Why do my lymph nodes require investigation?

Breast cancer can spread along fine lymph channels to the lymph nodes (glands) in the armpit. At present there is no simple test or scan that can tell us whether the nodes in the armpit contain cancer or are cancer free. This means that during breast cancer surgery the surgeon also needs to remove some glands from the armpit. These glands can be analysed under a microscope to find out if the cancer has started to shed cells to the nodes. This information can then help you and your doctors decide on what further treatment you may require to treat your breast cancer. Currently removal of four or more lymph nodes is regarded as standard care.

Removal of the lymph nodes can sometimes have side effects:

• seroma - a temporary collection of fluid in the armpit,
• neuralgia - pain in the armpit region, usually temporary,
• lymphoedema - swelling of the arm, which can be temporary or permanent,
• numbness, soreness or a stiffness of the shoulder. This is usually temporary.

Because of these side effects surgeons have been looking for other accurate ways to find out what is happening in the lymph nodes. A new technique of assessing the armpit glands is called Sentinel Lymph Node Biopsy (SLNB).  However before any Breast unit can offer SLNB they need to be confident they can accurately find the SLN.  This means that the breast team has to undergo further specialist training and this is where your help is needed. 

You are asked to consider taking part in this training programme. If you decide to take part there should be no additional risks to you.  If you decide not to take part then there will be no change to your care and you will receive the current standard treatment.

What is Sentinel Lymph Node (SLN) Biopsy?

The sentinel node (the chief node) is the first lymph node to which breast cancer can spread. Recent studies have shown that if the sentinel node is free of cancer cells it is very unlikely there is a further cancer in the armpit glands. So following removal of the SLN, if it is cancer free, a woman would not need to undergo any further armpit surgery. In six to eight out of ten women the armpit nodes are cancer free. Those who do have cancer in the SLN will require further treatment to their armpit. This may involve further surgery.

SLNB was developed in the USA and Europe and is being used successfully around the world. In the UK, clinical trials (the ALMANAC trial) have confirmed that the accurate identification of the sentinel lymph node is possible and that women who had SLNB had fewer side effects from their surgery. Many breast teams now want to offer their patients SLNB as it has been proven to be safe and reliable.

What is involved in SLNB?

• Before surgery a tiny amount of radioactive fluid is injected into the skin of your breast. The breast and armpit is then scanned and the position of the SLN is marked. The radioactivity used is less than that required for a mammogram.

• During surgery, while you are under general anaesthetic, a 5ml teaspoon worth of blue dye is injected into the breast near the nipple. The radioactive fluid and the dye are carried along the lymph vessels to the SLN.

• The surgeon can then remove the blue and radioactive node as this is the node most likely to be the SLN. At least four or more of the remaining armpit lymph nodes will then be removed as this is the current “standard” treatment in the UK.

• The SLN will be sent to the laboratory with the rest of the glands. In this way the pathologists can check that the surgeons have found the SLN.

 Once a Surgeon has demonstrated they can successfully find the SLN in thirty patients they can then perform just a SLNB i.e. just remove one or two glands. This will save six-eight women out of ten having further armpit surgery.

To summarise:

1. Currently the standard way of assessing lymph nodes in the UK is removal of four or more armpit nodes. This can result in a life-long risk of developing lymphoedema and other minor but irritating side-effects.

2. Sentinel lymph node biopsy is a new technique in the UK. It identifies the lymph node to which breast cancer is most likely to spread. If the sentinel node is free of cancer no further armpit surgery would be required. If the sentinel node contained cancer, further treatment of the armpit would be required.

3. We need your help before we can offer this new technique.

What are the possible risks to me volunteering to help this programme?

There should be no additional risks to you. The amount of radioactive fluid is tiny and quite safe. Allergic reactions to the dye are very rare (less than 0.1%). Allergic reactions can be treated if they occur.

 What are the disadvantages? 

• The radioactive injection may be slightly uncomfortable.
• The operation may take 10-30 minutes longer.
• The dye may temporarily stain your skin, your urine and stools.

What are the possible benefits?

You will not receive any direct benefit. Your surgeon will still be carrying out the standard removal of further lymph nodes once the sentinel node has been removed.

However, if we can show over the next year or two that we can accurately and reliably identify the sentinel lymph node, we can then reduce the amount of armpit surgery required for the majority of women.

What if I say ‘no’?

There will be no change to your care and you will receive the current standard treatment.

Many thanks for taking the time to read this information. If you have any further questions please do not hesitate in speaking to your breast care nurse on weekdays on telephone:

0191 2820207 or 2820208, Office hours: 8.30am- 4.30pm. (24 hour answerphone)

Please see 'Meet the Team' for further details if you prefer to email.

Published by the Breast Care Nurse Specialists

Newcastle Hospitals NHS Trust

Next Review: June 2008