Sentinel Lymph Node Biopsy

When a child is diagnosed with cancer, a sentinel (SEN-tin-ool) lymph node biopsy (SLNB) can help doctors find out if the cancer has spread to the lymph nodes or other organs.

The immune system consists of many infection-fighting cells and networks, including the lymphatic (lim-FAT-ick) system. When cancer spreads, it often moves through the lymphatic system, which houses the lymph nodes.

Lymph nodes are small, round structures that have immune system cells to fight off infections like bacteria and viruses. They are connected throughout the body by lymph vessels, which carry a clear fluid called lymph. Lymph is filled with immune cells that help remove toxins and protect the body from infection.

In an SLNB, doctors look for the sentinel lymph node, which is the closest node or group of nodes to the original tumor. The node is removed and sent to a laboratory to be tested for cancer.

• A negative SLNB means cancer has not yet spread to the lymph nodes.
• A positive SLNB indicates cancer at the sentinel lymph node and could mean that other lymph nodes or organs are infected.

Many types of pediatric cancers can spread through the lymphatic system, including:

• Bone, muscle, or connective tissue cancers (rhabdomyosarcoma, synovial sarcoma, epithelioid sarcoma).
• Kidney tumors (Wilms tumor).
• Lymphatic system cancers (Hodgkin or non-Hodgkin lymphoma).
• Skin cancers (melanoma, spitz nevus, and melanocytoma).

The results of SLNB help doctors diagnose the stage of cancer and create an appropriate treatment plan for your child. This plan may involve more surgeries to remove lymph nodes and tumors on other organs, if needed.

Complications of sentinel lymph node biopsy

Like any surgery, sentinel lymph node biopsy can cause some complications, including:

• Allergic reaction to the tracer.
• Bruising, numbness, swelling, or tingling near the surgery site.
• Inaccurate biopsy report — In some rare cases, the biopsy report returns a false-negative, meaning the tests say cancer is not present, but it has spread to other lymph nodes in the body.
• Infection.
• Lymphedema —Tissue swelling. More likely with more extensive lymph node surgery.
• Seroma — A mass from a buildup of lymph fluid near the surgery site.

Before surgery, talk with your child’s care team about risks, complications, and expectations so you can be prepared to help your child recover and know the signs of surgery complications.

Before the procedure

Before surgery begins, your child will receive an injection of tracer into the tissue right next to the tumor to help locate the sentinel lymph node. This tracer will travel along the lymphatic vessels the same way cancer cells would spread. It will collect in the sentinel lymph node, or the first lymph node that the lymphatic vessels meet along their way.

Surgeons use a special scanner device to watch the tracer as it moves around the body and identify the sentinel lymph node for removal. Once the tracer is placed, an anesthesiologist will give medication so your child goes to sleep. They will remain asleep for the duration of the procedure.

During the procedure

The surgeon will make a small incision near the sentinel lymph node that has been identified and carefully remove it from the body. Once the lymph node is removed, it will be sent to a lab for testing. A pathologist will determine if cancer cells are present in the lymph node.

In many cases, this part of the surgery is done at the same time that a primary cancer tumor is being removed. In some cases, additional lymph nodes may be removed during this procedure.

If the test shows cancer, your child may need another surgery later to remove regional lymph nodes in the same area.

After the procedure

Once the tumor and lymph node(s) are removed, the surgeon will close the incision. Some children may be ready to go home the same day of surgery, but others may need a short hospital stay to recover.

Your child’s care team will talk with you about the results of the surgery and next steps for treatment. Your child should be able to return to normal activities a few days to a week after surgery, depending on their diagnosis and overall health.

Is SNLB right for my child?

If your child’s care team is discussing a sentinel lymph node biopsy, it means they have already found cancer and are testing to see if the cancer has spread to other parts of the body.

If this procedure is an option for your child, it can help their care team understand their cancer so an individualized plan can be created.

An SLNB can become critical in catching later-stage and metastasizing cancer, which can help prevent death.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room to allow the anesthetic to wear off. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to their stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. This is a good time to ask questions about pain medications, diet, and activity.
• When your child is awake enough, they might be given a Popsicle® or “slushy” to drink in the recovery room.
• Once the anesthesiologist sees that your child is recovering and their pain is controlled, they will be moved to their hospital room. This usually takes about an hour, but every child is different, so times may vary.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.

During the surgery, your child will be given a numbing medication directly into the incision to relieve discomfort after the surgery.

After the surgery, your child will most likely have abdominal pain. Your child may take Tylenol^® or Motrin^®. If your child is still having pain, your child’s doctor may prescribe a stronger medication or a narcotic.

Before you go home, your doctor will prescribe pain medication for your child.

After your child is discharged and goes home, they should avoid strenuous activity for the next two to four weeks.

Bathing

• Your child may take a shower one to three days after the surgery; baths are allowed five to seven days after surgery.

Activity

Following the surgery, activity needs to be somewhat restricted.

• Your surgeon will determine when your child may resume normal activities.
• Your child may return to school when they feel up to it.
• Participation in contact sports and gym class is not permitted until cleared by the surgical team (typically two to four weeks after surgery).
• Swimming is permitted one to two weeks after surgery.
• Walking and stair climbing are encouraged.

If your child has a fever higher than 101.5 F, bleeding, or foul-smelling drainage from the area around the incisions, call your surgeon right away.

Also, call the doctor if your child has:

• Increased or unexplained pain.
• Increased swelling or redness at the incision site.
• Increased tenderness near the incision.
• Nausea, vomiting, diarrhea, or constipation that is not improving.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. After the surgery, you may call the Division of Pediatric General and Thoracic Surgery at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the follow-up visit, if needed.

If your child has any special needs or health issues you feel the doctor needs to know about, please call the Division of Pediatric General and Thoracic Surgery at UPMC Children's Hospital of Pittsburgh before the follow-up visit and ask to speak with a nurse. It is important to notify us in advance about any special needs your child might have.

At UPMC Children’s Hospital of Pittsburgh, every child facing a cancer diagnosis receives an individualized treatment plan and family-centered care.

• The surgeons at UPMC Children’s have trained at the nation’s leading pediatric cancer centers and have extensive experience in performing sentinel lymph node biopsies to diagnose and stage pediatric cancers.
• In addition, our cutting-edge research and the latest technology ensure our patients' best possible outcomes.