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Why do the lymph nodes need to be biopsied?

When breast cancer spreads (metastasizes), it usually first affects the nearby lymph nodes. Cancer cells can enter lymphatic channels from the breast and reach the lymph nodes, primarily located in the armpit (axilla). Less often, they may spread to lymph nodes between the ribs, in the neck, or to the other breast and armpit. It's crucial to find out if the cancer has spread to the lymph nodes. If it has, post-surgery treatments (adjuvant therapy) may be more intensive, including chemotherapy and hormonal therapy.

What is a sentinel Node?

The sentinel lymph node is the first lymph node that a breast cancer drains into and is the most likely to contain cancer if it spreads. It is usually located in the armpit on the same side as the breast cancer, but it can also be found between the ribs, in the neck, or in the opposite breast and armpit.

Before the early 1990s, every patient with breast cancer had their armpit lymph nodes removed, but about 60% of women did not have cancer in those nodes, meaning they faced risks like lymphedema without any benefit. This led to the development of the sentinel node biopsy, which only removes the most likely cancerous lymph node. If cancer is found, only then is further removal of lymph nodes considered. Over 80% of women qualify for this biopsy, allowing many to avoid unnecessary procedures and the risk of lymphedema.

How is the sentinel node located and removed

To find the sentinel lymph node, we use two methods: Lymphoscintigraphy and Blue Dye.

• Lymphoscintigraphy

Lymphoscintigraphy involves injection of a small amount of radioactive tracer into the breast before surgery. The tracer travels through the lymph channels to the sentinel node. A scan shows the surgeon its location and how many sentinel nodes there are (usually 2 or 3). During surgery, a 'Gammo Probe' is used to find the node. The probe detects the radioactive tracer and beeps when it gets close to the sentinel lymph node.

Blue dye injection

While you are asleep during surgery, a small amount of blue dye will be injected around your nipple. This dye moves through the lymph channels to the sentinel node, colouring it bright blue. This helps the surgeon locate and confirm the correct node for removal. The blue dye may stain your skin for a few weeks, but it will fade over time.

Can everyone have a sentinel node biopsy?

Most patients (over 80%) can have a Sentinel Node Biopsy, but not everyone is a good candidate. Its accuracy has only been proven for certain types of cancer. The biopsy takes a quick look at the axillary lymph nodes to check for cancer. If cancer is already found in the lymph nodes at diagnosis, then the sentinel node biopsy won't help, and you'll need an axillary dissection instead.

The criteria for a sentinel node biopsy are:

• No known cancer involving the axillary lymph nodes (May have targeted axillary dissection)

• Small tumours less than 5cm

• No previous axillary surgery.

What happens if the sentinel node has cancer in it?

Removing the sentinel node gives our team important information on how to treat your cancer. If cancer cells are found in the lymph nodes, it indicates the tumour is more advanced. While not every case with lymph node involvement will require chemotherapy, it is more likely to be recommended. Traditionally, a positive sentinel lymph node meant that all nearby lymph nodes had to be removed. However, since 2011, evidence suggests that only a complete lymph node removal is needed when multiple nodes are affected.

A sentinel node biopsy typically removes 1 to 4 lymph nodes. If only 1 node has cancer, further surgery is usually not needed, and radiation therapy will be recommended for the rest of the area. However, if multiple nodes are involved or if cancer has spread beyond the lymph node into surrounding tissue, a full lymph node removal may be suggested after the biopsy, which would require a second surgery.

Sentinel Lymph Node Biopsy Results

Negative - No cancer cells seen

Negative - In transit Cells = small number of cells up to 0.2mm

Positive - Micrometastasis - small cluster of cancer cells between 0.2 and 2mm

Positive - Macrometastasis - larger cluster of cancer cells over 2mm

 What is an axillary clearance?

Axillary clearance, also known as axillary lymph node dissection, is a surgical procedure performed to remove lymph nodes from the axilla (armpit) in patients diagnosed with breast cancer. This procedure is typically done when there is evidence that cancer has spread to the lymph nodes, which are crucial for staging the disease and determining the appropriate course of treatment. During axillary clearance, a number of lymph nodes are excised to assess for cancer involvement, which helps guide further treatment options, such as chemotherapy or radiation therapy. By removing potentially affected nodes, axillary clearance aims to reduce the risk of cancer recurrence and improve overall outcomes for patients. It also plays a critical role in staging the cancer, aiding in the development of a tailored treatment plan.

How many lymph nodes will be removed in an Axillary Clearance?

All lymph nodes that are connected to the breast in the armpit region will be surgically removed as part of the procedure. The exact number of lymph nodes varies from person to person, but it is typical for over 20 to be taken out during this process, with the count generally ranging from 10 to 40. To help minimize the risk of lymphedema, which is the swelling that can occur in the arm, the lymph nodes that are responsible for draining the arm will be preserved. This careful approach aims to balance effective treatment with the patient's overall well-being.

What is a Targeted Axillary Dissection?

Targeted Axillary Dissection (TAD) is a surgical technique used in breast cancer management to assess and remove lymph nodes in the axilla (armpit area) that are likely to contain cancer cells. TAD is specifically aimed at identifying and excising only the lymph nodes most likely affected by cancer, rather than removing all axillary lymph nodes, as is done in traditional axillary lymph node dissection. This approach focuses on two main types of nodes: sentinel lymph nodes (SLNs), which are the first nodes to which cancer cells are likely to spread, and any additional lymph nodes previously confirmed to be cancer-positive before treatment. TAD is often performed in cases where patients have received neoadjuvant (pre-surgical) chemotherapy. This targeted approach allows for more accurate staging and assessment of cancer spread while minimizing potential side effects associated with extensive lymph node removal, such as lymphedema, pain, and reduced arm mobility. By selectively removing only certain lymph nodes, TAD helps to balance effective cancer treatment with improved quality of life for patients.