What are the steps involved in a lumpectomy with sentinel lymph node (SLN) biopsy?

From the Guidelines

A lumpectomy with sentinel lymph node biopsy is a recommended breast-conserving surgical procedure for patients with clinically negative axillary lymph nodes, and it involves removing the cancerous tumor while preserving most of the breast tissue, along with sampling the first lymph nodes that drain the breast to check for cancer spread, as supported by the study 1. The procedure begins with the patient under anesthesia, positioned supine with the affected arm extended.

• First, a radiologist or surgeon injects a radioactive tracer and/or blue dye near the tumor or around the areola several hours before surgery, as described in the study 1.
• These substances travel through lymphatic channels to identify the sentinel nodes.
• In the operating room, the surgeon uses a handheld gamma probe to locate the radioactive nodes and plans the incision.
• For the lumpectomy portion, the surgeon makes an incision over the tumor site, removes the cancerous tissue along with a margin of healthy tissue, and places clips to mark the tumor bed for potential radiation therapy.
• For the sentinel node biopsy, the surgeon makes a separate incision in the axilla (armpit), identifies the blue-stained and/or radioactive nodes using the gamma probe, and carefully removes them, typically 1-3 nodes, as recommended by the study 1.
• The removed tissue is sent to pathology for immediate examination using hematoxylin-eosin (H&E) staining, as the study 1 suggests that current treatment decisions should be made based solely on H&E staining.
• If cancer is found in the sentinel nodes, additional lymph nodes may be removed during the same procedure, but the study 1 recommends considering either level I and II axillary dissection or no further axillary surgery for patients with T1 or T2 tumors and 1 to 2 positive SLNs. The surgeon closes both incisions with sutures and applies dressings.
• This approach minimizes lymphedema risk compared to complete axillary dissection while accurately determining if cancer has spread beyond the breast, which guides decisions about additional treatments like chemotherapy or radiation, as supported by the study 1. The key steps in a lumpectomy with sentinel lymph node biopsy include accurate identification and removal of the sentinel nodes, thorough examination of the removed tissue using H&E staining, and consideration of additional lymph node removal or radiation therapy based on the pathology results, as recommended by the study 1.

From the Research

Lumpectomy with Sentinel Lymph Node Biopsy Step by Step

• The procedure typically starts with the patient being given anesthesia, which can be either general anesthesia or monitored anesthesia care (MAC) 2.
• Once the patient is under anesthesia, the surgeon will make an incision in the breast to remove the tumor, this is known as a lumpectomy 3.
• After the tumor is removed, the surgeon will proceed with the sentinel lymph node biopsy (SLNB), which involves removing the first lymph node (or nodes) in the axilla that receives drainage from the breast 4, 5.
• The SLNB can be performed using different techniques, including dual mapping or technetium alone, and may involve breast massage to aid in the uptake of the blue dye 4.
• The surgeon will then remove the sentinel lymph node(s) and send it to the pathologist for examination to check for cancer cells 6.
• If the sentinel lymph node is found to have cancer, the surgeon may need to remove additional lymph nodes, this is known as axillary lymph node dissection (ALND) 6.
• The patient will then be taken to the recovery room to recover from the anesthesia and the surgery, and will be monitored for any complications, such as lymphedema 4.

Possible Complications

• Lymphedema, which is a swelling of the arm or hand, is a possible complication of SLNB, and the risk is higher if more lymph nodes are removed 4.
• Other possible complications include infection, bleeding, and seroma (a collection of fluid at the surgical site) 3.
• The surgeon will discuss the possible complications with the patient before the surgery and will monitor the patient closely after the surgery to minimize the risk of complications.

Postoperative Care

• After the surgery, the patient will need to follow the surgeon's instructions for postoperative care, which may include taking pain medication, wearing a compression sleeve to prevent lymphedema, and avoiding heavy lifting or strenuous activities 2.
• The patient will also need to follow up with the surgeon to remove any stitches or drains and to check for any complications.
• The patient will also need to follow up with the oncologist to discuss the results of the pathology report and to determine the next steps in treatment, which may include radiation therapy, chemotherapy, or hormone therapy 6.