Breast Cancer Lymph Node Dissection

Types Of Lymph Node Surgery

Even if the nearby lymph nodes are not enlarged, they will still need to be checked for cancer. This can be done in two different ways. Sentinel lymph node biopsy is the most common way and only a few lymph nodes are removed. But in some cases, an axillary lymph node dissection , which removes more lymph nodes, might be needed.

Lymph node surgery is often done as part of the main surgery to remove the breast cancer, but sometimes it might be done as a separate operation.

What Is A Sentinel Lymph Node Biopsy

A sentinel lymph node biopsy is a procedure in which the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present. It is used in people who have already been diagnosed with cancer.

A negative SLNB result suggests that cancer has not yet spread to nearby lymph nodes or other organs.

A positive SLNB result indicates that cancer is present in the sentinel lymph node and that it may have spread to other nearby lymph nodes and, possibly, other organs. This information can help a doctor determine the stage of the cancer and develop an appropriate treatment plan.

Indications Of Level Iii Axillary Lymph Node Dissection

The NCCN Guidelines for clinical practice in breast cancer indicate that in the absence of gross disease in level II nodes, lymph node dissection should include tissue inferior to the axillary vein from the latissimus dorsi muscle laterally to the medial border of the pectoralis minor muscle .2 Only in cases with gross diseases in level I/II, level III dissection to the thoracic inlet should be performed.

Early clinical studies of the extent of lymph node metastasis in positive lymph node breast cancer patients found that 2058% of patients with axillary lymph node metastasis were restricted to level I 2029% and 1632% of patients with lymph node metastasis were confined to levels I+II and levels I+III, respectively. About 20% of patients were diagnosed with pathological level III metastasis.23,24 The level metastasis rate was highest in Khafagys study.25 Of 59 positive axillary lymph node patients, 31 had level III axillary lymph node metastasis. In a study by Tao et al, of 87 positive axillary lymph nodes patients, 18 had level III axillary lymph node metastasis.26 Yildirim reported a level III axillary lymph node metastasis rate of 1531%.21 In a study of T0-2 axillary lymph node-positive breast cancer patients who received neoadjuvant chemotherapy, 0.9% of patients had level III axillary lymph node invasion.27

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Stage 3a Breast Cancer

Stage 3A breast cancer refers to one of the following situations:

• The doctor doesnt find a tumor in the breast, or if there is a tumor, it may be of any size. Additionally, cancer is found in four to nine axillary lymph nodes or in the lymph nodes closest to the breastbone
• The tumor is larger than 5 centimeters, and there are small groups of breast cancer cells between 0.2 millimeters and 2 millimeters in size in the lymph nodes.
• The tumor is larger than 5 centimeters, and the cancer has spread to one to three axillary lymph nodes or to the lymph nodes near the breastbone.

Eighteen Sensations After Breast Cancer Surgery: A Comparison Of Sentinel Lymph Node Biopsy And Axillary Lymph Node Dissection

Roberta H. Baron

Purpose/Objectives: To evaluate prevalence, severity, and level of distress of 18 sensations at 3-15 days , 3 months, and 6 months after breast cancer surgery to compare sentinel lymph node biopsy to SLNB with immediate or delayed axillary lymph node dissection to evaluate the Breast Sensation Assessment Scale© for reliability and validity.

Design: Prospective, descriptive.

Setting: Evelyn H. Lauder Ambulatory Breast Center at Memorial Sloan-Kettering Cancer Center in New York City.

Sample: 283 women with breast cancer 187 had SLNB, and 96 had SLNB and axillary lymph node dissection.

Methods: Patients completed the BSAS© at baseline, three months, and six months after surgery.

Main Research Variables: Prevalence, severity, and level of distress of sensations in patients who had breast cancer surgery.

Findings: Sensations were less prevalent, severe, and distressing following SLNB compared with axillary lymph node dissection at all three time points. Tenderness and soreness remained highly prevalent following SLNB at the three time points. Tenderness, soreness, tightness, and numbness were among the most severe and distressing symptoms in both groups. The BSAS© demonstrated good reliability and validity.

Implications for Nursing: Nurses should be familiar with prevalent sensations patients experience after SLNB and axillary lymph node dissection so they can provide education and support.

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A Swollen Arm Or Hand

You are at risk of long term swelling in your hand and arm after surgery to remove your lymph nodes in the armpit. This is swelling caused by lymph fluid that can’t drain away. It can happen any time after surgery and radiotherapy to your armpit.

Not everyone will get this and it is less likely to happen if you only have a few nodes removed. But it is very important to speak to your specialist nurse or surgeon if you think your arm or hand may be swollen.

Unfortunately, once you have lymphoedema it cant be cured. But early treatment can help to control it. Your nurse will talk to you about ways of preventing lymphoedema.

Findings From A Sentinel Node Biopsy

• Lymph node-negative. None of the sentinel nodes contain cancer. So, its unlikely other lymph nodes have cancer. Surgery to remove more lymph nodes wont be needed.
• Lymph node-positive. At least one sentinel node contains cancer. More lymph nodes may be removed with a procedure called axillary dissection. The goals of axillary dissection are to check how many lymph nodes have cancer and to reduce the chances of cancer returning in the lymph nodes.

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Talk With Others Who Understand

MyBCTeam is the social network for people with breast cancer and their loved ones. On MyBCTeam, more than 58,000 members come together to ask questions, give advice, and share their stories with others who understand life with breast cancer.

Have you or a loved one been diagnosed with stage 3 breast cancer? Share your experiences in the comments below, or start a conversation by posting on MyBCTeam.

Forgoing Select Lymph Node Dissection Linked With Superior Outcomes In Early

Updates from the ongoing INSEMA trial suggest that patients with early-stage breast cancer maintain superior quality of life by forgoing sentinel lymph node biopsy and axillary lymph node dissection.

Patients with early-stage breast cancer who did not undergo either a sentinel lymph node biopsy or axillary lymph node dissection experienced superior quality of life compared with patients in the same population who received these operations, according to data presented from the INSEMA trial during the 2021 San Antonio Breast Cancer Symposium. Despite these findings, data also suggested that patients experienced improved arm symptoms and functioning with SLNB vs ALND.

The findings from the INSEMA trial were presented at the 2021 San Antonio Breast Cancer Symposium by Bernd Gerber, MD, from the Department of Obstetrics and Gynecology at the University of Rostock in Germany.

In the study, researchers assessed patient-reported outcomes at baselinewhich was administered pre-surgeryas well as at 1, 3, 6, 12, and 18 months after final axillary surgery. They used the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire and its breast cancer module to assess patient quality of life .

Postoperative whole-breast irradiation was required for all participating patients. Ipsilateral axillary region was not included in the clinical target volume.

Reference

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Limited Arm And Shoulder Movement

You might also have limited movement in your arm and shoulder after surgery. This is more common after ALND than SLNB. Your doctor may advise exercises to help keep you from having long-lasting problems .

Some women notice a rope-like structure that begins under the arm and can extend down toward the elbow. This is sometimes called axillary web syndrome or lymphatic cording. It is more common after ALND than SLNB. Symptoms may not appear for weeks or even months after surgery. It can cause pain and limit movement of the arm and shoulder. This often goes away without treatment, although some women may find physical therapy helpful.

Getting Ready For Surgery

You and your care team will work together to get ready for your surgery. Help us keep you safe during your surgery by telling us if any of the following statements apply to you, even if youre not sure.

• I take a blood thinner, such as:

Preventing pregnancy

If theres any chance you could become pregnant before your surgery, be sure to use a form of birth control that doesnt have hormones. For example, you can use a condom, a diaphragm, or a copper intrauterine device .

If you have questions about birth control or want help choosing the type of birth control thats right for you, talk with your gynecologist .

Fertility preservation

Many people should avoid becoming pregnant during their treatment. If your doctor told you to avoid getting pregnant for some time and you want to have children in the future, you may want to think about freezing your eggs. For more information, read the resource Fertility Preservation: Options for Females Starting Cancer Treatment

About Drinking Alcohol

The amount of alcohol you drink can affect you during and after your surgery. Its important to talk with your healthcare providers about how much alcohol you drink. This will help us plan your care.

Here are things you can do before your surgery to keep from having problems:

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Scar Tissue In The Armpit

Some women develop scar tissue in the armpit after lymph node removal. The connective tissues in the armpit get inflamed, which forms one or more tight bands. This usually happens within the first few weeks or months after the operation.

The scar tissue is called cording or banding or axillary web syndrome. It can feel something like a guitar string. It can extend down the arm past the elbow, possibly as far as the wrist or thumb.

Cording is harmless but can be painful and can limit your arm movement. Massaging the area regularly can help. Tell your breast care nurse if you develop cording. They can refer you to a physiotherapist. They can show you how to massage the area and teach you stretching exercises. It usually gets better within a few months. Taking anti inflammatory painkillers may also help. Speak to your nurse or doctor about taking these.

• Early Breast Cancer: ESMO Clinical Practice Guidelines 2019F Cardoso and others

• Scottish Intercollegiate Guidelines Network, September 2013

• A systematic review of axillary web syndrome WM Yeung and others

Sentinel Lymph Node Biopsy

In a sentinel lymph node biopsy , the surgeon finds and removes the first lymph node to which a cancer is likely to spread . A radioactive substance and/or a blue dye is injected into the tumor, the area around it, or the area around the nipple. Lymph vessels will carry these substances along the same path that the cancer would likely take. The first lymph node the dye or radioactive substance travels to will be the sentinel node.

After the substance has been injected, the sentinel node can be found either by using a special machine to detect radioactivity in the nodes, or by looking for nodes that have turned blue. Sometimes, both methods are used. The surgeon cuts the skin over the lymph node area and removes the node containing the dye or radioactivity.

The few removed lymph nodes are then checked closely in the lab for cancer cells by a pathologist. Sometimes, this is done during the surgery. Because there is a chance that other lymph nodes in the same area will also have cancer if cancer is found in the sentinel lymph node, the surgeon may go ahead with an axillary dissection to remove more lymph nodes while you are still on the operating table. If no cancer cells are seen in the node at the time of the surgery, or if they are not checked by a pathologist at the time of the surgery, they will be examined more closely over the next several days.

Based on the studies that have looked at this, skipping the ALND may be an option for:

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What Are Lymph Nodes

You have hundreds of lymph nodes throughout your body. Your lymph nodes are part of your lymphatic system, which, in turn, is part of your immune system.

Lymph nodes are little bean-shaped structures that contain immune cells that help fight infection. Theyre connected by a system of lymph vessels that carry fluid throughout your body. As fluid passes through your lymph nodes, they filter out harmful substances.

Cancer spreads when cancer cells break away from the primary tumor. In breast cancer, these cells are most likely to reach the lymph nodes closest to the affected breast.

Usually, these lymph nodes are under the arm, but there are also clusters of lymph nodes near the collarbone and breastbone.

The ones that are closest to your breast are called sentinel lymph nodes. The nodes under your armpit are called axillary lymph nodes.

Even if cancer has reached nearby lymph nodes, it doesnt mean it has spread to other areas. But cancer that reaches the lymph system or bloodstream has a greater potential to travel to other parts of the body.

Breast cancer that has spread to lymph nodes may be treated more aggressively than if it hadnt reached these nodes.

The 5-year survival rate for breast cancer that hasnt reached nearby lymph nodes is 99 percent versus 86 percent when it has.

Checking The Lymph Nodes Before Surgery

Before your surgery you have an ultrasound scan to check the lymph nodes in the armpit close to the breast. This is to see if they contain cancer cells.

You usually have a biopsy of any lymph nodes that look abnormal. The biopsy is sent to the laboratory to check for cancer cells.

If this shows that the cancer has spread to the nodes in the armpit, you will have surgery to remove all or most of them. You have this at the same time as your breast surgery. This is called an axillary lymph node dissection or clearance.

If the lymph nodes look normal during the ultrasound scan, you dont have a biopsy. But you will have a sentinel lymph node biopsy at the same time as your breast surgery. You have this to check if cancer cells have spread to the nearby lymph nodes.

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What Happens During And After The Surgery

An axillary lymph node dissection usually removes nodes in levels I and II. For patients with invasive breast cancer, this procedure usually accompanies a mastectomy- it may be done at the same time as, or after, a lumpectomy through-a separate incision.

Based on the surgeons physical exam and other indicators about the possibility that cancer has spread to the lymph nodes, the surgeon will generally remove five to thirty nodes during a traditional axillary dissection. The total number of affected lymph nodes is more important than the extent of cancer in any one particular node.

As with any other surgery, ALND also come with a risk of side effects. For example, the removal of lymph nodes may increase the risk of lymphedema. This condition occurs as a result of lymph fluid that collects in the area where the lymph nodes used to be.

What Is A Complete Axillary Dissection

Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or remove lymph nodes. Axillary dissection has been the standard technique used in the staging and treatment of the axilla in breast cancer.

What is the axillary lymph node dissection?

Axillary lymph node dissection is a procedure to remove these lymph nodes. ALND happens after cancer cells are found during a sentinel lymph node biopsy. ALND can remove lymph nodes located above, below or directly underneath a muscle that runs along the side of the upper chest.

How long does a lymph node removal take to heal?

You will probably be able to go back to work or your normal routine in 3 to 6 weeks. It will also depend on the type of work you do and any further treatment. You may be able to take showers 24 to 48 hours after surgery.

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Within 30 Days Of Your Surgery

Presurgical Testing

Youll have a PST appointment before your surgery. The date, time, and location will be printed on the appointment reminder from your surgeons office. You can eat and take your usual medications the day of your appointment.

Its helpful to bring these things to your appointment:

• A list of all the medications youre taking, including prescription and over-the-counter medications, patches, and creams.
• Results of any tests done outside of MSK, such as a cardiac stress test, echocardiogram, or carotid doppler study.
• The names and telephone numbers of your healthcare providers.

During your PST appointment, youll meet with a nurse practitioner . They work closely with anesthesiology staff . Your NP will review your medical and surgical history with you. You may have tests to plan your care. Examples are:

• An electrocardiogram to check your heart rhythm.

Your NP may recommend you see other healthcare providers. Theyll also talk with you about which medications to take the morning of your surgery.

Identify Your Caregiver

Your caregiver plays an important role in your care. Before your surgery, you and your caregiver will learn about your surgery from your healthcare providers. After your surgery, your caregiver will take you home when youre discharged from the hospital. Theyll also help you care for yourself at home.

For Caregivers

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