Lymph Node Surgery for Breast Cancer

Axillary surgery plays a vital role in the diagnosis and treatment of breast cancer. It involves evaluating and managing the lymph nodes in the underarm (axilla) to determine the extent of cancer spread and guide further treatment. The decision about the type of surgery is influenced by the extent of disease spread and the cancer's biology, including how it responds to treatment. This tailored approach ensures the most effective and appropriate care for each patient. Below are the available options for managing the axilla:

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• Sentinel Node Biopsy ​

• Axillary Dissection

• Targeted Axillary Dissection

Sentinel Node Biopsy 

A sentinel lymph node biopsy (SLNB) is a minimally invasive procedure used to assess the first lymph nodes (sentinel nodes) to which breast cancer may spread. It is typically performed on patients with clinically node-negative (cN0) breast cancer, meaning no lymph node abnormalities are detected through physical examination or imaging before surgery. Lymphatic mapping, conducted prior to the biopsy, involves injecting a tracer (radioactive substance or blue dye) near the tumour site to identify the sentinel nodes. These nodes are then surgically removed and examined microscopically. If no cancer is found, further lymph node removal is usually unnecessary, reducing complications like lymphedema, which occurs in only a small percentage of SLNB patients (0–7%).

If cancer is detected in the sentinel nodes, additional treatments or surgeries may be considered, though recent research suggests some patients with limited node involvement may not require further axillary surgery. This approach balances effective cancer management with minimising surgical morbidity. SLNB is a critical tool in staging breast cancer and guiding treatment decisions while ensuring a less invasive and safer procedure for most patients.

Sentinel node mapping

Sentinel node mapping is a precise technique to identify sentinel lymph nodes, the first nodes to which cancer is likely to spread from the breast. This procedure is performed before a sentinel lymph node biopsy (SLNB) to ensure accurate targeting during surgery. The process begins with the injection of a safe tracer, such as a radioactive substance (technetium-99m) or a blue dye, near the tumour site. The tracer follows the natural lymphatic pathways, travelling from the tumour to the sentinel nodes.

Imaging techniques, such as lymphoscintigraphy (a specialised scan) or visual identification during surgery, are then used to locate the tracer-marked nodes. The radioactive tracer can be detected with a handheld gamma probe, while the blue dye visually stains the sentinel nodes, making them easy for the surgeon to identify and remove. This mapping method enhances the accuracy of SLNB, ensuring only the relevant nodes are removed. By minimising unnecessary tissue removal, sentinel node mapping reduces the risk of complications, such as lymphedema, and improves surgical outcomes.

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​Axillary Lymph Node Dissection (ALND)

Axillary lymph node dissection (ALND) is a surgical procedure performed to remove multiple lymph nodes from the underarm (axilla) when cancer is detected in the sentinel lymph nodes or other axillary nodes. The primary goal of ALND is to thoroughly evaluate and manage the spread of cancer, particularly in cases where the disease has advanced beyond the breast. This procedure provides critical information about the extent of cancer involvement, helping guide further treatment decisions such as chemotherapy, radiation, or systemic therapies.  

During ALND, a surgeon removes a group of lymph nodes, typically ranging from 10 to 30, depending on the extent of disease involvement. These lymph nodes are then examined microscopically to assess the presence and extent of cancer. The procedure is usually performed under general anaesthesia and is often combined with breast surgery, such as mastectomy or lumpectomy.  

While ALND remains an effective tool for managing axillary disease, it is generally reserved for patients with confirmed lymph node involvement because it is more invasive than sentinel lymph node biopsy (SLNB).

To minimise complications, ALND is performed with careful surgical techniques, and post-operative care often includes physiotherapy to improve arm mobility and reduce the risk of lymphedema. In recent years, research has focused on balancing the effectiveness of ALND with less invasive approaches, such as targeted axillary dissection or the omission of ALND in select patients with minimal sentinel node involvement.  

ALND is an essential component of breast cancer treatment in appropriate cases, offering comprehensive management while ensuring that the benefits outweigh the risks. At Breast and Wellness, we ensure this procedure is tailored to the patient’s unique clinical situation, focusing on safety, recovery, and long-term outcomes.  

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Targeted Axillary Dissection (TAD)

Targeted axillary dissection (TAD) is an innovative surgical approach that combines the benefits of sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) to provide precise management of the axilla in breast cancer patients. This procedure is particularly useful for patients with limited lymph node involvement who have received preoperative treatment, such as neoadjuvant chemotherapy, which may have reduced or eradicated cancer in the lymph nodes.  

TAD involves the removal of specific lymph nodes that are identified preoperatively as suspicious or cancerous, along with sentinel lymph nodes. This process starts with placing a small marker, such as a clip, in the affected lymph nodes during a pre-treatment biopsy. After neoadjuvant therapy, imaging techniques like ultrasound or a gamma probe are used to locate the marker during surgery. Additionally, sentinel node mapping is performed to identify sentinel nodes. Both the marker-marked nodes and sentinel nodes are removed and examined for residual cancer.  

This dual approach allows for a more targeted assessment of the axilla, reducing the need for a complete ALND in many cases. By focusing on nodes most likely to contain cancer, TAD minimises the invasiveness of surgery while maintaining diagnostic accuracy.  

The advantages of TAD include:  

• Reduced Surgical Morbidity: Fewer lymph nodes are removed compared to ALND, lowering the risk of complications like lymphedema, shoulder stiffness, and nerve injury.  

• Accurate Staging: TAD provides a comprehensive evaluation of the axilla by targeting both previously involved and sentinel nodes.  

• Preservation of Lymphatic Function: This approach preserves more healthy lymph nodes, reducing disruption to the lymphatic system and improving long-term outcomes.  

TAD is especially beneficial for patients with node-positive disease who respond well to preoperative therapy, as it helps avoid unnecessary removal of unaffected lymph nodes. At Breast and Wellness, we prioritise advanced techniques like TAD to ensure precise, personalised care while minimising the physical impact of surgery on our patients. This cutting-edge approach represents a significant step forward in the management of axillary disease in breast cancer.  

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