Questions for your Breast Surgeon:
- Am I a candidate for a “sentinel lymph node biopsy?”
- If I have a “positive node” how will that change my treatment plan?
- Under what situations might I need an “axillary dissection?”
- What will you do if you find one or two nodes with cancer?
- What are the side effects of the biopsy?
- Can I avoid lymph node surgery altogether?
Why are “Axillary Lymph Nodes” important?
Knowing your “lymph node status” helps determine which combination of therapies are best for treating your unique cancer. Only about 30% of all patients diagnosed with invasive breast cancer are found to have cancer in their lymph nodes. If cancer travels to the lymph nodes, these cells typically go to the axillary lymph nodes under the arm on the same side of the newly diagnosed breast cancer. These cells usually lodge in the first 1, 2, or 3 lymph nodes (known as “sentinel nodes”) and grow there. Research suggests that cancer typically spreads to the sentinel nodes before the other 10 to 20 axillary nodes everyone has under the arm.
If you are found to have cancer in your lymph nodes, you will likely be offered chemotherapy if you can tolerate it. It is less likely you will need chemotherapy if your lymph nodes are “negative.” Your lymph node status is one of many factors in deciding your treatment options.
“Sentinel Node Biopsy” vs. “Axillary Dissection”
A sentinel lymph node biopsy has replaced the more extensive “axillary dissection” for most early stage breast cancer surgeries. A sentinel node biopsy is easier to perform, is just as accurate, and causes fewer side effects than an axillary dissection. An axillary dissection is a more extensive surgery that removes all of the axillary lymph nodes and results in more armpit sensation loss and an increased risk of lymphedema (swelling of the arm) than the less invasive sentinel node biopsy.
There are some situations where an axillary dissection is still clearly needed. Having detected cancer in the lymph nodes before surgery is usually an indication for an axillary dissection. In some instances, if you are found to have cancer present in the sentinel nodes, you might need an axillary dissection. Our goal with this course is to give you an outline on axillary surgery so you can better make these decisions with your breast surgeon.
How is a sentinel lymph node biopsy performed?
Hours before your breast surgery, you will likely undergo a small injection into the skin of your breast of a mildly radioactive “tracer.” This tracer slowly filters through the lymphatic system of the breast to the first one or two axillary lymph nodes (sentinel nodes) under your arm. These are the same lymph nodes that breast cancer cells would first travel to from the breast. A blue dye injection is also commonly used in addition to the radioactive tracer.
Your surgeon will use a small probe (similar to a Geiger counter) during surgery to find your sentinel nodes. The dye can also turn the same sentinel nodes blue in color, assisting your surgeon in finding them. The term “biopsy” implies taking just a piece of these nodes. In fact, these “sentinel nodes” are removed intact. The average number of sentinel nodes removed is only about three of the 10 – 20 lymph nodes normally present under the arm.
Are there side effects of a sentinel node biopsy?
Sentinel node surgery is a much less invasive procedure than an axillary dissection. The risks do include pain and discomfort in the armpit that does improve over time. You may have some permanent, partial sensation loss in the armpit and upper, inner arm. There is a slight risk of mild lymphedema. If your surgeon uses “blue dye” during the surgery to help find the sentinel nodes, there is a 1 to 2 % chance of having an allergic reaction to the dye.
Does a “positive” sentinel node mean an axillary dissection?
Until recently, surgeons would remove the sentinel lymph nodes and immediately have a pathologist evaluate the nodes under the microscope to see if cancer was present. For years, if any cancer was found in a sentinel node, surgeons would go ahead and remove all the nodes during the same surgery. This “axillary dissection” results in more long-term side effects than a sentinel node biopsy surgery.
In 2011, the ACOSOG Z00011 clinical trial showed that carefully selected women with early stage cancer undergoing a lumpectomy can now avoid an axillary dissection if only one or two sentinel nodes are found to be involved with a small amount of cancer. We can now wait for the final pathology report from your surgery before considering more extensive surgery in the axillary region. In other words, checking the sentinel node during surgery is done much less today. This position statement (here) “Management of the Axilla in Patients with Invasive Breast Cancer” outlines these practice-changing recommendations that followed the release of the ACOSOG Z00011 trial results. Women who meet these criteria may avoid an axillary dissection if they proceed with radiation and systemic therapy after lumpectomy surgery. This approach does not apply to women undergoing a mastectomy who have a sentinel node biopsy.
Who may be a candidate for a Sentinel Node Biopsy?
- Early stage invasive breast cancer
- No evidence of cancer in your axillary lymph nodes
- Diagnosis of DCIS when a mastectomy is to be performed
- No evidence of axillary node involvement after neoadjuvant chemotherapy
- Someone that is likely to tolerate the surgery
If I am over 70, can I avoid a sentinel node biopsy?
It is possible. If you are in your 70s and are active and healthy, you should proceed with a sentinel node biopsy if it is recommended. You will likely be able to tolerate the surgery. The information gained about your cancer could change your therapy.
For those who are older and struggling health wise, it is worth discussing with your breast surgeon if a sentinel node biopsy is even needed. If someone is weak and struggles to move independently, any surgery performed under the arm can make these essential activities more difficult. If you are not healthy enough to even consider chemotherapy, a lymph node surgery may not provide you helpful information.
This page about “Sentinel lymph node biopsy and axillary dissection” (here) outlines the two procedures. This site is created for patients by the American Society of Breast Surgeons.
The National Cancer Institute’s general page on “Sentinel Lymph Node Biopsy” (here) is comprehensive. The NCI is a governmental agency that is dedicated to distributing information to the public about cancer and cancer research trials.
This is a detailed outline of treatment options (here) for women with breast cancer, written specifically for patients. Choose the brochure that best reflects your own unique situation. The NCCN is a consortium of organizations and governmental agencies to promote quality breast cancer care.
An outline of “Lymph node biopsy for breast cancer” is located (here). The American Cancer Society is an organization that supports patients with cancer and funds research for cancer of all types.
This position statement (here) outlines the reasons against “Routine use of Sentinel Node Biopsy in Women Older than 70.” Choosing Wisely is an initiative by the American Board of Internal Medicine, Consumer Reports and the American Society of Breast Surgeons to discourage physicians and patients from using unneeded tests and treatments for breast cancer.
More Detailed References:
This position statement (here) “Management of the Axilla in Patients with Invasive Breast Cancer” outlines the practice changing recommendations that followed the release of the ACOSOG Z00011 trial results. The American Society of Breast Surgeons is a leading organization of surgeons who treat diseases of the breast.
“Performance and Practice Guidelines for Sentinel Node Biopsy in Breast Cancer Patients” outlines (here) in great detail what is involved in this procedure and who may benefit from this minimally invasive procedure. The American Society of Breast Surgeons is a leading organization for surgeons who treat diseases of the breast.
If you want to get deep into the details, this free 200-page pdf document has guidelines to help clinicians to make treatment recommendations about nearly all aspects of breast cancer. You can easily register (here) as a non-professional to get access.