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Surgery for the Armpit

Sentinel Lymph Node Biopsy (SLNB)-Removal of Axillary Lymph Nodes

The direction of lymph flow in the breast tissue is largely towards the axillary lymph nodes. For this reason, cancer cells that spread usually first go to the axillary lymph nodes. Knowing the status of axillary lymph nodes in breast cancer patients is important for diagnosis, treatment and follow-up.

Removal of the axillary lymph nodes applies to invasive tumors. In-situ cancers (confined within the milk ducts) theoretically do not need to be removed from the armpit as they do not travel to the lymph nodes.

Technique: Blue dye (isosulfan blue or methylene blue) alone or in combination with a radioactive substance is injected into the tumor site or under the nipple. Paint 5-7 min. It reaches the first (sentinel) lymph node in the armpit. The number of sentinel lymph nodes can be more than one; the average is 2. These lymph nodes are removed to check whether they contain tumor cells. If no tumor cells are seen, the procedure is terminated; other lymph nodes in the armpit do not need to be removed. If cancer cells are found in these lymph nodes, the axillary lymph nodes must be removed.

Removal of axillary lymph nodes (axillary lymph node dissection) has 3 purposes:

  • Accurate staging of the disease
  • Guiding concomitant therapies
  • Ensuring local tumor control in patients with lymph node involvement

The presence or absence of axillary lymph node involvement is the most important parameter for the prognosis of breast cancer (how much it threatens the patient’s life).

While removal of the lymph nodes related to the breast fulfills the above-mentioned objectives, there is a risk of side effects such as swelling in the arm, which is rare. Some precautions are taken to prevent these risks, such as protecting the patient’s hand and arm from injury.

An average of 20-30 lymph nodes are removed with standard axilla dissection. Recent studies have shown that at least 10 lymph nodes need to be removed for accurate sampling of the axilla.

Thanks to the success of breast cancer screening programs and women becoming more aware of breast cancer, the majority of breast cancer cases can now be caught at an early stage. Today, we know that approximately 60% of all breast cancers and 75% of early stage breast cancers do not involve the axilla lymph nodes at the time of diagnosis.

If lymph node involvement can be demonstrated in these patients, axilla dissection is not necessary. For this purpose, the technique of sentinel lymph node sampling has been developed in recent years.

In patients in whom no enlarged axillary lymph node is detected on examination, sentinel lymph node sampling is performed to obtain information about axilla lymph node involvement. Axilla dissection is not necessary in patients with negative sentinel lymph nodes.

The reliability of sentinel lymph node sampling in detecting axillary lymph node involvement has been proven in many studies. It requires a certain learning process, but when done correctly, it is a safe method and there are no side effects such as swelling in the arm.

Points to Consider After the Operation

In patients undergoing axillary dissection, it is very important to protect the arm from trauma and infection. As lymph flow may be affected, swelling in the arm (lymphedema) may develop.

The risk of lymphedema is closely related to how large the axillary lymph nodes are removed. This rate is considerably lower after sentinel lymph node sampling. Radiotherapy to the armpit after surgery further increases the risk.

There may be temporary, rarely permanent limitation of movement in the arm and shoulder. Arm exercises are started after the drains are removed. It is especially useful to start some exercises that increase the movements of the shoulder joint.

After the drains are removed, lymph fluid may collect in the armpit and under the skin of the breast (seroma). There is no need to intervene as long as it does not reach dimensions that disturb the patient. Otherwise, it can be drained with a syringe.