• If breast cancer begins to spread to other parts of the body, it often affects nearby lymph nodes first.
• Removing and studying the lymph nodes helps doctors determine how aggressive the breast cancer is.
• Knowing whether your lymph nodes contain cancer cells can help your doctor recommend a treatment plan that will be as effective as possible.

Lymph node removal is a common aspect of surgery for breast cancer. The main reason for removing the lymph nodes is to figure out how far within the body cancer has spread. This procedure is generally performed at the same time as a lumpectomy (removal of a small part of the breast) or mastectomy (removal of all the breast tissue). In some cases, the lymph nodes may be removed in a second surgery before or after a lumpectomy.

Why Do Lymph Nodes Need To Be Removed?

Your lymph nodes are part of your lymphatic system — a collection of vessels, organs, and other tissues. The lymph nodes help remove germs and waste products from your body. They can also filter out cancer cells from your lymphatic system.

One of the main ways that cancer metastasizes (spreads from the original site to other parts of the body) is by traveling through the lymphatic system. Cancer that is spreading from the breast first reaches the lymph nodes in the armpit or chest, so doctors remove lymph nodes to check for cancer cells. This information helps determine the breast cancer stage (how far the cancer has spread), which helps doctors understand which breast cancer treatments are likely to work best.

Additionally, when a lymph node containing cancer cells is removed, these cells can no longer spread. It could prevent cancer from moving to other lymph nodes or metastasizing to other locations.

Types of Lymph Node Removal

Two main types of surgery allow doctors to remove lymph nodes. The type of procedure you undergo determines how many lymph nodes will be removed, which affects the side effects you are likely to experience.

Sentinel Lymph Node Biopsy

Sentinel lymph node biopsy (SLNB) is the most common type of lymph node removal procedure. During this procedure, only a small number of lymph nodes — typically, one to three — are removed.

An SLNB allows the doctor to find the lymph node or set of lymph nodes most likely to contain cancer cells. Lymph nodes are linked in a particular order — when fluid near your tumor drains out of your breast, it first reaches one lymph node or a set of nodes before continuing to others nearby. The initial nodes are called sentinel nodes. If breast cancer cells spread, they will come to these lymph nodes first.

To find a sentinel node, the surgeon injects either a colored dye or a radioactive substance near the tumor or the skin over the tumor. In some cases, both dye and radioactivity are used. Either substance is designed to travel to the sentinel nodes, which the surgeon can then remove and check for cancer. Most of the nearby nodes will be left in place.

Axillary Lymph Node Dissection

Surgeons remove more lymph nodes during an axillary lymph node dissection (ALND) compared with an SLNB. In some cases, up to 40 lymph nodes from the underarm area may be taken out, although it’s more common to remove fewer than 20.

Surgeons may recommend an ALND if previous tests revealed cancer cells in the lymph nodes. This procedure may also be a good idea for those who have enlarged lymph nodes or very large tumors that have spread outside the area of the lymph nodes.

Removing many lymph nodes used to be a common treatment for breast cancer but is done less often now. Taking out extra nodes won’t help get rid of cancer cells that have already metastasized beyond the armpit area, and it can lead to additional side effects. Instead, treatments like chemotherapy that travel throughout the bloodstream aim to destroy cancer cells in other locations.

Deciding on a Lymph Node Surgery

Your doctor may check for cancer in the lymph nodes before you undergo surgery. They may look for enlarged lymph nodes, which will feel like hard lumps in your underarm area or near your collarbone, and use imaging tests such as an ultrasound to search for signs of cancer. If there is evidence that your lymph nodes may contain cancer, your doctor typically removes them for a biopsy and checks for cancer cells, using a microscope. Less commonly, a needle biopsy can be done to sample the tissue in the lymph node and avoid the procedure of sentinel lymph node removal.

If cancer is found in the sentinel lymph nodes before surgery, your surgeon may plan to remove a larger number of nodes with an axillary node dissection. Otherwise, they may suggest a sentinel node biopsy. Before surgery, you may want to ask your doctor which procedure they plan to perform and explore the benefits and risks of each.

Preparing for Surgery

Make sure to follow all your doctor’s instructions for getting ready for your surgery. They may tell you to stop taking certain medications such as blood thinners or supplements before the operation. Your surgeon may also say that you can’t eat anything the day of surgery.

SLNB involves using a dye to check the lymph nodes. This dye may be injected a couple of hours before surgery or during the operation.

What To Expect During Surgery

Before surgery, you will be placed under general anesthesia so that you can’t feel or remember anything.

Your surgery’s length depends on the procedures being performed. For example, a lumpectomy plus SLNB may take about an hour. A mastectomy with an ALND, or a procedure that involves breast reconstruction, could take three hours or longer. The type of surgery and your overall health will determine whether you go home the same day or stay in the hospital for a couple of nights.

What To Expect After Lymph Node Removal

In the days following surgery, you will need help getting back on your feet. Additionally, you’ll have to watch out for potential long-term problems.

Meanwhile, the removed lymph nodes will be examined in the laboratory for cancer cells. Any cancer cells present will be studied in detail for clues that help your doctor predict the cells’ growth patterns. As your doctor receives lab results, they may begin to recommend which treatments, if any, should come next.

Recovering From Surgery

Any surgery comes with potential complications. Your surgical team should explain which problems can arise during or after the procedures. Signs and symptoms to watch out for may include:

• Redness, soreness, or swelling around your incision, which could indicate an infection
• A collection of fluid or blood around your incision site, which sometimes needs to be drained
• Lots of pain or swelling in your leg or chest pain and shortness of breath, which could be a sign of blood clots

Make sure to follow any other instructions from your surgeon. They should explain how to care for your incision and whether you need to change any bandages. Your surgeon may also tell you to avoid certain types of activities or movements or perform certain exercises that can help you heal.

Surgery will likely affect your daily activities for several weeks, and during that time you also may experience ongoing soreness or tiredness. Your surgeon will tell you when you are cleared to go about your usual activities, such as driving and returning to work.

If you underwent an SLNB and your surgeon used blue dye to find a sentinel node, you may have blue or green urine or notice blue markings under your skin for a couple of days after surgery.

Determining Your Stage

When determining your cancer stage, doctors will consider three factors:

• How big the initial tumor is
• Whether cancer can be found in the lymph nodes
• Whether cancer cells are present in other parts of the body

You won’t know your cancer stage until after the breast lump is removed and after the lymph node removal surgery.

If cancer is found in the lymph nodes, you have a more advanced cancer stage. For example, stage 1 tumors are generally small and have not spread to the lymph nodes or metastasized. Stage 4 breast cancer, however, includes tumors of various sizes, may have spread to many lymph nodes, and has metastasized to other locations.

Your doctors will use this information to help plan your treatment. For example, advanced-stage tumors require more aggressive treatment options compared with early-stage breast cancer.

Next Steps for Treatment

During an SLNB, doctors sometimes find out right away whether the nodes contain cancer. In this case, they may take out additional lymph nodes during your surgery. In other cases, it may take several days to get your results.

Having lymph nodes that are free of cancer means that there is no reason to take out any more lymph nodes. Your doctor may then recommend additional treatments like radiation therapy, chemotherapy, targeted therapy, or hormone therapy to make sure any cancer cells are stopped from growing.

The presence of cancer cells in your lymph nodes may be a sign that the cancer has moved elsewhere. Therefore, you may need to undergo imaging tests to see whether cancer cells can be detected in other locations in your body.

You may also need to have more lymph nodes taken out in a second surgery if your sentinel nodes contain cancer. However, further lymph node removal isn’t always helpful, especially for those with early-stage cancer who have undergone a lumpectomy, so doctors don’t recommend additional this surgery as often as they used to.

Long-Term Side Effects of Lymph Node Removal

One of the most common long-term effects of lymph node removal surgery is lymphedema. This condition occurs when too much fluid collects in the breast, arm, chest, or abdomen and the area swells up. You are more likely to experience lymphedema if you have an ALND, you undergo a mastectomy, or your lymph nodes are treated with radiation. Smoking cigarettes and having diabetes are also lymphedema risk factors.

You can lower your risk of lymphedema by avoiding tight-fitting clothing or jewelry, including rings and watches, on the arm that was operated on. If you get any cuts or wounds on that arm, wash the area and use an antibiotic ointment to avoid infections. Additionally, avoid getting blood draws, shots, or blood pressure readings on that arm.

Other surgery complications may also last long-term. For example, surgery may lead to nerve damage that causes numbness or tingling. These sensations often decrease over time but in some cases may be permanent.

You may also have a hard time moving your arm and shoulder around after surgery. Certain exercises from your doctor may help you regain flexibility in this joint.

Talk With Others Who Understand

MyBCTeam is the social network for people with breast cancer and their loved ones. On MyBCTeam, more than 58,000 members come together to ask questions, give advice, and share their stories with others who understand life with breast cancer.

Have you already undergone lymph node removal? What advice would you share with those facing this procedure? Share in the comments below, or start a conversation by posting on your Activities page.