Lesson 3: Surgery

Sentinel Node Biopsy

Sentinel Node Biopsy (SNB) is a special type of biopsy. It is used to see if breast cancer has spread outside of the breast area, to the lymph nodes. I had SNB in 1998. During that time period, it was still considered an experimental procedure at the hospital where I had my surgery. I consented to be part of the "trial" and my SNB was followed by axillary dissection, or the removal of the lymph nodes.

SNB is a fairly new diagnostic tool to help determine the "staging" of your breast cancer. Generally, your cancer is determined to be Stage I, II, III or IV, with I being the least complicated. Before the onset of SNB, most women had to undergo the removal of most of their underarm lymph nodes. The lymphatic system is the body’s plumbing plant. It is responsible for the drainage of the lymph fluid. The "sentinel node" is the first lymph node that collects fluid from the breast tissue. If you visualize the lymph nodes as the pipes under your kitchen sink, it is a bit easier to understand. Before any clogs can get from your sink to the pipes that go out to the sewer or cesspool, the clog has to go down the drain and through the main pipe, which branches off into the other pipes. That main drain pipe is the sentinel node. The theory behind this procedure is that if the first node is negative for cancer, then the remaining nodes SHOULD be clear.

The procedure is generally done when you are having another type of breast surgery, such as a lumpectomy. You will be injected with either a radioisotope, or tracer, and/or a neon blue dye. You have to wait a while for your body to absorb the materials. In my case, I was injected by a nuclear medicine resident, waited about one hour (I’m not positive of the time frame), and then went to the operating room. In the operating room, I was scheduled for a Sentinel Node Biopsy, a wide excision (fancy name for a larger lumpectomy) and an axillary dissection.

Since the procedure was still in the testing phase, the head of the breast surgery team at my hospital did the SNB. I was attached to an IV, lightly sedated and was aware of my surroundings, in a kind of drug-induced haze. The doctor waved this wand around my arm. The wand was attached to a small machine that resembled an applause meter. (That gives away my age!) The general reference states that it is similar to a Geiger counter. When my underarm started clicking, the surgeon proclaimed that he had found the sentinel node and the surgical team removed it. (I was hoping for a little drama and a cry of "Eureka!").

This is a great new tool, both for surgeon and the patient. Women who undergo axillary dissection have a greater risk for pain, limited range of motion, paresthesia (nerve damage), numbness and lymphedema. On a personal note, after axillary dissection, I had limited range of motion (which cleared up after 6 weeks of physical therapy), numbness (to this day, but to a lesser extent) and lymphedema (which is controlled, but not cured, by special physical therapy, known as MLD - manual lymphatic drainage).

While SNB considerably limits the possibility for all of the above side effects, it does NOT eliminate them. If you are scheduled for any lymph node testing, please research the subject of lymphedema and cellulitis thoroughly before agreeing to axillary dissection in lieu of sentinel node biopsy.

Sentinel Node Biopsy is a powerful tool for assessing the stage of breast cancer. It is not foolproof, but the National Comprehensive Cancer Network (NCCN) has deemed the number of false negatives acceptable. Some women are not good candidates for this procedure: women with large tumors, multicentric cancers (more than one tumor) and/or patients who already have a large empty breast space due to prior breast biopsies/surgeries. Please feel free to discuss this with your doctor. If he/she doesn’t offer this procedure to you, you are well within your rights as an informed patient to ask for clarification.

If SNB is an option, the NCCN guidelines recommend an experienced team. This means that the surgeon has performed a minimum of 30 axillary dissections and that the nuclear med staff, the OR nurses, the pathology department and the oncologists are familiar with the procedure and confident in their abilities.

The SNB itself should take less than one hour. Since the procedure is usually done in conjunction with other breast surgery, you will probably be "on the table" longer than that. You may come out of the surgery with your skin a nice shade of blue, but that wears off quickly. Sometimes the area around your surgery will be blue for a few weeks. I believe that most large medical centers now routinely consider Sentinel Node Biopsy as a preferred option and no longer an experimental procedure. The National Surgical Adjuvant Breast and Bowel Project (NSABP) is investigating the potential benefit, if any, of full axillary dissection in women who have a negative sentinel node.

In my own opinion, based on my experience with both procedures – if you are offered SNB, go for it! Axillary dissection gave me greater stress, more discomfort and longer-lasting side effects than my lumpectomy, wide excision and/or mastectomy alone or in combination.

http://www.cancernews.com/articles/senti...

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