Sentinel Lymph Node vs. Axillary Lymph Node

cinnamonsmiles

I was looking at my pathology report from my BMX from 1/11/11. After reading these boards all these months, I sure have gained more knowledge and could understand it better. HOWEVER, my surgeon had told me that she did sentinel lymph nodes only, but after reading the pathology report, three axillary lymph nodes were removed and one sentinel lymph node on the right cancer side. Only three sentinel lymph nodes were taken out on the left. I have severe post mastectomy pain syndrome/neuropathy which is worse on the right. My surgeon poo-pooed the idea of me taking lymphedema precautions because in her words, it was only the sentinel lymph nodes removed, but according to the path. report, it was actually axillary nodes (Since then , I now refuse all bps and needle pricks on my arms). Could this explain my worse symptoms on the right and should this make me more cautious of lymphedema developing as opposed to only having the sentinel nodes removed?My surgeon has long been fired for other reasons and I have no oncologist so I really don't have a dr. to ask.

Erica3681

What you had actually sounds like a sentinel lymph node biopsy, not an axillary dissection. Often when the drainage path from the lymph nodes is tracked from the tumor site to the nearest lymph node, it turns out that there's a tiny cluster of lymph nodes in that spot, rather than just one sentinel node. In that case, the surgeon generally removes anywhere from one to five lymph nodes. Even a single sentinel node is an axillary node. The term sentinel node just means that it's the first node to which the tumor drains.

My first SNB resulted in removal of 5 tiny lymph nodes that were all in a cluster. My second one, three years later, resulted in removal of 3 lymph nodes. And my surgeon was the head of breast surgery at a major Boston teaching hospital. She was committed to taking as few lymph nodes as possible. Sometimes it's not possible to take just one.

Regarding the connection of all this to lymphedema, while a full axillary dissection (involving many more than five nodes) would probably put you at higher risk for developing lymphedema, there are women who get lymphedema even after an SNB (sentinel node biopsy). Based on that, I do take some precautions but try not to drive myself crazy about it.

Barbara

otter

Just to add a bit to what Erica/Barbara said...

I don't know for sure why the pathologist distinguished between "sentinel nodes" and "axillary nodes" in that report.  What I imagine is that some of the sentinel nodes on the right side were located in the armpit, so they were identified on the submission form as "axillary lymph nodes," but one was not in the armpit.

For some women, all the nodes that light up with the radioactive tracer or are stained blue with the dye in the sentinel node biopsy procedure are located in the armpit (axilla). For other women, none of those nodes are in the armpit. My surgeon removed 3 marked/stained nodes, and none was in my armpit.  One was pretty close, but the other 2 were farther down alongside my breast.

This is just speculation, however.  Only your surgeon knows for sure whether all the nodes she removed had taken up radioactivity and/or blue dye, or she removed other, un-marked nodes too.  It isn't unusual for nodes to be clustered together (as Erica/Barbara said), and buried in fatty tissue, making it difficult for anyone besides the pathologist to know exactly what's in that piece of tissue.  I doubt the surgeon would have spent a lot of time teasing apart a single, marked node from others that were tightly clustered with the marked one. 

Some LE researchers think the risk of LE isn't just from removal of nodes -- it also comes from cutting, tearing, and otherwise messing around with the tissues the surgeon is leaving behind.  There are a lot of tiny, delicate lymphatic vessels in all that tissue that cannot be seen except through a microscope.  If those are sufficiently torn up during the surgery, it might not make much difference exactly how many nodes are removed. 

I'm probably overstating the case a bit.  Full axillary dissection -- removal of all the axillary nodes -- does pose a greater risk of LE than removal of just the sentinel nodes. 

A question for the crowd:  Has anyone documented a difference in risk of LE depending on where the sentinel nodes were located?  I recall some discussion awhile back that suggested the risk of truncal LE might be higher than it used to be, because sentinel nodes tend to be located on the upper lateral chest wall, closer to the breast than the axilla.

otter

firebird

otter, you got me curious enough to dig out my Surgical Pathology Report and see what it said about the SNB in particular:



Under the list of Specimen Descriptions it lists #3 as "Left Axilla Sentinel Node #1" and as #4 "Left Axillary Sentinel Node #2" and that is how each is described in the more detailed descriptions of each item that was sent to the lab from the O.R. The detailed description gives the size of each lymph node along with how it was dissected.



After reading the comments about about how some lymph nodes can 'cluster', I was interested to notice that the node labeled as #1 was quite small: only 0.5 cm in diameter; that one was cut in half and tagged as #1 Block A and #1 Block B for pathology. The other sentinel node (#2) was larger (3cm x 2.5 cm x 1.5 cm); that one was divided into "a portion" as #2 Block A, and "the remainder" as #2 Block B.



The difference between calling one "axilla" and the other "axillary" was probably just how the pathologist happened to either tape-record or transcribe it.



I did have two separate tumors, one larger (2.3 cm in greatest dimension) and the other smaller (only 0.4 cm at the largest point). I don't know, and didn't think it mattered enough to bother asking, whether the smaller lymph node was connected to the smaller tumor and the larger node to the larger tumor(the whole shebang was removed, so it seemed a moot point, LOL). Also the tumors were right next to each other and so I just always assumed the larger one kind of "pupped", assuming they do that sort of thing. ;-)



mycinnamon, your path report does seem written "confusingly" ... it sounds to me as if 4 nodes were removed on your right, plus 3 on your left. I agree with otter that "Axillary" is a location designation (under the armpit) and that "Sentinel" is an activity designation (having responded in some way to the dye). Thus an underarm sentinel (dye-responsive) node that is located under the left armpit would be properly and completely described as a "left axilla(ry) sentinel node". I think my question for the surgeon/pathologist would be "Just tell me how many nodes were removed from each side" and then base your risk of LE on that number.



I think some people assume that a SNB means that only part of the "dyed" node was removed; my understanding is, which reading of a pathology report should confirm, that the entire node gets removed and biopsied. Not like when a suspicious lump gets a core or needle biopsy and the rest is left in place pending the results of same.