Axillary Management in Breast Cancer: Sentinel Biopsy and the LYMPHA Technique

Surgery alone, all-inclusive, costs roughly $5,000. Chemotherapy adds around $10,000, and radiation is roughly $3,500 to $4,000. Extended targeted therapy such as trastuzumab can add another $10,000, though that portion can often be continued at the patient's home location. As a rough guide, surgery plus basic chemotherapy runs around $15,000 for most patients, and cases involving genuine financial hardship can always be discussed.

A whole-abdomen ultrasound, not just the upper abdomen, checks for liver metastasis and also covers the ovaries and uterus. A chest X-ray checks for lung metastasis. For bone, a skeletal survey, plain X-rays covering the spine, skull and limbs, substitutes for a bone scan where nuclear medicine isn't available. This combination is less accurate than PET CT but is a reasonable, optimal fallback when resources are limited.

For a young patient with early, well-localised disease, breast conservation surgery is advisable over mastectomy: a wide excision with lymph node dissection or sentinel biopsy, followed by pathology review. If the oestrogen receptor is positive on the final specimen, tamoxifen is started after surgery, and chemotherapy is added if indicated by the pathology. Starting tamoxifen before surgery is not advisable.

Neoadjuvant chemotherapy should be started before referral in two situations: triple-negative breast cancer, and locally advanced disease, meaning a tumour over 5 cm, ulceration, peau d'orange skin change, satellite nodules, or bulky or supraclavicular nodes. In locally advanced disease, surgery follows after around four to four and a half months of chemotherapy. In genuinely advanced or metastatic disease, treatment is systemic only, chemotherapy or hormone therapy, with no surgery. For anything in between, it is always better to discuss the specific case jointly before deciding independently whether and when to start treatment.

No, a BRCA1 and BRCA2 test should be done first. Indications for testing are all triple-negative breast cancer, a strong first-degree family history (a sister, mother, or maternal or paternal aunt with breast cancer), and any history of male breast cancer in the family, which alone is enough to warrant testing. If the BRCA test comes back positive, mastectomy of the affected breast should be combined with prophylactic mastectomy of the opposite side. If BRCA testing isn't available locally, it can be arranged through Dr. Jain's centre.

When axillary nodes are not clinically or radiologically palpable. Two to four sentinel nodes are removed and checked on frozen section; if negative, complete dissection is avoided, if even one is positive, complete dissection follows.

A microvascular technique performed at the time of primary axillary surgery, anastomosing a lymphatic channel in the arm to a tributary of the axillary vein under a microscope. It adds around 20 minutes to surgery but prevents the arm lymphoedema that would otherwise follow complete axillary clearance or radiation.