Tina J. Hieken, M.D., Breast/Melanoma Surgery, Mayo Clinic: Hi, I'm Tina Hieken. I'm a surgical oncologist and an associate professor of surgery, and one of the breast surgeons here at Mayo Clinic in Rochester. Today I'd like to talk with you about lymph node surgery that's done for women with newly diagnosed breast cancer. Sometimes the lymph node surgery is the part of breast cancer treatment that women have the greatest fears and concerns about. One of the reasons that we evaluate lymph nodes for women with newly diagnosed breast cancer is to make sure that we stage the disease accurately, and that we provide you with the best treatment.

Our first step in our practice here in looking at lymph nodes is to do an axillary ultrasound. So we look at the lymph glands under the arm but we call the axillary lymph nodes using an ultrasound probe. For women who don't have lymph nodes that are enlarged that we can feel, most of the time when they have the lymph node ultrasound, the nodes will be normal but sometimes they will look abnormal. In those cases, we have you get a little needle biopsy of those lymph nodes so we know about them ahead of time. For those cases where the lymph nodes are normal -- and that's most women -- the next step is to discuss with you what we do from a surgical standpoint to manage the lymph nodes. For most women with normal lymph nodes under the arm and normal lymph nodes on the ultrasound, what we recommend to stage the lymph nodes and treat them is to do a sentinel lymph node biopsy. This involves getting an injection into the breast of a tracer done prior to surgery, and then at the time of operation, an injection of a blue dye that's done while you're asleep. This dual tracer method allows us to be really accurate. Those tracers actually trace out where cells might leave from the breast into the lymph glands if they were to travel from the primary breast tumor into the lymph nodes under the arm. Then in operation, we remove those lymph nodes -- usually we remove one or two or three; sometimes more -- and give them to the pathologist.

There's been some recent studies that have suggested that for some women who undergo breast conserving treatment (a lumpectomy) along with the sentinel lymph node biopsy, especially women with small tumors, especially women whose tumors are estrogen receptor-positive and women who plan to have radiation to the whole breast after their lumpectomy that we don't need to take out more lymph nodes from under the arm if there is a very small amount of cancer in only one or two lymph nodes.

Usually we remove two or three sentinel lymph nodes at the time of operation; sometimes we only find one and sometimes we may remove five or six or more. Usually we have this information about the lymph node status at the time of operation and the pathologist lets us know not only the number of involved nodes but the size and the extent of the nodal involvement. Sometimes, however, we think that everything is fine on the day of operation and we receive that information only when the pathologists review the permanent sections where they look in greater detail at the lymph nodes that we've removed at operation. If they find only a little bit of cancer in one or two lymph nodes, it's unlikely that we would recommend that you come back and at a second operation have surgery to remove more lymph nodes from under the arm; however, sometimes they may find lymph nodes that are large in size, that have large size metastasis in them, or ... when the cancer has spread outside of the lymph nodes that may make us want to make a recommendation to do more surgery. We would discuss the risks and benefits of axillary lymph node dissection in a second operation with you and make a decision about how best to proceed.

When the pathologist finds only a few abnormal cells or small clusters of cells in the lymph node, then we might not want to take more lymph nodes out from under the arm. However, sometimes when the pathologist finds either a large size lymph node metastasis or multiple nodes, or lymph nodes with spread of the cancer outside of the capsule of the lymph node, we may wish to take more lymph nodes from under the arm. What happens if we do this? Well the complications that can occur with either a sentinel lymph node biopsy or a lymph node dissection are pretty similar. The most common complication is numbness under the arm in the inner upper arm after surgery that sometimes goes away but sometimes persists, and the most feared complication is swelling of the arm; that can be swelling in the hand, the forearm, the arm, or even in the tissues of the breast or the chest wall.

One recent study that looked at sentinel lymph node biopsy patients and patients who had a sentinel lymph node biopsy followed by an axillary lymph node dissection found that the percentage of women who had swelling of the arm or lymphedema three years after surgery was about 14% in the women who needed more lymph nodes taken out -- so a sentinel lymph node biopsy and an axillary dissection -- and about 7% in the women who had a sentinel lymph node biopsy alone. There are some things that we do from a technical standpoint to minimize the risk that you will develop lymphedema.

It's really encouraging that we have made so many advances in the surgical treatment of breast cancer over the last few years, and there's a lot of exciting areas of research and investigations to improve care. Here, we really focus hard on working together as a multidisciplinary team to formulate a bunch of treatment plans for patients. We're also here to help you sort through all these options and formulate a choice that's the best personal choice for you.