Sentinel Lymph Node Dissection Or Biopsy

The widespread use of tangential breast irradiation for local control of recurrence has brought a new kind of lymphedema, different from the upper limb lymphedema commonly related to axillary surgery and radiation -- BREAST LYMPHEDEMA. The incidence of breast lymphedema, sometimes referred to as "delayed breast cellulitis" has been found to be on the order of 23% (clinical) and over 70% preclinical (Reference Rönkä 2004-5 and other investigators). So the reduction of number of nodes dissected for staging has reduced the risk of upper limb lymphedema from 24 to 7 percent, but the adjuvent radiotherapy to the breast increases risk of breast lymphedema a similar amount. Yes, it is; though the risk for lymphedema is markedly reduced with sentinel node biopsy compared to full axillary dissection.

In addition to degree of dissection, other risk factors for lymphedema have been identified: obesity, advanced age and extensive axillary involvement with tumor.

There are two lymph node surgical procedures used to either identify or treat lymph node disease. The most accurate and reliable test to identify axillary disease is the sentinel lymph node biopsy. The sentinel lymph node is the "gate keeper node" of all the lymph nodes in the armpit. If cancer has spread from the breast to the nodes in the armpit, it will reliably travel to the sentinel lymph node before going to other nodes. The accuracy of this biopsy is about 99%. Women with invasive breast cancer who do not have evidence of lymph node disease should undergo a sentinel lymph node biopsy at the time of either lumpectomy or mastectomy.

If the sentinel lymph node biopsy shows evidence of cancer, the patient should discuss with their surgeon and medical oncologist whether they would benefit from removal of additional lymph nodes from the armpit. In the past, surgeons routinely removed additional lymph nodes when there was evidence of cancer in the sentinel lymph node. However, new data this year has implied that some women undergoing lumpectomy and radiation may not benefit from the removal of additional nodes. Therefore, at our institution we take these patients on a case by case basis to determine whether they would benefit from further surgery.

If patients have evidence of axillary lymph node disease prior to surgery, they should undergo a lymph node dissection at the time of either lumpectomy or mastectomy in order to remove the disease from the armpit. Traditionally, this involved the surgical removal of about 10 lymph nodes. Anytime a woman has cancer involvement of lymph nodes and has surgical removal, there is a risk of lymphedema after the surgery. Lymphedema is the chronic swelling of the arm which has no curative treatment. Other risk factors for developing lymphedema are obesity and radiation to the armpit after surgery. There are two lymph node surgical procedures used to either identify or treat lymph node disease. The most accurate and reliable test to identify axillary disease is the sentinel lymph node biopsy. The sentinel lymph node is the "gate keeper node" of all the lymph nodes in the armpit. If cancer has spread from the breast to the nodes in the armpit, it will reliably travel to the sentinel lymph node before going to other nodes. The accuracy of this biopsy is about 99%. Women with invasive breast cancer who do not have evidence of lymph node disease should undergo a sentinel lymph node biopsy at the time of either lumpectomy or mastectomy.

If the sentinel lymph node biopsy shows evidence of cancer, the patient should discuss with their surgeon and medical oncologist whether they would benefit from removal of additional lymph nodes from the armpit. In the past, surgeons routinely removed additional lymph nodes when there was evidence of cancer in the sentinel lymph node. However, new data this year has implied that some women undergoing lumpectomy and radiation may not benefit from the removal of additional nodes. Therefore, at our institution we take these patients on a case by case basis to determine whether they would benefit from further surgery.

If patients have evidence of axillary lymph node disease prior to surgery, they should undergo a lymph node dissection at the time of either lumpectomy or mastectomy in order to remove the disease from the armpit. Traditionally, this involved the surgical removal of about 10 lymph nodes. Anytime a woman has cancer involvement of lymph nodes and has surgical removal, there is a risk of lymphedema after the surgery. Lymphedema is the chronic swelling of the arm which has no curative treatment. Other risk factors for developing lymphedema are obesity and radiation to the armpit after surgery.

Each of us has about 50 lymph nodes under each armpit. The purpose of lymph nodes is to filter the lymphatic circulation. If a breast cancer was to spread, it would travel to the sentinel lymph node or "gate keeper node" first before spreading to the other lymph nodes in the armpit. The sentinel lymph node is identified by injecting either one or two dyes into the breast. The most common "dye" is a radiotracer that the nuclear medicine doctor injects into the breast before the surgery. Another dye is a blue dye injected by a surgeon into the breast during the surgery while the patient is asleep. Each dye is picked up by the lymphatic circulation in the breast and travels to the sentinel lymph node making it either radioactive or blue. This is how the surgeon can identify the node and surgically remove it to have the pathologist check it for cancer.

Most surgeons will use a combination of both the radiotracer and blue dye to identify the sentinel lymph node. However, some surgeons will rely on only one type of dye. In my practice, I usually only use the radiotracer since the blue dye can result in a blue stain on the skin and in rare cases an allergic reaction. There is no way to surgically find the sentinel lymph node without the injection of either the radiotracer or blue dye into the breast. Each of us has about 50 lymph nodes under each armpit. The purpose of lymph nodes is to filter the lymphatic circulation. If a breast cancer was to spread, it would travel to the sentinel lymph node or "gate keeper node" first before spreading to the other lymph nodes in the armpit. The sentinel lymph node is identified by injecting either one or two dyes into the breast. The most common "dye" is a radiotracer that the nuclear medicine doctor injects into the breast before the surgery. Another dye is a blue dye injected by a surgeon into the breast during the surgery while the patient is asleep. Each dye is picked up by the lymphatic circulation in the breast and travels to the sentinel lymph node making it either radioactive or blue. This is how the surgeon can identify the node and surgically remove it to have the pathologist check it for cancer.

Most surgeons will use a combination of both the radiotracer and blue dye to identify the sentinel lymph node. However, some surgeons will rely on only one type of dye. In my practice, I usually only use the radiotracer since the blue dye can result in a blue stain on the skin and in rare cases an allergic reaction. There is no way to surgically find the sentinel lymph node without the injection of either the radiotracer or blue dye into the breast.

Sentinel node biopsy recommendations, although individually tailored to the presenting disease, have not changed for our center but the frozen section at the time of sentinel node biopsy is no longer routine. If the patient is found to have positive nodes on permanent path then they may or may not undergo a completion node dissection if no more than two nodes are positive. The decision to “go back” is a joint decision between breast team (medical, surgical, radiation oncology) and the patient. Sentinel node biopsy recommendations, although individually tailored to the presenting disease, have not changed for our center but the frozen section at the time of sentinel node biopsy is no longer routine. If the patient is found to have positive nodes on permanent path then they may or may not undergo a completion node dissection if no more than two nodes are positive. The decision to “go back” is a joint decision between breast team (medical, surgical, radiation oncology) and the patient.

Sentinel node biopsy involves mapping the breast (or skin in the case of melanoma) to determine which 1-4 (average 2) lymph nodes drain the breast. This allows precise removal of the lymph nodes most likely to harbor metastases form the breast cancer. A standard axillary biopsy is a removal of 1 or more lymph nodes that are abnormal - usually by size criteria. A standard axillary lymph node dissection is the removal of all the lymph nodes in a certain anatomic area (the 3 dimensiaonl triangle between the lateral border of the pectoralis major muscle (anterior border), the axillary vein (superior border), and the lateral border of the lattisimus dorsi muscle (posterior border). There are typically 10-15 lymph nodes under each arm but like most things in biology the number is a bell shaped curve with some people having a few (6 or less) and some people having a lot (30 or more).
Sentinel node biopsy involves mapping the breast (or skin in the case of melanoma) to determine which 1-4 (average 2) lymph nodes drain the breast. This allows precise removal of the lymph nodes most likely to harbor metastases form the breast cancer. A standard axillary biopsy is a removal of 1 or more lymph nodes that are abnormal - usually by size criteria. A standard axillary lymph node dissection is the removal of all the lymph nodes in a certain anatomic area (the 3 dimensiaonl triangle between the lateral border of the pectoralis major muscle (anterior border), the axillary vein (superior border), and the lateral border of the lattisimus dorsi muscle (posterior border). There are typically 10-15 lymph nodes under each arm but like most things in biology the number is a bell shaped curve with some people having a few (6 or less) and some people having a lot (30 or more).

There is nothing better to assess axillary lymph node status than sentinel lymph node biopsy. PET scanning has been tried. This involves radioactive glucose injected into the patient's venous system. This radioactive glucose is taken up by cancer more readily than non-cancerous tissue and therefore becomes slightly radioactive. This radioactivity can then be detected by scanning the axilla or the entire patient. However PET scanning cannot detect small amounts of cancer in the lymph node (anything <5 mm).

However, a better question might be - Why do we need to know the status of the axillary lymph nodes in breast cancer? Removing the lymph nodes in breast cancer has always been thought of as prognostic (helping determine how well a patient will do and how much chemotherapy to give) but not therapeutic (helping to improve survival). We are now able to determine the prognosis of the patient by looking at the biology of their cancer with newer advanced pathologic tests such as MammaPrint, OncotypeDX, MammaStrat and others. I believe we will stop doing sentinel node biopsy and axillary surgery in general (outside of removing bulky lymph nodes) in the very near future. There is nothing better to assess axillary lymph node status than sentinel lymph node biopsy. PET scanning has been tried. This involves radioactive glucose injected into the patient's venous system. This radioactive glucose is taken up by cancer more readily than non-cancerous tissue and therefore becomes slightly radioactive. This radioactivity can then be detected by scanning the axilla or the entire patient. However PET scanning cannot detect small amounts of cancer in the lymph node (anything <5 mm).

However, a better question might be - Why do we need to know the status of the axillary lymph nodes in breast cancer? Removing the lymph nodes in breast cancer has always been thought of as prognostic (helping determine how well a patient will do and how much chemotherapy to give) but not therapeutic (helping to improve survival). We are now able to determine the prognosis of the patient by looking at the biology of their cancer with newer advanced pathologic tests such as MammaPrint, OncotypeDX, MammaStrat and others. I believe we will stop doing sentinel node biopsy and axillary surgery in general (outside of removing bulky lymph nodes) in the very near future.

The vast majority of women with breast cancer should be getting no more than a sentinel lymph node biopsy. The exceptions are patients that have large (clinically positive) lymph nodes at the time of their diagnosis that have undergone a biopsy of their lymph node that shows cancer(fine needle aspiration or needle core biopsy typically). Women undergoing lumpectomy who have 1-2 sentinel nodes with cancer in them can now forego a completion dissection based on the recent ACOSOG study - Z0011 that was published in JAMA in February. The caveat is that they have to have whole breast irradiation (not partial breast irradiation). Also this does not apply to patients having a mastectomy (with or without reconstruction). If they have a positive sentinel node, they should have a completion dissection. The vast majority of women with breast cancer should be getting no more than a sentinel lymph node biopsy. The exceptions are patients that have large (clinically positive) lymph nodes at the time of their diagnosis that have undergone a biopsy of their lymph node that shows cancer(fine needle aspiration or needle core biopsy typically). Women undergoing lumpectomy who have 1-2 sentinel nodes with cancer in them can now forego a completion dissection based on the recent ACOSOG study - Z0011 that was published in JAMA in February. The caveat is that they have to have whole breast irradiation (not partial breast irradiation). Also this does not apply to patients having a mastectomy (with or without reconstruction). If they have a positive sentinel node, they should have a completion dissection.

I too was not prepared for this surgery properly. I suffered permanent nerve damage from the doctor cutting the nerves and not being able to repair. It has been 8 yes or so and I still have no feeling in part of my arm, chest and shoulder plus my arm is much weaker and I have constant pain. I did have therapy more than once but was told because of the damage it would likely not get much better. I have also gotten bad Burns with infections because I could not feel the heat that i was putting on the area to try to relieve the pain.

I am curious about the standard protocal for number of nodes to remove when the test is negative. If i remember correctly, my doctor removed 10-15, which seemed unnecessary to me. I do let patients know that while the sentinel node procedure is done through a very small incision (usually 1/2 inch or smaller), it can be the most painful part of the surgery. The lymph nodes are tucked deep in the underarm, below the pectoralis (chest wall) muscle - in order to get to them (especially through a small incision), some retraction on the muscle during surgery is needed.

I always give patients a booklet on exercises prior to surgery (there's a good little one put out by the American Cancer Society) and recommend that they start doing the exercises before surgery - it's good to get your body used to the stretches and other exercises before you're having any discomfort. And I encourage an early return to activity - initially the stretching exercises, followed by more regular exercise. Some patients do require physical therapy and we try to identify this sooner rather than later.

There are several different types of breast surgery - the 2 basic categories are lumpectomy and mastectomy. Lumpectomy (also referred to as partial mastectomy) generally refers to removing the breast cancer with a rim of normal surrounding tissue, the margin. Mastectomy refers to removal of the entire breast, and often is accompanied by reconstructive surgery. With both lumpectomy and mastectomy, usually a sentinel lymph node biopsy is performed - a few underarm lymph nodes are removed to confirm if the cancer has spread or not.

For benign breast tumors (not cancer), generally an excisional biopsy is performed - this simply means removal of the breast lump. There are several different types of breast surgery - the 2 basic categories are lumpectomy and mastectomy. Lumpectomy (also referred to as partial mastectomy) generally refers to removing the breast cancer with a rim of normal surrounding tissue, the margin. Mastectomy refers to removal of the entire breast, and often is accompanied by reconstructive surgery. With both lumpectomy and mastectomy, usually a sentinel lymph node biopsy is performed - a few underarm lymph nodes are removed to confirm if the cancer has spread or not.

For benign breast tumors (not cancer), generally an excisional biopsy is performed - this simply means removal of the breast lump.