Removing lymph nodes

The lymph nodes in the armpit (axillary lymph nodes) are often the first place breast cancer cells spread to outside the breast. To see whether the cancer has spread, some or all of the lymph nodes are removed and checked for cancerous cells.

The operation to remove lymph nodes is called axillary surgery. It is usually performed during breast surgery, but may be done in a separate operation. There are two main types of axillary surgery: sentinel node biopsy and axillary dissection.

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Sentinel node biopsy

When breast cancer first spreads beyond the breast, it is likely to go to particular lymph nodes in the armpit or sometimes near the breastbone (sternum). There may be one, two or a few of these lymph nodes, which are known as the sentinel nodes. A sentinel node biopsy finds and removes them so they can be tested for cancer cells. The procedure is outlined in the box below.

If the sentinel nodes are clear of cancer cells, no further surgery is needed. If one or more sentinel nodes contain cancer cells, axillary dissection or radiation therapy to the armpit may be considered.

Axillary dissection (clearance)

In an axillary dissection, also known as axillary clearance, the surgeon will remove most or all of the axillary lymph nodes (usually 10–20 nodes). If the removed lymph nodes contain cancer cells, your doctor may recommend chemotherapy, radiation therapy, targeted therapy and/or hormone therapy.

Side effects

Possible side effects of both types of axillary surgery include: arm or shoulder stiffness; numbness in the arm, shoulder, armpit and parts of the chest; lymphoedema; and seroma (fluid collecting near the surgical scar). However, these side effects are usually less severe after a sentinel node biopsy than after axillary dissection because fewer lymph nodes are removed. Your surgeon will discuss the potential side effects with you before the operation and explain how they can be managed.

Finding the sentinel nodes

In a sentinel node biopsy, the treatment team works out which lymph nodes are the sentinel nodes through the following procedures:

1. Lymphatic mapping

This is done either the day before or on the morning before the biopsy. A small amount of a radioactive substance is injected into the breast. A scan is taken to show which nodes the substance flows to first. These are likely to be the sentinel nodes.

2. Blue dye injection (not always used)

For the biopsy, you will have a general anaesthetic. If blue dye is being used, it will be injected into the breast. The dye moves into the lymphatic vessels and stains the sentinel nodes blue first. Because of the dye, you will have bluish urine the next day and may have a blue patch on the breast for some weeks.

3. Handheld probe

As well as looking at where the blue dye travels to first, the surgeon uses a handheld probe during the operation to detect the radioactive substance that was injected during the lymphatic mapping. This helps to confirm that the correct sentinel nodes have been identified and the surgeon can then remove them for testing.

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