Lymph Node Surgery
Surgery to the Lymph Nodes (Axilla)
Any operation for breast cancer includes removing some or all of the lymph glands from the underarm area (axilla). The axilla contains about 15 - 40 lymph nodes, the number varying between individuals. Approximately 35 - 40% of all breast cancers will have spread to one or some of these nodes by the time the cancer is diagnosed.
Why is it necessary?
All breast cancer has the potential to spread to other areas of the body. One of the first places breast cancers can spread to is the lymph glands. Removing these allows them to be analysed under the microscope for the presence of cancer cells. If some are found to contain cancer cells then additional treatment will be necessary.
How many lymph nodes are removed?
The aim of surgery to the lymph nodes is to remove the smallest number of nodes necessary to prove whether breast cancer has spread to them or not. It used to be the case that all of the lymph glands were removed (axillary node clearance) for every woman with breast cancer but this meant that most women had these glands removed for no reason.
As axillary node clearance is commonly associated with some problems after surgery, it should only be performed in women who need it.
Every effort is made to identify whether nodes are involved with breast cancer or not prior to surgery. Thus, every woman has an ultrasound scan of these nodes and any nodes that fulfil our criteria are biopsied. This identifies nearly half of all women who have breast cancer in the lymph nodes. Such women are recommended to have an axillary node clearance. For women in whom the ultrasound scan or biopsy shows no evidence of cancer cells in the lymph nodes, a sentinel node biopsy and node sample is performed. This removes a minimum of 4 nodes but aims to cause very little disruption to the axilla, so causing very few problems after surgery.
Sentinel Node Biopsy and Node Sample
The sentinel node is the lymph node that should be encountered first by any cancer cells spreading from the breast. It is identified by injecting the breast with some blue dye. This injection is done while you are asleep under anaesthetic, just before surgery. It often leaves a blue stain around the nipple that (if you are having a wide local excision) can persist for several weeks. It also turns your urine a green colour for the rest of that day. Between 1 and 3 sentinel nodes are usually found.
As the sentinel node is not 100% accurate at predicting cancer spread to the lymph nodes, other nodes that could be abnormal are also removed. Thus the total number of nodes removed is about 4. The operation is usually associated with discomfort to the under-arm area for a few days afterwards. Some women are aware of one or two fine cord-like thickenings in the upper arm a few days after this operation which can be a bit tender but usually settle after 2 or 3 weeks.
Occasionally the operation can cause a small area of numbness affecting the under-arm or upper arm area. This usually resolves but can take some months to do so. Women who have lymph nodes that are affected with breast cancer may be recommended to have all the nodes removed (axillary node clearance). This would involve a second operation. Some women with only 1 or 2 nodes affected may be suitable to have radiotherapy to the underarm area instead of further surgery.
Axillary Node Clearance
This operation involves removing all lymph nodes from the under-arm area (axilla). It is performed when there is definite spread of breast cancer to these nodes. A drain is left in the wound after this operation and often requires to be left in for up to a week.
The main effects of this operation are that your shoulder is quite stiff for the first few days. A near full range of movement can be expected after 2 - 6 weeks with regular shoulder exercises, which you will be taught. Some women experience an area of numbness in the upper arm area that can be permanent but often improves with time. Approximately 10 - 20% of women develop a slight swelling in the arm that can be permanent but may improve with appropriate treatment.
Aftercare and Recovery
Stitches will be dissolvable and a waterproof dressing of special glue will be applied to the scar. After this time, aqueous moisturiser can be applied to the whole underarm area including the wound. Shoulder exercises will begin on the first day after surgery and gradually become more extensive over the following few days. It would be normal for most women to regain a full range of movement of the shoulder within 6 weeks of this operation. Occasionally it is necessary to drain some fluid (seroma) that collects in the wound a couple of weeks after surgery. This is done painlessly at the clinic.
Q.What happens if my arm becomes swollen after axillary node clearance?
Answer - If this does happen, early treatment is important. You will be taught how to massage the arm and encouraged to apply moisturiser to it. If it is uncomfortable, a compression sleeve will be fitted. Treatment is aimed at controlling and reducing the swelling.
Q. What will the scar be like?
Answer - If you are having a mastectomy, then surgery to the lymph nodes is usually performed through the mastectomy scar. If you are having wide local excision, the scar is usually separate from the breast scar, but is placed within the skin creases under the arm and usually heals as a faint white line.
Q. When can I go home after the operation?
Answer - You can go home the following day if you wish, although you would still have your drain in. You can be taught how to empty the drain yourself or can attend the ward every couple of days to have the drain emptied. The range of stay in hospital is 1 - 7 days depending upon your own circumstances.
Complications - What can go wrong?
Any operation can be associated with infection or bleeding. Wound healing can be particularly affected by infection and smoking. Any operation can be associated with anaesthetic problems (nausea in particular), venous thrombosis (although precautions are taken routinely) and allergic reaction to drugs or dressings. Every effort is taken to minimise the risk of these problems.