Axillary lymph nodes

Breast cancer

Breast cancer is a disease that has many risk factors associated with it such as:

• advancing age
• genetic
• oestrogen exposure

Risk factors for raised oestrogen exposure include early menarche, late menopause, combined oral contraceptive use, oestrogen containing hormone replacement therapy, no pregnancies, and lack of breastfeeding.

Every breast lump is assessed with triple assessment. This is a three phase process that has a very high rate of detection of cancerous masses.

1. The history and clinical examination of the patient is the first part.
2. The next step is imaging, where the preferred imaging modality is ultrasound (if the woman is younger and the breast tissue is dense - fibrous), or mammography (if the woman is older and the breast tissue is more fatty and less dense - less fibrous).
3. The final step is to gain a histological sample through biopsy. This is usually performed as a fine needle aspiration, with a followup core biopsy if the initial fine needle aspiration shows potential cancer cells. The biopsy is reviewed by a pathologist.

All cancerous masses are removed surgically. This is either as a mastectomy (removal of the breast) or a lumpectomy (removal of affected tissue vs. whole breast), with or without a wide local excision of the axillary lymph nodes. Mastectomy procedures are used for central large masses and the lumpectomy is used in smaller, more peripheral masses. A degree of clinical decision making and patient preference is important in determining the choice of operation.

A radical mastectomy is removal of breast, pectoralis major and pectoralis minor muscles, as well as the axillary lymph nodes. This is the most radical surgical option and is referred for highly invasive and dangerous cancers. The amount of axillary lymph node removal depends upon the investment and degree of metastasis of cancer. Partial mastectomies are employed for patients who wish to preserve as much of the breast tissue as possible and they have a smaller more focal disease. There is a higher degree of recurrence of cancer in these patients.

A lumpectomy is a more focused excision of the cancerous lump. The sentinel node (the first node that drains the breast) is identified and a histological section is checked for the presence of cancer. If there is cancer present, then all the lymph nodes surrounding with investment in the sentinel node are removed, as they could all theoretically have cancer cells within them. If these are found to be free of cancer then the process stops, if these are found to be positive for cancerous cells then the process continues until the lymph nodes are free and clear of cancer. This procedure may cause damage to the nerves, vessels, and tissue of the region. There is also a risk of postoperative lymphoedema, where the lymph drainage of the breast and upper limb may be compromised, resulting in a swelling over these regions.

All patients who have a lumpectomy and wide local excision have postoperative radiotherapy, as do mastectomy patients with more than a certain number of positive lymph nodes in the axilla. Medical treatment of breast cancer is dependent on the hormonal status of the cancer. Specifically, it depends on the receptors the cancer cell has on its surface. If the cancer is oestrogen receptor positive, then tamoxifen is the treatment in premenopausal women. Aromatase inhibitors are used in postmenopausal women. Those with HER2 receptor positive cancers may have Herceptin, which is a monoclonal antibody.

Virchow’s node

In cases of gastric malignancy, there may be a visibly enlarged lymph node in the left supraclavicular fossa. This is a good clinical sign, but is not necessarily present in all patients who have abdominal or pelvic cancers that metastasize.

Lymphoma

This is a cancer involving the lymph nodes and is divided into Hodgkin’s and non-Hodgkin’s types. Hodgkin’s lymphoma is defined by the presence of Reed-Sternberg cells. Signs and symptoms include:

• night sweats
• weight loss
• rubbery enlargement of the cervical lymph nodes
• systemic fever

Treatment of both types is chemotherapy and radiotherapy in some cases.