Breast and Axilla - Our team's view
Introduction
Breast cancer can spread along small lymph channels to the lymph nodes in the armpit. At present there are no investigations available which can reliably tell us whether the nodes in the armpit are involved with cancer cells or not. Sometimes lymph nodes are thought to be involved as a result of clinical examination and ultrasound scans can sometimes detect involved lymph nodes , but a normal test does not rule out involvement. During your breast cancer surgery Mr or Mrs Jones will remove lymph glands from your armpit to see whether your cancer has started to spread. This information helps you and the team of breast specialists decide on what further treatment will be recommended to treat your breast cancer. Until recently the only way of knowing if the nodes in the armpit contain cancer cells was by removing several or all of the nodes and examining them under the microscope. Unfortunately this procedure can occasionally cause seroma (a temporary collection of fluid in the armpit), neuralgia (temporary pain in the armpit), lymphoedema (swelling of the arm), numbness, soreness or a stiffness of the shoulder.
In about 6 out of 10 women the nodes turn out to be free of cancer. Breast teams have, therefore, been looking for ways to avoid removing all the glands with associated side effects.
Sentinel Node Surgery
It has now been well established that the "sentinel node" (lead node) technique may provide an accurate assessment of nodes in the armpit in a patient's breast cancer. The sentinel node is the first lymph node in the armpit to which breast cancer would spread. If we are able to find and remove the sentinel node accurately, and prove this is free of cancer cells, then for these women no further surgery in the armpit would be needed.
The sentinel lymph node biopsy procedure was first developed in the USA and Europe and is now being used successfully in breast units around the world. In the United Kingdom many clinical trials, including our own, have shown that it is possible to accurately identify the sentinel lymph node and that women that had sentinel lymph node biopsy had less pain and discomfort than a full axillary node clearance. In Maidstone Mr and Mrs Jones routinely offer this procedure when the clinical examination of the armpit (axilla) and an ultrasound examination of the armpit (axilla) show no abnormality.
However, although restricting axillary node surgery to sentinel node biopsy is being widely promoted, it is important to understand that there are some potential disadvantages. Sentinel node biopsy inherently accepts the small but significant risk of leaving unrecognised cancer in the axilla which could jeopardise the chances of cure.
In other words there is a "false negative" rate. When the sentinel node is negative there is at most about a 1 in 20 (or 5%) risk that other nodes left behind may contain cancer cells from the breast. The published false negative rates vary, but recent studies are mostly about 5% or less. There is growing recognition that suboptimal locoregional treatment and local recurrence are independent factors reducing 5 and 10 year survival rates and that formal axillary node clearance is associated with increased survival, even when the primary tumour is small. It seems logical to accept that cancer recurring in the breast or remaining undetected and untreated in the axilla is just as likely to metastasise as the original primary tumour.
However, it is also important to emphasise that although sentinel node biopsy techniques have now been used for nearly ten years there is absolutely no published evidence that it is having an adverse effect on the outcomes or chances of being cured of breast cancer. In our own preliminary studies using the blue dye technique only we were able to achieve a very low 4% false negative rate and now that we are using the combined technique with a radio-labelled isotope we expect this to fall to around about the 2% level.
To Summarise
1. The standard treatment in the UK has been formal axillary lymph node clearance. This procedure is the most reliable way of assessing the glands in the armpit, but results in a lifelong risk of developing lymphoedema and other more minor, but irritating, side effects.
2. Sentinel node biopsy aims to identify the first lymph node in the armpit which breast cancer would spread to. This is removed and analysed in the laboratory.
3. When the sentinel node is free of cancer no further armpit surgery will be required. If the sentinel node contained cancer further surgery will be advised to remove the remainder of the armpit lymph nodes and thereby perform a full axillary node clearance.
Details of the Technique
1. The radioactive dye
On the day before surgery, or sometimes early in the morning of surgery, you will be asked to attend the Nuclear Medicine Department in the Oncology Centre at the Maidstone Hospital. Dr Donaldson or his colleague will inject a small amount of radioactive dye into the breast close to the nipple. Shortly afterwards a whole body scan will be performed and a mark made on the skin with a pen to show the area or areas of highest uptake. This normally corresponds to the situation of the sentinel node.
You will be admitted to hospital as us
ual on the morning of surgery and on the day of your operation, once you are in theatre and anaesthetised, Mrs or Mr Jones will inject a blue dye into your breast under the nipple area.
Mrs or Mr Jones use 2 - 4ml of a blue dye (Patente Blue V).
When the operation starts Mrs or Mr Jones use a purpose built gamma probe to detect the hot (lymph) node (lymph gland) and by this method and by tracing the blue dye from your breast to the sentinel node Mrs or Mr Jones will be able to find the sentinel node or sentinel nodes very accurately. They will then proceed with the rest of your breast surgery.
2. What are the possible risks?
You will notice blue discolouration at the site of the injection and this can persist for many months. You will also notice a slight blue colour in your urine for the first twenty-four hours after the operation as the dye is removed by your kidneys. The dye has been used in many hundreds of patients throughout the world in the last few years with no severe side effects. However, there is a very small risk of severe allergic reaction, but this is very rare and said to be less than 1%. Allergic reactions to the dye are so rare that there are no published figures. There are standard treatments for allergic reactions when they do occur.
3. What are the disadvantages?
Using the combined radioactive and blue dye techniques it is very rare not to be able to identify the sentinel lymph node, but when this does occur we recommend proceeding to an axillary node clearance you will be asked to consider consenting for this before your operation.
There is a very small risk that when the sentinel node is free of any cancer cells that other lymph nodes could be affected. This is known as the "false negative" rate and has been dealt with above.
Perhaps the main inconvenience of this procedure is that when the lymph node does come back as being involved with cancer Mrs and Mr Jones will always recommend a second operation to remove the remaining lymph nodes and perform what is now termed a completion level III axillary node clearance.
We attempt to reduce the risk of patients having to undergo a second operation by very careful clinical assessment of the armpit and by routinely performing an ultrasound of the armpit in all women who have been found to have breast cancer. If any suspicious nodes are found by clinical examination or on ultrasound a needle biopsy is recommended under local anaesthetic in the same way that the original breast biopsy was performed.
Mrs and Mr Jones were keen to demonstrate that they could both accurately identify sentinel lymph nodes by the above techniques and have undergone formal training and undertaken a validation study. This involved removing the sentinel nodes in 100 consecutive women with breast cancer and then going on to complete a full axillary node clearance at the same time. These were all women who had formally consented to participating in this validation study. They were able to demonstrate that they could achieve results at least as good as any other breast centre in the world.
AXILLARY NODE CLEARANCE
You should read this after the Sentinel Lymph Node Biopsy section (above)
Women may undergo axillary node clearance if they have chosen this procedure instead of sentinel lymph node biopsy, particularly if they have the type of breast cancer where there is a high risk of spread to the lymph nodes. Women will also be strongly advised to undergo an axillary node clearance if a sentinel node biopsy was positive on subsequent testing. Axillary node clearance is also recommended routinely when pre-operative tests have confirmed the lymph node is involved.
The operation called axillary node clearance therefore may be carried out in the same operative session as the breast surgery or on a separate occasion.
The breast, like other organs, generates a fluid called lymph, which, through slender but long channels, returns to the blood stream to go on re-circulating. Lymph nodes are about 1 cm kidney bean shaped nodules through which lymph passes &, in some ways, they are filter stations. Most of the lymph from the breast travels upwards to pass through the axillary lymph nodes - there are about 15 or so.
Unfortunately cancer cells can also travel through these channels & get deposited in these nodes. It is for this reason that the lymph nodes need to be removed for examination with the microscope (histology).
Removing the lymph nodes means that fluid from your upper limb (arm, forearm & hand) will need to find other channels to return to the main circulation. New channels open & existing ones may enlarge to make up for the lost lymph channel to return lymph from your upper limb (arm, forearm & hand) to the circulation.
Nevertheless, this could be a disadvantage in circumstance when fluid load in the upper limb increases - for example, after it is injured or infected when transient swelling may occur. Some months or years after the operation there is a small chance of swelling of the arm/forearm/hand which may be temporary or sometimes permanent. This is a small risk for us to accept as the benefits of removing the glands are substantial.
What are the axillary nodes?
The axillary nodes are a group of glands situated in the armpit. They form part of the lymphatic system (which helps to clear debris etc., from the blood) and contribute toward the body's defence mechanism against infection and disease.
Why do I need to have these removed?
After a breast cancer has been removed it is not always possible to determine whether any cells from that growth have split off. One way in which the cancer cells can be transported is via the lymphatic vessels, to the axillary lymph nodes. By removing these nodes and examining them under a microscope your doctor can tell if any cells have broken away from the breast cancer. This will help him to determine the most appropriate follow-up treatment for you.
Do all women with breast cancer have the nodes removed?
No, the surgery for breast cancer is not the same for all women. It depends mainly on the type of breast cancer being treated.
How long will I be in hospital?
The average stay is about 1 - 2 days.
What happens next?
If, after examination of the nodes, there is no evidence of any cancer cells the follow up treatment will probably include radiotherapy to the breast and Tamoxifen tablets. If, on the other hand, some of the cancer cells are found in any of the nodes, a course of chemotherapy may be recommended as well.
What can I expect after the operation?
You will have one or two drains (plastic tubing) coming from the operation site. These will stay in place for 4 - 7 days. You may be allowed home with a drain still in place, under the care of the District Nurse.
Are there any side effects following the surgery?
Numbness or tingling
There will probably be a permanent numbness or tingling down the back of your upper arm. This will become less noticeable as time goes by and will not affect the use of your arm in any way.
Shoulder stiffness
Because of the underarm surgery, there will be a natural tendency to limit arm movement. Therefore some gentle exercise will be given to you whilst you are in hospital starting the first day after surgery and will help to restore your arm movements to normal.
Underarm swelling
Occasionally, a collection of fluid (seroma) accumulates under the armpit. This sometimes clears of its own accord but if it swells to the point of discomfort the doctor will draw the fluid off. This is a minor procedure and can be done in the outpatient clinic. You will be given an information sheet by the breast care nurse before you leave hospital explaining whom to contact.
Pain
Some pain is inevitable following any surgical procedure. Painkillers will be prescribed for you after your operation and the physiotherapy should help prevent any stiffness/pain problems in the longer term.
Arm swelling (lymphoedema)
A small group of woman may experience arm swelling following removal of the lymph nodes. This is a result of ineffectual drainage of the lymphatic fluid. Special care of your arm is essential (see separate care sheet). It is important for you to know that lymphoedema is treatable and any woman noticing arm swelling at any time post-operatively, should seek early medical advice and referral to our lymphoedema clinic, for treatment by our specialist team. You will be given an information sheet by the breast care nurse before you leave hospital explaining whom to contact.
