Axillary Lymph Node Dissection (ALND)
What the Examiner Expects
Surgical removal of axillary lymph nodes at levels I and II (lateral and posterior to the pectoralis minor muscle) for staging and regional control of breast cancer. The examiner expects you to know the anatomic boundaries of the axilla (axillary vein superiorly, latissimus dorsi laterally, chest wall medially), identify and preserve the long thoracic and thoracodorsal nerves, and harvest a minimum of 10 nodes. ALND is indicated for clinically node-positive disease confirmed by biopsy, patients not meeting Z0011 criteria with positive SLN, or inflammatory breast cancer after neoadjuvant therapy.
Key Examiner Focus Points
- Levels I and II nodes removed (lateral and posterior to pectoralis minor)
- Level III (infraclavicular) dissection only if grossly involved
- Minimum 10 lymph nodes for adequate staging
- Preserve long thoracic, thoracodorsal, and medial pectoral nerves
- Lymphedema risk 15–25%; higher with concurrent radiation
Common Curveballs
Postop seroma develops under the skin flaps
Seroma is the most common complication of ALND (occurs in nearly all patients to some degree). Manage with serial percutaneous aspiration. Drains are placed intraoperatively and removed when output is < 30 mL/day. Persistent seroma may require sclerotherapy.
Three positive sentinel nodes in a patient undergoing mastectomy (not lumpectomy)
Z0011 does not apply to mastectomy patients. Completion ALND is indicated. The Z0011 data is specific to breast-conserving surgery with whole-breast radiation — the radiation field covers the low axilla and provides regional control.