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Checking Lymph Nodes Before Surgery

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If you have invasive breast cancer, your treatment team will want to check if any of the lymph nodes under the arm contain cancer cells. This helps them decide whether youll benefit from any additional treatment after surgery.

Usually an ultrasound scan of the underarm is done before surgery to assess the lymph nodes.

If this appears abnormal, youll have a fine needle aspiration or a core biopsy to see if the cancer has spread to the lymph nodes.

  • FNA uses a fine needle and syringe to take a sample of cells to be looked at under a microscope.
  • Core biopsy uses a hollow needle to take a sample of tissue to be looked at under a microscope.

How Is The Sentinel Node Found

There are different ways of finding the sentinel node. The best way is to use a combination of two substances one is a low-grade radioactive fluid and the other is a blue dye. The dye and radioactive fluid show the surgeon to which lymph node breast cancer cells are most likely to travel.

Sometimes, either the blue dye or the radioactive fluid alone is used to look for the sentinel node. However, fewer studies have been done using blue dye or radioactive fluid alone to show whether these are as good at finding the sentinel node as the combined method.

How Are The Sentinel Lymph Nodes Identified

  • Sentinel Node Imaging : Lymphatic mapping is performed the day before, or on the morning of surgery within the nuclear medicine department. A small amount of radioactive material is injected into the breast The radioactive tracer travels to the sentinel nodes, along the same lymphatic channels that cancer cells could travel and can be seen on a nuclear medicine scan . Lymphoscintigraphy can also identify atypical drainage patterns to internal mammary, intramammary, interpectoral or infraclavicular nodes.This scan only shows where the sentinel node is located, but not whether it contains tumour or not.
  • Blue Dye Injection : The blue dye is injected into the breast once the patient is asleep in theatre. This dye travels to and stains the sentinel nodes blue, thereby assisting the surgeon to find the correct lymph nodes.

    The blue dye discolouration may be visible following surgery on the nipple, but usually fades over the following weeks or months. Some of the blue dye passes into the bloodstream and is passed out in the urine, which may turn blue for 24 hours after surgery. There have been rare instances of allergy to the dyes used in sentinel node biopsy. Allergic reactions are usually mild and easily treatable.

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    What Happens During An Slnb

    First, the sentinel lymph node must be located. To do so, a surgeon injects a radioactive substance, a blue dye, or both near the tumor. The surgeon then uses a device to detect lymph nodes that contain the radioactive substance or looks for lymph nodes that are stained with the blue dye. Once the sentinel lymph node is located, the surgeon makes a small incision in the overlying skin and removes the node.

    The sentinel node is then checked for the presence of cancer cells by a pathologist. If cancer is found, the surgeon may remove additional lymph nodes, either during the same biopsy procedure or during a follow-up surgical procedure. SLNB may be done on an outpatient basis or may require a short stay in the hospital.

    SLNB is usually done at the same time the primary tumor is removed. In some cases the procedure can also be done before or even after removal of the tumor.

    What Is Surgery To The Lymph Nodes

    Post Physical therapy drainage after bilateral prophylactic mastectomy ...

    Your surgeon may remove some or all the lymph nodes in your armpit to check for cancer cells. This can:

    • remove any lymph nodes that contain cancer cells but you may need more treatment to the armpit if only some lymph nodes were removed
    • gives information about the stage of the cancer this helps when making decision about having other treatments.

    There are different ways some or all the lymph nodes may be removed:

    • a test called a sentinel lymph node biopsy that removes 1 to 3 lymph nodes for testing
    • an operation to remove all the lymph nodes under the arm that is called an axillary lymph node dissection.

    If you have DCIS you only have a SLNB if you are having a mastectomy. They are done at the same time.

    With invasive breast cancer you have an SLNB when the ultrasound of the lymph nodes or fine needle aspiration are normal. If the SLNB shows cancer cells you usually need the remaining lymph nodes in the armpit removed or treated.

    Some people have all the lymph nodes from the armpit are removed. This is called an axillary lymph node dissection. You usually have this when tests on the lymph nodes or an SLNB show there are cancer cells in the lymph nodes or there is a high risk of this.

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    Number Of Sns Removed

    The number of SNs removed is an important quality indicator of the technique . The FN rate decreases with the number of SN removed for up to 4 nodes . The usual recommendation is to remove all blue and/or hot nodes, up to 4 .

    However, the ideal mean number should be around 2 . In our study, the mean number of nodes removed was similar and in accordance with the recommended standards, with 2.14 in the ISO group and 1.91 in the COMBI group . Significantly more patients had only 1 SN removed in the COMBI group than in the ISO group . These results indicate that the ISO technique is not associated with a significant reduction in the number of SNs removed. The same results were found in the randomized trial .

    Is Sentinel Node Biopsy Always Accurate

    In a small number of women, the sentinel node doesnt have cancer cells, even though there are cancer cells in other lymph nodes in the armpit. This is called a false-negative result.

    A false-negative result sometimes occurs because lymphatic vessels running to the lymph nodes that have cancer cells in them are blocked by cancer cells. This means that the dye goes into other normal lymph nodes instead.

    To minimise the chance of a false-negative result, the surgeon may remove any enlarged nodes that are found at the time of surgery, even if they do not contain the dye.

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    Q: Is Hair Dye Safe For Patients With Cancer

    A: We dont have good data on hair dye use for patients undergoing cancer treatment. The studies weve discussed were examining people who were not diagnosed with breast cancer. The available data doesnt give us a clear answer about current patients.

    Q: What about chemical hair straighteners and breast cancer risk?

    A: Some chemical straighteners contain formaldehyde, a known carcinogen. The Sister Study looked at hair straighteners and found some increased breast cancer risk associated with them.

    Straightener use in the 12 months before enrollment in the study was associated with an 18% higher breast cancer risk, with more frequent use associated with higher risk. For example, those that used straighteners every 5 to 8 weeks had a 31% higher breast cancer risk.

    Checking The Lymph Nodes Before Surgery

    Doctors Using Glowing Dyes To Help Detect Cancers During Surgery

    You have an ultrasound scan of the lymph nodes under your arm at the same time as having other tests to diagnose breast cancer.

    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 during your surgery.

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    Volume Of Patent Blue V Dye Injected

    In 24 cases , 1.0 ml of Patent Blue V dye was injected, 2.0 ml was injected in 70 cases and the volume of injected Patent Blue V dye was not documented in 66 cases . All 1.0 ml injections were not diluted apart from one which was diluted with 2.0 ml of saline. About 40% of 2.0 ml injections were not diluted and 60% were diluted with 3.0 ml of saline.

    Fluorescent Tracers Help Surgeons Remove Breast Cancer Tumors And Preserve Healthy Tissue

    Radiologists look at a scan of a breast tumor. Methods to look at a tumor in real-time may soon be… able to help surgeons to more accurately remove tumors and preserve healthy tissue. Photo credit: Getty Royalty Free.

    Researchers in The Netherlands have tested a fluorescent tracer dye tethered to a cancer drug, which may help surgeons more accurately remove breast tumors and preserve healthy tissue.

    The research in Nature Communications looks at a fluorescent compound called 800C, tethered to bevacizumab , a common cancer drug which targets developing blood vessels. Bevacizumab is FDA-approved for the treatment of several tumor types but was approved then unapproved by the FDA for use in breast cancer due to a lack of evidence for its efficacy justifying its use. However, it is used at a 1000-fold lower dose as a tracer and has thus far shown no toxic side-effects in either human or animal trials.

    Currently, surgeons mostly rely on visual inspection, conventional scanning methods like MRI, CT scans and ultrasounds and feeling the tumor with their fingers or hands. Despite this, 20% of women have tumor tissue remaining in their breasts after surgery.

    We want to detect these patients who have remaining breast cancer tissue at the time of the operation so we can do something about it, said van Dam.

    As well as guiding surgeons to remove all of the tumor tissue, making tumor regrowth more unlikely, the use of tracer dyes has another important benefit for patients:

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    Breast Reconstruction After Surgery

    Many woman having surgery for breast cancer might have the option of breast reconstruction. A woman having a mastectomy might want to consider having the breast mound rebuilt to restore the breasts appearance after surgery. In some breast-conserving surgeries, a woman may consider having fat grafted into the affected breast to correct any dimples left from the surgery. The options will depend on each womans situation.

    There are several types of reconstructive surgery, but your options depend on your medical situation and personal preferences. You may have a choice between having breast reconstruction at the same time as the breast cancer surgery or at a later time .

    If you are thinking about having reconstructive surgery, its a good idea to discuss it with your breast surgeon and a plastic surgeon before your mastectomy or BCS. This gives the surgical team time to plan out the treatment options that might be best for you, even if you wait and have the reconstructive surgery later.

    To learn about different breast reconstruction options, see Breast Reconstruction Surgery.

    New Techniques For Sentinel Node Biopsy In Breast Cancer

    Clean Margins in Cancer Surgery Made Possible by Glowing Dye: Study ...

    Massimo Ferrucci1, Gianluca Franceschini1, Michael Douek2,3

    1 Multidiciplinary Breast Center, Fondazione Policlinico Universitario Agostino Gemelli , Università Cattolica del Sacro Cuore , Division of Cancer Studies, Department of Research Oncology , Guys & St. Thomas Hospitals NHS Foundation Trust , , UK

    Contributions: Conception and design: M Ferrucci, M Douek Administrative support: None Provision of study materials or patients: M Ferrucci Collection and assembly of data: M Ferrucci Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors.

    Correspondence to:

    Keywords: Breast cancer sentinel node biopsy indocyanine green superparamagnetic iron oxyde microbubble

    Submitted Nov 02, 2017. Accepted for publication Feb 01, 2018.

    doi: 10.21037/tcr.2018.02.07

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    What To Expect On The Day

    You will usually be admitted to the hospital on the morning of your operation or occasionally the day before. You will have pre-surgery checks that include a visit from the anaesthetist and a doctor from the surgical team.

    Once the pre-surgery checks have been done, youll be taken to the anaesthetic room. Youll be given a combination of drugs into a vein. This will usually include an anaesthetic, pain relief and anti-sickness drugs.

    Youll usually be asked to take deep breaths and as the anaesthetic takes effect you will fall into a deep sleep. Once you are fully anaesthetised you will be taken into the theatre.

    For more information about going into hospital, see our booklet Your operation and recovery.

    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.

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    Wire Localization To Guide Surgery

    Sometimes, if the cancer in your breast cant be felt, is hard to find, and/or is difficult to get to, the surgeon might use a mammogram or ultrasound to guide a wire to the right spot. This is called wire localization or needle localization. If a mammogram is used you may hear the term stereotactic wire localization. Rarely, an MRI might be used if using the mammogram or ultrasound is not successful.

    After medicine is injected into your breast to numb the area, a mammogram or ultrasound is used to guide a thin hollow needle to the abnormal area. Once the tip of the needle is in the right spot, a thin wire is put in through the center of the needle. A small hook at the end of the wire keeps it in place. The needle is then taken out. Once in the operating room, the surgeon uses the wire as a guide to find the part of the breast to be removed.

    The surgery done as part of the wire localization may be enough to count as breast-conserving surgery if all of the cancer is taken out and the margins are negative. If cancer cells are found at or near the edge of the removed tissue , more surgery may be needed.

    It should be noted that a wire-localization procedure is sometimes used to perform a surgical biopsy of a suspicious area in the breast to find out if it is cancer or not.

    There are other ways a surgeon can be guided to the tumor, but these techniques are newer and not used in every facility.

    Drawbacks Of Blue Dye

    Breast Cancer Surgery with Lymph Node Biopsy – Radioactive Injection – What to Expect

    The main drawback is the risk of allergic reactions, from a simple skin rash to an anaphylactic shock , with a risk of death. This risk is unpredictable, and not related to atopic history .

    The second drawback is a persistent subcutaneous blue stain. This is observed in 70% of the patients at 3 months, and in 41% at 1 year with a subdermal injection . In this study, all blue dye injections were made deeper in the subcutaneous plane and all blue staining of the skin had disappeared at 3 months.

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    Complications Of Methylene Blue Dye In Breast Surgery: Case Reports And Review Of The Literature

    FJ Reyes1, MB Noelck2, C Valentino3, L Grasso-LeBeau3, JE Lang1

    1. Department of General Surgery, Division of Surgical Oncology, University of Arizona, Tucson, AZ 85724, USA2. University of Arizona College of Medicine University of Arizona, Tucson, AZ 85724, USA3. University of Arizona Department of Pathology, Tucson, AZ 85724, USA

    Corresponding author: Julie E. Lang, MD, Fax: 520-694-1820 Email:

    Citation:J Cancer

    Contrast Enhanced Ultrasound With Microbubbles

    This is an innovative technique where microbubble contrast agent, based on the use of dispersion with sulfur hexafluoride gas, is injected intradermally around the areola. Breast lymphatics are then visualized by CEUS and followed to identify and biopsy SLNs .

    Sever et al. tried to standardize a protocol . They performed a periareolar intradermal injection of 0.20.5 mL phospholipid-stabilised microbubbles containing sulphur hexafluoride gas with a mean diameter of 2.5 µm reconstituted with 2 mL sterile saline. The breast was massaged for 1030 s and lymphatic channels were visualised immediately on contrast pulse sequencing and followed into the axilla. The transit time from injection to arrival in the axillary nodes was 1545 s. Areas of contrast accumulation were imaged with greyscale or live dual images to confirm the presence of an architecturally defined LN. The CEUS-identified SLNs were then localized with guidewires before undergoing SLNB with the standard dual technique. It resulted in SLN identification in 89% of patients . In a larger series by Cox et al. the technique failed to visualise or successfully biopsy 13.3% of patients, identifying positive SLN in 87.7%. There were 22 false-negative results, which meant that sensitivity was 61% and specificity 100% .

    In the review by Ahmed et al. the standard dual technique was significantly better than CEUS in terms of SLN identification rate which anyway was between 87.7% and 89% .

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    What Should I Take With Me To Hospital

    Your hospital team should give you information about your admission and hospital stay as well as what to take with you.

    You will usually be given a telephone number at your pre-assessment appointment. You can call if you have any questions about preparing for surgery, or are unclear about any instructions you have been given .


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