What are the possible complications from Modified Radical Mastectomy (MRM) and Axillary Lymph Node Dissection (ALND)?

Complications of Modified Radical Mastectomy (MRM) and Axillary Lymph Node Dissection (ALND)

Modified Radical Mastectomy (MRM) and Axillary Lymph Node Dissection (ALND) are associated with significant complications including lymphedema, seroma formation, wound infections, neurologic/sensory deficits, and shoulder dysfunction that can substantially impact patient morbidity and quality of life.

Common Complications

Lymphedema

• Occurs in approximately 9-13% of patients undergoing ALND 1, 2
• Risk factors include:
  • Extent of surgery
  • Use of radiation therapy
  • Length of follow-up
• Significantly lower rates with Sentinel Lymph Node Biopsy (SNB) compared to ALND (1% vs 2-13%) 1

Seroma Formation

• One of the most frequent complications:
  • 15-29% after MRM 3, 4, 2
  • 18% after tylectomy with ALND 4
• Risk factors include:
  • Age over 60 years 4
  • Drainage volume >30mL in 24 hours prior to drain removal 4
  • Surgical technique used for axillary dissection 5
  • Body mass index 5

Wound Infections

• Occurs in approximately 9-11% of patients 3, 2
• Usually develops around postoperative day 5-7 3
• Higher rates with MRM compared to tylectomy with ALND (49% vs 35%) 4
• Risk factors include:
  • Obesity (particularly in tylectomy with ALND) 4
  • Prolonged drainage 5

Neurologic/Sensory Deficits

• Numbness and paresthesia reported in 22% of patients 2
• Persistent severe sensory phenomena in 5-10% of patients beyond 3 months 1
• Specific nerve-related complications:
  • Intercostobrachial nerve (ICBN) damage: sensory loss, paresthesia, dysesthesia, and persistent pain syndromes 6
  • Long thoracic nerve damage: serratus anterior muscle paralysis, winged scapula, shoulder dysfunction, and pain 6

Shoulder Dysfunction

• Shoulder discomfort and impaired range of motion 1
• Axillary web syndrome: transient development of tender lymphatic cords along the upper inner arm 1
• Risk significantly higher with ALND compared to SNB 1

Other Complications

• Epidermolysis (18% in MRM) 4
• Allergic reactions to dye used in SNB (1-2%, with true anaphylaxis in 0.25-0.5%) 1
• Hematoma formation 4
• Prolonged hospital stay 7
• Delayed adjuvant therapies 3

Comparison of ALND vs. Sentinel Node Biopsy (SNB)

Multiple studies demonstrate that SNB significantly reduces complications compared to ALND:

• Lymphedema: 1% with SNB vs. 2-13% with ALND (p<0.001) 1
• Shoulder discomfort: significantly lower with SNB 1
• Sensory deficits: significantly lower with SNB 1
• Infections: lower rates with SNB (p=0.0026) 1
• Quality of life: superior with SNB 1

Prevention Strategies

Surgical Technique Considerations

• Careful identification and preservation of nerves during surgery 6:
  • Intercostobrachial nerve
  • Long thoracic nerve
  • Thoracodorsal nerve
  • Medial pectoral nerve
• Meticulous dissection techniques with good visualization of the surgical field 6
• Avoid excessive traction on tissues 6
• Consider nerve-sparing approaches when oncologically appropriate 6

Drain Management

• Closed suction drainage is typically advisable after ALND 6
• Volume of drainage >30mL in 24 hours prior to removal is associated with seroma formation 4
• However, a "no drains" policy may be considered as it has been shown not to increase seroma formation while allowing earlier hospital discharge 7

Surgical Team Experience

• Success and safety depend significantly on surgical expertise 6
• An experienced sentinel lymph node team is mandatory for accurate mapping and excision 6
• Surgeons should have a low threshold to convert to ALND when the SNB procedure is technically unsatisfactory (occurs in approximately 5.6% of cases) 6

Impact on Quality of Life

The American Society of Clinical Oncology guidelines emphasize that these complications can significantly impact quality of life 1:

• Physical morbidity from lymphedema, pain, and limited mobility
• Psychological morbidity from body image changes and functional limitations
• Delayed return to normal activities
• Potential impact on adjuvant therapy timing

Clinical Implications

Based on the evidence, the following approach is recommended:

1. Consider SNB over ALND when appropriate: SNB has been shown to significantly reduce complications while maintaining oncologic outcomes in eligible patients 1

2. For patients requiring ALND:

   • Implement meticulous surgical technique with nerve preservation
   • Provide comprehensive patient education about potential complications
   • Establish early rehabilitation protocols
   • Monitor closely for early signs of complications

3. For patients undergoing MRM:

   • Recognize the higher risk of complications compared to breast-conserving approaches
   • Consider patient-specific risk factors (age, BMI, smoking status)
   • Implement appropriate preventive measures

The evidence clearly demonstrates that while MRM and ALND remain important surgical options for breast cancer treatment, they carry significant risks of complications that impact quality of life. When clinically appropriate, less invasive approaches like SNB should be considered to minimize these complications.