Collective Reviews
Sentinel node biopsy in breast cancer1,

Presented at the American College of Surgeons 84th Annual Clinical Congress, Orlando, FL, October 1998 at a General Session moderated by Armando E Guiliano, MD, FACS.
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Sentinel node concept

Sentinel node biopsy technique is based on the sentinel node concept: the tumor-bearing status of the first node in the regional nodal basin draining a primary tumor reflects the tumor status of the entire nodal basin. This concept was first proposed by Cabanas in 1977 for penile carcinoma.23 He noted that radioopaque material injected through the dorsal penile lymphatics in patients with penile carcinoma consistently flowed to a specific draining lymph basin. Subsequently he performed 46 blind

Feasibility trials of breast sentinel node biopsy

The success of SNB in accurately identifying nodal involvement in melanoma stirred interest in applying this technique in breast cancer where identification of nodal metastases also has prognostic significance. But the technique of SNB may not be the same in breast cancer (a parenchymal tumor) because the kinetics of lymphatic flow and the distribution of lymphatic pathways may be different from melanoma (a cutaneous tumor). With any introduction of a new technique into the clinical setting,

Validation studies of sentinel node biopsy in breast cancer

The results of our feasibility trial enabled us to define the optimal technique and patient population for SNB. Three of the 5 false-negative SNBs were related to misidentification of blue-stained fat as a sentinel lymph node. Introduction of frozen section analysis on the sentinel node prevented this problem in subsequent patients. In our feasibility study, sentinel nodes were only examined by hematoxylin and eosin (H&E) staining. One of the sentinel nodes that was negative for metastases on

Patient selection

Selection of appropriate patients is the first step to successful and rational application of SNB in breast cancer management. Ideal SNB patients are those with low probability of harboring axillary metastases, but in whom the presence of axillary nodal involvement would change adjuvant systemic therapy, ie, patients with small primary tumors. There are no absolute contraindications for SNB except patients with a history of hypersensitivity reaction to the lymphatic mapping materials. Patients

Discussion

The introduction of intraoperative lymphatic mapping and sentinel node biopsy may alter the current surgical management of patients with invasive breast cancer. For patients with small primary tumors, an accurate and minimally morbid axillary staging tool like SNB is especially invaluable. Although the likelihood of axillary metastasis in a patient with a small lesion is low,58, 59, 60, 61 the tumor status of the axilla is frequently the deciding factor for the need and type of adjuvant

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      Various techniques have been investigated with this nuclear medicine approach, all using technetium-99m tracers that can be imaged in terms of their pattern of spread or simply detected manually by gamma-probes in the axilla. Injection into the peritumoral site, the subdermis, or the subareolar complex produces satisfactory results, consequent to the development of the lymphatic system [55]. In addition, different tracers have been studied with variable success, including sulfur colloid (filtered and ultrafiltered), human serum albumin colloid, dextran 40, microlite, and cardiolite, as well as combinations of isosulfan blue and technetium radiotracers.

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    Supported in part by funding from the Ben B. and Joyce E. Eisenberg Foundation, Los Angeles, CA, and the Fashion Footwear Association of New York.

    1

    No competing interests declared.

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