Sentinel node biopsy

Sentinel node biopsy is a procedure in which a small tissue sample is taken to test if the cancer has spread into the lymphatic system or lymph nodes. Lymph nodes are oval-shaped small organs, considered to be a part of the immune system, and present in various parts of the body. They are usually present near the internal organs like lungs, intestines, and stomach, and in areas like neck, armpits, and groin. Sentinel node biopsy is performed to detect melanoma and breast cancer. Sentinel nodes are the primary lymph nodes in which the drainage of the tumor is commonly observed. Usually, a tracer material is injected during the surgery, which helps the surgeon to locate the sentinel lymph nodes clearly. After the sentinel lymph nodes are removed from the body, they are further sent to the lab for detailed analysis. If the sentinel lymph nodes do not contain cancer cells, then the removal of additional lymph nodes is not required. However, if the cancer is present in the sentinel lymph nodes, then the additional lymph nodes are required to be removed for the doctor to examine the cancer spread.


Why it’s done? What are the risks? How to prepare for the procedure? Expected results from the procedure FAQ Section

Sentinel node biopsy is usually performed to check the growth of the cancer cells and its spread in the lymphatic system. The procedure is advised in the people with the following problems:

  • Melanoma
  • Breast cancer
  • Colon cancer
  • Stomach cancer
  • Esophageal cancer
  • Thyroid cancer
  • Lung cancer
  • Neck cancer
  • Head cancers
  • Any swollen or enlarged lymph nodes detected during physical examination.

Sentinel node biopsy is a safe procedure. However, it does carry some amount of risk and complications with it, as mentioned below.

Risks associated with any surgical procedure, which are linked to Sentinel Node Biopsy also, are as mentioned

  • Heavy bleeding
  • Infections e.g. pneumonia
  • Pain

After waking up from the effect of general anesthesia, some patients might face some of the following problems:

  • Nausea
  • Vomiting
  • Uneasiness
  • Dizziness
  • Breathing difficulty
  • A temporary state of confusion
  • A feeling of cold or shivering
  • Allergic reactions to the medicine given during the biopsy procedure.

Reactions due to the contrast or dye used during the sentinel node biopsy may include

  • Skin Rashes
  • Itching
  • Redness
  • Hives
  • Warm feeling
  • Breathlessness
  • Kidney diseases
  • Constipation
  • Increased heartbeat
  • Feeling of nausea
  • Vomiting
  • Sweating
  • Hypertension or hypotension

Some of the other complications, associated with the Sentinel node biopsy procedure are as listed below.

  • Lymphedema – This is a condition in which the lymph vessels of the patient become incompetent in draining lymph fluid from a particular area of the body. This leads to fluid retention and severe swelling. The lymphedema occurs when multiple lymph nodes are removed from a particular area.
  • Tenderness around the site of biopsy.
  • Accidental nerve damage can occur which may lead to numbness.
  • The doctor takes a complete medical history and physical examination test before performing the surgical procedure. The patient may be asked about the age and weight of the patient, any past surgeries, allergies to any medicines, previous personal history and family history of heart attacks. In the physical examination, the doctor examines the patient very carefully for any other concerning signs and symptoms.
  • The doctor also advises some tests such as some blood investigations, before the surgery
  • If a patient is diabetic, the patient is advised to ask the doctor if he/she should continue taking insulin before the procedure or not. The patient is also asked to inform the doctor about any past allergies or surgeries, if any.
  • The patient is advised to quit smoking, avoid alcohol, avoid drinking or eating anything after midnight or one night before the bypass surgery.
  • The patient is advised to empty the urinary bladder and bowel, before the test.
  • The patient has to remove or avoid any jewelry, eyeglasses, hairpins, electronic gadgets or any metal objects and is asked to change into a hospital gown, during the procedure.

During the procedure:

  • Locating the sentinel lymph nodes: This is the foremost step during the procedure. There are two methods to locate the position of the sentinel lymph nodes as highlighted below.
    • Radioactive solution - In this method, a weak radioactive solution is administered near the tumor cells. This radioactive solution travels through the lymphatic system, highlighting the sentinel lymph nodes. This solution is administered in the patient a day or several hours before the removal of sentinel lymph nodes.
    • Blue dye - In this method, a blue colored harmless dye is administered near the tumor cells. This blue dye travels through the lymphatic system, highlighting the sentinel lymph nodes in a blue color. This dye is administered just before the surgical procedure of sentinel lymph nodes removal.

The choice of contrast media depends only on the doctor performing the procedure. Some doctors may use both the contrast media in the same procedure.

  • The vital signs of the patient are checked. The pulse rate and the amount of oxygen in the blood are checked through a pulse oximeter. A blood pressure cuff is tied on the arm of the patient to monitor the blood pressure.
  • General anesthesia is given to the patient to prevent from feeling any pain during the surgery.
  • When the patient is unconscious, a breathing tube may be inserted in the mouth and attached to the ventilator on the other end. This helps the patient to breathe normally during and even after the surgery (for some time).
  • A small incision or cut is then made over the area of the sentinel lymph nodes. This incision is done on the area where the radioactive solution gets accumulated or the blue dye which colors the lymph nodes blue.
  • In order to detect the accumulation of the radioactive solution, the doctor uses a hand-held small instrument known as the gamma detector. With the help of the gamma detector, the doctor can easily locate the area of the sentinel lymph nodes.
  • The doctor then removes the sentinel lymph nodes. In many cases, the sentinel lymph nodes are 2 to 3 in number, and the doctor removes all of them.
  • The removed nodes are then sent to the lab for further detailed analysis.
  • In some cases, the sentinel lymph node biopsy is performed before, during or after the cancer treatment surgery.

 

After the procedure:

After the surgery, the patient is shifted in the recovery room, wherein, he/she is kept under continuous monitoring and observation. The vital signs e.g. pulse rate, body temperature, oxygen levels or breathing rate, and heart rate, are monitored continuously.

The patient is allowed to go home the same day of the surgery if no additional procedure is to be done with the patient. The patient can return back to normal routine activities but only after consulting with the doctor.

If the sentinel biopsy is performed as a part of the procedure during the treatment of cancer or cancer surgery, then the stay in the hospital will be extended till the time the condition of the patient is completely stable.

  • If the report of the sentinel lymph node biopsy is normal, it means that no further evaluation of the lymph nodes is needed as there are no signs of cancer.
  • If an abnormality is detected in the biopsy report, it means that there are signs of cancer and the doctor would discuss the treatment plan with the patient.
  • If the sentinel lymph nodes do not contain cancer cells, it means that the cancer has not spread and the removal of additional lymph nodes is not required. If the cancer is present in the sentinel lymph nodes, then the additional lymph nodes are required to be removed for the doctor to examine the cancer spread.
  • In some cases, the sentinel lymph node biopsy is performed before, during or after the cancer treatment surgery.
  • The patient is asked to avoid taking bath or showers for a few days after the procedure, however, sponging is allowed.
  • The site of the biopsy is to be kept clean, dry and moisture free.
  • Some problems like tenderness and pain exist for some days even after the procedure is done and hence, proper care should be taken of the biopsy site and of the overall health condition of the patient.
  • The doctor should be called immediately if any of the following signs are observed:
    • Chills
    • Severe or uncontrollable pain
    • Fever
    • Heavy bleeding from the biopsy site
    • Drainage or discharge from the biopsy site
    • Severe itching or any signs of infection at the biopsy site
    • Swelling
    • Redness
    • Warm feeling

 

If the report of the biopsy detects any cancer cells, then the doctor might diagnose the following conditions in the patient

  • Melanoma
  • Breast cancer
  • Colon cancer
  • Stomach cancer
  • Esophageal cancer
  • Thyroid cancer
  • Lung cancer
  • Neck cancer
  • Head cancers
  • Hodgkin’s lymphoma
  • Non – Hodgkin’s lymphoma
  • Oral cancer
  • leukemia

If the sentinel node biopsy report detects abnormal results, it may also be an indication of an immune system disorder or infection, as mentioned below

  • Rheumatoid arthritis
  • Some sexually transmitted diseases (STDs) like HIV, chlamydia or syphilis.
  • Skin infection
  • Mononucleosis
  • Tuberculosis
  • An infected tooth
  • The systemic lupus erythematosus (SLE), or lupus.
  • Cat scratch fever

Q1. What is the advantage of a Sentinel node biopsy?

A1. The surgical procedure of sentinel node biopsy is very effective and useful in identifying the affected lymph nodes, without the risk of removing all the cancerous lymph nodes.

Also, before other surgical procedures like mastectomy or lumpectomy are performed, the sentinel node biopsy is used. This technique helps to remove only a few sentinel nodes (the first few lymph nodes) as a sample for laboratory testing. 

Historically, multiple axillary nodes were removed as a sample for testing, which resulted in many complications after the surgery e.g. swelling in the hand or arm, or lymphedema.

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