Lymph node and armpit ('axilla') surgery

Checking for cancer cells in the lymph nodes is an important part of breast cancer treatment. It helps your doctors assess how far the cancer has spread and plan the treatments best for you.

Most people have either:

• a sentinel lymph node biopsy (SLNB) or
• an axillary dissection

Your surgeon will make a decision between axillary dissection and SLNB based on:

• whether your lymph nodes felt enlarged when your doctor examined you 
• whether there were any suspicious findings after your diagnostic imaging tests or biopsy
• your type of breast cancer 

About lymph nodes

Everyone has lymph nodes all around their body, including:

• armpit
• groin
• stomach
• chest
• neck.

Lymph nodes are small, rounded glands that act like filters. They are connected to small vessels called lymphatic vessels, which are close to the blood vessels.

The lymph nodes in the armpit drain ‘lymph fluid’ from nearby areas, including the breast. They are important to the immune system and filter bacteria and waste products from the body.

The armpit (‘axilla’) usually has around 15 to 30 lymph nodes. The total number varies from person to person.

The sentinel node is the first lymph node or nodes outside the breast to receive drainage from the breast. It acts as a filter or 'gatekeeper' and can show whether any cancer cells have spread to the lymph system. People usually have 1, 2 or 3 sentinel lymph nodes.

Why lymph nodes are removed

If the breast cancer has spread, the first place it usually appears is in the sentinel lymph nodes in the armpit (‘axilla’). 

This does not mean that cancer has spread to other parts of the body, but it increases the potential to spread.
Surgeons remove one, some or all lymph nodes to:

• remove any breast cancer that may be in the armpit area
• determine the stage of breast cancer (how much it has spread)
• plan the best future treatment.

About the procedures

These procedures are often done during your breast cancer surgery. Sometimes the surgeon uses the same cut (‘surgical incision’), depending on where the tumour is.

In a sentinel lymph node biopsy, the surgeon removes around 1 to 3 sentinel nodes from your armpit. A biopsy is a procedure to take tissue or cells from your body so they can be tested.

If your surgeon suspects before surgery that the lymph node(s) contain cancer cells, they will suggest a biopsy to check.

A radiologist will do either: 

• a fine needle biopsy – a needle and syringe are used to take a sample of tissue to examine under a microscope, or 
• a core biopsy – a hollow needle takes a sample of tissue to examine under a microscope. 

Procedure to identify the sentinel nodes (‘lymphoscintigraphy’)

Before your breast surgery and before the sentinel lymph node biopsy, doctors need to find the sentinel nodes.

You may have only 1 or as many as 5 sentinel lymph nodes in your armpit.

The procedure to find them is called a ‘lymphoscintigraphy’. Usually you go to the hospital’s radiology or nuclear medicine department for this.

It may happen on the same day as your breast cancer surgery or before.

A small amount of radioactive tracer is injected into the breast. The tracer travels through the breast to the first lymph nodes that drain the breast. It gives off energy in the form of gamma rays. A special camera detects these rays and creates images of the inside of your body. These images help the surgeon find the sentinel node(s) to remove during surgery.

Your surgeon may also inject blue dye during your breast surgery to find the sentinel node(s). This can cause your urine and faeces to turn blue or green for a few days after surgery. It can also leave a blue stain in the breast that lasts from 1 to 6 months.

Results and next steps

Around 20 to 40% of people have cancer cells in the lymph nodes in their armpit when their breast cancer is diagnosed.
If the pathology report shows no sign of cancer cells, the cancer is only in the breast. You do not need more surgery to the nodes.

If the report shows some sign of cancer cells, there is a higher chance that cancer has spread into the bloodstream.
The treatment depends on how much cancer is found. Your surgeon and treating team will use the pathology results to decide on treatment. They may recommend:

• axillary dissection or clearance to remove more or all lymph nodes from your armpit
• radiotherapy to the armpit, sometimes as an alternative option to axillary dissection
• chemotherapy or hormone-blocking therapy after breast cancer surgery as a whole body (‘systemic’) treatment
• chemotherapy before breast cancer surgery (‘neoadjuvant therapy’), to try and reduce how many lymph nodes need to be removed.

Recovery after armpit surgery

Wound care

You will have a small dressing on your skin to cover the area from where the lymph node(s) were removed. This will be waterproof, so you should be able to have a shower.

Sometimes you will have a drain tube under your arm. This drains fluid and blood into a bottle from where lymph nodes were removed. The bottle often has a low vacuum to help remove the fluid.

The more lymph nodes you have removed, the more likely you are to have a drain left in.

The drain tube stays in place for several days to weeks, often until after you go home. The nurses or your surgeon will tell you how to manage the drain tube until it is removed.

Pain relief and comfort

You will be given medication to relieve wound pain and discomfort.

Movement and exercise

A physiotherapist or breast care nurse will give you advice on safe exercises to do after the surgery. These are important to help with shoulder stiffness and to improve your range of motion.

Once your wound has healed, your surgeon or breast care nurse will show you how to massage the scar. This also helps with the range of motion.

Side effects of sentinel lymph node biopsy

After a sentinel lymph node biopsy, some people experience: 

• pain or bruising at the biopsy site
• mild numbness where the biopsy was done in the armpit or breast
• stiffness in the arm and shoulder 
• mild swelling or the build-up of fluid (‘seroma’).

Less common side effects include:

• an allergic reaction to the dye
• an infection
• cording (‘axillary web syndrome’). Some people develop cords like rope, which can be seen and felt under the skin of the inner arm 
• lymphoedema, although the risk is low. Lymphoedema is swelling of the arm on the side where the surgery was performed. It is more likely when many lymph nodes are removed from one area.

Side effects of axillary dissection

The risk of side effects is higher with axillary dissection than SNLB. This is because more tissue is removed in the axillary procedure. You may experience:

• stiffness in your shoulder or arm soon after surgery, as scar tissue forms in the armpit.
• mild swelling or the build-up of fluid (‘seroma’) after your drain tube is removed. Your treating team may need to drain the fluid using a needle and syringe. 
• cords like rope (called ‘cording’ or ‘axillary web syndrome’) that you can see and feel under the skin of the inner arm. These can develop anytime from a few days to months after surgery.
• numbness of the inner arm, shoulder, armpit and parts of the chest, if the nerves are damaged. This usually improves over time, but some areas will always stay numb.
• lymphoedema – swelling of the arm on the side where the surgery was performed. Lymphoedema can develop within a few weeks of surgery, or years later. Early treatment of any swelling can reduce the risk.
• infection. Contact your doctor straight away if you have signs of infection. Symptoms of infection include pain, or your skin may be hot, red, tight, shiny or swollen. You may also have a fever or chills. Antibiotics are a common treatment. Your risk of infection is higher in the affected arm, hand and upper body when many lymph nodes are removed.