Palpable and Sentinel Axillary Lymph Node Biopsies
Laura A. Adam
Simple node excisions are utilized for excision of palpable nodes and in conjunction with sentinel lymph node injections for cancer staging. Although the technique remains essentially the same, anatomy is, of course, variable based on the location of the nodal excision. Most commonly, simple node excisions are performed in the groin or the axilla; however, suspicious palpable nodes can be excised from any nodal basin including the cervical chain, supraclavicular region, preauricular region, and others. The surgical anatomy of the axilla and groin are detailed in Chapters 21 and 119, respectively.
SCORE™, the Surgical Council on Resident Education, classified sentinel lymph node biopsy for melanoma as an “ESSENTIAL UNCOMMON” procedure. SCORE™ has not classified sentinel lymph node biopsy for breast.
STEPS IN PROCEDURE
Palpable Node
Make incision over node
Incise axillary fascia
Elevate node into incision
Clip or ligate hilar pedicle and remove node
Obtain hemostasis and lymph stasis and close incision in layers
Sentinel Lymph Node Biopsy
Lymphoscintigraphy with a radiocolloid is performed preoperatively
Inject blue dye in operating room, if desired
Prep and drape breast and axilla in the usual fashion
If a large breast hangs over and compromises exposure of the axilla, use a sterile adhesive drape to retract it medially and cephalad, improving access
Use a sterile gamma probe to identify location for incision based upon greatest activity and obtain baseline Geiger count
Open axillary fat and enter axillary fascia
Use sterile gamma probe to identify hot spots
Seek blue lymphatics which will lead to blue nodes (if blue dye is used)
Excise any blue, radioactive, or abnormally palpable nodes
Elevate fat surrounding target node into incision
Clip and divide lymphatics and hilar pedicle
Obtain ex vivo count
Check base of incision for radiation—base should be less than 10% of counts of hottest node
Repeat procedure until all blue, radioactive, or abnormal nodes have been removed—but consider terminating after six nodes have been excised
Obtain hemostasis and lymph stasis and close incision without drains
HALLMARK ANATOMIC COMPLICATIONS
Lymphocele
Injury to intercostobrachial or other nerves
False negative biopsy
LIST OF STRUCTURES
Langer’s Lines
Tension lines of Kraissl
Axillary Fascia
Pectoralis major
Latissimus dorsi
Serratus anterior
Suspensory ligament of the axilla
Clavipectoral fascia
Axillary Nodes (Haagensen’s System)
Lateral group (axillary)
Subscapular (scapular)
Pectoral (external mammary)
Central (central)
Apical (subclavian)
Superficial fascia of the groin
Fascia lata of the thigh
Inguinal Nodes
Superficial inguinal nodes
Deep inguinal nodes
Iliac nodes
Inguinal ligament
Saphenous, femoral, and iliac vessels
Selective sentinel lymphadenectomy refers to excision of a single node or small number of lymph nodes identified by dye staining or lymphoscintigraphy technology. Sentinel lymph node resection is based on the idea that metastasis occurs in a systematic fashion. Because a negative sentinel lymph node strongly predicts a negative nodal basis, patients can have a more extensive lymphadenectomy averted. Sentinel lymph node technology is primarily used in cutaneous malignancies and breast cancers, but has been employed in other cancers, including colorectal, gastroesophageal, lung, urologic, gynecologic, and head and neck. This chapter discusses the technical modifications surrounding palpable and sentinel lymph node biopsies (SLNBs) in the axilla primarily related to breast cancer.
Excisional biopsy of a palpable node is rarely required and should be done only upon careful consideration. Fine needle aspiration for cytology or core needle biopsy (with ultrasound assistance, if necessary) will generally be used first, with excision reserved for difficult cases in which these modalities fail.
Accuracy of sentinel lymph node rates is found to be 97% with a 9.8% false negative rate with multiple trials validating SLNB. In addition, SLNB has been evaluated in other previously controversial breast cancer conditions. High rates of accuracy have been found in multicentric and multifocal breast cancer patients and can be utilized for ductal carcinoma in situ when a mastectomy is being performed. Also SLNB can be used in pregnancy after 30 weeks’ gestation when utilizing only a radiocolloid (not blue dye). Controversy still remains as to which patients receive benefit from axillary lymph node dissection after a positive SLNB.
Palpable Node Biopsy (Fig. 20.1)
Technical Points
Position the patient supine with the appropriate extremity exposed. For an axillary node excision, the ipsilateral arm should be extended on an armboard. If necessary, place a small folded sheet under the shoulder to improve exposure. The anatomy of the axilla and location of node groups significant for breast cancer are shown in Figure 20.1A.
Palpate and mark the node before prepping because it may become difficult to palpate the node after infiltration of local anesthetic. In most cases, plan a transverse incision over the area of the palpable node, keeping in mind that the incision may need to be included in a future lymph node dissection. In the case of an axillary node excision, plan to make the incision below the hair-bearing region of the axilla and raise a flap, if necessary, to avoid this area.
Infiltrate the area with local anesthetic and incise the skin. As you begin to dissect, keep in mind that lymph nodes often feel deceptively superficial. To assist in exposure, raise flaps as necessary to expose the node and place a fixed retractor to expose the node (Fig. 20.1B). A traction suture through the node may be used to help elevate it out the wound. Excise the node by dissecting investing tissues off the node circumferentially
coming around the node. A vascular and lymphatic channel pedicle will be present that should be ligated with a hemoclip or suture before excision. After assuring hemostasis, close the incision in two layers with absorbable suture.
coming around the node. A vascular and lymphatic channel pedicle will be present that should be ligated with a hemoclip or suture before excision. After assuring hemostasis, close the incision in two layers with absorbable suture.
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