Lymph node surgery

Lymph node surgery

To determine if the breast cancer has spread to axillary (underarm) lymph nodes, one or
more of these lymph nodes may be removed and looked at under the microscope. This is
an important part of staging and determining treatment and outcomes. When the lymph
nodes contain cancer cells, there is a higher chance that cancer cells have also spread
through the bloodstream to other parts of the body. The presence of cancer cells in the
lymph nodes under the arm is often an important factor in deciding what treatment, if
any, is needed after surgery (adjuvant therapy).
Axillary lymph node dissection (ALND): In this procedure, anywhere from about 10 to
40 (though usually less than 20) lymph nodes are removed from the the area under the
arm (axilla) and checked for cancer spread. ALND is usually done at the same time as the
mastectomy or BCS, but it can be done in a second operation. This was once the most
common way to check to see if breast cancer has spread to nearby lymph nodes, and it is
still done in some patients. For example, an ALND may be done if a previous biopsy has
shown one or more of the underarm lymph nodes have cancer cells.
Sentinel lymph node biopsy (SLNB): Although axillary lymph node dissection (ALND)
is a safe operation and has low rates of most side effects, removing many lymph nodes
increases the chance that the patient will have lymphedema after surgery (this side effect
is discussed further on). To lower the risk of lymphedema, the doctors may use a sentinel
lymph node biopsy (SLNB) procedure to check the lymph nodes for cancer. This
procedure is a way of learning if cancer has spread to lymph nodes without removing as
many of them.
In this procedure the surgeon finds and removes the first lymph node(s) to which a tumor
is likely to drain. This lymph node, known as the sentinel node, is the one most likely to
contain cancer cells if they have started to spread. To do this, the surgeon injects a
radioactive substance and/or a blue dye into the tumor or the area around it. Lymphatic
vessels will carry these substances into the sentinel node(s).
A special device can be used to detect radioactivity in the nodes that the radioactive
substance flows into or can look for lymph nodes that have turned blue. These are
separate ways to find the sentinel node, but are often done together as a double check.
The surgeon then cuts the skin over the area and removes the node(s) containing the dye
(or radiation). A pathologist then looks closely at these nodes (often 2 or 3).. (Because

fewer nodes are removed than in an ALND, each one can be looked at more closely for
any cancer).
The lymph node can sometimes be checked for cancer during surgery. If cancer is found
in the sentinel lymph node, the surgeon may go on to do a full axillary dissection. If no
cancer cells are seen in the lymph node at the time of the surgery, or if the sentinel node
is not checked at the time of the surgery, the lymph node(s) will be examined more
closely over the next several days. If cancer is found in the lymph node, the surgeon may
recommend a full ALND at a later time.
If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to
other lymph nodes, so no further lymph node surgery is needed. The patient can avoid the
potential side effects of a full ALND.
Until recently, if the sentinel node(s) had cancer cells, the surgeon would do a full ALND
to see how many other lymph nodes were involved. But one study has shown that this
may not always be needed. In some cases, it may be just as safe to leave the rest of the
lymph nodes behind. This is based on certain factors, such as what type of surgery is used
to remove the tumor, the size of the tumor, and what treatment is planned after surgery.
Right now, skipping the ALND is only an option for patients having breast-conserving
surgery (for tumors that are not large) followed by radiation. It is not considered an
option for patients having a mastectomy.
SLNB is done to see if a breast cancer has spread to nearby lymph nodes. This procedure
is not done if any of the lymph nodes are known to contain cancer. If any of the lymph
nodes under the arm or around the collar bone are swollen, they may be checked for
cancer spread directly. Most often, a needle biopsy (either a fine needle aspiration biopsy
or a core needle biopsy) is done. In these procedures, the surgeon inserts a needle into the
lymph node to remove a small amount of tissue, which is then looked at under a
microscope. If cancer cells are found, a full ALND is recommended.
Although SLNB has become a common procedure, it requires a great deal of skill. It
should be done only by a surgeon who has experience with this technique. If you are
thinking about having this type of biopsy, ask your health care team if they do them
regularly.