Senior Consultant, Surgical Oncology, Fortis Hospital, Noida
Part 7 of 9 in Diagnosis and Management of Breast Cancer
Axillary Management: Lymph Node Dissection vs Sentinel Node Biopsy
November 17, 2024
Axillary surgery is done for staging as much as treatment: knowing whether the nodes are positive or negative determines what further treatment a patient needs, since the axilla is the first station breast cancer typically spreads to.
Full dissection or just the sentinel nodes
Axillary lymph node dissection removes nodes across three anatomical levels relative to the pectoralis minor muscle. Sentinel lymph node biopsy is the newer, more selective alternative: a radioisotope or blue dye is injected into the tumor and the surrounding subareolar area, travels through the lymphatic drainage to the axilla, and is detected in whichever node picks it up first, the sentinel node. Only that node, or a small number of them, is removed and sent for biopsy, rather than clearing the whole axilla.
Why avoiding full dissection matters
Full axillary dissection carries its own complications, and sentinel node biopsy avoids them in patients with early breast cancer and limited nodal involvement, without giving up any real oncological benefit. Where sentinel node biopsy is positive but a full dissection is not performed, or where dissection is inadequate in a high-risk patient, radiation to the axilla is used instead to cover the same ground.
This article is based on a Jivo Masterclass session conducted by Dr. Jalaj Baxi, Senior Consultant, Surgical Oncology, Fortis Hospital, Noida. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Jalaj Baxi taught doctors across Africa on November 17, 2024.
FROM THE LIVE Q&A
Moderator
A 65-year-old woman has metastatic breast cancer and mastectomy is not feasible; she is currently on chemotherapy. What chemotherapy regimens are appropriate?
Dr. Jalaj Baxi
The regimen depends on the tumor's biology, specifically its ER, PR, and HER2 status. Treatment is usually a combination approach built around anthracycline-based chemotherapy along with hormonal therapy where relevant, and HER2-targeted therapy is added when HER2 is positive. A typical course runs six to eight cycles, though HER2-directed therapy in HER2-positive disease can extend to around 18 to 20 cycles.
Frequently Asked Questions
Can chemotherapy be combined with hormonal therapy, and what other management plans and success rates apply in metastatic disease?▼
Yes, combining chemotherapy with hormonal therapy is possible. Further management depends on how the patient responds to treatment. Roughly 30 to 35% of metastatic breast cancer patients respond well, and where the response is strong enough, it can become possible to address the metastatic sites and the primary tumor surgically as well.
If a patient remains symptomatic after eight cycles of chemotherapy, what other treatment options are available?▼
Immunotherapy can be added, and second-line or third-line chemotherapy regimens are available, including CDK4/6 inhibitors. Next-generation sequencing of the tumor helps identify which newer targeted drugs are likely to be effective for that specific patient.
Why do many patients' health seem to deteriorate immediately after a breast cancer diagnosis?▼
This is largely psychological rather than driven by the disease itself, a kind of cancer phobia that sets in once the diagnosis is given, where the patient loses a sense of control over their own life and fears dying early or being treated inadequately. Educating patients about their specific disease and realistic treatment outcomes helps restore the sense that there is still a fight to be had, which improves how they cope.
In what situations is prophylactic mastectomy appropriate in early-stage breast cancer?▼
Only in patients with a genetically determined risk, specifically those who test positive for BRCA1 or BRCA2 mutations. BRCA testing itself is only done when there is a family history of breast cancer.
What modalities help prevent reactions to anti-cancer drugs and reduce mortality during chemotherapy?▼
Mortality in chemotherapy is a fairly rare event, and when it happens it is almost always due to bone marrow suppression. The key is giving chemotherapy under close supervision so that this suppression is caught early, since early detection is what actually prevents mortality.
What is sentinel lymph node biopsy?▼
A technique where a radioisotope or blue dye is injected into the tumor and traced through the lymphatic drainage to the axilla; only the node or nodes that pick up the tracer first, the sentinel nodes, are removed and biopsied, avoiding a full axillary dissection.
When is radiation given to the axilla instead of, or in addition to, surgery?▼
When a sentinel node is positive but a full dissection is not performed, or when axillary dissection is inadequate in a patient who is otherwise high risk, radiation to the axilla is used to cover the same ground that surgery would otherwise address.
In This Series: Diagnosis and Management of Breast Cancer
- 1.Diagnosis and Management of Breast Cancer
- 2.How Breast Cancer Presents: Warning Signs Every Referring Doctor Should Know
- 3.The Triple Assessment: Clinical, Radiological and Pathological Workup
- 4.Biopsy Techniques and Receptor Testing in Breast Cancer
- 5.Staging Breast Cancer and How Tumor Biology Drives Treatment Sequencing
- 6.Breast Conservation Surgery vs Mastectomy: When Each Is Appropriate
- 7.Axillary Management: Lymph Node Dissection vs Sentinel Node Biopsy
- 8.Radiation Therapy After Breast Cancer Surgery: When It's Needed
- 9.Chemotherapy, Hormonal and Targeted Therapy: Regimens and Managing Metastatic Disease