Underarm Surgery

Sentinel Lymph Node Biopsy (SLNB) - Removal of the Underarm Lymph Nodes

Lymph flow within the breast tissue is largely directed to the underarm lymph nodes. Therefore, cancer cells that have acquired the ability to spread generally first migrate to the underarm lymph nodes. Knowing the status of the underarm lymph nodes in breast cancer patients is important for diagnosis, treatment, and follow-up.

Removal of the underarm lymph nodes is only effective for invasive tumors. In situ cancers (those confined to the milk ducts) theoretically do not need to be removed from the armpit because they do not travel to the lymph nodes.

Technique: A blue dye (isosulfan blue or methylene blue), either alone or in combination with a radioactive substance, is injected into the tumor area or under the nipple. The dye reaches the first (sentinel) lymph node in the armpit within 5-7 minutes. The number of sentinel lymph nodes may be more than one; the average is two. These lymph nodes are removed and examined for tumor cells. If no tumor cells are seen, the procedure is terminated; there is no need to remove the other axillary lymph nodes. If cancer cells are found in these lymph nodes, the axillary lymph nodes must be removed.

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

• Accurate staging of the disease
• Guideing concomitant treatments
• Local tumor control in patients with lymph node involvement

The presence or absence of axillary lymph node involvement is the most important parameter determining the course of breast cancer (and the degree to which it threatens the patient's life).

While removing breast-related lymph nodes meets the above-mentioned objectives, there is a risk of side effects, such as swelling in the arm, which is rarely seen. To prevent these risks, precautions are taken, such as protecting the patient's hand and arm from injury.

With a standard axillary dissection, an average of 20-30 lymph nodes are removed. Recent studies have shown that at least 10 lymph nodes need to be removed to accurately sample the axilla.

Thanks to the success of breast cancer screening programs and increased awareness among women about breast cancer, the majority of breast cancer cases can now be detected at an early stage. Today, we know that approximately 60% of all breast cancers and approximately 75% of early-stage breast cancers do not have axillary lymph node involvement at the time of diagnosis.

If it can be demonstrated that there is no lymph node involvement in these patients, axillary dissection is unnecessary. This is the purpose of this study. In recent years, the sentinel lymph node sampling technique has been developed.

In patients who do not find an enlarged axillary lymph node during examination, sentinel lymph node sampling is performed to determine whether axillary lymph node involvement is present. Axillary 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 numerous studies. It requires a certain learning curve, but when performed correctly, it is a safe procedure and does not cause side effects such as arm swelling.

Postoperative Considerations

In patients undergoing axillary dissection, it is crucial to protect the arm from trauma and infection. Because lymphatic drainage may be compromised, arm swelling (lymphedema) may develop.

The risk of lymphedema is closely related to the extent of the axillary lymph nodes removed. This rate decreases significantly after sentinel lymph node sampling. Radiotherapy to the armpit after surgery further increases the risk.

Temporary, and rarely permanent, limitation of movement in the arm and shoulder may occur. Arm exercises are started after drains are removed. It is particularly beneficial to begin exercises that increase shoulder joint mobility.

After drains are removed, lymph fluid may accumulate in the armpit and under the skin of the breast (seroma). Unless it reaches a level that bothers the patient, intervention is not necessary. Otherwise, the patient can be injected with a syringe.It can be drained by planting.