Axillary lymph nodes in breast cancer

Lymph nodes are small round organs that are part of your body’s lymphatic system. The lymphatic system is a part of the immune system. It consists of a network of vessels and organs that contains lymph, a clear fluid that carries infection-fighting white blood cells as well as fluid and waste products from the body’s cells and tissues. In a person with cancer, lymph can also carry cancer cells that have broken off from the main tumor. Many types of cancer spread through the lymphatic system, and one of the earliest sites of spread for these cancers is nearby lymph nodes. Axillary lymph nodes status is an essential component in tumor staging and treatment planning for patients with breast cancer ¹. If breast cancer spreads, the lymph nodes in the underarm called axillary lymph nodes are the first place it’s likely to go. During breast surgery, some axillary nodes may be removed to see if they contain cancer cells. This helps determine breast cancer stage and guide treatment. Axillary lymph nodes status is a critical prognostic factor and has significant impact on tumor staging and treatment planning in patients with breast cancer ². Currently, axillary lymph node dissection continues to be a primary procedure for nodal metastasis in breast cancer, which might increase the risk of developing short-term, and long-term complications, such as pain, numbness, impaired shoulder mobility, and lymphedema ³.

Lymph is filtered through lymph nodes, which are found widely throughout the body and are connected to one another by lymph vessels. Groups of lymph nodes are located in the neck, underarms, chest, abdomen, and groin. The lymph nodes contain white blood cells (B lymphocytes and T lymphocytes) and other types of immune system cells. Lymph nodes trap bacteria and viruses, as well as some damaged and abnormal cells, helping the immune system fight disease.

A sentinel lymph node is defined as the first lymph node to which cancer cells are most likely to spread from a primary tumor. Sometimes, there can be more than one sentinel lymph node. Sentinel lymph node biopsy serves as an optimal choice for those without clinical or radiological evidence of axillary lymph node metastasis ¹. It has been considered to be an ideal procedure for patients whose sentinel lymph node are negative ⁴ or those with 1–2 positive sentinel lymph node ⁵. However, second procedure of axillary lymph node dissection or radiotherapy is unavoidable to adequately deal with axilla if sentinel lymph node metastasis was found ⁶. Therefore, finding a reliable imaging modality to identify axillary lymph node metastasis preoperatively becomes particularly important.

Mammography, ultrasonography, and magnetic resonance imaging (MRI) are conventional imaging techniques for breast lesion evaluation, as well as for axillary lymph node status assessment ⁷. However, mammography is not a reliable modality for evaluating axillary lymph node status, primarily due to the difficulty in fully exposure of the whole axilla ⁸. Combination of ultrasonography with mammography was found to improve the sensitivity of metastatic nodes detection, however, the accuracy of axillary lymph node status evaluation with ultrasonography is mainly dependent on the operator’s experience ⁹. Recently, the value of MRI (magnetic resonance imaging) in the evaluation lymph node status has been increasingly recognized. Whereas, due to time-consuming procedure and high cost of the examination, it remains not widely used in clinical practice ¹⁰.

Multidetector-row computed tomography has emerged as a novel imaging technique in recent years. It is increasingly accepted by clinician to preoperatively assess regional lymph node status in a variety of cancers ¹¹. Multidetector-row computed tomography can obtain high-quality multiplanar images in fast scan time and allow three-dimensional reconstruction ¹². Furthermore, preoperative multidetector-row computed tomography can be performed with the patient in the supine position, which facilitates simultaneous localization of the lesion, and evaluation of its extent, as well as examination of the skin, chest wall, and regional lymph nodes, including both axillae, internal mammary, and supraclavicular chains ¹³. However, preoperative multidetector-row computed tomography for evaluating axillary lymph node status in patients with breast cancer remains under-investigated ¹⁴.

Sentinel lymph node dissection

A sentinel lymph node is defined as the first lymph node to which cancer cells are most likely to spread from a primary tumor. Sometimes, there can be more than one sentinel lymph node. Sentinel lymph node biopsy is the most common way to check the axillary lymph nodes for cancer. 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 sentinel lymph node biopsy result suggests that cancer has not yet spread to nearby lymph nodes or other organs.

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

First, the sentinel lymph node (or nodes) must be located. To do so, a surgeon injects a radioactive substance called a tracer and/or a blue dye, or both into the breast near the tumor. These substances help the surgeon find the lymph nodes to remove. 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. The first lymph node(s) to absorb the tracer or dye is called the sentinel node(s). This is also the first lymph node(s) where breast cancer is likely to spread. Once the sentinel lymph node is located, the surgeon makes a small incision (about 1/2 inch) in the overlying skin and removes the the sentinel node(s). The lymph node is sent to the lab so a pathologist can check if the lymph node(s) contain cancer cells. If cancer is not found, it’s likely the other lymph nodes do not contain cancer. So, no more surgery is needed. If the lymph node(s) do contain cancer, the surgeon may remove additional lymph nodes, either during the same biopsy procedure or during a follow-up surgical procedure called axillary dissection. Sentinel lymph node biopsy may be done on an outpatient basis or may require a short stay in the hospital.

Sentinel lymph node biopsy 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 (depending on how much the lymphatic vessels have been disrupted) removal of the tumor.

Is sentinel lymph node biopsy used to help stage all types of cancer?

No. sentinel lymph node biopsy is most commonly used to help stage breast cancer and melanoma. It is sometimes used to stage penile cancer ¹⁵ and endometrial cancer ¹⁶. However, it is being studied with other cancer types, including vulvar and cervical cancers ¹⁷, and colorectal, gastric, esophageal, head and neck, thyroid, and non-small cell lung cancers ¹⁸.

The use of sentinel lymph node biopsy in breast cancer

Breast cancer cells are most likely to spread first to lymph nodes located in the axilla, or armpit area, next to the affected breast. However, in breast cancers close to the center of the chest (near the breastbone), cancer cells may spread first to lymph nodes inside the chest (under the breastbone, called internal mammary nodes) before they can be detected in the axilla.

The number of lymph nodes in the axilla varies from person to person; the usual range is between 20 and 40. Historically, all of these axillary lymph nodes were removed (in an operation called axillary lymph node dissection) in women diagnosed with breast cancer. This was done for two reasons: to help stage the breast cancer and to help prevent a regional recurrence of the disease. (Regional recurrence of breast cancer occurs when breast cancer cells that have migrated to nearby lymph nodes give rise to a new tumor.)

However, because removing multiple lymph nodes at the same time increases the risk of harmful side effects, clinical trials were launched to investigate whether just the sentinel lymph nodes could be removed. Two randomized phase 3 clinical trials have shown that sentinel lymph node biopsy without axillary lymph node dissection is sufficient for staging breast cancer and for preventing regional recurrence in women who have no clinical signs of axillary lymph node metastasis, such as a lump or swelling in the armpit that may cause discomfort, and who are treated with surgery, adjuvant systemic therapy, and radiation therapy.

In one trial, involving 5,611 women, researchers randomly assigned participants to receive just sentinel lymph node biopsy, or sentinel lymph node biopsy plus axillary lymph node dissection, after surgery ¹⁹. Those women in the two groups whose sentinel lymph node(s) were negative for cancer (a total of 3,989 women) were then followed for an average of 8 years. The researchers found no differences in overall survival or disease-free survival between the two groups of women.

The other trial included 891 women with tumors up to 5 cm in the breast and one or two positive sentinel lymph nodes. Patients were randomly assigned to receive sentinel lymph node biopsy only or to receive axillary lymph node dissection after sentinel lymph node biopsy ²⁰. All of the women were treated with lumpectomy, and most also received adjuvant systemic therapy and external-beam radiation therapy to the affected breast. After extended follow-up, the two groups of women had similar 10-year overall survival, disease-free survival, and regional recurrence rates ²¹.

The use of sentinel lymph node biopsy in melanoma

Research indicates that patients with melanoma who have undergone sentinel lymph node biopsy and whose sentinel lymph node is found to be negative for cancer and who have no clinical signs that cancer has spread to other lymph nodes can be spared more extensive lymph node surgery at the time of primary tumor removal. A meta-analysis of 71 studies with data from 25,240 patients found that the risk of regional lymph node recurrence in patients with a negative sentinel lymph node biopsy was 5% or less ²².

Findings from the Multicenter Selective Lymphadenectomy Trial II also confirmed the safety of sentinel lymph node biopsy in people with melanoma with positive sentinel lymph nodes and no clinical evidence of other lymph node involvement. This large randomized phase 3 clinical trial, which included more than 1,900 patients, compared the potential therapeutic benefit of sentinel lymph node biopsy plus the immediate removal of the remaining regional lymph nodes called completion lymph node dissection with sentinel lymph node biopsy plus active surveillance, which included regular ultrasound examination of the remaining regional lymph nodes and treatment with completion lymph node dissection if signs of additional lymph node metastasis were detected.

After a median follow-up of 43 months, patients who had undergone immediate completion lymph node dissection did not have better melanoma-specific survival than those who had undergone sentinel lymph node biopsy with completion lymph node dissection only if signs of additional lymph node metastasis appear (86% of participants in both groups had not died from melanoma at 3 years) ²³.

What are the benefits of sentinel lymph node biopsy?

Sentinel lymph node biopsy helps doctors stage cancers and estimate the risk that tumor cells have developed the ability to spread to other parts of the body. If the sentinel node is negative for cancer, a patient may be able to avoid more extensive lymph node surgery, reducing the potential complications associated with having many lymph nodes removed.

What are the possible harms of sentinel lymph node biopsy?

All surgery to remove lymph nodes, including sentinel lymph node biopsy, can have harmful side effects, although removal of fewer lymph nodes is usually associated with fewer side effects, particularly serious ones such as lymphedema. The potential side effects include:

• Lymphedema or tissue swelling. During lymph node surgery, lymph vessels leading to and from the sentinel node or group of lymph nodes are cut. This disrupts the normal flow of lymph through the affected area, which may lead to an abnormal buildup of lymph fluid that can cause swelling. Lymphedema is a build-up of lymphatic fluid. Lymphedema causes swelling in your arm or other areas such as the hand, fingers, breast, chest or back. This may keep fluid from leaving your arm or hand and cause swelling or tightness. Lymphedema may cause pain or discomfort in the affected area, and the overlying skin may become thickened or hard. Lymphedema can happen weeks, months or years after treatment. The risk of lymphedema increases with the number of lymph nodes removed. There is less risk with the removal of only the sentinel lymph node. In the case of extensive lymph node removal in an armpit or groin, the swelling may affect an entire arm or leg. In addition, there is an increased risk of infection in the affected area or limb. Very rarely, chronic lymphedema due to extensive lymph node removal may cause a cancer of the lymphatic vessels called lymphangiosarcoma. Today, sentinel node biopsy is the preferred way to remove lymph nodes (only a few nodes are removed). So, most people don’t get lymphedema.
• Seroma, or a mass or lump caused by the buildup of lymph fluid at the site of the surgery
• Numbness, tingling, swelling, bruising, or pain at the site of the surgery, and an increased risk of infection
• Difficulty moving the affected body part
• Skin or allergic reactions to the blue dye used in sentinel lymph node biopsy
• A false-negative biopsy result—that is, cancer cells are not seen in the sentinel lymph node even though they have already spread to regional lymph nodes or other parts of the body. A false-negative biopsy result gives the patient and the doctor a false sense of security about the extent of cancer in the patient’s body.

Axillary lymph node dissection

Axillary lymph node dissection also called axillary dissection is surgery to remove axillary lymph nodes from under your arm. The goals of axillary dissection are to check how many lymph nodes have cancer and to reduce the chances of cancer coming back in the lymph nodes. Axillary dissection removes more lymph nodes and disrupts more of the normal tissue in the underarm area than a sentinel lymph node biopsy. So, it’s more likely to affect arm function and cause lymphedema. For this reason, sentinel lymph node biopsy is the preferred first step to check the axillary lymph nodes.

Axillary lymph node dissection is usually done during your lumpectomy or mastectomy. During axillary node dissection, your doctor will remove lymph nodes that have cancer and those that cancer could easily spread to. This surgery reduces the chance that the cancer could come back. It also helps your doctor plan further treatment for you.

After the surgery, you may go home the same day. Or you may need to spend the night at the hospital. You will probably be able to go back to work or your normal routine in 3 to 6 weeks. This depends on the type of work you do and any other treatment you may need.

After your lymph nodes are removed, you will be at greater risk for swelling in your arm. This is called lymphedema. You will have to take good care of your affected arm. Wear loose sleeves and bracelets. Don’t carry heavy things with that arm. Your doctor or physiotherapist can teach you arm exercises. Doing these can help you move your arm as you always have.

Axillary lymph node dissection may be done at the same time as other breast surgeries. If this is the case, how you prepare may be different.

Axillary lymph node dissection recovery

Right after axillary dissection you will probably feel weak, and your shoulder area will feel sore and stiff for a few days. It may be hard to move your arm and shoulder in all directions. Your doctor or physiotherapist will teach you some arm exercises. You now have a higher chance of swelling in the affected arm. This is called lymphedema. From now on, you will have to be careful when using your arm.

You will have a scar under your arm that will fade over time. You may also notice a hollow area in your armpit. It may also feel like you have a lump in your armpit. You may lose some feeling under your arm, or the arm may have a tingling or burning feeling. The loss of feeling may last only a little while, or it may last the rest of your life.

You will probably be able to go back to work or your normal routine in 3 to 6 weeks. This depends on the type of work you do and any further treatment. If cancer was found in the lymph nodes, you will probably need more treatment.

An axillary node dissection may be done at the same time as other breast cancer surgeries. If this is the case, your recovery may be different.

How to care for yourself at home

Incision care

• If you have strips of tape on the cut (incision) the doctor made, leave the tape on for a week or until it falls off.
• After 24 to 48 hours, wash the area daily with warm, soapy water and pat it dry. Keep the area clean and dry.
• You may cover the area with a gauze bandage if it weeps or rubs against clothing. Change the bandage every day.
• You may have a drain in your armpit. Follow your doctor’s instructions to empty and care for it.

Activity

• Rest when you feel tired. Getting enough sleep will help you recover.
• Try to walk each day. Start by walking a little more than you did the day before. Bit by bit, increase the amount you walk. Walking boosts blood flow and helps prevent pneumonia and constipation.
• Avoid strenuous activities, such as biking, jogging, weightlifting, or aerobic exercise, until your doctor says it is okay. This includes housework, especially if you have to use your affected arm. You will probably be able to do your normal activities in 3 to 6 weeks. But for the next 3 to 6 months, be careful when you do tasks that use the same motions over and over, such as vacuuming, weed pulling, or window cleaning.
• For 4 to 6 weeks, avoid lifting anything that weighs more than 4.5 to 7 kilograms or that would make you strain. This may include heavy grocery bags and milk containers, a heavy briefcase or backpack, cat litter or dog food bags, a vacuum cleaner, or a child.
• Ask your doctor when you can drive again.
• 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 (unless you have a drain in your incision) 24 to 48 hours after surgery. Pat the cut (incision) dry. Do not take a bath for the first 2 weeks, or until your doctor tells you it is okay. If you have a drain coming out of your incision, follow your doctor’s instructions to empty and care for it.
• Take precautions to prevent infection and swelling in your arm. This is called lymphedema.
  • Wear gloves when you garden, handle garbage, wash dishes, and clean house.
  • Protect your hands and arms from burns, including sunburns.
  • Do not wear tight sleeves, elastic cuffs, bracelets, wristwatches, or rings on the affected arm.
  • Do not let anyone take blood pressure, draw blood, or give shots in that arm.
  • Do not carry heavy purses, suitcases, grocery bags, and other heavy items with that arm.
  • Keep the skin of that arm well moisturized.
  • Do not cut your cuticles.
  • Use an electric shaver if you shave your armpits.
  • Protect yourself from insect bites on the arm.
  • Wear medical alert jewellery that says you can develop lymphedema.

Exercise

• You will need to do arm exercises once your doctor tells you it is okay. Do the range-of-motion exercises as instructed by your doctor.

Elevation

• Prop up your arm on a pillow anytime you sit or lie down. Try to keep it above the level of your heart. This will help reduce swelling.

Diet

• You can eat your normal diet. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt.
• You may notice that your bowel movements are not regular right after your surgery. This is common. Try to avoid constipation and straining with bowel movements. You may want to take a fibre supplement every day. If you have not had a bowel movement after a couple of days, ask your doctor about taking a mild laxative.

Medicines

• Your doctor will tell you if and when you can restart your medicines. He or she will also give you instructions about taking any new medicines.
• If you take blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, be sure to talk to your doctor. He or she will tell you if and when to start taking those medicines again. Make sure that you understand exactly what your doctor wants you to do.
• Be safe with medicines. Take pain medicines exactly as directed.
  • If the doctor gave you a prescription medicine for pain, take it as prescribed.
  • If you are not taking a prescription pain medicine, ask your doctor if you can take an over-the-counter medicine.
• If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.
• If you think your pain medicine is making you sick to your stomach:
  • Take your medicine after meals (unless your doctor has told you not to).
  • Ask your doctor for a different pain medicine.

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