Surgery to remove lymph nodes

Breast cancer can spread to other parts of the body. If it does spread, it usually first spreads to the lymph nodes in the armpit (axilla) close to the breast. These lymph nodes drain the lymphatic fluid from the breast and arm.

It is important to know if there are cancer cells in the lymph nodes in the armpit and how many. This helps the doctors work out the stage of your cancer and plan the best treatment for you.

Checking the lymph nodes before surgery

Before your surgery you have an ultrasound scan to check the lymph nodes in the armpit close to the breast. This is to see if they contain cancer cells. 

You usually have a biopsy of any lymph nodes that look abnormal. The biopsy is sent to the laboratory to check for cancer cells.

If this shows that the cancer has spread to the nodes in the armpit, you will have surgery to remove all or most of them. You have this at the same time as your breast surgery. This is called an axillary lymph node dissection (ALND) or clearance.

If the lymph nodes look normal during the ultrasound scan, you don’t have a biopsy. But you will have a sentinel lymph node biopsy (SLNB) at the same time as your breast surgery. You have this to check if cancer cells have spread to the nearby lymph nodes.

Checking lymph nodes during surgery (sentinel lymph node biopsy)

The sentinel node is the first node that fluid drains to from the breast into the armpit. This means it’s the first lymph node the breast cancer could spread to.

Your surgeon usually carries out a sentinel lymph node biopsy (SLNB) during the operation to remove your breast cancer. You have about 1 to 3 nodes removed to see if they contain cancer cells.

How you have a sentinel lymph node biopsy

A few hours before the operation, you have an injection of a small amount of mildly radioactive liquid into your breast close to the cancer. You usually have this in the nuclear medicine department in the hospital. The radioactive liquid is called a tracer.

During the operation, your surgeon may also inject a small amount of blue dye into the breast. The dye and the tracer drain away from the breast tissue into nearby lymph nodes.

The surgeon can see which group of lymph nodes the dye reaches first. They also use a radioactive monitor to see which group of lymph nodes the tracer gets to first.

Your surgeon removes between 1 to 3 nodes. They are sent to the laboratory to be looked at by a specialist called a pathologist. 

The dye can stain your breast slightly blue. It gradually fades over a few weeks or months. The dye also turns your urine green for a few days.

What happens after a sentinel node biopsy?

If the lymph nodes do not contain cancer cells, you won’t need to have any more nodes taken out.

If cancer cells are in the sentinel nodes, you have another operation to remove most or all of the lymph nodes under your arm. This is an axillary lymph node dissection or clearance. You generally have it about 2 weeks after you get the results.

Some people have radiotherapy to the armpit to destroy any remaining cancer cells instead of surgery.

Getting the results during surgery

In some hospitals, the surgeon gets the results of the sentinel lymph node biopsy during the operation. This is called an intra operative assessment. They can remove the rest of the nodes (axillary lymph node dissection) if necessary. You then avoid having a second operation.

Your surgeon will explain this to you before your operation, so you know what to expect. 

Removing most or all of the lymph nodes

An operation to remove most or all of the lymph nodes under the arm is called an axillary lymph node dissection or axillary clearance.

You have a general anaesthetic for this operation. You will be asleep the whole time.

The surgeon makes a small cut in your armpit to remove the lymph nodes. Generally, they remove between 10 and 15 lymph nodes. But the number of nodes in the armpit varies from person to person.

The surgeon sends the lymph nodes to the laboratory. A pathologist checks them for cancer cells. You get the results at your follow up appointment, about 2 weeks after surgery.

Some people will have radiotherapy to the lymph nodes instead of surgery.

Problems after removing lymph nodes

There are some possible problems after having surgery to the lymph nodes in your axilla. Not everyone will have these but there is a bigger risk if you have an axillary dissection.

A swollen arm or hand

You are at risk of long term swelling (lymphoedema) in your hand and arm after surgery to remove your lymph nodes in the armpit. This is swelling caused by lymph fluid that can't drain away. It can happen any time after surgery and radiotherapy to your armpit. 

Not everyone will get this and it is less likely to happen if you only have a few nodes removed. But it is very important to speak to your specialist nurse or surgeon if you think your arm or hand may be swollen. 

Unfortunately, once you have lymphoedema it can’t be cured. But early treatment can help to control it. Your nurse will talk to you about ways of preventing lymphoedema.

Shoulder stiffness

Your shoulder might become stiff and painful after breast surgery to the lymph nodes.
Your nurse or a physiotherapist will show you exercises to do after your operation to help improve movement in the shoulder.

Scar tissue in the armpit (cording)

Some women develop scar tissue in the armpit after lymph node removal. The connective tissues in the armpit get inflamed, which forms one or more tight bands. This usually happens within the first few weeks or months after the operation.

The scar tissue is called cording or banding or axillary web syndrome. It can feel something like a guitar string. It can extend down the arm past the elbow, possibly as far as the wrist or thumb.

Cording is harmless but can be painful and can limit your arm movement. Massaging the area regularly can help. Tell your breast care nurse if you develop cording. They can refer you to a physiotherapist. They can show you how to massage the area and teach you stretching exercises. It usually gets better within a few months. Taking anti inflammatory painkillers may also help. Speak to your nurse or doctor about taking these.