Breast Cancer

Lesson 3: Surgery

Axillary Dissection

Axillary dissection is the removal of the lymph nodes under your arm. The lymph nodes filter your body fluids. The nodes under the armpit, or axilla, help drain the breast fluids. Axillary dissection is not usually recommended for a diagnosis of DCIS (ductal carcinoma in situ). Since Sentinel Node Biopsy (the previous Lesson) is not generally recommended for multicentric tumors (more than one location) or large tumors or women who have already had breast surgery, resulting in a large void in the chest cavity, it is important to recognize the pros and cons of axillary node dissection.

This surgery does not lead to a cure, but rather is an important diagnostic tool. Except for the fairly new SNB, there is no way to determine if cancer has spread to the lymph nodes without removing them. There are three levels of lymph nodes in the underarm area.

The bottom lymph nodes (B) are located just below the pectoralis major muscle (A). The second level of nodes (C) lies under the pectoralis major muscle. The third level (D) is above the pectoralis major muscle. There are also lymph nodes just above your collarbone, known as the supraclavicular nodes (E) and there are internal mammary lymph nodes (F), within the breast itself.

This surgical procedure is usually done in conjunction with a lumpectomy, wide excision or mastectomy. I had my lymph nodes removed along with a wide excision. I was sedated, in the operating room, and went home the same day. The surgeon removes a clump of fat from under your arm and this tissue is sent to the pathology department. The lymph nodes are then painstakingly separated from the surrounding fat and examined for any evidence of cancer. There are not a set number of lymph nodes under your arm. Some woman will say, "My doctor took out 30 nodes", while another may have only 10 removed. It does not matter how many nodes are removed – what counts is the number of nodes that are positive. (The higher the incidence of cancer in the nodes, the poorer the diagnosis). For the record, the doctor removed 15 of my nodes and they were all negative. The reason that the number of lymph nodes vary is based on your individual body structure, the exactness with which the pathologist searches for the lymph nodes and can only be made from the sample which your surgeon has sent to pathology.

You will generally be sent home with a drain attached to the surgical site. After approximately one to two weeks, you will have your drain removed and your stitches, if necessary.

Every woman will have a different tolerance for pain, inconvenience, aesthetics and the whole breast cancer process. Please remember that this is merely my personal opinion, based on my own experience. I did not feel severe pain after this surgery. The attached drain grossed me out. It was inconceivable to me that this tubing and turkey baster-type rubber bulb was attached to my body. It was inconvenient to find clever ways to disguise this bulge in my clothes when I went out. Collecting and measuring the output of fluid on a daily basis was just another chore. Wearing a tight sports bra made me feel secure. My wide excision scars and black and blue breast didn’t bother me a lot. My axilla dissection site, however, was a different story. My underarm was black and blue and ugly beyond belief.

There are many potential side effects of axillary node dissection, and most women might experience one or two of them, to a moderate degree. It was just my luck to get all the side effects. I lost the sensation in the underside of my bicep. This feeling has returned minimally over about eighteen months. This numbness, or loss of sensation, is hard to describe. It is not uncomfortable, nor painful, but it is strange. They suggest that you shave with an electric razor after axillary dissection. This is a good idea because due to the decreased sensation, you could cut yourself and never know until you notice the dripping blood under your arm!

Another possibility is loss of arm mobility. Before you are discharged, you will generally be given a list of exercises to do to return your arm to normalcy. I looked at the list and chuckled. These exercises would be a piece of cake! Boy, was I ever wrong. The first exercise was to raise both arms from my sides to waist height in front of me. My right arm flew up to the ceiling, while my left arm barely raised to hip level. Persistent practice of the exercises got my left arm back to working condition.

There is the remote possibility of developing a seroma, which is a pocket of lymph fluid. I developed this and cellulitis, which is an infection that grows due to the collection of bacteria stagnating in the lymph fluid. The seroma is easily, and painlessly, drained. Then, I developed cellulitis, which landed me back in the hospital for a week. We'll discuss cellulitis in conjunction with lymphedema.

The worst potential side effect of axillary dissection is lymphedema. Most surgeons still like to believe that lymphedema is caused by radiation. The oncologists like to blame it on the surgeons. The truth is lymphedema is a result of varying breast cancer treatments, which can be exacerbated by repetitious motion, flying, insect bites, scratches, and trauma to the affected side. I firmly believe that the number of cases of lymphedema is severely underreported. If you are having axillary dissection, please check out all the lymphedema links. Lymphedema is not a fatal complication, but it can be a lifelong concern and you need to be vigilant in protecting your affected side.

I know that I have painted a rather bleak picture of axillary dissection, but it really is not that bad. I thought my underarm was ugly; it was inconvenient and the side effects were nasty, but most of the side effects were short-term. It was important for my diagnosis to know if the cancer had spread to the lymph nodes, so that the oncologist could determine the best course of action for my treatment.

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