Lymph Node-Sparing Surgery

What is lymph node-sparing surgery?

Removal or injury to lymph nodes and lymph vessels in the armpit may cause lymphedema or chronic arm swelling in up to 10-30% of women undergoing axillary node dissection (removal of most of the underarm lymph nodes) and about 5% of women undergoing sentinel node biopsy (removal of 1-3 lymph nodes).  Lymphedema is swelling of the hand, forearm, and/or arm resulting from blockage of water drainage from the arm.

Under usual circumstances, a surgeon is unable to distinguish lymph nodes and lymph vessels that drain the breast from those that drain the arm because they look the same and are located in the same area of the armpit.  Lymph node-sparing surgery using the axillary reverse mapping technique utilizes a blue dye that is injected into the arm which turns the arm lymph nodes blue. This distinguishes the arm nodes and lymphatics from the breast nodes and lymphatics, and which allows the arm nodes and lymphatics to be seen and voided by the surgeon.

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When is lymph node-sparing surgery performed?

Lymph node-sparing surgery begins with identifying which patients can avoid lymph node surgery altogether.  In general, women aged 70 and older with stage I, estrogen-sensitive may avoid lymph node surgery altogether since the risk of lymph node involvement and lymph node recurrence are very low.

Patients with known positive lymph nodes are generally advised to have many lymph nodes removed.  However, the option to receive radiation of the lymph node area after surgery makes it possible to limit the number of lymph nodes that are removed with the goal of reducing the risk of lymphedema.

Another strategy for sparing lymph nodes is to offer women with positive lymph nodes chemotherapy prior to surgery with the goal of clearing away cancer within the nodes.  If positive nodes can be converted to normal or negative lymph nodes with the use of chemotherapy, then Dr. Holmes can reduce the number of lymph nodes that must be removed at the time of lymph node surgery.

For patients requiring lymph node removal, axillary reverse mapping at the time of sentinel node biopsy or axillary node dissection can identify arm lymph nodes and lymph vessels which may be avoided or spared. However, it is sometimes necessary to remove arm-draining nodes which increases the risk of lymphedema. In such cases, Dr. Holmes can perform simplified lymphatico-venous anastomosis to connect the lymphatic vessels draining the arm to a nearby vein to maintain arm lymphatic drainage.

How is lymphedema treated?

Lymphedema or chronic arm swelling occurs in approximately 5% women undergoing sentinel node biopsy and 15-30% of women undergoing axillary node dissection, depending on whether or not radiation is also needed.  Lymphedema is treatable with the use of compression garments, specialized exercises, and massage.  You may also be referred to a surgeon who specializes in restoring lymphatic drainage utilizing microsurgical procedures. However, the best solution for lymphedema is prevention by limiting the number of lymph nodes  removed and avoiding removal or disruption of lymph nodes and vessels that drain the arm.  Early detection of lymphedema can also make it easier  to be treated to prevent the development of permanent lymphedema.

Are you a candidate for lymph node-sparing surgery?

Anyone undergoing lymph node surgery is potentially a candidate for lymph node-sparing surgery. However, the women that benefit most from lymph node-sparing surgery are women with positive lymph nodes.

What are early signs of lymphedema and how can it be detected early and managed to prevent permanent lymphedema?

Obvious signs and symptoms of lymphedema include swelling and discomfort or tightness of the hand, forearms, and/or arm. Swelling can be obvious and visible to the eye. However, at first, the swelling might be so subtle that it is invisible to the eye.

To facilitate early detection of lymphedema, Dr. Holmes recommends checking the baseline arm volume prior to surgery, and then rechecking arm volume after surgery at regular intervals during the first year. Technology that detects early build-up of arm fluid can detect lymphedema long before it causes symptoms. If early signs of lymphedema are detected, steps can be taken to reverse or reduce the process and possibly prevent development of long-term, symptomatic lymphedema.

For more information about lymph node surgery, visit Dr. Holmes’s YouTube Channel here.