Lymph Node Surgery - Treating Breast Cancer: Breast Cancer

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Lymph node surgery

The lymph nodes under the arm, called axillary nodes, are the major drainage sites for the lymphatic system of the breast. During breast surgery, the doctor usually removes one or more of the nodes, which a pathologist then examines under a microscope to see if cancer cells are present. In general, the fewer the nodes that are positive (containing cancer cells), the earlier the stage. If any lymph nodes are positive, the chance that the cancer has metastasized is greater than if none are positive. This is because one way that cancer cells metastasize is through the lymphatic system. If all the nodes are negative, metastasis is less likely - although not impossible, as cancer cells can also spread by way of the blood vessels.

Doctors can choose from two procedures to examine the axillary lymph nodes. The newest, least invasive procedure is a sentinel node biopsy, in which only the first node to receive lymphatic drainage from the site of the primary tumor - the sentinel node - is removed and analyzed (see "Removing only the .sentinel' node"). If the sentinel node contains cancer cells, a more extensive procedure called axillary dissection is done to remove another 10-20 lymph nodes for laboratory analysis.

Not all women can opt for sentinel node biopsy. This procedure is not appropriate if there is cancer in more than one area of the breast; if a swollen, suspicious node can be felt under the arm; if you have had neoadjuvant chemotherapy or prior lymph node surgery; or if you are pregnant or nursing.

Not all surgeons have received specialized training to perform sentinel node biopsies. Many studies have correlated the effectiveness of this procedure with the actual experience of the surgeon performing the sentinel node biopsy. It is important to ask if your surgeon has had specialized training in performing this procedure.

If you have an axillary dissection, the doctor will place a drain at the site of the surgery to prevent lymphatic fluid from building up there. You will need to empty the drain at least twice a day. The drain can be removed after about a week. Sometimes during axillary dissection (see Figure 6) sensory nerves are divided, and you might experience numbness or a burning sensation under the arm. Surgical scarring may result in limited shoulder movement.

Lymphedema

Removal of axillary lymph nodes can cause side effects when surgery and scarring disrupt lymphatic channels. This can leave too few lymphatic channels to carry all the lymph fluid that needs to drain from the arm. The fluid backs up and accumulates in the soft tissue of the arm. The result is lymphedema, a swelling of the arm and hand that affects 10%-25% of women after lymph node surgery.

The swelling can range from barely noticeable to a very obvious, uncomfortable enlargement that may disable the upper arm. Lymphedema may appear soon after breast surgery or months or years later, and it can be short-lived or permanent.

Repeated episodes of severe lymphedema, in which the swelling overwhelms the arm and hand, may lead to tissue inflammation and produce rough, leathery, thickened skin and underlying fat tissue. Indeed, many women experience continuing problems with lymphedema. It can be the major cause of discomfort following the surgical management of breast cancer.

The more lymph nodes that are removed, the more likely that lymphedema will occur. Having radiation therapy to the armpit increases the chance of developing lymphedema; so does being obese. Older women and women with arthritis may be at increased risk of developing this complication.

Figure 6: Finding the sentinel lymph node To help determine the stage of an invasive cancer, the axillary (underarm) lymph nodes are examined under the microscope for cancer cells. In conventional lymph node surgery, the surgeon removes level I and II nodes (see image). But removal of these nodes disrupts lymph channels and may injure nerves. In sentinel node biopsy, the surgeon locates the first node into which the tumor drains (the sentinel node) and examines it for the presence of cancer cells. To identify the sentinel node, the surgeon injects the tumor with a radioisotope and/or blue dye, which travels through the breast lymph channels to the first node in the underarm chain. This sentinel node is removed and examined microscopically for signs of cancer.

Preventing lymphedema. Anything you can do to avoid an increase in lymph production or a buildup of lymph fluid can help prevent lymphedema. Here are some specific steps to take:

• Avoid trauma or injuring the skin in any way. An infection can cause scarring and narrowing of the lymphatic vessels. Use an antibacterial soap when bathing. Use an electric shaver or wax to remove underarm hair, to minimize the chance of nicking the skin. Be careful when trimming fingernails on the affected side. Wear gloves when you work outside and when you wash dishes. Thoroughly clean any injury or infection - large or small - with antibacterial soap, apply antibiotic ointment, and then cover the wound with a bandage.

• Avoid blocking lymph transport in the susceptible arm and hand. Tight sleeves, jewelry, narrow bra straps, or the strap of a shoulder bag can aggravate lymph blockage, as can carrying a heavy handbag, shopping bags, or a child on the affected arm.

• Wear loose fitting clothing

• Don't strain your muscles. Vigorous exercise and some arm movements increase blood flow and lymph production and may overwhelm the remaining lymph channels. Use the affected arm as normally as possible. Avoid heavy lifting with the affected arm. If you perform any weight lifting or strength training, consider wearing an elasticized compression sleeve. To avoid overstressing the arm, alternate training among the arm and other body parts, limit repetitions to 10, and advance very slowly when increasing the amount of weight.

• Avoid heat and sunburn. Heat and burns can increase lymph production. Protect your arm from hot sun and hot water, and apply sunscreen before going out in the sun. Also avoid exposing the arm to excessive cold temperatures.

• If possible, avoid getting blood drawn or receiving any intravenous injection on the affected side.

• Try to keep the arm at the level of your heart or higher.

• Maintain a normal weight.

• Tell your surgeon or primary care provider about even the slightest swelling, tightness, or feeling of heaviness in the arm after lymph node surgery.

Treating lymphedema. If you have lymphedema, take meticulous care of your skin to keep it supple and to prevent infections. Use a compression sleeve to provide external support to the lymph system, especially if you plan to exercise, work hard, or travel by airplane.

Schedule regular manual lymphatic drainage by a trained therapist, to direct fluid toward the functioning lymph channels. The physical therapist will instruct you in applying a compression bandage to wear after manual lymph drainage. The therapist will also instruct you in range-of-motion exercises.

Created by the Faculty of the Harvard Medical School

Copyright Harvard Medical School, Harvard University, 2007

Last updated:	April 23, 2007