Lymph Node Status

Lymph nodes are bean-shaped glands under a woman's armpit or axilla that are part of the body's lymphatic system. The lymphatic system is a series of lymph glands that deliver lymphocytes (cells that fight infections found in the lymph fluid) to other parts of the body. Lymph nodes are an important part of the body's immune system that wards off infection. When lymph nodes contain breast cancer cells, the cancer is considered to be node positive. When the lymph nodes are clear of cancer cells then they are said to be negative. To determine if there are any cancer cells in the lymph nodes, the doctor will examine a sample from the lymph nodes under a microscope.

There are two tests that are used to indicate node status: the sentinel lymph node biopsy and the axillary lymph node dissection. The sentinel lymph node biopsy is a newer and now-routine procedure that usually involves injecting both a blue dye and a radioisotope into the central part of the breast. These materials will drain from the breast to a lymph node in the axilla. The first node reached is called the “sentinel” node. Using a Geiger counter-type device, the isotope is identified and the surgeon can see the blue dye. This allows the sentinel node to be removed for examination. If the sentinel node is negative, then it is assumed with a fair amount of accuracy that the rest of the nodes will be negative as well, and the woman is spared from having a large amount of lymph node tissue removed as it is in a routine axillary node dissection.

If the sentinel lymph node is positive, then a full node dissection is usually done with the added risk of possible chronic arm edema. With axillary node dissection, the risk of serious arm swelling (lymphedema) increases because the lymphatic system, which helps with natural fluid circulation and drainage in the upper arms and extremities, is disturbed. The sentinel lymph node procedure is minimally painful. Medication is given before the procedure and anti-anxiety medication can also be given if the patient and her doctor feel that it is necessary. Axillary lymph node dissections are more involved and usually done under general anesthesia.

In Her Own Words

I have a large swollen arm from my fingertips to my armpit. Total strangers come up to me and ask, “What is wrong with your arm?” My five year-old granddaughter asks if Grandma's arm will ever get small. Mine is from the radiation to the lymph nodes in my armpit. I have to wear compression sleeves — one during the day and another at night. I have to use a pump with my arm in a sleeve to reduce the swelling. I have gotten infections, cellulitis, from bug bites and from no reason at all, and had to go to the hospital for intravenous antibiotics. I can't go in hot tubs. I can't get cuticles clipped on that hand or have my blood pressure measured, or shots in that arm. Lymphedema is a nuisance, but considering the alternatives, I am a very thankful woman.

— Marian, age 68, 15-year survivor

Lymph node involvement indicates how aggressive the tumor is. Previously, lymph node dissections were routinely done during breast cancer surgery and a large sample of nodes were examined individually to see if any cells were present. Lymph node involvement is thought of in terms of three types: minimal (microscopic), which has one to three-node involvement; significant (macroscopic), which has involvement of four to nine nodes; and extra-capsular extension, in which the tumor takes over the entire node and goes outside the wall of the lymph node and into the surrounding tissue. Doctors use the following categories to categorize lymph node involvement:

  • No lymph nodes involved

  • One to three nodes involved

  • Four to nine nodes involved

  • Ten or more nodes

  • It is thought that the more lymph nodes involved, the greater the risk that the cancer has spread to distant organs (metastasized). he specific involvement in each node is not as important as the total number of lymph nodes involved. More recently, the sentinel node biopsy is done before a full node dissection and since most breast cancers are node-negative, many women are spared the more involved procedure.

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