© 2007 My Breast

Site Designed by Medical Pages




Axillary Surgery in Breast Cancer


Mr Gerald PH Gui MS FRCS FRCS(Ed)

Consultant Breast Surgeon

The Royal Marsden Hospital

Surgery of the axilla is necessary at the time of breast surgery to stage the tumour. This means we need to know if the breast cancer has spread to the glands under the arm. Staging of the axilla can be achieved by (i) targeted sampling of the underarm using sentinel lymph node biopsy (SLNB); (ii) a random sampling of four or five lymph nodes from the axilla; (iii) formal dissection to take the block of axillary lymph nodes that drain the breast (axillary clearance); (iv) a smaller axillary resection to take part of the axilla.

Sentinel lymph node biopsy (SLNB)

Sentinel lymph node biopsy is a modern method to evaluate the axilla, using a minimally invasive surgical approach. The principles of this procedure are as follows. A tracer material is used to map which of the lymph glands in the underarm are most likely to drain the region of the breast that the tumour is located in. The tracer materials most commonly used are a blue dye, called Patent Blue V, and/or a radioisotope called 99technetium colloid. This is injected into the breast at the time of surgery, in the case of the dye, or the day before, when the radioisotope is used. The radioisotope contains a small amount of radioactivity which is a fraction of the amount used in a standard spine (back) x-ray. The tracer material is taken up by the lymphatic channels in the same way that tumour cells might utilise these natural structures to arrive in the lymph glands under the arm. The dye stains the sentinel node(s) blue, which allows its visualisation at the time of surgery. The isotope is measured by a special counter (like a modified Geiger counter) that allows the same node or nodes to be targeted. A positive sentinel node, identified by the blue dye or isotope, is not necessarily one that is involved with cancer but is the first draining node of the region of the breast and therefore representative of the rest of the axillary lymph node basin. There is often more than one sentinel lymph node, and usually two to four nodes are biopsied. This is a safe technique that allows the axilla to be staged (to determine whether the nodes are positive or negative) without major surgery. The advantages of this procedure are that there is a short recovery time, requiring only an overnight stay in hospital at most, with minimal effect on shoulder stiffness or function of the arm. The results of the sentinel lymph node biopsy are usually available a few days after the surgery. The disadvantage of the sentinel lymph node procedure is that if the nodes are found to be positive, you will require further treatment to the underarm. This is usually a formal axillary dissection operation (see below).

The blue dye from the sentinel lymph node stains the skin and takes some weeks, sometimes months, before it fades. There have been cases where a faint blue staining has persisted for several months, and on occasion over a year. The first time that you pass urine after the operation, you are likely to find that this is stained blue or green. This is usually gone by the second passage of urine. Sometimes the bowel motion is also discoloured in this way. There are no long-term sequelae of this. The radioisotope has a short half life and there are no long term effects. It should not be used in pregnancy.

Sentinel lymph node biopsy is a sophisticated way of performing an axillary sample. Before sentinel node method became available, techniques described to sample the axilla were based on random methods, which have, in the main, been superseded. When undirected axillary sampling (as opposed to sentinel node biopsy) is performed, usually four to five nodes are taken from the axilla to ensure reliability of the random node sample.

Axillary dissection

Five or more years ago, the standard method of staging (to identify if lymph nodes were negative or positive) and treating the axilla was by removal of the block of lymph nodes that drain the axilla. Typically, there are around 20 lymph nodes. This number of lymph nodes is far from absolute and can range widely between individuals. The surgical dissection involves removing a block of tissue in the axilla (armpit) within the boundaries of blood vessels, nerves and muscles that determine the extent of the surgical resection. The pathologist subsequently identifies lymph nodes from within this block of fat that are carefully assessed under a microscope. A pathology result is usually obtained several days after the surgery.

The axilla is a pyramid made up of unequal thirds. It may be anatomically divided into levels 1, 2 and 3. Up to 75% of lymph nodes may be found in level 1, a further 20% in level 2, and the remainder in level 3. A level 1 dissection may be offered in breast cancer that has a very low risk of spreading, and may be an alternative to more extensive axillary surgery. A level 2 dissection has been the standard axillary operation. In early breast cancer, a level 1 or level 2 axillary dissection may be an alterative to a full axillary clearance. Even if the lymph nodes subsequently are found to be positive, there is usually no need for further treatment to the axilla, especially if only the low axillary nodes are affected.

Axillary dissection or level 3 clearance is a much larger operation than sentinel lymph node biopsy. After axillary dissection there will usually be a drain placed to remove any blood or fluid that can collect in the underarm in the few days after your surgery. This drain remains in place for approximately five days, until the volume of fluid falls to a minimum value. You may go home from hospital with your drain in place, after the second day. If you wish to stay in hospital until the drain comes out, this is usually five days after your operation.

A seroma is a collection of fluid that may occur in the axilla after the drain is removed. It can present as a discomfort, stiffness or swelling. If it becomes full of fluid and tense, a needle and syringe may need to be used to aspirate the fluid. Sometimes, this may need to be repeated on more than one occasion.

Sentinel lymph node biopsy v. axillary dissection

You will be recommended to have a sentinel lymph node biopsy if you have a relatively small tumour, and the likelihood of the lymph nodes being involved under your arm is small. In general terms, if the lump that can be felt is small, there is approximately a ? chance that the nodes are negative. If the nodes are negative and this is reliably shown by sentinel lymph node biopsy, you will need no further treatment to the underarm. If the lymph nodes are positive on sentinel lymph node biopsy, you will require an axillary dissection operation at a second procedure, usually one or two weeks after the first operation.

Sentinel lymph node biopsy, being a minimally invasive surgical technique, is associated with a smaller scar and fewer adverse effects compared to axillary dissection. Adverse effects in the early days include wound infection or blood clots at the site of surgery. Fortunately, these events are rare. Other later complications include stiffness of the shoulder, numbness near the scar or in the inner border of the upper arm, or hypersensitivity in these regions. Most of these symptoms are self-limiting.

Apart from the longer hospital stay associated with axillary lymph node dissection surgery, the risks of adverse effects following axillary clearance are higher. The scar following axillary dissection is longer. There is a higher risk of shoulder stiffness. To counteract this, you will be offered physiotherapy from an early stage whilst you are an in-patient in hospital. The risk of arm swelling (lymphoedema) with modern methods of surgery and selective use of radiotherapy affects 10% to 15% of patients in their lifetime. Most symptoms of arm swelling are transient and resolves on treatment with no long-term problems of arm use or function. You will need to take great care of your skin and hands to avoid accidental injury that can precipitate episodes of infection and cellulitis that could predispose to lymphoedema and might become recurrent. After any axillary surgery, there might be local problems in the early days after surgery, such as wound infection and bleeding. This is more common after axillary lymph node dissection compared to sentinel lymph node biopsy. In addition, scar pain, reduced sensation and hypersensitivity are also more common after axillary lymph node dissection.

Sentinel lymph node biopsy is a sensible way of staging the axilla, thereby selecting women who need axillary dissection for treatment, only if they are node positive. If there is only a 30% chance that you are node positive, then the majority (about 70%) of patients do not need axillary dissection surgery. Sentinel lymph node biopsy is one efficient way of identifying those women who need the more major surgery of axillary dissection.

Axillary Surgery and Mastectomy

Whilst having a mastectomy, if you have pre-invasive breast cancer or ductal carcinoma in situ (DCIS), the probability of having any involved axillary lymph nodes is only in the region of about 5%. This is related to a tiny degree of invasion associated with widespread DCIS termed 'microinvasion'. This is more likely if there is a wider area of involvement of DCIS which is the usual reason why women with DCIS are recommended to have a mastectomy. Some form of axillary sampling is therefore necessary at the time of mastectomy to exclude any chance of cancer spread. This can be achieved either by sentinel lymph node biopsy (see above) or a random four or five nodes sample.

If surgery is being performed for a small invasive carcinoma, the probability of there being a lymph node involved is approximately 30%. If the sentinel lymph node biopsy or axillary sample is positive, the axilla would not have been treated and therefore further therapy will be required, either in the form of completion axillary dissection at a second operation, or radiotherapy. If an immediate breast reconstruction is being considered at the time of the mastectomy, a return to theatre for another axillary operation or axillary radiotherapy may either be technically difficult or affect the outcome of the breast reconstruction. Under these circumstances, a formalised axillary dissection which is less than a full axillary clearance may be offered in women with smaller tumours.

<back | top^

About Us
What's New
A to Z
z y x w v u t s r q p o n m l k j i h g f e d c b a A to Z