Palpable and Sentinel Lymph Node Biopsies
Laura A. Adam
Simple node excisions are utilized for excision of palpable nodes and in conjunction with a sentinel lymph node biopsy procedure. Although the technique remains essentially the same, anatomy is 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, and preauricular region, for example. The surgical anatomy of the axilla is detailed in Chapter 19, as well as in the chapter on mastectomies (Chapter 16), whereas the surgical anatomy of the inguinal lymph node region is detailed in Chapter 96.
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 for Breast Cancer
If blue dye is to be used, inject it in the operating room
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 sterile gamma probe to identify location for incision based upon greatest activity
Open axillary fat
Use sterile gamma probe to identify hot spots
Seek blue lymphatics which will lead to blue nodes
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 Kreissl
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 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, about 80% of 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 in the axilla. Chapter 97 describes sentinel lymph node biopsy for truncal melanoma.
Palpable Node Biopsy (Fig. 18.1)
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. In the groin, externally rotate and abduct the ipsilateral hip. Similarly, a folded sheet can be placed under the distal thigh to improve exposure.
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