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Sentinel lymph node biopsy

The surgical exploration of the armpit is an integral part of surgical treatment for breast cancer. This way we can see if the disease has spread to the lymph nodes of the armpit. This piece of information is very important in determining the stage of the disease, assessing the prognosis and selecting the required post-operative systemic treatment.

In the past, the exploration of the armpit was performed by means of the so-called axillary lymph node dissection, i.e. the removal of all lymph nodes of the first two levels of the armpit (at least 10 in number). This procedure is accompanied by high morbidity levels.

 The most common complications of axillary lymph node dissection are:

  • Post-operative hematoma.
  • Persistent seroma (accumulation of fluid in the area of the procedure which may last for many days or even months).
  • Shoulder dyskinesia.
  • Shoulder dyskinesia.
  • Upper extremity lymphedema. It is an edema (swelling) of the ipsilateral hand, which in the most severe cases causes serious disability.
  • Development of malignant lymphangiosarcoma where a lymphedema already exists (rare complication).

        Lymphedema of the right upper extremity             Lymphedema of the left upper extremity          Lymphangiosarcoma of the right upper extremity

Nowadays, the procedure of choice for the assessment of the armpit in women who do not show any clinical signs of cancer dissemination is the sentinel lymph node biopsy. The sentinel lymph node is the first axillary lymph node that receives lymph (a bodily fluid) from the breast and constitutes the first station in the dissemination of cancer. No metastasis to this first lymph node means no metastasis to the entire system of axillary lymph nodes.

The sentinel lymph node biopsy technique is described in the steps bellow:

  • Injection of a radioisotope (Technetium 99) in the breast around the tumor or around the area of the nipple. The radioactive agent is transferred from the breast through the lymph vessels and is accumulated to the first axillary lymph node it meets (sentinel lymph node).
  • Lymphoscintigraphy (special scintigram) that visualizes the area of the armpit where the radioisotope has been accumulated.
  • In operating theater, right after general anesthesia,injection of a blue dye (Patent blue or methylene blue) around the tumor or around the area of the nipple.
  • Detection of the axillary point where the radioisotope has been accumulated using a special radioactive signal tracer as a guide. Performance of a short incision at the armpit.
  • Detection and removal of the sentinel lymph node (it is stained blue and produces a radioactive signal). Dispatching of the sentinel lymph node to the pathologist for a frozen section.
  • If the sentinel lymph node is negative, the procedure in the armpit ends. If the sentinel lymph node is positive, the procedure is followed by axillary lymph node dissection.
  • In case of positive sentinel lymph node, axillary lymph node dissection can be omitted, if all of the following conditions are true:
    • Tumor size is 5 cm or less
    • Positive sentinel lymph nodes are 2 or less
    • Breast conserving surgery has been planned
    • Whole breast irradiation has been planned
    • Patient hasn’t received preoperative chemotherapy

In most cases more than one sentinel lymph nodes are detected and removed (usually 2-4).

Detection of the sentinel lymph node is possible only by means of the radioisotope method or the blue dye method. However, the combination of both methods guarantee higher detection rates.

Sentinel lymph node biopsy is a safe and reliable method for evaluating the axillary lymph nodes. It is easy to perform, with a very low possibility for complications and a short surgical scar. It saves at least 70% of the patients from lymph node dissection and its possible complications.

Photo Gallery
Pre-operative lymphoscintigraphy. The presence of the sentinel lymph node is marked by an arrow.
Injection of the blue dye in the area of the nipple.
Search for the sentinel lymph node using the special radioactive tracer.
The sentinel lymph node has been found and obtained through a small incision at the armpit.
The sentinel lymph node has been removed and the radioactive signals are monitored using the tracer.
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