ArticlesSentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes
Introduction
Axillary lymph nodes are the commonest site of metastasis in breast carcinoma. Metastatic involvement of the axilla is known to progress regularly, from the first, via the second, to the third axillary level; skip metastases are found in roughly 2% of cases only.1, 2
Axillary-node status is one of the most important prognostic indicators in breast cancer, and of particular value in the choice of adjuvant therapy.3, 4 The prognostic information is gained from histological examination of all or most axillary nodes; the treatment of operable breast carcinoma almost always involves lymph-node dissection.5 However, if a non-invasive or minimally invasive diagnostic procedure could provide accurate preoperative staging of the axilla, axillary dissection could be avoided in patients with no involved nodes. Sentinel-node biopsy has been developed for this purpose. The technique was first used by Morton and colleagues with blue dye,6, 7 and later by van der Veen and colleagues8 with lymphoscintigraphy to select melanoma patients for regional node dissection. These researchers showed that early metastasis of melanoma almost always occurs in the first node, or sentinel node, to receive lymph from the area containing the primary tumour. In breast cancer, cells that detach from the primary tumour are likely to arrive at, and be held by, the first node to receive lymph from the involved breast area. If this sentinel node can be reliably identified, and if careful examination reveals no cancer cells, the other axillary nodes should also be clear.
In most previous investigations of the sentinel node, blue dye was injected into the peritumoral area, and the coloured node was sought through axillary incision.9 A few studies on small series of patients used the lymphoscintigraphic technique.10, 11 The validity of the sentinel-node strategy has thus been established in breast cancer.
We designed this study to assess the value of sentinel-node biopsy in breast cancer by means of a lymphoscintigraphic technique and, in particular, a γ-ray detection probe to facilitate identification and dissection of the lymph node. We had three objectives: first, to assess the reliability of external-body lymphoscintigraphy for identification of the node that receives lymph from the region of the primary carcinoma; second, to assess the usefulness of a γ-ray detection probe in identification and removal of the sentinel node during axillary surgery; and, third, to measure, by histological analysis of all axillary nodes, the extent to which the sentinel node is a predictor of axillary-node status.
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Patients
We studied 163 consecutive patients with operable breast carcinoma (T1-T3) scheduled to receive axillary dissection at the European Institute of Oncology, from March to December, 1996. We excluded pregnant or lactating women, those who had previously undergone biopsy or received radiotherapy to the breast. Patients with clinically extensive metastatic involvement were also excluded, as were those with tumours shown to be non-infiltrating on histological examination. Patients with carcinomas of
Results
The status of the axillary nodes correlated with several pathological variables (table 2). The most important predictive factor was peritumoral vascular invasion.
Discussion
We found radioguided resection of sentinel nodes in breast cancer simple and effective. Lymphoscintigraphy revealed the first lymph node within 30 min in most cases, and this node was the most radioactive in later scans in all cases. In 104 cases, one lymph node was identified by the probe and removed, 41 cases had two lymph nodes identified, and, 15, three nodes.
An incision of 2–3 cm was sufficient to permit removal of the sentinel node; this process was made much easier by use of the probe
References (20)
- et al.
Management of early-stage melanoma by intraoperative lymphatic mapping and selective lymphadenectomy: an alternative to routine elective lymphadenectomy or “watch and wait”
Surg Oncol Clin N Am
(1992) - et al.
Distribution of axillary node metastases by level of invasion: an analysis of 539 cases
Cancer
(1986) - et al.
Extent of metastatic axillary involvement in 1446 cases of breast cancer
Eur J Surg Oncol
(1990) - et al.
The accuracy of clinical nodal staging and of limited axillary dissection as a determinant of histological nodal status in carcinoma of the breast
Surg Gynecol Obstet
(1981) Adjuvant chemotherapy for breast cancer
JAMA
(1985)- et al.
Axillary node dissection for early breast cancer: some is good, but all is better
J Surg Oncol
(1992) - et al.
Technical details of intraoperative lymphatic mapping for early stage melanoma
Arch Surg
(1992) - et al.
Gamma-probe-guided sentinel node biopsy to select patients with melanoma for lymphadenectomy
Br J Surg
(1994) - et al.
Lymphatic mapping and sentinel lymphadenectomy for breast cancer
Ann Surg
(1994) - et al.
Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe
Surg Oncol
(1993)
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