What are Axillary Nodes? 

The axillary lymph nodes are a key part of the lymphatic system, and they play an important role in draining fluid from the breast, carrying out immune functions, and removing bacteria. They are located in the underarm. Most individuals have anywhere from 20 to 30 lymph nodes in each axilla but the exact number can vary.

Their location is very close to multiple nerves and blood vessels that supply the shoulder and upper extremity. Often, they are oriented as a linear chain of lymph nodes, or as a chain that branches into two separate chains of lymph nodes.

What is Axillary Node Dissection?

Axillary node dissection is a surgical procedure in which axillary lymph nodes are removed. This is usually done as part of a mastectomy, lumpectomy or other breast cancer surgery. A sentinel lymph node biopsy may be done first to see if the axillary lymph nodes are affected by cancer. A special dye is used to locate the sentinel lymph node, which is the first lymph node to which the primary tumor drains. If additional nodes other than the sentinel node are involved, then an axillary node dissection will be performed. During an axillary node dissection, the surgeon will make an incision in the armpit and remove one or several axillary lymph nodes. This procedure is typically done under general anesthesia, and it usually takes 1-2 hours to complete. Recovery time varies depending on the individual, but most people feel well enough to return home the same day or within a few days. Axillary node dissection is a fairly common procedure, and it is generally considered to be safe and effective.

What is the Purpose of Axillary Node Dissection?  

This surgery is typically performed to treat breast cancer and direct the next steps in the cancer treatment plan of care.

What Are Risks and Complications Associated with Axillary Node Dissection?

As with any surgery, there are risks of surgical site infection after axillary node dissection. The healing period can also involve soreness, tightness, limited arm range of motion, and scarring from the incision. 

Lymphedema, or chronic swelling from disruption of the lymphatic system, may also develop in the underarm, breast, or arm, depending on the extent of surgery and other factors such as radiation, seroma, delayed healing, and development of infection. Risks of developing lymphedema after breast surgery are also discussed here. 

How to Prepare for Axillary Node Dissection Surgery

As with any surgery, there are risks of surgical site infection after axillary node dissection. The healing period can also involve soreness, tightness, limited arm range of motion, and scarring from the incision. 

Lymphedema, or chronic swelling from disruption of the lymphatic system, may also develop in the underarm, breast, or arm, depending on the extent of surgery and other factors such as radiation, seroma, delayed healing, and development of infection. Risks of developing lymphedema after breast surgery are also discussed here. 

How Physical Therapy Can Help You Before You Go for Axillary Node Dissection 

If you are scheduled for an axillary node dissection, you may be wondering "What difference would physical therapy make? I'm moving around just fine."

First, it is important to understand that this surgery can have a significant impact on your arm and shoulder function. The removal of lymph nodes can cause swelling and scarring, which can lead to reduced range of motion in the shoulder. In addition, the surgery can also cause numbness and pain in the arm, underarm, lateral breast, and lateral torso. 

Physical therapy for assessment of shoulder range of motion, neck range of motion, and prescription of exercises to address any deficits you may not be aware of, can help to reduce these side effects and improve your overall recovery after surgery. This means faster return to using your arm normally, and smoother return to work, exercise, leisure, caring for family, and moving forward in the next steps of your treatment plan. 

For example, exercises that improve or maintain range of motion of the neck and shoulders and strengthen the muscles around the shoulder can help to prevent or minimize stiffness and pain. These exercises can be started prior to surgery and be done as simply as 1-2 times a day. 

Your physical therapist will develop a personalized treatment plan for you based on the finding during an initial screening or evaluation of your total body movement.

How Physical Therapy Can Help You After Axillary Node Dissection

Beginning range of motion and postural exercises after axillary node dissection is critical to help you regain function, return to work, and continue with the next steps of the breast cancer treatment plan. If range of motion limitations are present, this could prevent you from being able to achieve the arm positioning needed to receive radiation treatments. This can be additionally limited if a seroma develops after breast surgery.

Once such story has happened to a patient of ours in the past. She developed a painful seroma in her axillary area, which limited her ability to achieve the overhead positioning needed to set her up properly for radiation. The critical issue when she told me her story, is that her seroma, pain, and limited range of shoulder range motion was preventing her from going to the next step of her cancer treatment!

According to the Clinical Practice Guidelines for Breast Cancer Rehabilitation (1), physical therapy is advised to begin one day after surgery. Protocols for therapy may vary widely depending on the invasiveness of the procedure, the surgeon's preference, and the extent of pre-existing shoulder limitations.  

According to the practice guidelines, 

Gentle shoulder range of motion can begin within 1 week.  

Light strengthening exercise can begin within 4 to 6 weeks after surgery.  

It is advisable to start stretching exercises about 1 week after any drains are removed. 

Continued daily stretching should be continued for at least 6 weeks or until normal shoulder range of motion is achieved.

Additional Considerations with Axillary Node Dissection

Normal range of motion typically involves motions of shoulder flexion, shoulder abduction, shoulder internal rotation, and shoulder external rotation.  

What frequently occurs is that patients my have limitations in their range of motion that they were not aware of prior to going in for surgery.  

If you are having pain with your exercises or activities, it is important to note that this is not unusual and to inform your physical therapist.

Manual therapy techniques such as manual lymph drainage for lymphedema, myofascial release, and other soft tissue mobilization techniques can help to reduce pain and improve range of motion after axillary node dissection. These techniques are often used in combination with exercises for the best results.

Summary

If you or a loved one are facing an axillary lymph node dissection, know that there are things that can be done to speed your recovery and your cancer treatment journey! Physical therapy both before and after your surgical procedure can help minimize risks of complications and help you heal more quickly, so can move on to the next step.

If you need help preparing for your procedure or guidance during your recovery, contact deBorja Physical Therapy to learn more and get your specific questions answered. 



Sources: 

Kyriacou H, Khan YS. Anatomy, Shoulder and Upper Limb, Axillary Lymph Nodes. [Updated 2021 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559188/

Shao YW, Shu Q, Xu D, Teng H, Wu GS, Hou JX, Tian J. Effect of different rehabilitation training timelines to prevent shoulder dysfunction among postoperative breast cancer patients: study protocol for a randomized controlled trial. Trials. 2021 Jan 6;22(1):16. doi: 10.1186/s13063-020-04954-3. PMID: 33407753; PMCID: PMC7789409.

Harris SR, Schmitz KH, Campbell KL, McNeely ML. Clinical practice guidelines for breast cancer rehabilitation: syntheses of guideline recommendations and qualitative appraisals. Cancer. 2012;118(8 Suppl):2312–2324. doi: 10.1002/cncr.27461 https://pubmed.ncbi.nlm.nih.gov/22488705/

Dr. Angie deBorja is a Doctor of Physical Therapy and founder of deBorja Physical Therapy in Baltimore. She has been helping patients since 2001. Her clinic specializes in helping adults 40+ in Baltimore, MD after cancer treatment, surgery, and injury, with a gentle approach to overcome pain and stiffness, move better, and get back to the active life they once enjoyed.