the Need for Lymph Node Surgery Before Breast Cancer Radiation

Regarding breast cancer radiotherapy?

Is it necessary to perform another surgery to remove lymph nodes from the axilla for examination before radiation therapy for breast cancer, in order to determine the radiation dose, number of sessions, and whether the radiation field should be expanded to include the axilla? Previously, one lymph node was removed during surgery, and a breast-conserving surgery was performed on the left breast.
However, I do not understand why my doctor wants to perform this surgery again to remove more lymph nodes.
What is the difference between choosing to undergo radiation therapy that includes the axillary area without the recommended surgery versus having the surgery first?

Linlin, 20~29 year old female. Ask Date: 2016/09/10

Dr. Lai Yicheng reply Oncology

Dear Miss Lin,
Thank you for your letter.
Here are my responses:
1.
Due to the incomplete information you provided, I am unable to give you more accurate advice.
It is essential to review the pathology report and PET scan to determine the subsequent treatment and therapy options.
2.
a.
Traditional breast cancer treatment primarily involves mastectomy.
However, for patients with early-stage breast cancer or ductal carcinoma in situ, a lumpectomy followed by postoperative radiation therapy can achieve breast conservation.
For patients with larger tumors or a greater number of involved axillary lymph nodes, total mastectomy and axillary lymph node dissection are recommended.
Subsequent treatment decisions, including the addition of postoperative radiation therapy, should be based on the number of risk factors to improve local control rates and survival rates.
b.
Breast-conserving therapy essentially involves local surgery combined with postoperative radiation therapy.
Local surgery includes the excision of the primary tumor and sentinel or axillary lymph node dissection.
The excision of the primary tumor must achieve clear margins.
Women with stage I and II breast cancer are suitable candidates for breast-conserving therapy, provided that the local tumor is excised with clear margins and the cosmetic appearance of the breast remains satisfactory.
c.
Radiation therapy scope: For patients without axillary lymph node metastasis, treatment should focus solely on the breast itself.
For patients with axillary lymph node involvement, treatment should generally include the breast and supraclavicular lymph nodes.
If the tumor is located on the inner side of the breast, efforts should be made to include the internal mammary lymph nodes in the treatment area.
If the patient has undergone axillary lymph node dissection, radiation should be avoided to reduce the risk of lymphedema.
However, if only sentinel lymph node surgery has been performed without further axillary lymph node dissection, radiation therapy should include the axillary lymph nodes to achieve similar disease control outcomes while minimizing the risk of lymphedema.
Changhua Hospital cares about you.
Department of Radiation Oncology
Dr.
Lai Yi-Cheng
Thank you for your consultation.

Reply Date: 2016/09/10

More Info

When it comes to breast cancer treatment, the decision to perform additional surgery to remove axillary lymph nodes before radiation therapy is a nuanced one that depends on several factors, including the initial surgery performed, the pathology results, and the overall treatment plan.
In general, the purpose of removing axillary lymph nodes is to assess whether cancer has spread beyond the breast. This is typically done through a procedure called sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). If cancer is found in these lymph nodes, it can significantly influence the treatment plan, including the need for additional therapies such as chemotherapy or radiation.

For patients who have already undergone surgery that included some level of lymph node removal, the need for further surgery before radiation therapy is determined by the following considerations:
1. Pathology Results: If the initial surgery revealed that cancer was present in the lymph nodes, additional surgery may be warranted to remove more nodes. This is particularly true if there is a concern that the cancer may have spread further.

2. Radiation Therapy Planning: Radiation therapy is typically targeted to the area where the cancer was located, including the breast and possibly the axilla (underarm area) if there is a risk of lymph node involvement. If lymph nodes were previously removed and found to be free of cancer, the radiation oncologist may decide to include the axillary area in the radiation field to ensure comprehensive treatment. However, if there is uncertainty about the status of the lymph nodes, further surgery may be recommended to clarify this before radiation begins.

3. Risk of Lymphedema: One of the concerns with radiation therapy to the axillary area is the potential for lymphedema, which is swelling due to lymph fluid buildup. If a patient has already had lymph nodes removed, the risk of lymphedema can increase with additional surgery or radiation. Therefore, careful consideration is given to the need for further lymph node removal versus the potential risks involved.

4. Individualized Treatment Plans: Each patient's situation is unique, and treatment plans are often tailored based on individual risk factors, cancer characteristics, and patient preferences. The decision to proceed with additional surgery before radiation should involve a thorough discussion between the patient and their healthcare team, including the surgeon, medical oncologist, and radiation oncologist.

If a patient chooses to proceed directly to radiation therapy without the recommended lymph node surgery, it is essential to understand the implications. Radiation may still be effective in targeting the breast and surrounding tissues, but if there are undetected cancer cells in the axillary lymph nodes, this could lead to a higher risk of recurrence in that area. Conversely, if the lymph nodes are confirmed to be cancer-free, the radiation treatment can be more focused and potentially less extensive.

In summary, the decision to perform additional lymph node surgery before radiation therapy is based on a combination of pathology results, the extent of previous surgeries, and the overall treatment strategy. It is crucial for patients to have open discussions with their healthcare providers to understand the rationale behind the recommendations and to make informed decisions about their treatment options.

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