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Sentinel Lymph Node Biopsy of the Breast

prof. Usman Jafferprof. Usman Jaffer

Introduction

The sentinel or axillary lymph nodes are the first lymph nodes that the fluid around the breast cancer tissue drains into. Lymph nodes are part of a system called the lymphatic system which drains fluid from tissues as well as having a role in your immune system. They are an important factor in determining how advanced your cancer is, or the prognosis. The results are useful in determining further treatment. 

In the past the axilla or armpit would be cut into, to reach the lymph nodes, this is called axillary dissection. Particularly in patients with early stages of breast cancer, this has been replaced by sentinel lymph node biopsy SLNB. Your lymph nodes will be examined prior to having breast surgery, if they are assessed as being negative for cancer a SLNB will be performed. Axillary lymph node dissection ALND is used for those with more advanced breast cancer, who have been assessed to have cancer in lymph nodes prior to surgery. Both procedures have been shown to have similar recurrence rates with improved rates of early breast cancer detection due to better screening and imaging. These rates are only set to rise.   

Evidence suggests that regardless of the site of the tumour, the whole breast mostly drains into particular lymph nodes so a dye can be injected to detect which lymph nodes these are. Once these are found with a dye, and tracer, a biopsy is taken. A biopsy is a less invasive and therefore a safer procedure, in which a device is inserted through the skin and into the tissues of the armpit to take a small sample of the sentinel lymph nodes. This is then examined for cancerous tissue by laboratory tests. 

Breast Cancer - Women's Health Issues - Merck Manuals ...
Diagram of the breast with lymph nodes and tumour.

  

Diagram showing a lymph node
Diagram of lymphatic system.

What is it?

SLNB is a highly accurate procedure in predicting the cancer status of the sentinel lymph nodes correctly in 90-95% of cases. This is one of the most important prognostic factors in women with breast cancer, so can be used to determine how advanced your cancer is and help determine treatment or monitoring options. It is mainly used instead of ALND for early breast cancer because it has less complications which can be avoided with similar accuracy rates.   

Why is it done?

SLNB is indicated in patients with early breast cancer, with cancer negative lymph nodes as assessed by your doctor irrespective of whether you will have a surgical procedure. This is to help stage your cancer and determine the next steps in treatment. 

It is used in patients with both ductal carcinoma in situ DCIS and a planned mastectomy, which is a removal of some or all the breast tissue, or those with suspicious features of their DCIS. These features may include a large DCIS which is more than 5cm or a DCIS with a mass that can be felt by your doctor when you are examined.  

It may also be used if you have had a recurrence of your breast cancer in the same breast. 

Will I need to do any preparation?

You will need to arrange for someone to escort you home due to the use of general anaesthesia during the surgery, they should also stay with you for 24hours.  

A range of dyes which have been shown to be reliable with a radiotracer, may be used, such as Paten V blue. Isosulfan blue tracer is commonly used but may be avoided if you are pregnant as it can affect the growth of the foetus. This may be injected into a range of sites in the breast and no particular site has been shown to have superior outcomes for the procedure.   

Technique

Anaesthesia

General anaesthesia will most likely be used for SLNB. On top of this local anaesthetic is often injected into the wound to reduce pain after the operation. See our article on anaesthesia to understand more about this process and the risks involved.   

What does it involve?

Once you have made the necessary preparations and received relevant local and general anaesthesia the operation may begin. 

1) Usually on the day of the surgery a radioactive tracer and dye, discussed in detail below, will be injected into the skin of the axilla or armpit. Technetium-99 is commonly used as the radioactive tracer, this will emit small amounts of radiation which are picked up by a handheld device called a gamma or G-probe. This will be used to find the sentinel lymph nodes as the dye will drain to these first.  

2) Some lymph nodes will appear blue as they uptake the dye and radiotracer, these are the sentinel lymph nodes. These will be removed, and all those with at least 10% of the uptake of the hottest node, in terms of uptake, will be removed. A 5cm cut or incision will be made with a small surgical knife (scalpel) in the axilla if further surgery is planned this may be placed strategically by your surgeon to minimise the number of scars for both procedures. This will be clamped as shown in the diagram below.

Sentinel Lymph Node Biopsy for Melanoma | Basicmedical Key
Diagram of injection site A and surgical site B.

3) The surgeon will then remove the cancerous lymph nodes, minimising disruption to the surrounding tissue and any blood loss.  

4) A biopsy or tissue sample will also be taken to be tested in the lab, this may be during or after your operation. 

5) Finally, the wound will be closed in layers. 

6) You will be in the recovery room until you are fully awake and then will be able to return to the ward. 

How long does it take?


Post procedure course (follow up)

As discussed in the ‘will I need to do anything before the operation’, someone will need to take you home and stay with you for 24 hours after the operation. The wound will be dressed and may be closed with dissolvable stitches. If dissolvable stitches are not used, you will need to make a GP appointment in about a week to have them removed. You will receive a routine wound check. You will also be advised by the team on how to take care of your wound and what to look out for in terms of infection. An outpatient appointment will be arranged by the team to discuss the results of the biopsy in 5-10 days. You will be informed of this before you leave. 

Though drains are not normally required following this procedure, if you have a drain, your nurse will normally remove it when it has stopped draining large amounts of fluids. This may be the next day. Once this has been removed you will be able to leave. 

As discussed in the risks section, there is a small risk of seroma (collection of fluid beneath the skin, respectively). If you are found to have one and it is causing symptoms this may need to be drained. 

There may be a blue/ green colour present in your urine over the next few days. This is harmless and temporary and is just the presence of the dye which is used during the procedure.   

How long will I stay in hospital?

Usually, you will be able go home on the day of your procedure.  

Will I need someone to stay with me?

Someone will need to take you home and stay with you for 24 hours after the operation  

What follow up care is needed?

What happens following the procedure depends on the results of the biopsy or tissue sample which will take 5-10 days. They will be tested and examined under the microscope in the laboratory. Depending on the plan made with your surgeon ALND may be done immediately following your SLNB if the nodes are found to be positive for cancer. This means if tissue greater than 2mm is found to be cancerous. Alternatively, radiotherapy or chemotherapy may be arranged to clear the cancer in the lymph nodes. Your doctor will discuss the treatment options with you and a treatment plan will be made.  

If your sentinel lymph nodes are negative for cancer the results will still be used to help stage your cancer and contribute to your treatment or monitoring plan going forward. 


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