Author: Akshay Pokale

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Sentinel In Biopsy

SENTINEL LN BIOPSY

What is a sentinel node biopsy?

The word “sentinel” means a guard or someone keeping watch. Sentinel nodes are the first lymph nodes to which cancer cells might spread from a tumour. Lymph nodes are small organs that “filter” fluid in the body and help protect from illness. A sentinel lymph node biopsy (also called a sentinel node biopsy or SLNB) is a surgical procedure in which the surgeon removes the sentinel nodes and sends them to a lab to test for cancer cells.  

Why perform a sentinel node biopsy?

Sentinel node biopsy report helps your treating doctor to know if the cancer has spread beyond the original (primary) tumour. When breast cancer spreads, it usually spreads to the sentinel nodes in the axilla (armpit) first. Spread to regional lymph nodes is not the same as metastatic or stage 4 disease and the cancer is very treatable at this stage.  

When is a sentinel node biopsy performed?

A sentinel node biopsy is part of a process called staging i.e., how advanced the cancer is. Different cancer stages require different treatments. Surgeons generally (but not always) perform this test during the surgery for the primary tumour.    

What are sentinel nodes?

Sentinel nodes are simply the first nodes draining a cancerous region. For breast cancer, they are usually located in the armpit. That’s why healthcare providers test the sentinel nodes to see if cancer has spread beyond the original tumor. If there’s no sign of cancer in the sentinel nodes, it’s unlikely that cancer has spread to other lymph nodes. If the test detects cancer cells in the sentinel nodes, your provider may recommend removing other lymph nodes to check for cancer.    

What should I expect during the test?

VIn some cases, few hours before the procedure, you will receive a safe radioactive substance (tracer) in your vein which will lead the surgeon to the sentinel lymph nodes.
The actual procedure is done under general anaesthesia and you will be asleep during the procedure.
Once you are asleep, your surgeon:

  • Injects a blue and/or green dye around the tumor or under the nipple. Often, providers use both the dye and the radioactive tracer.
  • Makes a small cut in the armpit and removes the sentinel node or nodes. Most of the time, providers remove between one and six sentinel nodes. If you are undergoing complete removal of the breast or mastectomy, then the sentinel nodes are accessed through the same mastectomy incision.
  • Sends the sentinel nodes to a lab for frozen section pathology to check for cancer cells. Frozen section is quick freezing method used to make slices of the tissue for examination. Its accuracy is more than 90%. The report takes approximately 20-30 minutes and it informs your surgeon if cancer from the breast has spread to the lymph glands in the armpit. If the examined lymph nodes are clear, then no further surgery is required.
  • Closes the incision and secures it with stitches or staplers. A draining tube and container may be kept in the axilla for a few days after surgery.

What should I expect after the test?

After the procedure, you can expect some soreness and discomfort near your incision and drain site. Painkillers are prescribed after the surgery to reduce the pain. You will also be advised to do physiotherapy everyday. You can return to your day-to-day activity from the very next day but it is recommended that you wait a few weeks before starting more rigorous activities like running, exercising or lifting. You should ask your surgeon what is the best timeframe for you. You will need to keep your incision clean and give it time to heal.      

What are the benefits of this test?

A sentinel node biopsy allows your provider to stage cancer accurately. It may also help you avoid unnecessary surgery. If cancer cells are not in the sentinel nodes, it is highly unlikely that cancer has spread to other lymph nodes or other parts of the body. Your surgeon will not need to remove other lymph nodes. If the node comes positive for cancer, then the surgeon will remove all the lymph nodes in the area to remove all other positive nodes that may be present. The main job of SLNB is to provide more information about the stage at which your cancer is diagnosed and it also guides treatment after the surgery.      

What are the risks of this test?

Generally, a sentinel node biopsy is a safe procedure. But every surgery has some risks. Sentinel node biopsy risks include:
  • Problems at the incision site: Bleeding, bruising, swelling and pain can occur at the incision site. The incision can also become infected. Signs of infection include redness, swelling and fever.
  • Allergic reaction: Rarely, some people are allergic to the contrast dye providers use to locate the sentinel node. 
  • Lymphoedema: This condition can happen when the lymph nodes are removed. If lymphatic fluid (lymph) cannot flow through the lymph nodes, excess fluid builds up in the body’s soft tissues. The fluid build-up causes swelling and pain. Lymphedema occurs more often when providers remove several lymph nodes.

When should I know the biopsy results?

The frozen section report is available at the time of surgery and the final pathology report (paraffin section) takes 1-2 weeks. Depending on the results, your cancer care team will recommend additional treatments. In the rare case that your frozen section was negative and the final report is positive, you may need additional surgery to remove the remaining nodes in the area by a procedure called axillary dissection.

When should I call my healthcare provider?

Following a sentinel node biopsy, call your healthcare provider if you have:

  • Bleeding from the incision or in the drain
  • Fever
  • Pain that does not get better with pain medication
  • Swelling, warmth or redness near the incision site

 

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Breast Cancer

BREAST CANCER

How common is breast cancer?

In the western countries, 1 in every 8 women will develop breast cancer in their lifetime. The percentage here is comparatively less (1 in 22 in urban India and 1 in 64 in rural India) but because of our population, the overall number of people affected and the resultant cancer burden is quite high.

Who is at risk for breast cancer?

No one is immune to breast cancer. Non-modifiable factors that increase risk include female gender, increasing age, personal or family history of breast cancer, known mutation in breast cancer genes, early onset of menses or late menopause, some benign breast lesions, dense breasts on mammogram and history of radiation exposure. Modifiable risk factors are postmenopausal obesity, sedentary lifestyle, late or no childbearing, not breastfeeding, using prolonged hormone replacement therapy (HRT) or oral contraceptive pills (OCP) and consuming alcohol.  

How can I reduce my risk?

Eat healthy and maintain an active lifestyle. Try to have your first child before the age of 30 years and breastfeed for up to 1 year if possible. Limit any hormonal therapy to the shortest duration possible and limit alcohol consumption.  

How do I know if I have breast cancer?

Every woman over the age of 20 years should be aware of the possible breast cancer symptoms (i.e breast lump, nipple discharge or crusting, sunken nipple, any new fullness/flatness in the breast shape, thickness or orange peel appearance if the skin) and perform self breast examination every month 7-10 days after her first day of period. Postmenopausal women can chose any date for their monthly self exam. Starting at the age of 30, women should approach a breast specialist to have an annual clinical breast examination. At the age of 40, the need for biennial mammogram should be discussed and performed then or at 50 years based on her individual risk.    

I found something, now what?

Visit a physician at the earliest for a clinical breast examination, breast imaging and biopsy if advised.    
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Breast Cancer Risk and Screening

BREAST CANCER RISK AND SCREENING

Why should I learn about breast cancer?

Breast cancer is the most common cancer among women worldwide. In 2018, 1,62,468 new cases were reported in India, making it the most common cancer in females (27.7%). It is also the leading cause of cancer death responsible for 11.1% of all cancer deaths in 2018. In the western countries, 1 in every 8 women will develop breast cancer in their lifetime. The percentage here is comparatively less (1 in 22 in urban India and 1 in 64 in rural India) but because of our population, the overall number of people affected and the resultant cancer burden is quite high. Also, the average age of diagnosis in India is 46 years, while in the US it is 62 years. This is largely due to the comparatively younger population of India. That being said, there is a myth breast cancer is a disease of the old and breast symptoms are often ignored by patients and often enough by their primary physicians.  

Risk Factors for breast cancer

No one is immune to breast cancer. However, some individuals are at a higher risk and others are at a comparatively lower one. Breast cancer risk factors can be either modifiable or non-modifiable.

Non-modifiable factors (that we cannot control) increasing breast cancer risk include:

  • female gender,
  • increasing age,
  • personal history of breast cancer,
  • Family history of breast cancer,
  • known mutation in breast cancer associated genes,
  • early onset of menses or late menopause
  • A few benign breast lesions like LCIS,
  • dense breasts on mammogram 
  • history of radiation exposure.

Modifiable risk factors are things we can change, like:

  • postmenopausal obesity,
  • sedentary lifestyle,
  • late childbearing,
  • Not having any children (unfortunately this is sometimes non-modifiable),
  • not breastfeeding,
  • using prolonged hormone replacement therapy (HRT) or oral contraceptive pills (OCP)
  • consuming alcohol.

What about all the hormones in IVF treatment?

Multiple studies and well conducted research have shown no connection between IVF treatment and breast cancer. In fact, even patients treated for breast cancer in the past can safely undergo treatment for infertility.

What is my risk?

You can consult a breast specialist or an oncologist to understand your personal risk. There are a few BC risk calculators like the Gail model but they are not validated in the Indian population and should not be relied upon.  

How can I reduce my risk?

Eat healthy and maintain an active lifestyle. Watch your weight particularly after menopause. Try to have your first child before the age of 30 years Breastfeed for up to 1 year if possible. Use exogenous hormones for short durations only – HRT to 1 year and OCPs to 5 years Limit alcohol consumption.

What about screening and mammogram?

Screening is looking for a disease in an individual that has no symptoms or complains related to the disease. It is important that a screen detected disease be treatable and the earlier diagnosis due to screening have a positive effect of the treatment outcome. Fortunately, all of this are applicant to breast cancer. Mammogram is one of the tools of breast cancer screening. However, there are other modalities of screening which are equally important. These are:
  • Self Breast Examination (SBE),
  • Clinical Breast Examination (CBE), and,
  • Imaging modalities including ultrasound, mammogram and MRI.
For an average risk individual, every woman over the age of 20 years should be aware of the possible breast cancer symptoms (i.e breast lump, nipple discharge or crusting, sunken nipple, any new fullness/flatness in the breast shape, thickness or orange peel appearance if the skin) and perform self breast examination every month 7-10 days after her first day of period. Postmenopausal women can chose any date for their monthly self exam. Starting at the age of 30, women should approach a breast specialist to have an annual clinical breast examination. At the age of 40, the need for biennial mammography should be discussed by the physician and can be performed then or at 50 years based on her individual risk. SBE and CBE should continues even once mammography begins. All screening methods should continue till the age of 75 or later if the individual retains good health and performance status.  

What if I find something?

First of all, don’t panic. Majority of breast lumps are benign. Visit a physician at the earliest. Following a clinical breast examination, you will be asked to do breast imaging (usually an ultrasound/mammogram) and based on these findings, a biopsy may be advised. This is known as triple assessment and is essential to prove or refute a diagnosis of breast cancer.

I don’t want to screen, its too much effort

The earlier you detect a cancer, the better your chances of survival are. If mammogram shows limited disease as well, the tumour can be removed with a healthy margin without sacrificing the breast. 5 minutes a month can save your life!

I am a guy, why should I care?

1% of all breast cancers occur in males. Because of the lack of awareness and the relatively small amount of breast tissue, men typically consult a doctor at a later stages in the disease and almost always present after skin involvement/ulceration.