Treatment for Micrometastases in Lymph Nodes

Treatment for Micrometastases in Lymph Nodes

 Finding out that one has breast cancer is the kind of news no one wants to hear from their doctor, but for most women breast cancer is not a terminal diagnosis.1 Breast cancer is treatable. Breast cancer exists in different forms and stages which determine how aggressive treatment should be, what optimal treatment options are and how likely the cancer is to metastasize or spread.

This article addresses the topic of micrometastases. It will answer questions such as: What are micrometastases? What is the relationship between breast cancer and micrometastases? How is a surgeon likely to respond if micrometastases are found in the lymph nodes?

Micrometastases and Breast Cancer

 Micrometastases are small groups of cancer cells found outside the primary tumor. Micrometastases are sometimes located in lymph nodes near the tumor, and studies have shown that the presence of micrometastases is a good indicator of whether or not the cancer is spreading to other parts of the body.2

Previously, when lymph node excision was necessary, surgeons would routinely remove large sets of lymph nodes to prevent any remaining cancer from spreading through the body. These surgeries required long recovery times and would leave large scars. But newly published information has gradually changed how oncologists and surgeons practice. There is strong data to support less extensive and invasive methods of lymph node evaluation that are safe and effective.

One review entitled, “Breast Cancer and Sentinel Lymph Node Micrometastases: Indications for Lymphadenectomy and Literature Review,” published in the Journal of Surgery, examined different studies on the presence of micrometastases. The review concludes that women whose lymph nodes are negative for micrometastases need fewer nodes removed than women who had confirmed micrometastases in their nodes.3 The body of research on micrometastases has changed breast cancer treatment. Now, surgeons will perform a sentinel lymph node biopsy to determine the extent of nodal surgery a woman needs before large numbers of lymph nodes are removed.

What Is a Sentinel Lymph Node Biopsy?

 During a sentinel lymph node biopsy, the surgeon removes the sentinel lymph node to look for micrometastases.4 The “sentinel” lymph node is the node or nodes that are the “first” draining lymph nodes from the tumor and are most likely to be the next target of cancer cells before they move any further throughout the body. It is possible to have one or more sentinel lymph nodes removed during the “biopsy” as they are grouped together in small clusters and more than one node may be involved.

A sentinel lymph node biopsy is the first step before surgeons take further measures and remove additional lymph nodes. If a sentinel lymph node biopsy is negative for micrometastases, removal of additional nodes is usually not necessary. If the sentinel node biopsy results are positive for micrometastases, surgeons will use more invasive techniques to remove additional lymph nodes after the initial node evaluation.

Sentinel lymph node biopsies help surgeons and patients avoid unnecessary surgery. These biopsies require less recovery time and leave smaller scars than removal of multiple lymph nodes. A sentinel lymph node biopsy still has associated risks including swelling, fluid buildup at the biopsy site, numbness, tingling, discomfort and difficulty moving the affected body parts.4

Axillary Lymph Node Dissection

 An axillary lymph node dissection is a more invasive surgery than a sentinel lymph node biopsy. In an axillary lymph node dissection, additional lymph nodes are removed in order to evaluate the extent of nodal involvement and to prevent the cancer from spreading further. There are three different levels of axillary lymph nodes. Level I lymph nodes are found at the lower edge of the pectoralis minor muscles. Level II lymph nodes are located underneath the pectoralis minor muscles and level III lymph nodes are found above the pectoralis minor. An axillary lymph node dissection typically removes the first two levels of lymph nodes, sparing the nodes above the muscle.5

 Based on the number of lymph nodes that show signs of cancer, a surgeon will usually remove somewhere between five and 30 nodes. In determining whether to remove a given node, the surgeon looks for any evidence of cancer in the node rather than how much cancer is present.5 An axillary lymph node dissection usually happens at the same time as mastectomy or breast-conserving surgery, but can also be postponed if need be.6

 Historically, axillary lymph node dissection was the first method surgeons used to treat all breast cancer patients who needed lymph nodes removed. Since the body of knowledge surrounding the benefit of sentinel lymph node evaluation prior to axillary node dissection has been established, full node dissection is now used only in more extreme circumstances.6 Some of the situations in which a surgeon will recommend sentinel lymph node biopsy include breast cancer when there are multiple tumors, Ductal Carcinoma in Situ when mastectomy is planned, women with previous breast cancer or axillary node surgery, and women who have been treated with chemotherapy before .2

There is an ongoing debate about the effectiveness of axillary lymph node dissections. Some studies suggest that axillary lymph node dissections do not significantly improve a woman’s chances of survival, especially when only a small number of cancer cells are present in the sentinel lymph nodes.7 The Journal of the American Medical Association (JAMA) published research on this issue. In a randomized clinical trial, they found that women who received axillary lymph node dissection experienced more associated side effects as a result of the surgery, but did not see significant improvement in disease-free survival.8

 Studies like this need to be treated with healthy skepticism until further research is done. The authors recognized that there were certain flaws with the study, making it less than reliable for the time being. These flaws included low recurrence rates and a small sample size. However, it is important to remember that new research is being done to improve treatment options for women with micrometastases in their lymph nodes, and there are discoveries yet to be made.


Micrometastasis is just one of many topics you will learn about if you or someone you know has been diagnosed with breast cancer. Just know that at some point your doctor will look for micrometastases to get a better understanding of the extent of disease and how treatment should proceed. Depending on the status of micrometastases found in the sentinel lymph nodes, an oncologist may recommend a variety of different treatment options, such as further lymph node removal, radiation therapy, chemotherapy after surgery and treatment with hormonal therapy.2

Research continues and treatment options for those with micrometastases continue to improve over time. Given the current state of research, technology, diagnostic techniques and surgical technology, oncologists are well-prepared to address and manage micrometastases in breast cancer.


  1. Breast Cancer Survival Rates. American Cancer Society. Aug. 18. 2016.
  2. Micrometastases in Lymph Nodes Need Treatment. June 4, 2009.
  3. Zanghi G, Di Stefano G, Caporetto D, et al. Breast cancer and sentinel lymph node micrometastases: indications for lymphadenectomy and literature review. Journal of Surgery 2014;35(11-12):260-265
  4. Sentinel Lymph Node Biopsy. National Cancer Institute. National Institutes of Health. Aug. 11, 2011.
  5. Axillary Lymph Node Dissection. Jan. 22, 2015.
  6. Lymph Node Surgery for Breast Cancer. The American Cancer Society. June 1, 2016.
  7. Extensive Lymph Node Removal Doesn’t Improve Survival in Some Women with Early-Stage Breast Cancer. National Cancer Institute. National Institutes of Health. October 10, 2017.
  8. Giuliano A, Ballman K, McCall L, et al. Effect of Axillary Dissection vs No Axillary Dissection on 10-year Overall Survival Among Women with Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA 2017;318(10):918-926.

Breast MRI for Screening

It is estimated that an average of one in eight women in the United States will be diagnosed with breast cancer in her lifetime (1). This makes breast cancer the most commonly diagnosed cancer for women, and the second most cancer-related death for women (1). However, thanks to early detection, better treatment options, and increased awareness, the number of deaths as a result of breast cancer have been steadily declining since 1990. In fact, there are over 3.1 million breast cancer survivors living in the United States right now (1).

Risk Factors: Family History and Genetic Predisposition 

In addition to environmental risk factors, there are other factors which can increase the risk of breast cancer. There are certain genetic alterations that can increase the risk of breast cancer. The following are examples high risk factors related to family history and genetics (1):

  • BRCA1 or BRCA2 gene mutation or other less common genetic mutation, such as PALB2, PTEN, CHEK2, or ATM.
  • A close relative (such as parent, sibling, or child) who has been found to have a BRCA1 or BRCA2 gene mutation.
  • Family history of breast cancer.
  • Received radiation therapy to your chest to treat a different type of cancer, especially if you were between the ages of 10 and 30 years old.
  • A personal history of breast cancer.
  • Extremely heavy or unevenly dense breasts.

These factors increase a woman’s risk of developing breast cancer, and highlight the importance of genetic tests to assess your level of risk. They also highlight the importance of early detection.


Risk Factors: Environmental and other

There are various risk factors that can increase the likelihood of getting breast cancer based on the environmental. If one is aware of specific risk factors that could affect her, she will have a better chance of preventing, delaying, and/or treating breast cancer. Here are some environmental or lifestyle risk factors (1):

  • Radiation to the chest
  • Excessive alcohol consumption
  • Lack of physical activity
  • Poor diet e.g. high in saturated fat or lacking in fruits and vegetables
  • Being overweight or obese, especially after menopause

Most of these risk factors can be controlled or avoided. If one notices any of them are particularly problematic, then she may want to consider a lifestyle change.


Early Detection

There are several ways to assess breast health for early signs of breast cancer. Here are a few ways to screen for early detection (1):

  • Monthly breast self-exams feeling for:
    • Changes in how the breast or nipple feels (such as increased tenderness).
    • Lumps appearing or changes in skin texture.
    • Changes in size or shape of a breast (unexplained by other factors).
    • Any nipple discharge, if not breastfeeding.
  • Annual mammograms for women 45 and older.
  • Consult a healthcare provider about MRI screening in addition to annual mammograms if a moderate-high risk of breast cancer
  • Visit a qualified healthcare professional to perform a breast exam if there are any concerns about physical changes to the breasts.


Who Should Get an MRI for Breast Cancer Screening?

Not everyone needs an MRI when it comes to screening for breast cancer. However, if a woman is one of the aforementioned individuals at high-risk, she may want to consider it. Breasts are more thoroughly checked when an MRI is used in addition to annual mammograms. Occasionally, a mammogram will pick up something that was missed by an MRI or vice versa. Although an MRI is generally more sensitive than a mammogram, the increased sensitivity can occasionally result in a false positive (ref). A false positive occurs when a suspected mass is thought to be cancerous, but is actually benign. This could potentially result in a situation where a woman is undergoes additional procedures to confirm the original diagnosis. (1)

Neither mammograms or MRI are 100 percent effective when it comes to early breast cancer detection, but when used together, they have the best chance of catching any signs of cancer as early as possible. Women who may be a candidate for MRI breast cancer screening and should talk to a healthcare provider to determine if it’s appropriate. (1)


What are My Next Steps?

If you have already had your MRI screening, what should you do next? If your MRI scan result is negative, and you do not have any breast cancer symptoms, most women continue with routine surveillance under the supervision of their healthcare provider. Remember, even with previous negative scans, it is important to continue routine breast exams and annual screenings for early detection in the event that there is breast cancer in the future.

In the event that your MRI result displays signs of breast cancer, work with your doctor to determine a plan of action. The most important thing to remember is that by detecting the cancer early, your chances of survival are higher than cancers detected at later stages of disease progression (1)

Hopefully this has given you a better idea the pros and cons of MRI screening for breast cancer, and a good knowledge base before talking to your doctor.



  1. American Cancer Society. Breast Cancer Facts & Figures 2015-2016. Atlanta: American Cancer Society, Inc. 2015.


Menopausal status and mammogram frequency

Introduction reports that 1 in 8 women will develop breast cancer1 sometime in their life and 40,610 women are expected to die of breast cancer in the year 20171. Breast cancer is a serious disease that deserves well thought out medical policies on both detection and treatment

There is an ongoing debate on best practices when it comes to detection. Detection methods include self-breast exams, clinical-breast exams and mammograms. As more research comes out, it seems that different methods may have different benefits and drawbacks than others for detecting breast cancer as early as possible. It is important that women educate themselves on the different philosophies of breast cancer detection and take the proper steps to maximize their chances of early detection.


Current Practices

It’s important to detect breast cancer as early as possible. Early detection leads to early treatment which is more likely to lead to remission. One of the most effective ways to detect breast cancer is by getting a mammogram. Because of this, you might think that the more often a women can get mammograms, the better. However, the minimal risks associated with mammograms need to be balanced with the benefits and a woman’s individual risk of getting breast cancer. Therefore, the question that women need to ask themselves is, “How often do I need a mammogram?”

The American Cancer Society is one of the leading authorities on cancer research and treatment recommendations. In 2015 they updated their recommendations for who and how women should watch for breast cancer. These recommendations include standards for mammogram frequency.

Here’s the American Cancer Society’s recommendations for breast cancer screening.2

  1. Women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years. (Strong Recommendation)
    • Women aged 45 to 54 years should be screened annually. (Qualified Recommendation)
    • Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually. (Qualified Recommendation)
    • Women should have the opportunity to begin annual screening between the ages of 40 and 44 years. (Qualified Recommendation)
  2. Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer. (Qualified Recommendation)
  3. The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age. (Qualified Recommendation)

This is how often you should get a mammogram according to the ACS. It’s important to notice that their recommendations are based on age and not based on menopausal status or other factors.

Many doctors use this method, however, some doctors use a different one. Here’s that different method.


Comparing Age to Menopausal Status

Age related recommendations focus on how old a woman is rather than menopausal status. In a way, this makes sense. Breast cancer statistics and age seem to go hand-in-hand1, so it seems reasonable that age would be a factor when it comes to screening frequency. The age method tells women how often they should get a mammogram based off broad population statistics rather than a personalized data.

Studies have shown that there’s a different way to determine how screening recommendations should change for various groups of women. Those who support using menopausal status as an indicator, found hard data in a study called, “Breast Tumor Prognostic Characteristics and Biennial vs Annual Mammography, Age, and Menopausal Status” to support their method. This study shows that there is a different way to determine screening frequency for breast cancer.3

“Premenopausal women diagnosed as having breast cancer following biennial vs annual screening mammography are more likely to have tumors with less favorable prognostic characteristics,” the study found. “Postmenopausal women not using hormone therapy who are diagnosed as having breast cancer following a biennial or annual screen have similar proportions of tumors with less favorable prognostic characteristics.”3

That is the main takeaway from this study. Premenopausal women are more likely to be diagnosed with an aggressive form of breast cancer, and could therefore see a greater benefit from yearly mammograms. Postmenopausal women are more likely to be diagnosed with a less aggressive tumor and can safely reduce the frequency of mammograms to every two years.

Although the age method helps women reduce the number of mammograms they receive, it also gives aggressive tumors a head start. The menopausal status shortens that head start significantly, but also means that women are likely have to get screened more frequently over longer periods of time.

Both methods have benefits and drawbacks and a doctor will be able to best help a woman determine which method is best for her.


How Could Practices Be Updated

The way in which breast cancer screenings can be updated centers around the topic of how often should you get a mammogram. If doctors wanted to change from the age method to the menopausal status method, a fundamental change in thinking would need to happen.

No longer would we think of breast cancer detection as an issue related to likelihood and age, but as one related to aggressiveness and menopause. It’s easy to see why breast cancer has been viewed as an age-related issue since the risk of getting breast cancer does increase with age4, but that may only be half of the picture.

The question of how often you need a mammogram isn’t just about how likely you are to develop cancer, but how likely is it that the cancer is going to be aggressive if left untreated for a prolonged time. The study described previously showed that in premenopausal women, it’s much more likely that their cancer will become aggressive with time, whereas that’s not the case in postmenopausal women.

Continuing annual screenings until menopause is not a matter of dismissing age, but potentially catch more aggressive cancers sooner than later.


Questions To Consider Asking Your Doctor

Cancer is all about managing your risk factors, early detection and early treatment. In order to help more women win the fight against breast cancer, we need to encourage women to do those three things. That’s why it’s so important to detect breast cancer as early as possible, especially in premenopausal women.

Here are some questions to ask your doctor about your prevention plan;

  • How often do I need a mammogram and why?
  • What lifestyle changes can I make to lower my risks?
  • What can my genetic history tell me about my risks?
  • How likely am I to experience a more aggressive type of breast cancer?
  • Do you prefer the age or menopausal status method and why?
  • What are the benefits and drawbacks to each method?
  • What can I do to take care of myself between screenings?
  • What’s the harm if I’d prefer extra/less screenings?

Studies have found that breast cancer mortality is reduced by as much as 20 percent5 thanks to screening. It’s such an important tool in the breast cancer detection toolkit that you should talk to your doctor to fully understand his or her screening strategy.



So how likely are you to develop breast cancer? The answer is that it depends. Your risk of developing breast cancer depends on pre-existing risk factors like genetic mutations and breast density.6 It depends on lifestyle choices such as level of fitness and alcohol consumption.  It depends on past medical treatments and their respective risks.

There are steps you can take to reduce your risk of breast cancer but, in reality, predicting breast cancer is challenging. The next best thing you can do is get regular screenings.

So how often do you need a mammogram?

Talk to your doctor and ask about annual mammograms until you enter menopause. This maximizes the chance for early detection and allows for early treatment. After that, as if spacing out your mammograms to once every other year is an option for you if your chance of developing an aggressive cancer becomes reduced after menopause.

Take advantage of available opportunities to reduce your risk of breast cancer. Next time you have an appointment, talk to your doctor about how your menopausal status can affect your risk of developing breast cancer.



  1. U.S. Breast Cancer Statistics. March 10 2017.
  1. Oeffinger KC, Fontham ETH, Etzioni R, Herzig A, Michaelson JS, Shih YT, Walter LC, Church TR, Flowers CR, LaMonte SJ, Wolf AMD, DeSantis C, Lortet-Tieulent J, Andrews K, Manassaram-Baptiste D, Saslow D, Smith RA, Brawley OW, Wender R. Breast Cancer Screening for Women at Average Risk. 2015 Guideline Update From the American Cancer Society. JAMA. 2015;314(15):1599-1614. doi:10.1001/jama.2015.12783
  1. Miglioretti DL, Zhu W, Kerlikowske K, Sprague BL, Onega T, Buist DSM, Henderson LM, Smith RA, for the Breast Cancer Surveillance Consortium. Breast Tumor Prognostic Characteristics and Biennial vs Annual Mammography, Age, and Menopausal Status. JAMA Oncol. 2015;1(8):1069-1077. doi:10.1001/jamaoncol.2015.3084
  1. Breast Cancer Risk By Age. Centers for Disease Control and Prevention. Dec. 14 2015.
  1. Myers ER, Moorman P, Gierisch JM, Havrilesky LJ, Grimm LJ, Ghate S, Davidson B, Mongtomery RC, Crowley MJ, McCrory DC, Kendrick A, Sanders GD. Benefits and Harms of Breast Cancer Screening A Systematic Review. JAMA. 2015;314(15):1615-1634. doi:10.1001/jama.2015.13183
  1. What Are The Risk Factors for Breast Cancer? Centers for Disease Control and Prevention. April 4. 2016.

Long Term Effects of Radiation

Radiation therapy is a form of cancer treatment that is used to destroy cancer cells and reduce the size of tumors. It is also known as radiotherapy.1 In high doses, radiation therapy can be used to treat cancer or ease cancer related symptoms. Usually, radiation therapy is used in conjunction with other forms of treatment.1 For example, radiation therapy can be used before surgery to reduce the size of the tumor to the point where surgery is possible. It can also be used after surgery to destroy any remaining cancer cells that were not removed during the surgery.

Radiation therapy is an important part of cancer treatment for many patients, but like most treatments and procedures, it does have risks and side effects. This article will outline the long-term effects of radiation therapy and focus on the long-term effects of breast cancer radiation.


Types of Radiation Therapy

When talking about radiation therapy, there are two types of treatment that are normally considered. These are external beam radiation and internal radiation (also known as brachytherapy).2

External beam radiation is a form of radiation therapy where bursts of radiation are directed at the tumor or a specific area on the body where the cancer is located. This treatment is usually performed using a machine called a linear accelerator.3 Although external beam radiation targets specific areas of the body, it’s more likely than internal radiation therapy to damage surrounding tissue. External beam radiation short-term side effects include changes to the skin, nausea, and tiredness.3

Internal radiation therapy, or brachytherapy, is a process where radioactive material are inserted into the body.4 The radioactive material is inserted either in or near the cancerous tumor and left in the body for anywhere between several hours and several days, slowly irradiating the cancer. Side effects of internal radiation therapy are rarer than with external beam radiation, but include minor pain or discomfort around the area of the radioactive material as well as redness, bruising, breakdown of fatty tissue, and weakness.4,5


Radiation Long-Term Side Effects

The long-term effects of breast cancer radiation therapy vary from person to person. Two of the more common long-term effects of radiation include damage to the body and an increased risk of cancer in the future.6

Unfortunately, radiation can affect normal cells, not just the cancerous cells. Because of the damaging effects of radiation, one of the long-term side effects of radiation therapy includes the possible damage to other parts of the body in and around the site of irradiation. For example, it’s possible that radiation therapy targeted at cancerous breast tissue could damage organs behind the breast, such as the heart and lung.6

Another potential side effect is that radiation therapy can increase a patient’s risk of developing a cancer in the future. Radiation has been linked to an increased risk for other cancers later on in life. Several studies have been performed showing that, although radiation helps kill cancer cells, the neighboring healthy tissue that gets damaged in the process has a risk of becoming cancerous as well.6

Some specific types of radiation have unique long-term side effects. External beam radiation long-term side effects include, a reduction in breast size, problems breastfeeding, nerve damage, chest pain and weakness.5
Managing Long-Term Effects of Breast Cancer Radiation

Not all patients will experience long-term side effects of radiation.7 Armpit discomfort, chest pain, fatigue, heart problems, lowered white blood cell count, lung and skin problems are all possible  radiation long-term side effects of radiation therapy that a patient may or may not experience. It’s also important to remember that not all of these are necessarily symptoms of radiation treatment. For example, one can experience fatigue for a variety of reasons and it’s not necessarily due to the radiation therapy.

In the end, although radiation therapy can produce several negative side effects a women may prefer to avoid, the alternative is an incomplete cancer treatment. This is why it’s likely better to manage the long-term side effects than avoid them. Each of these side effects comes with it’s own methods of care and management. It’s important to pay close attention to physical changes and act in accordance with a doctor to manage these side effects.

One of the more common side effects patients experience during radiation therapy is skin damage. Radiation therapy is in some ways similar to sun exposure. The skin becomes red and irritated and the patient may experience some tenderness, itching and peeling.8 To manage this common problem, try treating the irritated skin as if it were sunburn. Replace hot water for warm water when showering and avoid direct water-to-skin contact, avoid tight fitting clothes and prolonged exposure to the sun.

A doctor should be able to help in managing other symptoms as they appear.

Radiation therapy is a serious treatment that has provided many patients with positive results regarding their cancer treatment. In no way does this mean that it doesn’t come at a cost. Although some may never experience short-term or long-term side effects, many will. With help however, these side effects are mostly manageable and within your ability to handle. Hopefully now you feel more prepared to handle the long-term effects of radiation.



  1. Radiation Therapy. National Cancer Institute at the National Institute of Health. Feb. 2, 2017.


  1. Radiation Therapy for Cancer. National Cancer Institute at the National Institute of Health. June 30, 2010.


  1. External Beam Radiation Therapy (EBRT). Cancer Treatment Centers of America. Accessed April 19, 2017.


  1. Dutta, Pinaki. Vachani, Carolyn. Internal Radiation Therapy. OncoLink. Dec 4, 2006.


  1. Radiation for Breast Cancer. American Cancer Society. Aug 18, 2016.