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One of the aims of breast cancer management is to assess the extent to which
the disease may have spread within the body. Breast cancer cells have the potential to
grow, multiply and enter the nearby blood and lymphatic vessels. Once inside the
vessels the cells can then travel to other parts of the body. Breast cancer cells may
spread via the lymphatic vessels to the lymph nodes in the armpit. Surgery to the armpit
is carried out to assess the degree to which the breast cancer cells may have spread.


A lymph node is part of the body’s lymphatic system. In the lymphatic system, a
network of lymph vessels carries clear fluid called lymph. Lymph vessels lead to lymph
nodes, which are small, round organs that trap cancer cells, bacteria, or other harmful
substances that may be in the lymph and thus plays a vital role in body’s defense
mechanism of fighting infections and tumors. Groups of lymph nodes are found in the
neck, underarms, chest, abdomen, and groin.


The word sentinel means “a guard” or “one who keeps watch”. The sentinel
lymph node is the first lymph node to which cancer is likely to spread from the primary
tumor. Cancer cells may appear in the sentinel node before spreading to other lymph
nodes. In some cases, there can be more than one sentinel lymph node. In most cases,
the sentinel node is in the armpit. However, sometimes the sentinel node is in a different
area of the body, such as under the breastbone or above the collar bone.


Sentinel node biopsy is a new surgical procedure, still being tested in clinical
trials. It is a procedure in which the sentinel lymph node is removed and examined
under a microscope to determine whether cancer cells are present. Sentinel lymph node
biopsy is based on the idea that cancer cells spread (metastasize) in an orderly way
from the primary tumor to the sentinel lymph node, then to other nearby lymph nodes.

A negative sentinel lymph node biopsy result suggests that cancer has not
spread to the lymph nodes. A positive result indicates that cancer is present in the
sentinel lymph node and may be present in other lymph nodes in the same area. This
information may help the doctor determine the stage of cancer and develop an
appropriate treatment plan.


Sentinel lymph node biopsy may be done on an outpatient basis or require a short
stay in the hospital.

➢ To identify the sentinel lymph node, the surgeon injects a radioactive substance
(technetium-labeled sulfur colloid) or blue dye (isosulfan blue) near the tumor in the
operating theatre just before breast surgery.

➢ Eutectic mixture of lidocaine and prilocaine (EMLA) cream may be applied to reduce
tracer injection pain unless contraindicated.

➢ The surgeon then uses a scanner to find the sentinel lymph nodes containing the
radioactive substance or looks for the lymph node stained blue with the dye.

➢ Once the sentinel lymph node is located, the surgeon makes a small incision (about
½ inch) in the skin overlying the sentinel lymph node and removes the lymph node.

➢ The sentinel node is checked for the presence of cancer cells by a pathologist.

➢ If cancer is found, then the patient may have to undergo a complete axillary lymph
node dissection. This is done to remove the remaining lymph nodes, which may
contain cancer and then radiotherapy may be planned.


➢ Sentinel lymph node biopsy is a simple, inexpensive and accurate procedure in

breast cancer patients
➢ Sentinel node biopsy has fewer side effects than the standard surgery to remove
lymph nodes (axillary lymph node dissection or axillary clearance (ALND).

If sentinel lymph node biopsy is done and the sentinel node does not contain
cancer cells, the rest of the regional lymph nodes may not need to be removed.
Because fewer lymph nodes are removed, there may be fewer side effects. When
multiple regional lymph nodes are removed, the patient may experience side effects
such as lymphedema, numbness, a persistent burning sensation, pain, infection, edema
of the arm, sensory disturbances, impairment of arm mobility, and shoulder stiffness.
➢ Sentinel lymph node biopsy has been reliably accurate as a minimally invasive
surgical alternative for identifying lymphatic breast metastasis.
➢ There is less pain and better arm mobility in the patients who undergo sentinel-node
biopsy only than in those who also undergo axillary dissection.
➢ There is no need for a drain, or physical therapy exercises.
➢ Usually the surgical scar is smaller and hence more rapid recovery.
➢ The procedure is successful in more than 90% of patients.


➢ Pain or bruising at the biopsy site

➢ Possibility of an allergic reaction to the blue dye used to find the sentinel node.

➢ Post operatively the patient’s urine may be blue for the next 24 hours after surgery,
and the skin of the breast may be blue which will fade in few months.

➢ In less than 5% (one in twenty) patients, the sentinel nodes cannot be identified.

➢ Sentinel lymph node biopsy procedure can’t be performed on patients who have had
radiation therapy or surgery in their breast or axilla as changes in the breast and
axilla from the radiation therapy or surgery may make the results inaccurate.
➢ People who have enlarged lymph nodes underneath their arm, or people who
already have breast cancer metastatic to their axillary lymph nodes. They should
undergo a traditional axillary lymph node dissection.
➢ People who already have had a mastectomy can’t undergo the procedure because
there is no accurate way to inject the dye to identify the lymph node.
➢ People with large tumors (greater then 5cm) have a higher incidence of lymph node
spread of their cancer, and may be better served by a traditional lymph node
➢ People in whom it will be difficult to accurately inject the dye. This includes those in
whom we are unable to find the primary breast tumor (an “occult” malignancy), and
people in whom the tumor is dispersed through more than one area of the breast (a
multifocal tumor).


➢ Sentinel lymph node mapping for breast cancer was first reported in 1994. Since
then, researchers have improved methods for finding the sentinel lymph node.

➢ Several studies have shown that when the sentinel node is negative, the remaining
nodes are usually negative.

➢ Other research has focused on the identification of the sentinel lymph node in
patients with cancer of the vulva, cervix, prostate, bladder, thyroid, head and neck,
colon, rectum, and stomach.

➢ Studies continue to examine the accuracy of sentinel lymph node biopsy and its
effect on survival of people with various cancers.

➢ Sentinel node biopsy is being tested in clinical trials to see:

• if it can accurately find out whether cancer cells have spread to the lymph nodes

• what side effects it has (if any).


Invasive breast cancer can spread through the lymph ducts and blood vessels to
other areas of the body. The sentinel lymph node is the first lymph node that the lymph
ducts drain into. Whether or not the cancer has spread to the sentinel lymph node
indicates whether the cancer has started to spread beyond the breast. A new technique
called sentinel lymph node biopsy identifies this lymph node, and allows only this lymph
node to be removed. Removing only the sentinel lymph node can allow breast cancer
patients to avoid many of the complications and side effects associated with a traditional
axillary lymph node dissection.
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