Morbidity following sentinel lymph node biopsy versus axillary lymph node dissection for patients with breast carcinoma

BACKGROUND: Axillary lymph node dissection for staging the axilla in breast carcinoma patients is associated with considerable morbidity, such as edema of the arm, pain, sensory disturbances, impairment of arm mobility, and shoulder stiffness. Sentinel lymph node biopsy electively removes the first lymph node, which gets the drainage from the tumor and should therefore be associated with nearly zero morbidity. METHODS: Postoperative morbidity (increase in arm circumference, subjective lymphedema, pain, numbness, effect on arm strength and mobility, and stiffness) of the operated arm was prospectively compared in 35 breast carcinoma patients after axillary lymph node dissection (ALND) of Level I and II and 35 patients following sentinel lymph node (SN) biopsy. RESULTS: Patient characteristics were comparable between the two groups. Postoperative follow-up was 15.4 months (range, 4-28 months) in the SN group and 17.0 months (range, 4-28 months) in the ALND group. Following axillary dissection, patients showed a significant increase in upper and forearm circumference of the operated arm compared with the SN patients, as well as a significantly higher rate of subjective lymphedema, pain, numbness, and motion restriction. No difference between the two groups was found regarding arm stiffness or arm strength, nor did the type of surgery affect daily living. CONCLUSIONS: SN biopsy is associated with negligible morbidity compared with complete axillary lymph node dissection.     

Axillary disease recurrence after sentinel lymph node dissection for breast carcinoma

BACKGROUND: Surgical recommendation for early-stage breast carcinoma includes removal of the primary breast tumor and evaluation of the axillary lymph nodes on the ipsilateral side. Sentinel lymph node dissection (SLND) is increasingly being used to evaluate axillary lymph nodes in clinically lymph node negative patients as an alternative to axillary lymph node dissection (ALND). Results from SLND are highly predictive of metastatic involvement in the axilla, and are associated with fewer side effects. However, the greatest concern with SLND alone is the potential for a higher rate of axillary lymph node recurrence. The purpose of the current study was to review data collected on 700 consecutive patients with early-stage breast carcinoma who underwent SLND without concomitant ALND. METHODS: A retrospective study was conducted using the oncology registry at Park Nicollet Health Services (Minneapolis, MN). Consecutive breast carcinoma cases with SLND only for axillary surgery, from January 28, 1999 to December 31, 2003, were included in the study. During this period, 700 patients with breast carcinoma were identified who had SLND alone. Fifty-two patients were excluded from the analysis because they had ductal carcinoma in situ. RESULTS: With a median follow-up of 33 months (range, 2-73 mos), axillary lymph node recurrence occurred in 4 of 647 (0.62%) patients overall. In these 4 patients, the axillary lymph node recurrences were isolated to the axillary lymph nodes and amenable to surgery. CONCLUSIONS: Data from the current study showed that axillary lymph node recurrence after SLND occurred very infrequently in early-stage breast carcinoma, and these results were comparable to other studies.     

Sentinel lymph node biopsy in breast cancer: scientific rationale and patient care

PURPOSE/OBJECTIVES: To describe the history of sentinel lymph node biopsy (SLNB), review the current scientific literature comparing the benefits and shortcomings of SLNB with traditional axillary lymph node dissection, and describe the nursing role that should be employed when instructing patients who are considering SLNB. DATA SOURCES: Journal articles, published research data, and clinical experience. DATA SYNTHESIS: Traditional axillary lymph node dissection has the potential to cause serious complications such as lymphedema, scarring, numbness, pain, and psychological distress. Given that approximately 70% of women with early-stage breast cancer will have no evidence of regional lymph node involvement at the time of surgery, determining who is likely to have negative nodes will spare women these potential complications. SLNB can significantly minimize the morbidity associated with axillary lymph node dissection while providing accurate diagnostic and prognostic information. CONCLUSION: SLNB has been well documented in the scientific literature from multiple phase III clinical trials as an accurate, safe, and fiscally conservative alternative to traditional axillary lymph node dissection for women who present with early-stage breast cancer. Furthermore, future results from multicenter, randomized clinical trials now under way ultimately will determine the role for SLNB in the years to come. IMPLICATIONS FOR NURSING PRACTICE: Nurses in the outpatient setting can help to minimize the anxiety and fear that patients have when they are considering SLNB versus the more traditional axillary lymph node dissection. Oncology nurses also serve as resources to other nurses, healthcare professionals, and the public as more information is learned concerning the role of SLNB in early-stage breast cancer.     

Sentinel lymph node biopsy at the time of mastectomy does not increase the risk of lymphedema: implications for prophylactic surgery

Women diagnosed with or at high risk for breast cancer increasingly choose prophylactic mastectomy. It is unknown if adding sentinel lymph node biopsy (SLNB) to prophylactic mastectomy increases the risk of lymphedema. We sought to determine the risk of lymphedema after mastectomy with and without nodal evaluation. 117 patients who underwent bilateral mastectomy were prospectively screened for lymphedema. Perometer arm measurements were used to calculate weight-adjusted arm volume change at each follow-up. Of 234 mastectomies performed, 15.8?% (37/234) had no axillary surgery, 63.7?% (149/234) had SLNB, and 20.5?% (48/234) had axillary lymph node dissection (ALND). 88.0?% (103/117) of patients completed the LEFT-BC questionnaire evaluating symptoms associated with lymphedema. Multivariate analysis was used to assess clinical characteristics associated with increased weight-adjusted arm volume and patient-reported lymphedema symptoms. SLNB at the time of mastectomy did not result in an increased mean weight-adjusted arm volume compared to mastectomy without axillary surgery (p?=?0.76). Mastectomy with ALND was associated with a significantly greater mean weight-adjusted arm volume change compared to mastectomy with SLNB (p?相似文献   

Lymphedema following axillary lymph node dissection for breast cancer

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.     

Intraoperative lymphatic mapping and sentinel lymph node dissection in breast cancer

Because the tumor status of the regional lymph nodes is the most important prognostic factor in patients with early-stage breast cancer, accurate histopathologic assessment of these nodes is essential for optimal management, including the selection of candidates for adjuvant systemic therapies. Intraoperative lymphatic mapping using a vital blue dye, with or without a radiocolloid, can identify the first axillary node to receive lymphatic drainage from a primary breast carcinoma. Focused histopathologic assessment of this sentinel node can be used to determine the tumor status of the entire axillary basin. The minimal morbidity and high accuracy of sentinel lymph node dissection (SLND) in breast cancer have been validated by multiple independent investigators, and the data suggest that this surgical technique may eventually replace complete lymph node dissection as the preferred axillary procedure for the management of early-stage disease. In experienced hands, SLND can be successfully performed in more than 90% of eligible breast cancer patients; the tumor status of the sentinel node accurately predicts the status of all axillary nodes in more than 95% of cases. This article reviews the current status, controversies, and future directions of SLND as a staging technique for patients with primary breast carcinoma.     

Morbidity after axillary sentinel lymph node biopsy in patients with cutaneous melanoma.

AIM: In this study, the short-term and long-term morbidity was assesed after axillary sentinel lymph node biopsy (SLNB) with or without completion axillary lymph node dissection (SLNB/ALND) in patients with cutaneous melanoma. METHODS: Between 1995 and 2003, 119 axillary SLNBs were performed for cutaneous melanoma. Fifty-eight patients met the inclusion criteria and entered the study. RESULTS: Forty-four patients underwent SLNB alone and 14 patients underwent axillary lymph node dissection after positive SLNB. Complications after SLNB alone: post-operative bleeding (n=2), seroma (n=1) and slight lymphedema 11%. Complications after SLNB/ALND: wound infections (n=2), seroma (n=5) and slight lymphedema 7%. There were differences between the two groups in short-term complications (p<.001) and functional limitations of the shoulder (p=.011). CONCLUSION: Axillary SLNB alone had a low complication rate. However, SLNB followed by completion ALND was associated with an increased risk of short- and long-term complications.     

Impact of axillary lymph node dissection on breast cancer outcome in clinically node negative patients

BACKGROUND:

The regional lymph node control and survival impact of axillary dissection in breast cancer has been the subject of multiple randomized trials, with various results. This study reviews and conducts a meta‐analysis of contemporary trials of axillary dissection in patients with early stage breast cancer.

METHODS:

A systematic MEDLINE review identified 3 randomized trials published between January 2000 and January 2007 of axillary dissection versus no dissection in clinically lymph node negative early stage breast cancer patients. A fourth trial of axillary radiotherapy versus no axillary treatment was also identified and included in this review. Meta‐analyses were performed for survival, axillary recurrence, metastatic disease, and ipsilateral breast recurrence.

RESULTS:

All trials reported a higher rate of axillary recurrence (1.5%‐3%, median follow‐up 5‐15 years) in the absence of axillary dissection or radiotherapy. Overall survival was similar with and without definitive axillary treatment in 3 of the 4 trials, with an increased rate of nonbreast cancer‐related death in the observation arm of the fourth trial. Meta‐analyses found no significant difference in overall survival (odds ratio [OR] 1.55; 95% confidence interval [CI], 0.74‐3.24), metastases (OR 0.91; 95% CI, 0.65‐1.29), or ipsilateral breast recurrence (OR 1.11; 95% CI, 0.68‐1.83) associated with axillary treatment. A significantly lower rate of axillary recurrence was seen after lymphadenectomy (OR 0.28; 95% CI, 0.11‐0.73, P<.01).

CONCLUSIONS:

Axillary dissection does not confer a survival benefit in the setting of early stage clinically lymph node negative breast cancer. Although the rate of axillary failure was increased in the absence of dissection, the absolute risk was found to be extremely low. Cancer 2009. © 2009 American Cancer Society.     

Predicting axillary lymph node metastases in breast carcinoma patients

Routine axillary dissection is primarily used as a means of assessing prognosis to establish appropriate treatment plans for patients with primary breast carcinoma. However, axillary dissection offers no therapeutic benefit to node negative patients and patients may incur unnecessary morbidity, including mild to severe impairment of arm motion and lymphedema, as a result. This paper outlines a method of evaluating the probability of harbouring lymph node metastases at the time of initial surgery by assessment of tumour based parameters, in order to provide an objective basis for further selection of patients for treatment or investigation. The novel aspect of this study is the use of Maximum Entropy Estimation (MEE) to construct probabilistic models of the relationship between the risk factors and the outcome. Two hundred and seventeen patients with invasive breast carcinoma were studied. Surgical treatment included axillary clearance in all cases, so that the pathologic status of the nodes was known. Tumour size was found to be significantly correlated (P < 0.001) to the axillary lymph node status in the multivariate analysis with age (P = 0.089) and vascular invasion (P = 0.08) marginally correlated. Using the multivariate model constructed, 38 patients were predicted to have risk of nodal metastases lower than 20%, of these only 4 (10%) patients had lymph node metastases. A comparison with the Multivariate Logistic Regression (MLR) was carried out. It was found that the predictive quality of the MEE model was better than that of the MLR model. In view of the small sample size, further verification of this model is required in assessing its practical application to a larger population.     

Sentinel lymph node mapping in breast cancer

Sentinel lymph node (SLN) biopsy is a rapidly emerging treatment option for patients with early-stage invasive breast cancer and a clinically negative axilla. In the era of mammographic detection, SLN biopsy has the potential to eliminate axillary dissection for the enlarging cohort of breast cancer patients who are node-negative. Using radioisotope, blue dye, or both methods, experienced surgeons can successfully localize SLNs in more than 90% of cases. The effects of isotope and blue dye may be additive. Sentinel lymph node biopsy reliably predicts axillary node status in 98% of all patients and 95% of those who are node-positive. The operation is best learned under a formalized protocol in which a backup axillary dissection is performed to validate the technique during the surgeon's early experience. Enhanced pathologic analysis, including serial sections and immunohistochemical (IHC) staining, is an essential element of the procedure. In experienced hands, SLN biopsy has less morbidity and greater accuracy than conventional axillary dissection.     

Sentinel node biopsy compared with complete axillary dissection for staging early breast cancer with clinically negative lymph nodes: results of randomized trial

Background: Sentinel lymph node (SLN) staging is currently used to avoid complete axillary dissection in breast cancer patients with negative SLNs. Evidence of a similar efficacy, in terms of survival and regional control, of this strategy as compared with axillary resection is based on few clinical trials. In 1998, we started a randomized study comparing the two strategies, and we present here its results.Materials and methods: Patients were randomly assigned to sentinel lymph node biopsy (SLNB) and axillary dissection [axillary lymph node dissection (ALND arm)] or to SLNB plus axillary resection if SLNs contained metastases (SLNB arm). Main end points were overall survival (OS) and axillary recurrence.Results: One hundred and fifteen patients were assigned to the ALND arm and 110 to the SLNB arm. A positive SLN was found in 27 patients in the ALND arm and in 31 in the SLNB arm. Overall accuracy of SLNB was 93.0%. Sensitivity and negative predictive values were 77.1% and 91.1%, respectively. At a median follow-up of 5.5 years, no axillary recurrence was observed in the SLNB arm. OS and event-free survival were not statistically different between the two arms.Conclusions: The SLNB procedure does not appear inferior to conventional ALND for the subset of patients here considered.     

Isolated retromammary lymph node metastasis of breast cancer without axillary lymph node involvement: a case report with a false-negative sentinel lymph node biopsy

A 54-year-old woman visited our hospital with a palpable tumor in her left breast, which was diagnosed as invasive ductal carcinoma. Breast-conserving surgery was performed, in association with a sentinel lymph node (SLN) biopsy and back-up dissection of the axillary lymph nodes. One dyed axillary lymph node with high radioactivity was defined as an SLN, and intraoperative frozen-section analysis of the SLN was negative for metastasis. The final pathological diagnosis of the tumor was invasive ductal carcinoma, and one small lymph node, located in the retromammary space, just under the tumor, was positive for metastasis. The backup axillary lymph nodes were not metastatic. This patient was diagnosed false-negative by SLN biopsy, despite being positive for retroMLN metastasis. It should be recognized that retroMLNs are difficult to detect preoperatively, or intra-operatively, using dye or radiocolloid, if they are located in the post-tumoral retro-mammary space. RetroMLNs may be a pitfall in SLN biopsies.     

Treatment implications of a positive sentinel lymph node biopsy for patients with early-stage breast carcinoma.

BACKGROUND: Sentinel lymph node (SLN) mapping and biopsy is emerging as an alternative to axillary lymph node dissection (ALND) in determining the lymph node status of patients with early-stage breast carcinoma. The hypothesis of the technique is that the SLN is the first lymph node in the regional lymphatic basin that drains the primary tumor. Non-SLN (NSLN) metastasis in the axilla is unlikely if the axillary SLN shows no tumor involvement, and, thus, further axillary interference may be avoided. However, the optimal treatment of the axilla in which an SLN metastasis is found requires ongoing evaluation. The objectives of this study were to evaluate the predictors for NSLN metastasis in the presence of a tumor-involved axillary SLN and to examine the treatment implications for patients with early-stage breast carcinoma. METHODS: Between June 1998 and May 2000, 167 patients participated in the pilot study of SLN mapping and biopsy at Westmead Hospital. SLNs were identified successfully and biopsied in 140 axillae. All study patients also underwent ALND. The incidence of NSLN metastasis in the 51 patients with a SLN metastasis was correlated with clinical and pathologic characteristics. RESULTS: Of 51 patients with a positive SLN, 24 patients (47%) had NSLN metastases. The primary tumor size was the only significant predictor for NSLN involvement. NSLN metastasis occurred in 25% of patients (95% confidence interval [95%CI], 10-47%) with a primary tumor size 20 mm (P = 0.005). The size of the SLN metastasis was not associated significantly with NSLN involvement. Three of 7 patients (43%) with an SLN micrometastasis (< 1 mm) had NSLN involvement compared with 38 of 44 patients (48%) with an SLN macrometastasis (> or = 1 mm). CONCLUSIONS: The current study did not identify a subgroup of SLN positive patients in whom the incidence of NSLN involvement was low enough to warrant no further axillary interference. At present, a full axillary dissection should be performed in patients with a positive SLN.     

Results of sentinel node biopsy not affected by previous excisional biopsy.

AIMS: Sentinel lymph node (SN) biopsy has been validated in the treatment of breast carcinoma. Patients with previous excisional biopsy are regarded as ineligible for SN biopsy. We evaluated the results of SN biopsy for this group of patients based on confirmatory axillary lymph node dissection. PATIENTS AND METHODS: From April 1997 all 88 patients with stage T(1-3) breast cancer who had previously undergone diagnostic excisional biopsy followed by complete axillary lymph node dissection, were enrolled into a prospective study to determine the validity of the sentinel node procedure. RESULTS: Lymphoscintigraphy visualized one or more axillary hot spots in 84/88 patients. A successful SN biopsy was performed in 87 patients. Complete axillary lymph-node dissection showed no false-negative SN biopsy among the 87 SN procedures. CONCLUSION: SN biopsy is a reliable and safe method following excisional biopsy as is confirmed by completion axillary lymph node dissection. Therefore, patients with previous excisional biopsy are eligible for sentinel node procedure and can be spared unnecessary axillary lymph node dissection.     

Sentinel lymph node dissection and the current status of American trials on breast lymphatic mapping

The current national sentinel lymph node (SLN) clinical trials for breast carcinoma address the prognostic and therapeutic utility of SLN dissection (SLND) in women with early-stage, clinically node-negative breast cancer. Following completion of these studies, overall survival, disease-free survival, morbidity, and quality of life of patients will be compared. Surgeon participation is crucial to the ongoing success of clinical trials in the field of breast cancer surgery.     

Contralateral uptake and metastases in sentinel lymph node mapping for recurrent breast cancer

BACKGROUND AND OBJECTIVES: Sentinel lymph node mapping as a constitutive component in the staging process for invasive breast cancer continues to gain acceptance. We have identified two patients with recurrent invasive breast cancer in whom contralateral sentinel lymph node uptake and metastases, respectively, were detected. Such findings have not been previously reported in our review of the medical literature between 1966 and October 2004. METHODS: Sentinel lymph node mapping was performed on two patients with recurrent invasive breast cancer at our institution. At the time of their index diagnosis, both had received breast conserving surgery and an axillary lymph node dissection with post-operative radiotherapy (RT). All lymph nodes and margins of resection were without tumor. Both patients remained with no evidence of disease for years until routine serial screening mammography was interpreted as suspicious. Each underwent a stereotactic biopsy of the ipsilateral breast corresponding to the mammographic abnormality. Pathology confirmed invasive ductal carcinoma. Both patients refused the recommended salvage mastectomy. PRINCIPAL RESULTS: During a second attempt at breast conservation, sentinel lymph node mapping--which is typically contraindicated for patients with prior axillary surgery--revealed contralateral axillary uptake for both patients. The respective contralateral sentinel node was excised with pathology revealing no tumor in one case, and a microscopic focus of metastatic carcinoma in the second case. MAJOR CONCLUSION: Some patients may benefit from sentinel lymph node mapping prior to salvage mastectomy. Identifying uptake in a contralateral sentinel lymph node may change the multi-disciplinary management of recurrent invasive breast cancer to include a contralateral axillary dissection, chemotherapy, and/or RT to the contralateral axilla.     

Optimal management of patients with a positive sentinel lymph node

Sentinel lymph node biopsy has revolutionized breast cancer surgery, obviating axillary lymph node dissection as a staging procedure in clinically node-negative patients. Concomitantly, improved pathologic assessment of the sentinel lymph node has led to the discovery of progressively smaller quantities of metastases, the clinical importance of which has not yet been established. Sentinel lymph node metastases can now be organized into three categories of decreasing size: macrometastases, micrometastases, and isolated tumor cells. Although the standard of care is to perform an axillary dissection for patients with macro- or micrometastases, certain subsets of patients may fare well without an axillary dissection. Axillary radiation in positive sentinel node management is also a subject of ongoing investigation, especially in light of long-term survival data equivalent to that of axillary lymph node dissection. Isolated tumor cells are of undetermined significance and do not require completion axillary dissection when discovered in the absence of other sentinel node findings. This article discusses management recommendations in the context of macrometastasis, micrometastasis, and isolated tumor cells.     

American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer.

PURPOSE: To develop a guideline for the use of sentinel node biopsy (SNB) in early stage breast cancer. METHODS: An American Society of Clinical Oncology (ASCO) Expert Panel conducted a systematic review of the literature available through February 2004 on the use of SNB in early-stage breast cancer. The panel developed a guideline for clinicians and patients regarding the appropriate use of a sentinel lymph node identification and sampling procedure from hereon referred to as SNB. The guideline was reviewed by selected experts in the field and the ASCO Health Services Committee and was approved by the ASCO Board of Directors. RESULTS: The literature review identified one published prospective randomized controlled trial in which SNB was compared with axillary lymph node dissection (ALND), four limited meta-analyses, and 69 published single-institution and multicenter trials in which the test performance of SNB was evaluated with respect to the results of ALND (completion axillary dissection). There are currently no data on the effect of SLN biopsy on long-term survival of patients with breast cancer. However, a review of the available evidence demonstrates that, when performed by experienced clinicians, SNB appears to be a safe and acceptably accurate method for identifying early-stage breast cancer without involvement of the axillary lymph nodes. CONCLUSION: SNB is an appropriate initial alternative to routine staging ALND for patients with early-stage breast cancer with clinically negative axillary nodes. Completion ALND remains standard treatment for patients with axillary metastases identified on SNB. Appropriately identified patients with negative results of SNB, when done under the direction of an experienced surgeon, need not have completion ALND. Isolated cancer cells detected by pathologic examination of the SLN with use of specialized techniques are currently of unknown clinical significance. Although such specialized techniques are often used, they are not a required part of SLN evaluation for breast cancer at this time. Data suggest that SNB is associated with less morbidity than ALND, but the comparative effects of these two approaches on tumor recurrence or patient survival are unknown.     

乳腺癌术中反向腋窝淋巴作图研究进展

腋窝反向淋巴作图是国外近两年提出的旨在保护上肢淋巴回流通路的一项新的微创技术,其目的在于通过作图示踪上肢淋巴回流通路,术中尽量予以保护,从而减少上肢水肿这一乳腺癌术后常见并发症的发生.     

染料法前哨淋巴结活检在乳腺癌手术中的应用价值

目的探讨前哨淋巴结活检（SLNB）在乳腺癌手术中的临床应用价值。方法采用亚甲蓝作为示踪染料对乳腺癌开展SLNB，并且对术中冰冻检查前哨淋巴结（SLN）阴性的病例分组施行部分腋窝淋巴结清扫术（PALND）及常规全腋窝淋巴结清扫（TALND），观察术后并发症、生存率等指标并比较分析。结果SLN检出率97．6％，假阴性率14．3％；接受PALND组术后并发症发生率明显低于传统的TALND组，差异有统计学意义（P〈0．05），而总生存率间的差异无统计学意义（P〉0．05）。结论腋区SLNB能准确反映乳腺癌腋窝淋巴转移状态，为临床缩小乳腺癌手术范围和减少术后并发症提供重要参考价值。