Almost every patient with invasive breast cancer will require surgery to the lymph glands under their arm (axilla) on the side where the cancer is.
The objectives of surgery to the axillary lymph glands are:
Axillary lymph node status is an important indicator of prognosis for breast cancer. Surgery to the axilla and histopathological assessment of axillary nodes is the most accurate way of obtaining this prognostic information.
Surgery also aims to remove local axillary disease, hopefully reducing the need for axillary radiotherapy and minimising the chances of axillary recurrence.
The choice between different axillary procedures is based on the balance between obtaining the best possible prognostic information and causing the least possible complications.
An Axillary Lymph Node Clearance is likely to be appropriate for the 35-40% of patients
with invasive cancer who have tumour in the axillary lymph nodes. There is strong evidence
that axillary clearance reduces the rate of axillary recurrence. Clearance is undoubtedly the
best treatment for operable axillary disease and leads to very low axillary relapse rates < 3%
After axillary lymph node clearance a drain is usually used for up to 7 days. There is a small but significant risk of lyphoedema (arm swelling), reduced shoulder mobility and arm numbness. These risks are minimized by careful surgery and excellent postoperative rehabilitation and exercises (see breast care nursing file)
Most patients (60-65%) however do not have spread to their lymph nodes and so an accurate but limited sampling of the closest lymph nodes to the breast is all that is required to check they are unaffected.
Sentinel Lymph Node Biopsy is now regarded as the standard of care
in Early Breast Cancer when there is no evidence on examination or scans that the lymph
nodes are involved. This carries a much lower chance of complications such as
lymphoedema, impaired shoulder function or nerve damage.
The Sentinel Node (or Nodes) can be defined as the first lymph node(s) on the lymphatic drainage route out of the breast from the primary tumour. The Sentinel node(s) will therefore be the first to be involved in tumour spread if lymphatic spread has reached the axilla.
A negative sentinel node (or nodes) therefore predicts for a negative axilla without the need for a full axillary node clearance. Its usefullness hinges on the he reliability of the technique and surgeon to be able to find and remove the sentinel node or nodes. The number of SLNs present is variable and different in every patient. Typically there may be 1,2 3 or 4 nodes depending on the number of final drainage routes out of the breast.
Dual modality, combined isotope and blue dye labeling of the sentinel node has been shown
in several randomized studies to provide the highest detection rates (and lowest false negative
1. Radioisotope - Technitium 99 labeled colloid (Nanocoll) – harmless radioactive medicine. Injected under the nipple (subareolar) once the patient is under anaesthetic. May also be injected into the tumour by the radiologist prior to surgery if the tumour is impalpable and needs to be located at surgery using the radioactivity detector (Isotope Localised Wide Local Excision)
2.Patent Blue Dye – 2mls Patent Bleu V, diluted with 3mls saline. Usually injected under the nipple (subareolar) once the patient is under anaesthetic. Small risk of allergic reaction (1:2000) Within 10 minutes of injection, the very low dose of radioactivity and the blue dye have travelled out of the breast along the lymphatics and been absorbed by the Sentinel Lymph Nodes. The surgeon will remove all the lymph nodes that are radioactive and /or blue in colour ie the Sentinel lymph Nodes
Patients will notice a blue complexion, green blue urine and possibly tears for the first 12-24
hrs. This is harmless and fully returns to normal.
There may be a blue green discolouration of the nipple and breast skin for a few weeks or months after surgery but in all but rare cases fully returns to normal.
If the Sentinel Nodes are Negative - then there is no need for furrther axillary treatment
If the Sentinel Nodes are Positive - then the Oncology Team will discuss with the patient the benfits of a completion axillary node clearance (at a second operation) versus axillary radiotherapy treatment.
In some patients (where there is a reasonably strong possibility that the lymph nodes may be
positive but preoperative tests have not been able to confirm it) it may be advantageous to test
the sentinel lymph nodes during the operation – Intraoperative Sentinel Lymph Node
The most reliable technique for this is OSNA (One Stop Nucleic Acid Analysis). OSNA
technology can detect cancer spread in the sentinel lymph nodes within an hour and can be
done whilst the rest of the breast cancer operation is being carried out. If the OSNA test
confirms spread to the lymph nodes then an axillary node clearance can be done at the same
operation. This saves the need for a second operation a few weeks after the first as would
otherwise be necessary.
OSNA is available at St Michaels Hospital for selected patients and its suitability for each individual patient should be discussed by the surgeon.
Whenever possible the axilla should be staged by sentinel lymph node biopsy prior to the
definitive mastectomy and immediate reconstruction operation. The main reasons for this
• If sentinel node biopsy is performed at the time of reconstruction and found to be
involved, subsequent axillary surgery (clearance) is both technically more difficult
and potentially detrimental to the reconstruction
• In view of the potentially harmful effects of radiotherapy to the reconstructed breast,
all attempts should be made prior to reconstruction to predict the likely need for
post mastectomy (and reconstruction) radiotherapy. The reassurance of a
negative sentinel node biopsy in addition to the rest of the staging information will
help inform a pre-operative discussion with the clinical oncologists about the likely
adjuvant treatment that will be required.
If the SLN is positive, in some circumstances it maybe more appropriate to proceed with simple mastectomy and completion axillary node clearance and a delayed reconstruction performed after all adjuvant treatment (including radiotherapy) has been completed.