An Overview of Lymph Node-Positive Breast Cancer

Symptoms, causes, diagnosis, treatment, and coping

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Table of Contents
Doctor examining patient's lymph nodes
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If you're diagnosed with lymph node-positive breast cancer, it means cancer has spread from the original tumor to the nearest lymph nodes, which are under your arm. When breast cancer spreads to lymph nodes it has essentially declared its "intent" to metastasize. These cancers, if left alone, would likely spread throughout the body and eventually cause death.

Metastases are responsible for 90 percent of breast cancer deaths, so swift, aggressive treatment is usually warranted.

Symptoms

The key symptom separating lymph node-positive breast cancer from other types of breast cancer is inflammation in the lymph nodes under your arm.

Breast tissue itself contains some lymph nodes, which process lymphatic fluid and pass it along. Breast tumors most commonly drain towards your axilla or underarm area. Checking the underarm lymph node location should be part of a clinical breast exam, as well as your breast self-exam. While swollen lymph nodes might be evidence that cancer has spread beyond your breast, the only way to know for sure is to have them removed and tested.

Causes

Breast cancer starts out with just a few cells, which group together in your breast tissue. They may camp out in the system where breast milk is produced—your milk ducts and lobes. As these cells grow and divide, they may also invade nearby tissue.

A growing tumor may shed a cell or a clump of cells. This independent cancer cell can use your blood or lymph system as a network of highways for traveling throughout your body. Your lymph system works with your circulating blood to provide nutrients to all your cells, as well as remove cellular waste products. The lymph nodes are the "pit stops" on this highway system, where the lymphatic fluid is filtered, mixed with immune cells (lymphocytes), and passed back into your circulating lymph fluid.

So, if a loose cancer cell makes it to your lymph nodes, it's also possible that it could get sent along to other parts of your body. If you get an infection, your lymph nodes near the affected area may swell because they have collected germs. And if you develop breast cancer, the lymph nodes in your armpit (axillary lymph nodes) are the most common place that cancer cells would lodge, causing those nodes to swell.

Diagnosis

Lymph node-positive breast cancer is diagnosed via a biopsy. Doctors use two procedures for lymph node biopsy.

In a sentinel lymph node biopsy, a dye and a radioactive marker are injected into your breast cancer. The first node or nodes that the dye travels to are called the sentinel lymph nodes—the first nodes to which cancer would be expected to travel.

An alternative to a sentinel lymph node biopsy is an axillary lymph node dissection. In this procedure, a surgeon removes all of the lymph nodes that they can find in your armpit. Research suggests that finding cancer cells in your sentinel lymph nodes is an excellent predictor of whether or not cancer will be found in any of your remaining lymph nodes.

Axillary lymph nodes are usually the first place breast cancer spreads to, but there are some exceptions. Breast cancers towards the middle of your chest may instead drain to lymph nodes between your breasts.

When lymph nodes are removed they are sent to the pathology department and examined under a microscope.

Lymph Node Status

The pathology report about your lymph node "status" tells whether or not any sign of cancer is present in your lymph nodes that were removed. You may hear words such as macrometastases or micrometastases when your surgeon discusses your nodes. With macrometastases, cancer in the lymph nodes is visible to the naked eye. Micrometastases can only be seen under the microscope.

If your lymph nodes are clear of cancer, your lymph node status is called negative and rated N0 according to the TNM staging of breast cancer. If you have a small tumor and clear nodes, it's less likely that you will need chemotherapy.

If you have cancer cells in your lymph nodes, your cancer is considered lymph node-positive. Based on TNM staging, your tumor would be called either N1, N2, or N3 based on how many lymph nodes contain cancer cells and how far away from the tumor the positive nodes are found.

Lymph Node Rating Meaning of Rating
N0 Negative or clear: Contains no cancer and no micrometastasis
N1 Positive: Cancer is found in 1-3 lymph nodes under the arm or lymph nodes within the breast
N2 Positive: Cancer is found in 4-9 lymph nodes under the arm or lymph nodes within the breast
N3 Positive: Cancer is found in 10 or more lymph nodes under the arm or has spread under or over the collarbone. It may have been found in the underarm nodes as well as lymph nodes within the breast

Treatment

If you have a negative sentinel node biopsy, you likely won't need to have an axillary lymph node dissection. However, if you have cancer cells in your sentinel lymph node, axillary node dissection may be included along with your breast cancer surgery. If your lymph nodes are positive, you will need to discuss further treatment options with your oncologist after surgery.

Having lymph nodes involved usually means you'll be advised to have adjuvant systemic therapy such as chemotherapy to kill any additional cancer cells that persist in your body. Adjuvant treatment refers to treatment that is given not because any cancer is seen, but because it is suspected that there may be additional cancer cells present.

For those who have estrogen receptor-positive tumors, hormonal therapy is usually recommended for 5 to 10 years after treatment. This may be tamoxifen for those who are premenopausal and an aromatase inhibitor for those who are postmenopausal. The most commonly recommended aromatase inhibitor is the bisphosphate medication Zometa (zoledronic acid). as it appears to reduce the risk of developing bone metastases. (The bones are the most common site of metastases with breast cancer.)

Radiation therapy may or may not be recommended depending on the number of positive lymph nodes and other findings related to your tumor.

Prognosis

Prognosis, also called outlook, is one way a doctor talks about how the odds for survival stack up for you after you've completed treatment. Remember, having just one cancer cell in your body is one too many. Treatment is designed to kill off as many of your cancer cells as possible.

If you had clear lymph nodes and a small, low-grade tumor, your prognosis after treatment is quite good. On the other end of the spectrum, if you had several lymph nodes involved or a larger tumor, your treatment will likely be more aggressive, and your outlook will be harder to determine until after you've finished all treatments. An article published in the New England Journal of Medicine shows a significant risk of recurrence in patients with four or more positive lymph nodes. Also. tumor size is an independent prognostic factor.

No matter where your diagnosis fits on that scale, please know that survival rates are improving, treatments are becoming more efficient and effective, and even metastatic breast cancer can sometimes be managed for a long period of time.

Coping

Dealing with any kind of cancer is scary, and facing the possibility or reality that it's spread to your lymph nodes likely exacerbates your fear.

While it may feel overwhelming, you can learn to cope with the fear in positive ways. It's also important to advocate for yourself when going through treatment.

Talk to your doctor about any problems you may have coping. They may be able to refer you to a good therapist or support group.

A Word From Verywell

If you have positive lymph nodes with early-stage breast cancer, treatments will likely be more aggressive and include chemotherapy, hormonal therapy, HER2 targeted therapy for those who are HER2 positive, and possibly radiation. That said, many people with lymph node-positive cancer remain cancer-free after treatment, and a positive lymph node status does not automatically mean your cancer will come back. 

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