Lymph Node Removal - Jane L Kakkis, MD, MPH
Dr Kakkis is one of the most dedicated and skilled breast cancer surgeons operating in the United States. Her love of the fine arts informs her work as a surgeon. Her patients are well assured that Dr Kakkis approaches her work diligently to assure the best cancer outcome and with the utmost concern for the aesthetic results. She has developed her own specialized techniques to restore the contour of the partially resected breast. Her unique approach to caring for her patients as individuals goes beyond the surgery itself and incorporates all aspects of their well being.
Lymph Node Removal
When you are diagnosed with invasive breast cancer, some of the lymph nodes under the arm on the breast cancer side need to be removed.
The pathways for debris and/or tumor cells as they leave the breast and enter the surrounding structures are through the lymph vessels and into lymph node tissue. The most common pathway is to the area under the arm known as the axilla. This is where the lymph nodes are sampled to see if the tumor has spread outside of the breast tissue. The goal is to correctly assess the possible spread of the disease as well as remove any cancer from the area.
There is a technique called Sentinel Lymph Node Sampling that removes fewer lymph nodes than a traditional complete Axillary Node Dissection. Many women are candidates for the sentinel lymph node technique, which has fewer complications than the complete axillary node dissection.
If, however, there is cancer present in the sentinel lymph nodes, then more nodes are removed and this is referred to as a complete Level 1 and Level 2 axillary lymph node dissection.
Diagnosis
The green areas represent cancer. Tumor cells leave the main tumor and travel through smaller channels to the area under the nipple, where they then travel through larger channels to the area under the arm and into the lymph nodes. The first lymph nodes that the cells encounter on the pathway are the sentinel lymph nodes, and are depicted in blue. The rest of the lymph nodes are depicted in pink.
Lymph Node Sampling
Specialized dye injections are placed under the nipple and travel to the first draining lymph node. The most accurate results are achieved by the use of both a blue staining dye called Lymphazurin and a radioactive dye.The first nodes then become stained blue and also become radioactive. A gamma probe (geiger counter) is used to hear the radioactivity, and the blue color is also used to identify the sentinel nodes. The number of sentinel nodes each patient has is variable, but typically ranges from 1-4.
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Lymphoscintigraphy
A special machine records the radioactivity as it leaves the breast and enters the tissue under the arm.
The lower dark circle should be labeled "injection site under the nipple"; the upper dark circle should be labeled "localization in the lymph node in the underarm area". This picture depicts the lymph node under the arm and the injection site in the breast.
Lymphatic Staining
The blue dye moves through the deeper tissues as well as stains the skin lymphatic vessels. Typically, the dye stains the urine for a few days. The breast loses most of the blue color within a month, although a faint blue color can persist for many months.
Intraoperative Gamma Probe
The geiger counter (radioactivity counter) is placed on the skin to detect the area of highest radioactivity which is when the sound is loudest.
When the sentinel node is identified, it appears blue and the radioactivity is confirmed by placing the geiger counter on it. This allows the surgeon to anticipate the location of the sentinel node before making the skin incision. The blue node(s) is (are) identified and removed and sent to pathology for examination for cancer cells.
Pathology Examination During Surgery
The pathologist takes a piece of the lymph node and looks under the microscope for evidence of breast cancer cells. He or she will notify the surgeon during the operation if he/she can see cancer cells in the sentinel nodes. If there are cancer cells present, then the surgeon will remove additional lymph nodes during the same surgery.
Conclusions
The goals of lymph node sampling are to remove the lymph nodes at high risk for containing cancer cells that have spread beyond your breast and into the tissue under your arm. This allows your team to better advise you on additional treatments you may need as well as removes the cancerous tissue from the area under your arm. This should be done with as little damage to the normal functioning of your arm and lymphatic system as possible.
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