surgical treatment lymph node

lymph node (axillary) surgery

This is usually a standard part of all invasive breast cancer surgery. In mastectomy for non- invasive breast cancer called ductal carcinoma in situ (DCIS), lymph node dissection is omitted. It is done to obtain information on whether the breast cancer has spread to the lymph nodes. As a rule if breast cancer spreads beyond the breast it generally is trapped in the axillary (armpit) lymph nodes first.

Axillary surgery is a standard part of treatment if an invasive cancer is found. It is not normally required for DCIS alone, but your surgeon may recommend it in individual cases. As a rule if breast cancer spreads beyond the breast it generally is trapped in the axillary (armpit) lymph nodes first. Axillary surgery is done for two reasons.

If the lymph nodes contain cancer, removing them can control the cancer and prevent recurrence in the axilla

Knowing if the lymph nodes contain cancer gives important information on prognosis and is used to plan further treatments (adjuvant treatment) after surgery.

Up until a few years ago, the only treatment available was to remove about half to two thirds of the lymph glands. This is known as an axillary node clearance. For many women this was over-treatment, and, although well tolerated by most women, could have side effects. A newer technique is to do a sentinel node biopsy.

Sentinal node biopsy
The sentinel node(s) are the first nodes to drain the tumour. If the sentinel nodes are clear of tumour, we can be confident that the rest of the axillary nodes are also clear. The sentinel node can be identified in more than 95% of cases.

Two dyes are used to identify the sentinel nodes. The first contains a radioactive tracer attached to a substance which is taken up by the lymphatic system. This is given as an injection a few hours before your surgery by one of our breast physicians. A very thin needle is used and the dye is placed just under the skin. The overall radiation used is very small and is equivalent to a single chest X-ray. All radiation has left the body before three days.

The second dye is a blue dye which is again picked up by the lymphatics. The surgeon uses this to lead him/her to the lymph nodes. The dye is injected under the skin just before the operation begins. You will already be fully anaesthetised. The blue colour can persist in the breast for several weeks or a few months. You will also notice that your urine is green coloured for 1 to 2 days.

To remove the lymph nodes, a small incision is placed in the armpit. A frozen section examination of the nodes is often done. A pathologist who is in the operating theatre looks at the tissue by a technique that freezes it and then uses special stains. This gives the surgeon the information required. The frozen section is not as accurate as normal pathology tests, and sometimes the formal histology report will show that nodes are involved even though the frozen section was clear.

If lymph nodes do contain cancer, an axillary clearance will be performed. If the frozen section was positive, this will be done immediately. If the positive nodes are only seen in the formal histology report, you will need a second operation to do this.

Lymph node clearance (Axillary clearance or axillary dissection)
If your cancer is not suitable for a sentinel node biopsy, or your surgeon is concerned that nodes are involved from other tests, you will be advised to have an axillary node dissection. There are 25 to 30 lymph nodes in each armpit. With lymph node dissection usually about one half to two thirds of the lymph nodes are removed. This is usually called a ‘level 2’ dissection (the lymph nodes are divided into three levels according to how high they lie in the axilla). There are enough lymph nodes left to carry on their usual function which is to fight infection locally. The surgeon cannot tell how many are removed at the time of surgery as the lymph nodes are buried in fat.

Side effects of lymph node surgery
Unfortunately, in removing the lymph nodes the skin nerves giving sensation to the underneath of the upper arm and armpit are sometimes bruised or cut. This is far more likely to happen if you have had a node dissection than of you have had a sentinel node biopsy. After the operation you may be aware of numbness and sometimes 'nerve' pain. The numbness and nerve pain does improve and even if there is not 100% recovery the body adjusts to this so that it is not a long-term problem.

If a lymph node clearance is done, a plastic tube is left in the armpit. This is connected to a plastic bottle and provides suction to drain excess fluids. The plastic bottle is easily portable and can be attached to clothing through means of a cloth bag. In a few cases some women will get a temporary build up of fluid in the armpit once the bottle is removed. It can feel like a golf ball sitting the armpit but it can be easily drained with a needle under local anaesthetic.

Removing lymph glands can sometimes lead to lymphoedema (swelling of the arm on the affected side). Lymphoedema is more likely to occur if a lot of nodes are removed, or if a lot of nodes are involved with cancer. Less commonly, it can occur if more than four lymph nodes are removed and radiotherapy is given to the remaining lymph glands.

Physiotherapy exercises
If the lymph nodes are dissected, there will be discomfort in moving the arm and it is important to follow instructions regarding exercises (see section on Physiotherapy). This will ensure that you do not end up with a frozen shoulder.