Lymph node surgery
For some women with a diagnosis of breast cancer, it is recommended that lymph node surgery is performed in addition to surgery of the breast. The recommendation for lymph node surgery is something Dr. Seagren does not take lightly. She will carefully review your diagnosis and will help personalize a treatment plan that provides the greatest benefit while minimizing unwanted side-effects. Lymph node surgery is NOT always necessary and sometimes, lymph node surgery leads to greater complications without any significant benefit to the patient. It is important that you review the risk v.s. benefit of lymph node surgery with your treatment team.
Sentinel Lymph Node Biopsy
Prior to surgery, a small amount of fluid is injected under the skin near the nipple-areolar complex. This fluid is absorbed by the lymphatic system in the breast and accumulates in the first lymph node that "drains" the breast. This is called the sentinel node. It is located in the axillary (armpit). The sentinel node(s) act as a sort of "gate-keeper" node. All lymphatic fluid from the breast must first flow through the "gate-keeper" before traveling to the other axillary lymph nodes. During surgery, a special probe is used to detect the special fluid that has accumulated in the sentinel node. This allows the surgeon to remove JUST the sentinel node and thus avoid damaging the other structures in the axilla. If the sentinel node is "negative" (i.e. no tumor cells have traveled from the breast tumor to the lymph nodes) there is no need for additional lymph node surgery to adequately "stage" the breast cancer.
Technetium (Tc 99m-sulfur colloid) is the most common radioisotope used in nuclear medicine. Its biologic half-life is 12 hours and it is eliminated from the body in a couple of days.
Methylene Blue Dye
Methylene blue (MB) is an older technique and is often added to Tc 99m. Due to the significant risk of skin necrosis and permanent staining at the injection site, Dr. Seagren avoids the use of MB. Numerous studies have shown that Tc 99m is a reliable tracer for sentinel node identification and does NOT require the addition of MB.
Isosulfan Blue Dye
Also known as Lymphazurin, is a blue dye that has been used for sentinel node identification. Due to the risk of life-threatening anaphylactic shock, that has been associated with this substance, Dr. Seagren never uses this technique.
Dr. Seagren is very excited about this latest technology in sentinel node surgery. Sienna+ is a superparamagnetic iron oxide particle suspension. It is safe and non-toxic. It naturally dissipates from the body and it reliably identifies the sentinel node. Once available for use in the US we plan to offer this to all of our patients.
Axillary Node Dissection
This is sometimes performed in addition to the sentinel node procedure or instead of the sentinel node procedure. In an axillary node dissection, numerous lymph nodes are removed.
Level I + II Lymph Node Removal
The lower lymph nodes in the axilla (armpit) are removed. Due to the risk of lymphedema (permanent arm swelling), Dr. Seagren rarely performs this surgery. In the past, breast surgery was very "aggressive" and included removal of all lymph nodes of the axilla (armpit). We now know, based on years of studies, that "aggressive" surgery is unnecessary AND has serious consequences for the patient. Treatment advances and improved surgical techniques allow patients to avoid unnecessary surgery. Your surgeon should be able to clearly explain the benefits of an axillary node dissection and why options, such as a sentinel node procedure, neoadjuvant chemotherapy (treatment prior to surgery; this can destroy the cancer cells in lymph nodes, thus obviating the need for axillary dissection) or radiation therapy is not an option. *Level III nodes should NEVER be removed as this significantly increases the risk of complications.
Targeted Axillary Dissection
This is the latest advancement in axillary surgery. For women with advanced breast cancer, who have lymph nodes that were positive (breast cancer cells have moved to the nodes) at the time of diagnosis, a "targeted" axillary dissection AFTER they receive neoadjuvant treatment (treatment BEFORE surgery) may be an option. In this procedure, only the sentinel node and the nodes that were positive at the time of diagnosis are removed.