An Overview of Lymph Node-Positive Breast Cancer

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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.

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

Causes

Breast cancer starts out with just a few cells, which group together in your breast tissue and may camp out in the ducts and lobes. As these cells grow and divide, they may also invade nearby tissue—including lymph nodes.

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. Lymph nodes are in various locations, including breast tissue itself.

A growing tumor may shed a cell or a clump of cells. It can use your blood or lymph system as a network of highways for traveling throughout your body. 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.

Symptoms

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 are the most common area that cancer cells will lodge, which also causes the nodes to swell.

In fact, 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 tumors most commonly drain toward your axilla, or underarm area. Checking this 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.

While axillary lymph nodes are usually the first place breast cancer spreads to, breast cancers towards the middle of your chest may instead drain to lymph nodes between the breasts, so inflammation would be present there instead.

Diagnosis

Lymph node-positive breast cancer is diagnosed via a biopsy, either during a breast surgery or as a separate procedure. Doctors use two procedures for lymph node biopsy:

  • Sentinel lymph node biopsy
  • Axillary lymph node dissection

"Axillary" means "of the armpit," and the axillary lymph nodes are typically the first place breast cancer spreads to. You have many axillary nodes, and the first ones cancer is likely to move into are called the sentinel lymph nodes.

Research suggests that finding cancer cells in your sentinel lymph nodes is an excellent predictor of whether cancer will be found in any of your remaining lymph nodes.

In a sentinel lymph node biopsy, those first nodes are identified by a dye and radioactive marker that are injected into the breast. Those nodes are then removed and checked for cancer.

An axillary lymph node dissection is an alternative to a sentinel lymph node biopsy. In this procedure, a surgeon removes all of the lymph nodes that they can find in your armpit (rather than just the sentinel nodes), and then examines them to see whether cancer is present.

Lymph Node Status

The pathology report about your lymph node status tells whether or not any sign of cancer is present in the 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.

Negative

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 negative sentinel node biopsy, you likely won't need to have an axillary lymph node dissection. If you have a small tumor and clear nodes, it's less likely that you will need chemotherapy.

Positive

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 depending 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 micrometastases
N1 Positive: Cancer is found in 1 to 3 lymph nodes under the arm or lymph nodes within the breast.
N2 Positive: Cancer is found in 4 to 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.

If you have cancer cells in your sentinel lymph node, axillary node dissection may be included along with breast cancer surgery, if surgery is part of your treatment plan.

Treatment

Treatment is designed to kill off as many of your cancer cells as possible. 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.

Having just one cancer cell in your body is one too many. 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 five 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 after you've completed treatment.

If you had clear lymph nodes and a small, low-grade tumor, your prognosis after treatment is quite good. On the other hand, 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.

No matter where your diagnosis fits on the scale, 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

Facing the possibility or reality of lymph node involvement only adds to the emotions that come with the idea of a breast cancer diagnosis itself.

While it may feel overwhelming, you can learn to cope with this 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 may include chemotherapy, hormonal therapy, targeted therapy, and radiation. Thankfully, 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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