Sentinel node biopsy

One of the first places breast cancer will spread if it is invasive is to the lymph nodes under the arm. Nearly all women with invasive cancer will be advised to have these nodes examined, and some surgeons think it prudent to examine the underarm nodes of women with noninvasive ductal carcinoma in situ (DCIS) as well, especially if it is a high-grade or aggressive form or there is reason to believe that DCIS is distributed throughout the breast.

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Until recently, surgeons would remove as many lymph nodes as possible in an axillary (underarm) node dissection. However, this process often caused lymphedema, a numbness and a serious swelling of the arm. The sentinel node biopsy checks for cancer in the first lymph nodes to receive lymph drainage from the breast--the most likely nodes to contain cancer if it has spread. If a sentinel node is removed and found to be healthy, the chance of finding cancer in any of the remaining nodes is very small, and no other nodes need to be removed. When performed by a skilled surgeon, this type of biopsy carries much less risk of lymphedema. Typically, doctors need to have performed about such 30 to 50 surgeries removing the sentinel node and then the rest of the underarm nodes as well, as a check, before they've got the hang of reliably isolating and removing the sentinel nodes. Breast surgeons are more likely to have had the requisite experience than are general surgeons.

To identify the sentinel lymph node or nodes, a surgeon can use one of two "tracers"--materials that are injected in the breast and then flow through the lymph channels into the axillary lymph nodes. One tracer contains a small amount of radioactive material. The surgeon then uses a hand-held Geiger counter to find radioactive lymph nodes. The second tracer is a blue dye, which also flows to the lymph nodes. By following the dye, the surgeon can identify the first lymph nodes reached. At the time of the biopsy, the surgeon will remove any other lymph nodes that feel suspicious.

If a sentinel lymph node is found to contain cancer, a complete axillary dissection typically is done to remove additional lymph nodes under the arm. These nodes also will be examined and if they are found to contain cancer, the chances that the cancer has spread to other parts of the body will be greater. In these situations more aggressive medications or treatment will be recommended.