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 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.
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?
Are There Any Risks To The Test
You may have a little bleeding, pain, or bruising at the biopsy site. There is also a small risk of infection, which can be treated with antibiotics. Allergic reactions to the tracer are rare and usually mild.
There is very little exposure to radiation in a sentinel lymph node biopsy. While radiation exposure from the tracer in a sentinel lymph node biopsy is safe for most adults, it can be harmful to an unborn baby. So be sure to tell your provider if you are pregnant or think you may be pregnant.
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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.
Significance Of Regional Nodal Involvement In Breast Cancer
The significance of tumor lymphatics and their role in tumor progression is debated. Whether the presence of tumor cells in regional nodes is merely a sign of regional progression or an indicator of systemic dissemination of disease is yet to be settled . However, axillary nodal involvement is already established as an indicator of poor prognosis, with the 5-year survival decreasing by approximately 28% to 40% in patients with such a condition . Thus, axillary surgery not only serves as a staging tool but also improves locoregional control, which may result to improved survival.
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Getting The Results During Surgery
In some hospitals, the surgeon gets the results of the sentinel lymph node biopsy during the operation. This is called an intra operative assessment. They can remove the rest of the nodes if necessary. You then avoid having a second operation.
Your surgeon will explain this to you before your operation, so you know what to expect.
What If My Report Mentions Her2/neu Or Her2
Some breast cancers have too much of a growth-promoting protein called HER2/neu . The HER2/neu gene instructs the cells to make this protein. Tumors with increased levels of HER2/neu are referred to as HER2-positive.
The cells in HER2-positive breast cancers have too many copies of the HER2/neu gene, resulting in greater than normal amounts of the HER2 protein. These cancers tend to grow and spread more quickly than other breast cancers.
All newly diagnosed breast cancers should be tested for HER2, because women with HER2-positive cancers are much more likely to benefit from treatment with drugs that target the HER2 protein, such as trastuzumab , lapatinib , pertuzumab , and T-DM1 .
Testing of the biopsy or surgery sample is usually done in 1 of 2 ways:
- Immunohistochemistry : In this test, special antibodies that will stick to the HER2 protein are applied to the sample, which cause cells to change color if many copies are present. This color change can be seen under a microscope. The test results are reported as 0, 1+, 2+, or 3+.
- Fluorescent in situ hybridization : This test uses fluorescent pieces of DNA that specifically stick to copies of the HER2/neu gene in cells, which can then be counted under a special microscope.
Many breast cancer specialists think that the FISH test is more accurate than IHC. However, it is more expensive and takes longer to get the results. Often the IHC test is used first:
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What Do The Sentinel Lymph Node Biopsy Results Mean
If the result of your sentinel node biopsy is negative, this means that no cancer cells were found in the biopsied lymph node. This is a good sign that your cancer hasnt spread to nearby lymph nodes or other organs.
A positive result on your biopsy means that the pathologist found cancer cells in the lymph node. This usually indicates that your cancer has spread from its original location to the sentinel lymph node and possibly other lymph nodes or organs.
The results of your sentinel lymph node biopsy will help your doctor determine the stage of your cancer and develop an appropriate treatment plan.
The results of your lymph node biopsy may also be used at the same time as the removal of a primary tumor, and your doctor may decide to remove more than one lymph node for testing.
When several lymph nodes are removed for testing, its called a lymph node dissection.
Theres a chance your doctor will not be able to identify a sentinel lymph node. But mapping is about 90 percent accurate in identifying the sentinel node, with only about a 10 percent false-positive rate.
Surgery To Remove Lymph Nodes
Breast cancer can spread to other parts of the body. If it does spread, it usually first spreads to the lymph nodes in the armpit close to the breast. These lymph nodes drain the lymphatic fluid from the breast and arm.
It is important to know if there are cancer cells in the lymph nodes in the armpit and how many. This helps the doctors work out the stage of your cancer and plan the best treatment for you.
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When Should I Know The Biopsy Results
Your healthcare provider will usually give you the results of the biopsy within a week. If your healthcare provider needs to discuss results with your cancer care team, it may take longer to receive results. Depending on the results, your provider will arrange follow-up cancer care, recommend additional treatments and monitor your health through regular checkups.
If you have breast cancer that has spread to the sentinel nodes, your healthcare provider may recommend a procedure called axillary lymph node dissection . During an ALND, your healthcare provider removes more lymph nodes . A lab tests the nodes for cancer cells.
Sentinel Lymph Node Biopsy In The Older Patient
Given its minimally invasive, highly sensitive and reproducible record, SLNB has been shown to be a safe and accurate operation in the investigation of breast cancer nodal disease including those patients who were 70 and older.41–44 The SLNB could negate the requirement for an ALND minimizing the risk of overtreatment in this age group. While the less invasive SLNB is viewed favorably in the older patient, there is still debate in whether or not the need for complementary ALND is necessary in the older age group. Javid et al. noted in the setting of a positive SLNB, that performing a completion ALND did not improve all-cause or breast-cancer-specific survival in women over 65 years of age.45 In a retrospective review of the Surveillance, Epidemiology, and End Results database, the five-year all-cause survival for patients with a positive sentinel node who underwent a completion ALND did not statistically differ from similar women who did not undergo an ALND , . In addition, there was no statistically significant five-year breast-cancer-specific survival . An analysis of prospective data is needed to confirm these retrospective findings.
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Are There Symptoms Of Breast Cancer In The Lymph Nodes
You probably wouldnt notice if a few cancer cells reached a lymph node. As the number of cancer cells grows, symptoms can include lumps or swelling in the armpits or around the collarbone.
Its possible to have enlarged lymph nodes even if you havent discovered a lump in your breast. There are also noncancerous conditions that cause enlarged lymph nodes in an area close to the breasts.
If you notice enlarged lymph nodes but no other symptoms or signs, schedule an appointment with a doctor.
- your genetics or inherited genes
What Are The Risks Of This Test
Generally, a sentinel node biopsy is a safe procedure. But every surgery has some risks. Sentinel node biopsy risks include:
- Problems at the incision site: Bleeding, bruising, swelling and pain can occur at the incision site. The incision can also become infected. Signs of infection include redness, swelling and fever.
- Allergic reaction: Rarely, some people are allergic to the contrast dye providers use to locate the sentinel node.
- Lymphedema: This condition happens when the lymph nodes are damaged. If lymphatic fluid cant flow through the lymph nodes, excess fluid builds up in the bodys soft tissues. The fluid buildup causes swelling and pain. Lymphedema occurs more often when providers remove several lymph nodes.
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A Brief History Of Sentinel Node Examination
Surgery has always used minimally invasive techniques in order to limit associated morbidities and facilitate post-operative surgical recovery. The examination of sentinel nodes was first performed in other types of cancer, before being applied to breast cancer. Below are some examples of this:
1977: The sentinel node technique was developed by R.M. Cabanas to evaluate nodal extension in penile cancers.
1992: The sentinel node technique was applied to melanoma:
1993: The sentinel node technique was applied to breast cancer.
2013: 20 years later, there is still no standardized and universally accepted protocol for anatomo-pathology analysis of the sentinel node. But, fortunately, there are recommendations and guidelines.
New Techniques For Sentinel Node Biopsy In Breast Cancer
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 Is The Position Statement For Management Of The Axilla In Patients With Invasive Breast Cancer
This position statement 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.
What If My Report Mentions Lymph Nodes
If breast cancer spreads, it often goes first to the nearby lymph nodes under the arm . If any of your underarm lymph nodes were enlarged , they may be biopsied at the same time as your breast tumor. One way to do this is by using a needle to get a sample of cells from the lymph node. The cells will be checked to see if they contain cancer and if so, whether the cancer is ductal or lobular carcinoma.
In surgery meant to treat breast cancer, lymph nodes under the arm may be removed. These lymph nodes will be examined under the microscope to see if they contain cancer cells. The results might be reported as the number of lymph nodes removed and how many of them contained cancer .
Lymph node spread affects staging and prognosis . Your doctor can talk to you about what these results mean to you.
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Does Lymph Node Count As Metastasis
Lymph node metastasis occurs in metastatic lymph nodes, lymph nodes that have been infected by cancer from elsewhere in the body. A part of the immune system, lymph nodes are tiny ovals placed throughout your body. When you have cancer, your doctor will check your lymph nodes to see if the cancer has metastasized.
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 Is The Lymph Node In The Breast Called
The sentinel lymph node is the underarm lymph node closest to a breast cancer. During surgery to remove early-stage breast cancer, the sentinel node often is removed and sent to a pathologist who determines if there is cancer in it. Removing just the sentinel node is called sentinel node biopsy or sentinel node dissection.
Indications For Sln Biopsy
Sentinel lymph node biopsy is indicated for staging patients with early T1-2 invasive breast cancer and clinically negative axillary nodes irrespective of surgical therapy on the breast.15 Women with DCIS undergoing mastectomy are SLNB candidates given the disruption of lymph channels during a mastectomy preventing accurate subsequent sentinel lymph node biopsies if invasion is identified.15 Other indications may include a patient with DCIS in whom large resection or oncoplastic procedure is required and may disrupt lymphatics a SLNB may be considered in that situation. SLNB can be considered in patients with ipsilateral recurrent breast cancer following breast conservative therapy or recurrence after mastectomy, while there have been case reports documenting successful SLNB after modified radical mastectomy or axillary dissection, this remains the exception rather than the norm.16
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Immune Response To The Sentinel Lymph Node In The Setting Of Breast Cancer
Much in the way of studying the immune response in a sentinel lymph node closest to the cancer has led to the findings that breast cancers and melanomas have the ability to down regulate a host’s immune response in the lymph node. The anti-tumor immune functions of the lymph node are blunted by the cancer’s ability to suppress the immune system because of cancer derived cytokines, prostaglandins, gangliosides, and lipoprotein antigens that are transmitted via the lymphatics from the tumor to the lymph nodes.11–14 With the recent interest in immune scores in the tumor microenvironment the immune response in the sentinel node may provide valuable clinical information regarding the host response to breast cancer.
What Is A Sentinel Node Biopsy
A sentinel node biopsy is a surgical procedure for people with cancer. During this procedure, the healthcare provider removes the sentinel nodes and sends them to a lab to test for cancer cells.
Sentinel nodes are the first lymph nodes where cancer cells might spread from a tumor. Lymph nodes are small organs that filter fluid in the body and help protect you from illness.
The word sentinel means a guard or someone keeping watch.
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How Many Lymph Nodes Do You Have Cancer In
These cells usually lodge in the first 1, 2, or 3 lymph 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