Article by Assoc. Prof. Dr. Yaowanut Kongdan and Dr. Pawina Leutthai
Normally, breast cancer surgery involves 2 areas: breast cancer and axillary lymph nodes, because the axillary lymph nodes are the first area where cancer spreads. In the past, surgery removed all the lymph nodes in the axilla, causing patients to often experience arm swelling and numbness after surgery, such as the forearm or side of the body. Patients who have undergone axillary lymph node dissection will receive the following recommendations:
Take care of your skin by eating a balanced diet, especially protein, keeping your skin moisturized, using gentle soaps, and using mild detergent to avoid allergies.
Care for the operated arm includes wearing loose clothing, raising your arm when sleeping or traveling, and doing appropriate exercises such as Tai Chi or swinging your arms. Wrapping an elastic bandage around the operated arm.
Precautions: Be careful of sunburn and insect bites, do not draw blood or measure blood pressure on the operated arm, do not lift heavy objects, and do not shave your armpits with a razor or pluck hair. It may cause irritation or wounds, do not let the arm touch high temperatures, if there is a wound, treat it with antibiotics, do not recommend to go for a tourniquet because it is a temporary solution, but it will have a long-term negative effect, it may cause more severe lymphatic congestion than before.
How do you know if you have lymphatic congestion or swelling after axillary lymph node dissection (Lympedema)?
1. Take a photo of your arm and compare it to both sides.
2. Measure the circumference above the elbow, it should be at least 10 cm different.
3. Measure the volume by displacing water from your hand to 15 cm above the elbow. The overflowing water will have a volume difference of at least 200 ml.
The best treatment for lymphatic congestion in the arm is to treat it from the beginning, it will heal normally, such as massage or bandage. If left for a long time, protein will leak, causing scar tissue in the arm. Even if massaged or bandaged, it will not return to normal.
Breast surgery techniques without arm swelling
From the concept of Sentinel lymph node dissection, a surgical method has been developed to reduce unnecessary lymph node dissection. During surgery, the surgeon will inject a dye called Isosulfan blue dye or Patent Blue V into the cancerous area. The injected dye will run to the first lymph node, making the lymph node green. The surgeon will then dissect the lymph node and send it for examination by Frozen section, which is a method of quickly freezing the lymph node for pathological examination. The biopsy result will be available within 1 hour. If the result shows that cancer cells have invaded the Sentinel, the surgeon will immediately dissect additional lymph nodes. If no cancer cells are found, no additional lymph nodes need to be dissected. The surgery can be completed in one go.
Later, a surgical method was developed to find the spread to the lymph nodes by injecting an “isotope”, a radiopharmaceutical, into the cancerous area. Then, scan to see which lymph node this isotope has traveled to. In the operating room, there will be a Grammar Probe to detect Sentinels. If there is a loud noise, it means that there is a collection of isotopes in that lymph node. Currently, both methods are used: Isosulfan blue dye injection and isotope injection together. Surgery using these 2 techniques is effective for patients because it does not require removing many lymph nodes, only the sentinel nodes.
Sentinel lymph node removal surgery has been further developed by using Indocyanine Green (except for those who are allergic to seafood, pregnant women cannot use it) as a reflective color. Then, an infrared camera is used to detect the fluorescence that can be seen from the outer skin, allowing the surgeon to see where the light is reflected and to operate in that area without having to open a large wound, reducing errors quite well. Sentinel lymph node removal surgery using the dye or isotope injection technique will be more beneficial to patients.
In summary, lymph node surgery in breast cancer should consider the following:
Sentinel lymph node removal should be performed, which is the first lymph node to receive cancer, to reduce the risk of arm swelling.
A good technique for finding sentinel lymph nodes is:
1. Dye injection, such as Isosulfan blue dye
2. Use of radiopharmaceuticals And detect lymph nodes with radiation with a radiation detector head
3. Inject Indocyanine Green and detect with a Near Infrared Fluorescence imaging camera
Using 2 or more detection techniques for accuracy in finding sentinel lymph nodes
1. In the case of breast reduction, if the cancer has spread to no more than 2 sentinel lymph nodes, it is not necessary to remove the lymph nodes, but additional treatment with radiation is required.
2. In the case of breast-conserving surgery combined with external radiation, if the cancer has spread to no more than 2 sentinel lymph nodes, it is not necessary to remove the lymph nodes.
After lymph node surgery, the patient should take care of the operated arm according to the doctor's advice.
Note:: There is no guarantee of fixed results and the results may vary depending on each individual.
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