Original Communications| Volume 128, ISSUE 1, P6-12, July 2000

The implementation of the sentinel node biopsy as a routine procedure for patients with breast cancer


      Background: The sentinel node procedure for breast cancer allows for accurate staging of the axilla while the axillary node dissection can be avoided in patients with no sentinel node metastasis. This study describes those patients in whom an axillary dissection is performed, depending on the outcome of the sentinel node procedure, with particular emphasis on the use of strict criteria for the procedure and its practical limitations. Methods: Preoperative lymphoscintigraphy was performed in 115 consecutive patients. The sentinel nodes were located with the use of a gamma probe and blue dye. Axillary dissection was performed at the same time when the sentinel node procedure was positive by frozen section or not successful by the criteria used. Results: The sentinel node procedure was successful in 106 patients, with the sentinel node being both radioactive and blue in 94% of these patients. The frozen section was positive in 21 of 37 patients with sentinel node metastases. Axillary dissection could be avoided in 69 patients. Conclusions: The triple technique (with the use of lymphoscintigraphy, the gamma probe, and the blue dye) gives a high success rate of the sentinel node procedure, even when strict criteria for a successful sentinel node procedure are used. Palpation of the open axilla for metastatic nonsentinel nodes is advocated. (Surgery 2000;128:6-12.)
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        • Krag D
        • Weaver D
        • Ashikaga T
        • Moffat F
        • Klimberg V
        • Shriver C
        • et al.
        The sentinel node in breast cancer: a multicenter validation study [see comments].
        N Engl J Med. 1998; 339: 941-946
        • Borgstein P
        • Pijpers R
        • Comans E
        • van Diest P
        • Boom R
        • Meijer S.
        Sentinel lymph node biopsy in breast cancer: guidelines and pitfalls of lymphoscintigraphy and gamma probe detection.
        J Am Coll Surg. 1998; 186: 275-283
        • Veronesi U
        • Paganelli G
        • Galimberti V
        • Viale G
        • Zurrida S
        • Bedoni M
        • et al.
        Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes [see comments].
        Lancet. 1997; 349: 1864-1867
        • Albertini J
        • Lyman G
        • Cox C
        • Yeatman T
        • Balducci L
        • Ku N
        • et al.
        Lymphatic mapping and sentinel node biopsy in the patient with breast cancer [see comments].
        JAMA. 1996; 276: 1818-1822
        • Giuliano AE
        • Kirgan DM
        • Guenther JM
        • Morton DL
        Lymphatic mapping and sentinel lymphadenectomy for breast cancer [see comments].
        Ann Surg. 1994; 220: 391-398
        • Giuliano AE
        Sentinel lymphadenectomy in primary breast carcinoma: an alternative to routine axillary dissection [editorial].
        J Surg Oncol. 1996; 62: 75-77
        • Borgstein P
        • Meijer S
        • Pijpers R.
        Intradermal blue dye to identify sentinel lymph-node in breast cancer [letter; see comments].
        Lancet. 1997; 349: 1668-1669
        • Hill A
        • Tran K
        • Akhurst T
        • Yeung H
        • Yeh S
        • Rosen P
        • et al.
        Lessons learned from 500 cases of lymphatic mapping for breast cancer.
        Ann Surg. 1999; 229: 528-535
        • Roumen RM
        • Geuskens LM
        • Valkenburg JG
        In search of the true sentinel node by different injection techniques in breast cancer patients.
        Eur J Surg Oncol. 1999; 25: 347-351
        • Wilhelm AJ
        • Mijnhout GS
        • Franssen EJ
        Radiopharmaceuticals in sentinel lymph-node detection: an overview.
        Eur J Nucl Med. 1999; 26: S36-S42
        • Pijpers R
        • Borgstein PJ
        • Meijer S
        • Krag DN
        • Hoekstra OS
        • Greuter HN
        • et al.
        Transport and retention of colloidal tracers in regional lymphoscintigraphy in melanoma: influence on lymphatic mapping and sentinel node biopsy.
        Melanoma Res. 1998; 8: 413-418
        • van Diest PJ
        • Torrenga H
        • Borgstein PJ
        • Pijpers R
        • Bleichrodt RP
        • Rahusen FD
        • et al.
        Reliability of intraoperative frozen section and imprint cytological investigation of sentinel lymph nodes in breast cancer.
        Histopathology. 1999; 35: 14-18
        • Feldman SM
        • Krag DN
        • McNally RK
        • Moor BB
        • Weaver DL
        • Klein P.
        Limitation in gamma probe localization of the sentinel node in breast cancer patients with large excisional biopsy.
        J Am Coll Surg. 1999; 188: 248-254
        • Carter CL
        • Allen C
        • Henson DE
        Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases.
        Cancer. 1989; 63: 181-187
        • Sacre RA
        Clinical evaluation of axillary lymph nodes compared to surgical and pathological findings.
        Eur J Surg Oncol. 1986; 12: 169-173
        • Fisher B
        • Wolmark N
        • Bauer M
        • Redmond C
        • Gebhardt M.
        The accuracy of clinical nodal staging and of limited axillary dissection as a determinant of histologic nodal status in carcinoma of the breast.
        Surg Gynecol Obstet. 1981; 152: 765-772
        • Bonnema J
        • van Geel AN
        • van Ooijen B
        • Mali SP
        • Tjiam SL
        • Henzen-Logmans SC
        • et al.
        Ultrasound-guided aspiration biopsy for detection of nonpalpable axillary node metastases in breast cancer patients: new diagnostic method.
        World J Surg. 1997; 21: 270-274
        • Mathiesen O
        • Carl J
        • Bonderup O
        • Panduro J.
        Axillary sampling and the risk of erroneous staging of breast cancer: an analysis of 960 consecutive patients.
        Acta Oncol. 1990; 29: 721-725
        • Fisher CJ
        • Boyle S
        • Burke M
        • Price AB
        Intraoperative assessment of nodal status in the selection of patients with breast cancer for axillary clearance.
        Br J Surg. 1993; 80: 457-458
        • Steele RJ
        • Forrest AP
        • Gibson T
        • Stewart HJ
        • Chetty U.
        The efficacy of lower axillary sampling in obtaining lymph node status in breast cancer: a controlled randomized trial.
        Br J Surg. 1985; 72: 368-369
        • Kissin MW
        • Thompson EM
        • Price AB
        • Slavin G
        • Kark AE
        The inadequacy of axillary sampling in breast cancer.
        Lancet. 1982; 1: 1210-1212
        • Dees EC
        • Shulman LN
        • Souba WW
        • Smith BL
        Does information from axillary dissection change treatment in clinically node-negative patients with breast cancer? An algorithm for assessment of impact of axillary dissection.
        Ann Surg. 1997; 226: 279-286
        • Recht A
        • Houlihan MJ
        Axillary lymph nodes and breast cancer: a review.
        Cancer. 1995; 76: 1491-1512
        • Cady B.
        The need to reexamine axillary lymph node dissection in invasive breast cancer [editorial].
        Cancer. 1994; 73: 505-508
        • Morrow M.
        Role of axillary dissection in breast cancer management [editorial].
        Ann Surg Oncol. 1996; 3: 233-234
        • van der Ent FW
        • Kengen RA
        • van der Pol HA
        • Hoofwijk AG
        Sentinel node biopsy in 70 unselected patients with breast cancer: increased feasibility by using 10 mCi radiocolloid in combination with a blue dye tracer.
        Eur J Surg Oncol. 1999; 25: 24-29
        • Morton DL
        • Wen DR
        • Wong JH
        • Economou JS
        • Cagle LA
        • Storm FK
        • et al.
        Technical details of intraoperative lymphatic mapping for early stage melanoma.
        Arch Surg. 1992; 127: 392-399
        • Strand SE
        • Bergqvist L.
        Radiolabeled colloids and macromolecules in the lymphatic system.
        Crit Rev Ther Drug Carrier Syst. 1989; 6: 211-238
        • Roumen RM
        • Valkenburg JG
        • Geuskens LM
        Lymphoscintigraphy and feasibility of sentinel node biopsy in 83 patients with primary breast cancer.
        Eur J Surg Oncol. 1997; 23: 495-502
        • Pijpers R
        • Meijer S
        • Hoekstra OS
        • Collet GJ
        • Comans EF
        • Boom RP
        • et al.
        Impact of lymphoscintigraphy on sentinel node identification with technetium-99m-colloidal albumin in breast cancer.
        J Nucl Med. 1997; 38: 366-368
        • Cox CE
        • Pendas S
        • Cox JM
        • Joseph E
        • Shons AR
        • Yeatman T
        • et al.
        Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer [see comments].
        Ann Surg. 1998; 227: 645-651
        • O'Hea BJ
        • Hill AD
        • El-Shirbiny AM
        • Yeh SD
        • Rosen PP
        • Coit DG
        • et al.
        Sentinel lymph node biopsy in breast cancer: initial experience at Memorial Sloan-Kettering Cancer Center [see comments].
        J Am Coll Surg. 1998; 186: 423-427
        • Noguchi M
        • Minami M
        • Earashi M
        • Taniya T
        • Miyazaki I
        • Mizukami Y
        • et al.
        Intraoperative histologic assessment of surgical margins and lymph node metastasis in breast-conserving surgery.
        J Surg Oncol. 1995; 60: 185-190
        • van Diest PJ
        • Peterse HL
        • Borgstein PJ
        • Hoekstra O
        • Meijer CJ
        Pathological investigation of sentinel lymph nodes.
        Eur J Nucl Med. 1999; 26: S43-S49
        • Veronesi U
        • Zurrida S
        • Galimberti V.
        Consequences of sentinel node in clinical decision making in breast cancer and prospects for future studies.
        Eur J Surg Oncol. 1998; 24: 93-95
        • Richter T
        • Nahrig J
        • Komminoth P
        • Kowolik J
        • Werner M.
        Protocol for ultrarapid immunostaining of frozen sections.
        J Clin Pathol. 1999; 52: 461-463