Can you drive after armpit biopsy?

Lymph node biopsy

A lymph node biopsy is when your doctor removes all or part of a lymph node. They send the sample to the laboratory to be looked at under a microscope. It is a simple procedure. You have a local or general anaesthetic depending on where the lymph node is.

• Read about lymph nodes and the lymphatic system

Why you might have it

There are many different reasons why you might have a swollen lymph node, such as an infection. A lymph node biopsy is the only way to find out for sure why a lymph node is swollen.

Preparing for your biopsy

Check your appointment letter for how to prepare for your biopsy. You will sign a consent form before you have the test. This is a good time to ask the doctor any questions.

If you normally take medicines to thin your blood, your doctor might ask you to stop them before your biopsy.

Local anaesthetic

You can usually eat and drink as normal before the biopsy if you’re having a local anaesthetic.

You usually have a local anaesthetic for swollen lymph nodes close to the surface of your body that are easy to reach. Your doctor gives you an injection to numb the area around the lymph node.

General anaesthetic

You usually can’t eat for about 6 hours before you have a general anaesthetic. You may be able to drink water up to 2 hours before the operation.

You usually have a general anaesthetic for lymph nodes that are deeper in your body. This means you are asleep for the procedure.

During the biopsy

You usually have the lymph node biopsy in the day surgery unit or imaging (radiology) department. The procedure may take up to half an hour.

Your nurse gives you a hospital gown to put on. Your doctor cleans the skin above the swollen lymph node. They make a small cut in the skin and remove all or part of the lymph node. They send this to the laboratory where a specialist doctor (pathologist) looks at it under the microscope.

Your doctor closes the cut with a couple of stitches. They usually cover it with a small dressing.

Core needle biopsy

Your doctor may use a special needle to remove a sample of tissue from a swollen lymph node instead of removing the whole thing.

CT and ultrasound guided biopsy

You might have a CT or an ultrasound scan before your doctor takes the biopsy. This is usually for abnormal lymph nodes that aren’t close to the surface of the skin. The scan helps your doctor guide the needle into the right place to take the biopsy.

• Find out more about what happens when you have a CT scan

• Find out more about what happens during a ultrasound scan

After the biopsy

Your nurse will check the dressing to look for signs of bleeding. If the dressing looks clean they are unlikely to take it off to look at the biopsy site. They also check your:

• blood pressure
• pulse and oxygen levels
• temperature

Most people go home the same day as the biopsy. You can usually go home shortly afterwards if you had a local anaesthetic.

It takes several hours to recover from a general anaesthetic. You can normally start drinking as soon as you’re awake, and eating once you’re hungry and don’t feel sick. You need someone to take you home and stay with you for the first 24 hours.

Your nurse will tell you how to look after the wound over the next few days. You need to go back to the hospital or your GP surgery about 7 to 10 days later to have your stitches out. The area around the wound may be swollen, bruised and tender for a few days.

Getting your results

You usually get the results within 2 weeks. The doctor who arranged the biopsy will give them to you.

Waiting for test results can be worrying. It may help to talk to a close friend or relative about how you feel.

For support and information, you can call the Cancer Research UK nurses on freephone 0808 800 4040. The lines are open from 9am to 5pm, Monday to Friday.

Possible risks

A lymph node biopsy is a safe procedure but your nurse will tell you who to contact if you have any problems after your test.

Pain
You may have some mild pain or discomfort around the site. Taking a painkiller, such as paracetamol, can help. Contact the hospital if you still have pain more than a week afterwards.

Infection
Contact your GP or the hospital if you have a high temperature or feel unwell. Or if there is redness, swelling or fluid (discharge) at the biopsy site.

Bleeding
There is a small risk of bleeding. Your nurse can normally stop this by pressing on the area. Contact the hospital or go to A&E if there is a lot of blood from the biopsy site after you go home.

References

• Guidelines for the first line management of classical Hodgkin lymphoma
  GA Follows, KM Ardeshna, SF Barrington and others
  British Journal of Haematology, 2014, Volume 166
• Hodgkin’s Lymphoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up
  DA Eichenauer, A Engert, M André and others
  Annals of Oncology, 2018, Volume 29 (Supplement 4)

Sentinel lymph node biopsy

A sentinel lymph node biopsy (SLNB) is a test to find the first lymph node or nodes that a melanoma may spread to. The doctor then checks to see if this lymph node contains cancer cells.

If your doctor thinks you need a sentinel lymph node biopsy, you have it at the same time as your operation to remove tissue around the melanoma (wide local excision).

What is a lymph node?

A lymph node is part of the lymphatic system. This is a network of thin tubes (vessels) and nodes that carry a clear fluid called lymph around the body. This is an important part of the immune system. It plays a role in fighting infection and destroying old or abnormal cells.

The nodes are bean shaped structures that filter the lymph fluid and trap bacteria and viruses, and cancer cells.

• Read more about the lymphatic system

Why you might have this test

The most common place that melanoma skin cancer spreads to is the nearby lymph nodes. You might have a sentinel lymph node biopsy (SLNB) if your doctor wants to check whether your nearby lymph nodes contain cancer cells.

You don’t always need to have a SLNB — it depends on the stage of your melanoma.

Your specialist might offer you a SLNB if your melanoma is deeper than 1mm (stage IB to IIC) or if you have other risk factors. You have it at the same time as your operation to remove tissue around the melanoma (wide local excision).

• Find out what happens at a wide local excision

Before your sentinel lymph node biopsy

The day before or morning of your wide local excision, you have a scan to show where the sentinel nodes are. You have the scan in the nuclear medicine department of the hospital.

You lie down on the treatment couch. You have small injections of a radioactive liquid into the area where your melanoma was.

About 15 minutes later, you have a scan. This picks up the radioactive liquid and traces it as it moves through the lymphatic vessels and into the lymph nodes. The first nodes that the tracer drains into are the sentinel nodes. The radiographer marks where these nodes are on your skin.

The scan takes about 90 minutes or more, depending on where the melanoma is and where the sentinel nodes are.

What happens

You have the sentinel lymph node biopsy under general anaesthetic. While you are asleep, the surgeon injects a blue dye into the area around the site of the melanoma. The dye will gradually drain into the sentinel nodes.

Your surgeon uses a handheld scanner to pick up the radioactivity in the sentinel lymph nodes. They make a cut into your skin over the area. They can see the blue dye, which also helps them identify the sentinel nodes. They remove these nodes and send them to the laboratory to see if they contain cancer cells.

The surgeon then continues with the operation to remove more tissue around the site of the melanoma (wide local excision).

They stitch the wounds closed and cover with a small dressing. They may leave a thin tube where they took out the lymph nodes. This is to drain fluid that may collect there.

After your sentinel lymph node biopsy

You can usually go home later the same day, if you don’t have a drain. Going home will also depend on the type of operation you had for the wide local excision.

As you have had a general anaesthetic, you will need someone to take you home and stay with you for 24 hours after the operation.

If you have a drain, your nurse will normally remove it the next day unless it is still draining a lot of fluid. Once they have taken this out, they will check your wounds and then you can go home.

The blue dye will make your urine look blue or green for the next couple of days. This is harmless.

About a week later, you have an appointment at the clinic or your GP surgery to have your stitches taken out, if needed.

Possible risks of a sentinel lymph node biopsy

A sentinel lymph node biopsy is normally a safe procedure but your nurse will tell you who to contact if you have any problems afterwards. Your doctors will make sure the benefits of having this test outweigh these possible risks.

Pain

You may have pain around the site of the sentinel lymph nodes. This might last up to 2 weeks. Taking mild painkillers can help. You might also feel stiff or tight around the area. It usually gets better over 6 weeks.

Infection

Contact your GP or the hospital if you have a high temperature or feel unwell. Or if your wound looks red, swollen or is leaking fluid (discharge). You might need antibiotics.

Fluid collection (seroma)

Fluid collecting near the wound can cause swelling and pain. It also increases the risk of infection. The fluid normally goes away on its own within a few weeks. Your nurse may need to drain it with a needle and syringe.

Blood collecting around the wound (haematoma)

Occasionally blood collects in the tissues around the wound. This can cause pain and swelling, and the area may feel hard.

It normally goes away on its own, but can take a few months. If necessary, your doctor or nurse can drain the swelling.

Scar tissue in the arm or leg (cording)

Some people may develop scar tissue in their arm or leg, depending on where the lymph nodes were taken from. It can cause tightness and feel uncomfortable.

It is usually temporary and will settle over the first few months.

Swelling (lymphoedema)

There is a small risk of developing lymphoedema. This is caused by lymph fluid that cannot drain away.

If your surgeon removes sentinel nodes from under your armpit, you may develop swelling in your hand or arm. If they take lymph nodes from your groin, you may develop swelling in your leg.

This is usually temporary, but in a small number of people it can be permanent.

Tell your doctor or nurse as soon as possible if you get swelling, pain or tenderness in your arm, hand or leg.

• Find out more about lymphoedema

Getting your results

It takes 1 or 2 weeks to get the results. Your doctor will usually discuss them with you at your next clinic appointment.

Waiting for test results can be worrying. You might have contact details for a specialist cancer nurse. You can get in touch with them for information and support if you need to. It may help to talk to a close friend or relative about how you feel.

You can also call the Cancer Research UK nurses on freephone 0808 800 4040. The lines are open from 9am to 5pm, Monday to Friday.

What happens next

A negative result means there are no cancer cells in the sentinel nodes. This means that the melanoma is unlikely to have spread to the other lymph nodes. So you won’t usually need any further tests or treatment.

A positive result means there are cancer cells in the sentinel nodes. This means the cancer has started to spread. Your doctor will talk to you about further treatment. You’ll also have scans to see if the cancer has spread anywhere else.

Advantages and disadvantages of sentinel lymph node biopsy

The National Institute for Health and Care Excellence (NICE) has produced guidelines about the diagnosis and treatment of melanoma. They list some advantages and disadvantages of this test. You can talk to your doctor about sentinel node biopsy. They can help you decide whether or not to have this test.

Advantages

• It can help doctors find out whether melanoma has spread to nearby lymph nodes, so they can offer you treatment for this.
• It is better than an ultrasound scan at finding very small cancers.
• Doctors can use the results to give you more information about what might happen to you in the future.
• You may be able to take part in clinical trials looking at new treatments (you may not be able to take part in these trials if you haven’t had a sentinel lymph node biopsy).

Disadvantages

• It isn’t a cure for your melanoma, and there is no good evidence that people who have a sentinel lymph node biopsy live longer than those who don’t have it.
• The results don’t always predict what might happen to you in the future.
• You need to have a general anaesthetic to have the operation.
• The operation has possible risks, such as infection or collection of fluid under the wound.

• Get more information on the NICE guidelines

References

• Melanoma: assessment and management
  National Institute for Health and Care Excellence (NICE), July 2015
• The Current Role of Sentinel Lymph Node Biopsy in the Management of Cutaneous Melanoma – a UK Consensus Statement
  Melanoma Focus, January 2019

Extensive Lymph Node Removal Doesn’t Improve Survival in Some Women with Early-Stage Breast Cancer

Long-term results from a large clinical trial confirm that, for some women with early-stage breast cancer who have lumpectomy as their surgical treatment, a less extensive lymph node biopsy approach is sufficient.

The trial showed that women with early-stage breast cancer who have cancer cells in one or two sentinel lymph nodes can skip axillary lymph node dissection (ALND) after breast-conserving surgery without affecting their long-term survival.

The findings are important for patients because ALND can cause chronic side effects such as numbness, decreased range of motion in the upper body, and lymphedema, said Armando Giuliano, M.D., of Cedars-Sinai Medical Center in Los Angeles, who led the trial.

Dr. Giuliano said he now feels comfortable telling patients that, in the long term, they would “suffer more from the axillary dissection than from the omission of the axillary dissection.”

Changing Views on Breast Cancer Metastasis

The axillary lymph nodes run from the breast tissue into the armpit. Early theories of breast-cancer metastasis held that cancer cells that had broken free from the main tumor would first travel through these lymph nodes on their way to other organs. That led doctors to believe that removing the axillary lymph nodes could reduce the risk of both cancer recurrence and metastases.

However, more-recent research has suggested that breast cancer may metastasize to other areas of the body through several different routes, explained Dr. Giuliano.

Also, modern treatment for early-stage breast cancer typically includes radiation therapy—which targets some of the same lymph nodes—along with breast-conserving surgery, Dr. Giuliano added.

Most patients additionally receive some sort of systemic treatment, such as hormone therapy, chemotherapy, and, more recently, targeted therapy, all of which can kill cancer cells throughout the body.

Less Lymph Node Surgery, Equivalent Survival

The trial, called ACOSOG Z0011, was designed to compare whether sentinel lymph node biopsy (SLNB) alone provided equivalent survival benefits to ALND after breast-conserving surgery among a subset of women who also received radiation and systemic therapy. The research team enrolled 891 participants into the study from 1999 to 2004.

Women who had stage I or II cancer and metastases in only one or two sentinel nodes were eligible to join the study. All women had undergone SLNB at the time of breast-conserving surgery.

Half of the trial participants received no further surgery, and the other half underwent ALND. Almost 90% of women in both groups had radiation therapy after surgery, and almost all received some type of systemic therapy.

In the initial results from the trial, published in 2010 and 2011, women who had only SLNB did not have worse overall survival than women who underwent full ALND. The two groups also had similar rates of disease-free survival and cancer recurrence in the lymph nodes.

These early results “were absolutely practice changing, and at this point the overwhelming majority of surgeons are not doing a full axillary lymph node dissection in patients with one or two positive [sentinel] nodes,” said Larissa Korde, M.D., head of Breast Cancer Therapeutics in NCI’s Division of Cancer Treatment and Diagnosis.

However, the cancer research community had lingering concerns about the trial, the authors of the new paper explained.

For example, the trial recruited fewer participants than initially planned. In addition, far fewer women than expected in both arms of the trial had any recurrence of their disease, making statistical comparisons between the groups difficult.

Most participants also had hormone receptor-positive breast cancer, which can recur many years after initial treatment.

However, after 10 years of follow-up, the initial results held: only about 50 women had died from any cause in each group. Overall survival was 86.3% in the SLNB group and 83.6% in the ALND group.

“It appears that less surgery, in the current era, is safe,” said Dr. Korde. Having the long-term data from the ACOSOG trial “makes us have a little more confidence in something we’ve been doing for quite a while,” she added.

Rates of negative side effects from surgery were much higher in the ALND group, with 70 percent of women experiencing wound infection, delayed healing, or pain compared with 25 percent of women in the SLNB-alone group. In addition, more women in the ALND group reported lymphedema. (The researchers reported complete data on side effects seen during the trial in a previous paper.)

A Lot to Learn about ALND in Other Patients

It’s important for doctors and patients to understand that these results can only be applied to women whose breast cancer and treatment regimen match those of the participants in the trial, the papers’ authors cautioned.

The results should not be used to direct the care of women with palpable axillary lymph nodes, women who had breast tumors larger than 5 cm in diameter, women with three or more positive sentinel lymph nodes, women who received chemotherapy or hormone therapy before surgery, and women who underwent mastectomy instead of breast-conserving surgery with radiation, they wrote.

“We still have a lot to learn about [the need for] ALND in other [treatment] settings,” commented Dr. Giuliano.

One trial, currently underway in Europe, is examining whether ALND can be skipped in some women who have a mastectomy for early-stage breast cancer, but results are not expected for years.

But for now, according to Edward Livingston, M.D., and Hsiao Ching Li, M.D., of the University of Texas Southwestern Medical Center, authors of an accompanying editorial, “The ACOSOG Z0011 trial has shattered a century of belief that all cancer containing axillary lymph nodes must be removed in women with breast cancer.”