumulation of lymphatic fluid in the arm after axillary lymphadenectomy, is a common and potentially debilitating complication, with a reported incidence of approximately 20% in the largest meta-analysis.[22] Lymphedema most commonly develops within the first 2 years following surgery, after which new cases are less likely. Risk factors include extensive lymphadenectomy, obesity, adjuvant chemotherapy, radiotherapy, and mastectomy performed alongside lymphadenectomy. While regular physical activity has also been associated with increased risk, its benefits often outweigh this concern. Diagnosis relies on clinical examination, with a high index of suspicion and routine arm circumference measurements at follow-up visits being essential for early detection.[23][24] Wound infections after axillary lymphadenectomy occur in 1% to 20% of cases, with most being superficial surgical site infections. Deep infections are less common but may necessitate operative drainage when present.[7] Nerve injury is a potential complication of axillary lymphadenectomy. Damage to the long thoracic nerve can weaken the serratus anterior muscle, leading to scapular winging, while injury to the thoracodorsal nerve causes latissimus dorsi denervation, resulting in weakened shoulder abduction. The intercostobrachial nerve is the most commonly injured during axillary lymphadenectomy, often being intentionally sacrificed, which results in anesthesia on the medial surface of the arm. Injury to the medial and lateral pectoral nerves can cause atrophy of the pectoralis major, which is particularly problematic for patients undergoing breast reconstruction with implants, resulting in poorer cosmetic outcomes.[25]

Nerve injury is a potential complication of axillary lymphadenectomy. Damage to the long thoracic nerve can weaken the serratus anterior muscle, leading to scapular winging, while injury to the thoracodorsal nerve causes latissimus dorsi denervation, resulting in weakened shoulder abduction. The intercostobrachial nerve is the most commonly injured during axillary lymphadenectomy, often being intentionally sacrificed, which results in anesthesia on the medial surface of the arm. Injury to the medial and lateral pectoral nerves can cause atrophy of the pectoralis major, which is particularly problematic for patients undergoing breast reconstruction with implants, resulting in poorer cosmetic outcomes.[25] Angiosarcoma of the extremity often develops in the context of chronic lymphedema following axillary lymphadenectomy—a condition known as Stewart-Treves syndrome. This malignancy is highly aggressive, with rapid progression and a strong tendency for distant metastasis, often leading to a fatal outcome. The typical latency period for angiosarcoma development after lymphadenectomy is approximately 10 years, with the risk further increased in patients who have undergone adjuvant radiation therapy. Management typically involves a multimodal approach, including surgical resection and systemic chemotherapy, although the prognosis remains poor, with limited long-term survival.[26] Axillary web syndrome is characterized by the development of fibrotic bands in the axilla, most commonly following axillary lymphadenectomy. However, it can also occur after less invasive procedures, eg, sentinel lymph node biopsy. These fibrous cords, primarily composed of scar tissue, typically appear within the first few weeks after surgery and resolve gradually over time. The bands become more prominent with arm abduction, often causing pain and limiting shoulder movement. The condition is self-limiting.[27]

Axillary lymphadenectomy is a crucial therapeutic procedure for patients with clinically positive lymph nodes in breast cancer, melanoma, or cutaneous squamous cell carcinoma. Effective management requires an interprofessional approach to ensure optimal, patient-centered care and improved outcomes. Physicians and advanced practitioners must collaborate to assess the necessity of the procedure, evaluate the feasibility of less invasive options, and tailor treatment plans to meet the individual needs of the patient. Interprofessional healthcare providers, including surgeons, radiologists, oncologists, and survivorship specialists, collaborate to develop comprehensive treatment strategies for patients undergoing the procedure. Nursing staff and physiotherapists support postoperative recovery and help prevent complications. Pharmacists are critical in managing pain, preventing infections, and addressing comorbidities. Effective interprofessional communication and seamless care coordination are vital for ensuring patient safety and team performance. By fostering a collaborative, patient-centered model that emphasizes shared decision-making, respect for autonomy, and the integration of interprofessional expertise, healthcare teams can improve outcomes and minimize the risks associated with axillary lymphadenectomy.