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Non-sentinel lymph node involvement in patients with breast cancer and sentinel node micrometastasis; too early to abandon axillary clearance
  1. M A den Bakker1,
  2. A van Weeszenberg1,
  3. A Y de Kanter2,
  4. F H Beverdam5,
  5. C Pritchard4,
  6. Th H van der Kwast1,
  7. M Menke-Pluymers3
  1. 1Department of Pathology, Erasmus Medical Centre Rotterdam, Daniel den Hoed Location, Groene Hilledijk 301, PO Box 5201, 3008 AE, Rotterdam, Netherlands
  2. 2Department of Radiotherapy, Erasmus Medical Centre Rotterdam
  3. 3Department of Surgery, Erasmus Medical Centre Rotterdam
  4. 4Department of Research and Development Support Unit, Royal Cornwall Hospitals Trust, Treliske Hospital, Truro, Cornwall, TR1 3LJ, UK
  5. 5Department of Surgery, Medisch Centrum Rijnmond Zuid, Location Zuider, 3075 EA Rotterdam, Netherlands
  1. Correspondence to:
 Dr M A den Bakker, Department of Pathology, Erasmus Medical Centre Rotterdam, Daniel den Hoed Location, Groene Hilledijk 301, PO Box 5201, 3008 AE, Rotterdam, Netherlands;
 michael{at}dbakker.demon.nl

Abstract

Aims: It has been suggested that patients with T1–2 breast tumours and sentinel node (SLN) micrometastases, defined as foci of tumour cells smaller than 2 mm, may be spared completion axillary lymph node dissection because of the low incidence of further metastatic disease. To gain insight into the extent of non-sentinel lymph node (n-SLN) involvement, SLNs and complementary axillary clearance specimens in patients with SLN micrometastases were examined.

Methods: A set of 32 patients with SLN micrometastases was selected on the basis of pathology reports and review of SLNs. Five hundred and thirteen n-SLNs from the axillary clearance specimens were serially sectioned and analysed by means of immunohistochemistry for metastatic disease. Lymph node metastases were grouped as macrometastases (> 2 mm), and micrometastases (< 2 mm), and further subdivided as isolated tumour cells (ITCs) or clusters.

Results: In 11 of 32 patients, one or more n-SLN was involved. Grade 3 tumours and tumours > 2 cm (T2–3 v T1) were significantly associated with n-SLN micrometastases as clusters (grade: odds ratio (OR), 8.3; 95% confidence interval (CI), 1.4 to 50.0; size: T2–3 tumours v T1: OR, 15; 95% CI, 2.18 to 103.0). However, no subgroup of tumours with regard to size and grade was identified that did not have n-SLN metastases.

Conclusions: In patients with breast cancer and SLN micrometastases, n-SLN involvement is relatively common. The incidence of metastatic clusters in n-SLN is greatly increased in patients with T2–3 tumours and grade 3 tumours. Therefore, axillary lymph node dissection is especially warranted in these patients. However, because n-SLN metastases also occur in T1 and low grade tumours, even these should be subjected to routine axillary dissection to achieve local control.

  • sentinel node
  • micrometastasis
  • breast cancer
  • pathological staging
  • CI, confidence interval
  • H&E, haematoxylin and eosin
  • IHC, immunohistochemistry
  • ITC, isolated tumour cell
  • LN, lymph node
  • n-SLN, non-sentinel lymph node
  • OR, odds ratio
  • SLN, sentinel lymph node

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