2 The procedure
2.1.1 Axillary clearance has been used as part of surgery for breast cancer. Biopsy of lymph node tissue helps in the staging of breast cancer, providing prognostic information and identifying patients who will benefit from systemic therapy.
2.1.2 Traditionally, surgeons remove lymph nodes for staging through an incision in the axillary skin under direct vision. However, this procedure may have side effects, including wound infection and lymphoedema. There are two surgical alternatives that are standard practice. The first involves clearance to level one, two or three of the axilla, taking up to 20 lymph nodes, which provides very accurate diagnostic information. The second requires sampling of a minimum of four lymph nodes, which causes less morbidity but provides only qualitative rather than quantitative information about the status of the axillary basin of lymph nodes. A new procedure is sentinel node mapping, which requires specific training in the use of imaging. Endoscopic techniques, sometimes combined with liposuction, have been developed as a less invasive approach to removing lymph nodes for diagnosis.
2.2.1 In endoscopic axillary lymph node retrieval, very small incisions are made in the axillary skin and nodes are removed using an endoscope and special instruments. The patient is placed in a supine position under general anaesthesia. Liposuction is used to remove excess axillary fat. An endoscope is inserted through the incision used for liposuction, and trocars are introduced through two additional small incisions. Fibrous tracts and small lymph and blood vessels are coagulated and cut, and lymph nodes are freed and removed. Following a saline rinse of the surgical field, the incisions are sutured. Drains are not normally required.
2.3.1 Conversion to open surgery was reported in 8% (4/53) of operations in a historically controlled study. In a large case series, only 2% (2/100) of operations were converted to open surgery.
2.3.2 In one randomised controlled trial, the operative time for endoscopic axillary lymph node retrieval was found to be significantly longer than for open surgery (mean time 61 and 33 minutes, respectively).
2.3.3 One quasi-randomised study found good shoulder–arm mobility at 7 days postoperatively, with more than 90% mobility being achieved after either endoscopic axillary lymph node retrieval or open surgery. Only 18% (7/40) of patients who had endoscopic axillary lymph node retrieval reported pain on the first postoperative day, compared with 33% (13/40) of patients who had open surgery. One small randomised controlled trial found that all ten patients reported no pain at 3 days after endoscopic axillary lymph node retrieval.
2.3.4 Length of hospital stay after endoscopic axillary lymph node retrieval varied from 2.5 days to 9 days, although one study reported that most of the later patients in the series were discharged within 24 hours.
2.3.5 Two case series reported no axillary recurrence among 100 patients followed up to 14 months, and 103 patients followed up to 18 months. For more details, refer to the Sources of evidence.
2.4.1 Data on the safety of the procedure were not reported consistently in the studies. The incidence of seroma reported after endoscopic axillary lymph node retrieval varied from 90% (36/40) to 4% (4/100). Similarly, rates of haematoma formation ranged from 16% (16/100) in one case series to 1% (1/103) in a second case series.
2.4.2 Other reported adverse events after endoscopic axillary lymph node retrieval included lymphocoele in 25% (5/20) of patients and wound infection in 5% (2/40) of patients. For more details, refer to the Sources of evidence.
2.4.3 The Specialist Advisors noted that theoretical adverse effects include bleeding, damage to nerves or the axillary artery, pneumothorax, lymphoedema and pain or sensory disturbance in the arm and shoulder.
2.5.1 These recommendations refer to the use of endoscopy rather than open surgery for the retrieval of selected axillary lymph nodes. They do not address clinical decisions about the number of lymph nodes that should be removed.
2.5.2 The Committee noted that this procedure is seldom carried out in the UK, and that sentinel node retrieval has become common practice.