Lymph nodes are small glands that work to filter a type of fluid called lymphatic fluid which gets rid of waste products from the body. If there is cancer nearby the lymph nodes may also trap some cancer cells that have moved from the cancer. There are many lymph nodes in your body which are often gathered together in groups; one such group is in the armpit, known as axillary lymph nodes.
Most surgery for breast cancer will also involve surgery to the axillary lymph nodes in on the affected side. This is because if breast cancer spreads from the breast it normally goes to the lymph nodes in the area; knowing whether there are cancer cells in these lymph nodes helps us to plan the best treatment for you. Most people with breast cancer do not have any cancer cells in the lymph nodes. There are 2 main types of lymph node surgery, either to take out a few, targeted, lymph nodes (Sentinel Lymph Node biopsy) or to take out most of the lymph nodes from under your arm (Axillary clearance).
At the time that we carry out a biopsy of an abnormality in the breast we may also check the lymph nodes under your arm with an ultrasound scan and may take a sample using a needle and syringe (fine needle aspiration). If you are found to have breast cancer but there is no problem with the ultrasound or needle test of the lymph nodes we will usually recommend you have a Sentinel Lymph node biopsy at the time of your breast surgery.
If we find cancer cells in the needle test from the lymph nodes we will recommend instead that you have an axillary clearance at the time of the breast cancer surgery.
Sentinel Lymph node biopsy
A Sentinel lymph node biopsy aims to remove just a few lymph nodes which are the ones most likely to be affected if cancer cells have spread from the breast. These lymph nodes are identified using two types of dye.
The first dye is a small dose of radioactive tracer which is injected into your breast in the x-ray department while you are awake prior to your surgery. The second is a blue dye that the Surgeon will inject into your breast after you have been put under a general anaesthetic for your operation. Both of these dyes travel from the breast to the lymph nodes under the arm and during your surgery the Surgeon can find the most important lymph nodes using a probe to detect the radioactivity and by seeing which nodes have turned blue.
The blue dye will cause a bright blue stain on the skin of the breast which will fade quite quickly to look like a bruise, but which may then be visible for up to a year after your surgery. After your operation you may notice when you pass urine that it is a green colour for about a day – this is normal and happens because the blue dye is passed out in your urine. Occasionally people have an allergic reaction to the blue dye; because it is given when you are already under a general anaesthetic you are safe if this happens, and we will deal with the allergy for you. Allergy to the blue dye is more common if you have allergies to dyes found in food, so please let us know if this is the case as we may avoid using the blue dye altogether for you.
Sometimes the dyes that we give do not identify any lymph nodes for us; in this case we will proceed to take either a sample of around 4 lymph nodes out, or proceed to do an axillary clearance, whichever we feel is best for you. Please let us know before your surgery if you would not want us to proceed to an axillary clearance in this situation.
If we find cancer cells in the sentinel lymph nodes we are likely to recommend that you have the rest of the lymph nodes removed (axillary clearance). If we can get the sentinel lymph nodes looked at under the microscope quickly while you are asleep we will do this and if cancer cells are seen we will do the axillary clearance then to avoid you having to have a second operation. If we can’t get the sentinel lymph nodes looked at under the microscope but they feel like they have cancer in we will usually do an axillary clearance unless you have asked us not to. If the sentinel lymph nodes are checked while you are asleep this is only a quick check; the lymph nodes always get a more thorough analysis afterwards, and there is the chance that some cancer cells may be found even though they weren’t seen at the time of your surgery.
Axillary Clearance
Axillary clearance is removal of most of the lymph nodes from under the arm. We are likely to recommend this if you have cancer cells detected in the lymph nodes, either from a needle test at the time of your breast ultrasound, or from having a sentinel node biopsy. After an axillary clearance you will normally have a small drain tube leading to a bottle to collect any extra fluid. You can go home with this drain in place and nurses will visit you to check on it and remove it when it is ready.
Side effects of lymph node surgery
You will normally have a scar in your armpit area after lymph node surgery. If you are having a mastectomy as your breast operation the armpit scar will not be separate but will form part of the scar that goes across your chest wall.
You may experience numbness of the skin of the upper inner arm following lymph node surgery, particularly if you have an axillary clearance. This is due to damage of a small nerve that supplies a patch of skin on your inner arm. This is not an area of your body that you need to have good sensation in and most people are not too troubled by the numbness. However, for the first few weeks this nerve may try to repair itself, and your body may feel that as a prickling or burning sensation. If this is troublesome then let us know as we can give special types of painkiller for it.
A fluid collection can form after any lymph node surgery; this is known as a seroma. Your body will eventually absorb this fluid and nothing needs to be done about it. If, however you are very uncomfortable, or you notice redness or increasing pain in the area, let us know as we can drain the fluid with a needle and syringe and if there are signs of infection you may need antibiotics.
You may experience some shoulder stiffness after lymph node surgery. You will have been given a leaflet of exercises to do and we would encourage you to take regular painkillers so that you can do these exercises comfortably. If you have had an axillary clearance you will also be seen by a physiotherapist after your surgery to give you advice and exercises.
Some people develop ‘cording’ in the armpit following lymph node surgery. This is due to scar tissue forming in a band, and it feels like a tight string. It is harmless but can be uncomfortable. Let us know if you think you may be getting this as we can help you with physiotherapy and massage which will help it settle down.
Lymphoedema of the arm can occur following lymph node surgery – this affects up to around 4 in 100 people having sentinel lymph node biopsy and up to 30 in 100 having an axillary clearance. Lymphoedema can occur at any time in the future after lymph node surgery and although we can help with it we can’t make it go away completely. Your breast care nurse will have given you information on things you can do to help prevent it, such as avoiding cuts, insect bites, sunburn or infections in the arm on the side where you have had the lymph node surgery
To download our patient information about lymph node surgery, please click here.