MANAGEMENT OF AXILLA

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Anatomy of the lymph drainage of the breast
Rationale behind the need for the treatment of the axilla in breast cancer
Axillary clearance versus axillary node sampling
Sentinel node biopsy
In-house policy on management of the axilla in breast cancer
Complications of axillary surgery
Surgical management of axilla in patients with breast cancers

Anatomy of the lymph drainage of the breast

The breast is drained by two sets of lymphatics:

1. The lymphatics of the skin over the breast
2. The lymphatics of the parenchyma of the breast

The lymphatics draining the skin on the outer aspect of the breast go to the axillary group of lymph nodes while those on the superior aspect may drain to the supraclavicular nodes. The skin on the inner aspect of the breast drains to the internal mammary chain of lymph nodes lying along the internal mammary artery in the parasternal region. The nipple and the areola are drained by lymphatics that along with lymphatics draining the parenchyma of the breast travel t the axillary group of lymph nodes.

The axillary nodes receive about 75% of the lymphatics from the breast tissue. They comprise of five sets of nodes:

1. The anterior (subpectoral) group
2. The posterior (subscapular) group
3. The lateral group along the axillary vein
4. The central group lying in the fat in the upper part of the axilla and
5. The apical group lying in relation to the neck of the first rib.

A single lymph channel leaves the apical group on each side and empties into the junction between the Internal jugular and Subclavian veins on the right side and the Thoracic duct on the left.

Most of the lymph drains into the anterior group of axillary nodes, some goes to the posterior group and internal mammary group. The anterior and posterior group drain into the central and apical groups and thence into the systemic circulation.

For practical purposes the axillary nodes are seen to lie in three stations divided as such by the Pectoralis minor muscle. The lowest (level l) lies lateral to the muscle, the intermediate group (level II) behind the muscle and the highest group (level III) medial to the muscle. The latter would correspond to the anatomically defined apical group.

The axilla with its contents is a pyramidal shaped region with the apex at the neck of the first rib. An axillary clearance involves removal of all the axillary fat ant the above nodes contained within it. The boundaries that define the limit of the dissection are the long thoracic nerve (of Bell or the nerve to Serratus anterior) medially, the nerve to latissimus dorsi posteriorly, the subcutaneous fat antero-laterally and the axillary vein superiorly.

If you require further advice or information please contact the
Macmillan Breast Care Nurses, Hazel Ricard and Hilary Rickwood on 020 8565 5885