The benefits and limitations of sentinel lymph node biopsy

  • Farin Amersi
  • Nora M. Hansen

Opinion statement

The status of the axilla is the single most important prognostic indicator of overall survival in patients with breast cancer. Staging is based on tumor size and on the presence of lymph node metastases. The number of lymph nodes, although prognostic, no longer impacts treatment options. Sentinel lymph node (SLN) mapping and dissection is a more sensitive and accurate technique for nodal evaluation and has been applied to staging of axillary lymph nodes in patients with breast cancer, providing prognostic information, with less surgical morbidity than with axillary lymph node dissection (ALND). When analyzed by an experienced pathologist with serial sectioning and immunohistochemical evaluation, SLN is the most accurate detection tool used in staging of breast cancer. In many centers that use these staging principles, ALND is no longer performed for histologically negative axillary SLNs. In addition, this technique may also be therapeutic because in most patients, the SLN is the only positive axillary node. SLN biopsy is justified in women with ductal carcinoma in situ who have a high risk of invasive carcinoma, such as those with large tumors, a mass, or high-grade lesions. SLN biopsy is performed in the setting of neoadjuvant chemotherapy and demonstrates accurate evaluation of the axilla in 90% of the cases. Women with locally advanced breast cancer may derive great benefit from a minimally invasive approach to the axilla because the extent of nodal involvement is unlikely to change further treatment. For clinically palpable nodes, ALND should be performed for therapeutic and local control. The use of sentinel node mapping in pregnancy is controversial. Vital blue dye is contraindicated in pregnant patients, although some have used radioactive colloid alone to map this subgroup of patients.

References and Recommended Reading

  1. 1.
    Cancer Facts and Figures 2005. Atlanta, GA: American Cancer Society; 2005.Google Scholar
  2. 2.
    Veronesi U, Cascinelli N, Mariani L, et al.: Twenty-year follow-up of a randomized study comparing breastconserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002, 347:1227–1232.PubMedCrossRefGoogle Scholar
  3. 3.
    Carter CL, Allen C, Henson DE, et al.: Relation of tumor size, lymph node status, and survival in 24,270 breast cancer cases. Cancer 1989, 63:181–187.PubMedCrossRefGoogle Scholar
  4. 4.
    Beenken SW, Urist MM, Zhang Y, et al.: Axillary lymph node status, but not tumor size predicts locoregional recurrence and overall survival after mastectomy for breast cancer. Ann Surg 2003, 237:732–738.PubMedCrossRefGoogle Scholar
  5. 5.
    Schijven MP, Vingerhoets AJ, Rutten HJ, et al.: Comparison of morbidity between axillary lymph node dissection and sentinel node biopsy. Eur J Surg Oncol 2003, 29:341–350.PubMedCrossRefGoogle Scholar
  6. 6.
    Fortin A, Larochelle M, Laverdiere J, et al.: Local failure is responsible for the decrease in survival for patients with breast cancer treated with conservative surgery and postoperative radiotherapy. J Clin Oncol 1999, 17:101–109.PubMedGoogle Scholar
  7. 7.
    Huston TL, Simmons RM: Locally recurrent breast cancer after conservation therapy. Am J Surg 2005, 189:229–235.PubMedCrossRefGoogle Scholar
  8. 8.
    Kissin MW, Querci della Rovera G, Easton D, et al.: Risk of lymphoedema following the treatment of breast cancer. Br J Surg 1986, 73:580–584.PubMedCrossRefGoogle Scholar
  9. 9.
    Keramopolous A, Tsionou C, Minaretzis D, et al.: Arm morbidity following treatment of breast cancer with total axillary dissection: a multivariated approach. Oncology 1993, 50:445–449.CrossRefGoogle Scholar
  10. 10.
    Petrek JA, Senie RT, Peters M, Rosen PP: Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 2001, 92:1368–1377.PubMedCrossRefGoogle Scholar
  11. 11.
    Burak WE, Hollenbeck ST, Zervos EE, et al.: Sentinel lymph node biopsy results in less postoperative morbidity compared with axillary lymph node dissection for breast cancer. Am J Surg 2002, 183:23–27.PubMedCrossRefGoogle Scholar
  12. 12.
    Swenson KK, Nissen MJ, Ceronsky C, et al.: Comparison of side effects between sentinel lymph node and axillary lymph node dissection for breast cancer. Ann Surg Oncol 2002, 9:745–753.PubMedGoogle Scholar
  13. 13.
    Schijven MP, Vingerhoets AJ, Rutten HJ, et al.: Comparison of morbidity between axillary lymph node dissection and sentinel node biopsy. Eur J Surg Oncol 2003, 29:341–350.PubMedCrossRefGoogle Scholar
  14. 14.
    Morton DL, Wen DR, Wong JH, et al.: Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992, 127:392–399.PubMedGoogle Scholar
  15. 15.
    Giuliano AE, Kirgan DM, Guenther JM, Morton DL:Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994, 220:391–398. This is the first study to describe the technique and inclusion criteria of SLN biopsy in patients with breast cancer.PubMedCrossRefGoogle Scholar
  16. 16.
    Giuliano AE, Dale PS, Turner RR, et al.: Improved axillary staging of breast cancer with sentinel lymphadenectomy. Ann Surg 1995, 222:394–401.PubMedCrossRefGoogle Scholar
  17. 17.
    Krag DN, Weaver DL, Alex JC, et al.: Surgical resection and radiolocalization of the sentinel node in breast cancer using gamma probe. Surg Oncol 1993, 2:335–340.PubMedCrossRefGoogle Scholar
  18. 18.
    Veronesi U, Paganelli G, Galimberti V, et al.: Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph nodes. Lancet 1997, 349:1864–1867.PubMedCrossRefGoogle Scholar
  19. 19.
    Krag D, Weaver D, Ashikaga T, et al.: The sentinel node in breast cancer: a multicenter validation study. N Engl J Med 1998, 339:941–946. This study is first large multicenter study investigating the accuracy of SLN biopsy in predicting the status of the axilla.PubMedCrossRefGoogle Scholar
  20. 20.
    McMasters KM, Wong SL, Tuttle TM, et al.: Preoperative lymphoscintigraphy for breast cancer does not improve the ability to identify axillary sentinel lymph nodes. Ann Surg 2000, 231:724–731.PubMedCrossRefGoogle Scholar
  21. 21.
    Miltenberg DM, Miller C, Karamlou TB, Brunicardi FC:Meta-analysis of sentinel lymph node biopsy in breast cancer. J Surg Res 1999, 84:138–142.CrossRefGoogle Scholar
  22. 22.
    Giuliano AE, Jones RC, Brennan M, Statman R: Sentinel lymphadenectomy in breast cancer. J Clin Oncol 1997, 15:2345–2350.PubMedGoogle Scholar
  23. 23.
    McMasters KM, Tuttle TM, Carlson DJ, et al.: Sentinel lymph node biopsy for breast cancer: a suitable alternative to routine axillary dissection in multi-institutional practice when optimal technique is used. J Clin Oncol 2000, 18:2560–2566.PubMedGoogle Scholar
  24. 24.
    Veronesi U, Paganelli G, Viale G, et al.: A randomized comparison of sentinel node biopsy with routine axillary dissection in breast cancer. N Engl J Med 2003, 349:546–553.PubMedCrossRefGoogle Scholar
  25. 25.
    Ernster VL, Barclay J: Increases in ductal carcinoma in situ (DCIS) of the breast in relation to mammography: a dilemma. J Natl Cancer Inst Monogr 1997, 22:151–156.PubMedGoogle Scholar
  26. 26.
    Ernster VL, Ballard-Barbash R, Barlow WE, et al.: Detection of ductal carcinoma in situ in women undergoing screening mammography. J Natl Cancer Inst 2002, 94:1546–1554.PubMedGoogle Scholar
  27. 27.
    Wilke C, White L, Dupont E, et al.: An update of sentinel lymph node mapping in patients with ductal carcinoma in situ. Am J Surg 2005, 190:563–566.CrossRefGoogle Scholar
  28. 28.
    Kell M, Morrow M: An adequate margin of excision in ductal carcinoma in situ. BMJ 2005, 331:789–790.PubMedCrossRefGoogle Scholar
  29. 29.
    Solin LJ, Fourquet A, Vicini FA: Long-term outcome after breast-conservation treatment with radiation for mammographically detected ductal carcinoma in situ of the breast. Cancer 2005, 103:1137–1146.PubMedCrossRefGoogle Scholar
  30. 30.
    Morrow M, Strom EA, Bassett LW, et al.: Standard for the management of ductal carcinoma in situ of the breast (DCIS). CA Cancer J Clin 2002, 52:277–300.PubMedCrossRefGoogle Scholar
  31. 31.
    Hartmann LC, Schaid DJ, Woods JE, et al.: Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999, 340:77–84.PubMedCrossRefGoogle Scholar
  32. 32.
    Stefanek M, Hartmann L, Nelson W: Risk reduction mastectomy: clinical issues and research needs. J Natl Cancer Inst 2001, 93:1297–1306.PubMedCrossRefGoogle Scholar
  33. 33.
    Dupont EL, Kuhn MA, McCann C, et al.: The role of sentinel lymph node biopsy in women undergoing prophylactic mastectomy. Am J Surg 2000, 180:277.CrossRefGoogle Scholar
  34. 34.
    FisherB, Anderson S, Bryant J, et al.: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002, 347:1233–1241. This is the largest phase III randomized trial with 20-year follow-up looking at outcomes in patients with invasive breast cancer who underwent lumpectomy with or without radiation compared with mastectomy.PubMedCrossRefGoogle Scholar
  35. 35.
    Haigh P, Hansen N, Qi K, et al.: Biopsy method and excision volume do not affect success rate of subsequent sentinel lymph node dissection in breast cancer. Ann Surg Oncol 2000, 7:21–27.PubMedCrossRefGoogle Scholar
  36. 36.
    Wong S, Edwards M, Chao C, et al.: The effect of prior breast biopsy method and concurrent definitive breast procedure on success and accuracy of sentinel lymph node biopsy. Ann Surg Oncol 2002, 9:272–277.PubMedGoogle Scholar
  37. 37.
    Luini A, Galimberti V, Gatti G, et al.: The sentinel lymph node biopsy after previous breast surgery: preliminary results on 543 patients treated at the European Institute of Technology. Breast Cancer Res Treat 2005, 89:159–163.PubMedCrossRefGoogle Scholar
  38. 38.
    Intra M, Trifiro G, Viale G, et al.: Second biopsy of axillary sentinel lymph node for reappearing breast cancer after previous sentinel lymph node biopsy. Ann Surg Oncol 2005, 12:895–899.PubMedCrossRefGoogle Scholar
  39. 39.
    Carter CL, Allen C, Henson DE: Relation of tumor size, lymph node status, and survival in 24,470 breast cancer cases. Cancer 1989, 63:181–197.PubMedCrossRefGoogle Scholar
  40. 40.
    Trudeau M, Sinclair SE, Clemons M, et al.: Neoadjuvant taxanes in the treatment of non-metastatic breast cancer: a systematic review. Cancer Treat Rev 2005, 31:283–302.PubMedCrossRefGoogle Scholar
  41. 41.
    Mauriac L, MacGrogan G, Avril A, et al.: Neoadjuvant chemotherapy for operable breast carcinoma larger than 3 cm: a unicentre randomized trial with a 124-month median follow-up. Ann Oncol 1999, 10:47–52.PubMedCrossRefGoogle Scholar
  42. 42.
    Perloff M, Lesnick A, Korzun F, et al.:Combination chemotherapy with mastectomy or radiotherapy for stage III breast carcinoma: a Cancer and Leukemia Group B study. J Clin Oncol 1988, 6:261–269.PubMedGoogle Scholar
  43. 43.
    Scholl SM, Fourquet B, Asselain JY, et al.: Neoadjuvant versus adjuvant chemotherapy in premenopausal patients with tumors considered too large for breast conserving surgery: preliminary results of a randomized trial. Eur J Cancer 1994, 30:645–652.CrossRefGoogle Scholar
  44. 44.
    DeLena M, Varini M, Zucali D, et al.: Multimodal treatment for locally advanced breast cancer. Results of chemotherapy-radiotherapy versus chemotherapy-surgery. Cancer Clin Trials 1981, 4:229–236.Google Scholar
  45. 45.
    FisherB, Brown A, Mamounas A, et al.: Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol 1997, 15:2483–2493. This study is the largest study to determine if neoadjuvant therapy with doxorubicin and cyclophosphamide decreases the size of breast tumors, allowing for breast conservation instead of mastectomy.PubMedGoogle Scholar
  46. 46.
    Abrial C, Van Praagh I, Delva R, et al.: Pathological and clinical response of a primary chemotherapy regimen combining vinorelbine, epirubicin, and paclitaxel as neoadjuvant treatment in patients with operable breast cancer. Oncologist 2005, 10:242–249.PubMedCrossRefGoogle Scholar
  47. 47.
    Pu RT, Schott AF, Sturtz DE, et al.: Pathologic features of breast cancer associated with complete response to neoadjuvant chemotherapy: importance of tumor necrosis. Am J Surg Pathol 2005, 29:354–358.PubMedCrossRefGoogle Scholar
  48. 48.
    Rajan R, Esteva FJ, Symmans WF: Pathologic changes in breast cancer following neoadjuvant chemotherapy: implications for the assessment of response. Clin Breast Cancer 2004, 5:235–238.PubMedGoogle Scholar
  49. 49.
    Mamounas E: Sentinel node biopsy after neoadjuvant systemic therapy. Surg Clin North Am 2003, 83:931–942.PubMedCrossRefGoogle Scholar
  50. 50.
    Julian TB, Patel N, Dusi D, et al.: Sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer. Am J Surg 2001, 182:407–410.PubMedCrossRefGoogle Scholar
  51. 51.
    O’Hea BJ, Hill AD, El-Shirbiny AM, et al.: Sentinel lymph node biopsy in breast cancer: initial experience at Memorial Sloan-Kettering Cancer Center. J Am Coll Surg 1998, 186:423–427.PubMedCrossRefGoogle Scholar
  52. 52.
    Tafra L, Verbanac KM, Lannin DR: Preoperative chemotherapy and sentinel lymphadenectomy for breast cancer. Am J Surg 2001, 182:312–315.PubMedCrossRefGoogle Scholar
  53. 53.
    Hsueh E, Hansen N, Giuliano AE: Intraoperative lymphatic mapping and sentinel lymph node dissection in breast cancer. CA J Clin 2000, 50:279–291.CrossRefGoogle Scholar
  54. 54.
    Veronesi U, Paganelli G, Galimberti V, et al.: Sentinel node biopsy to avoid axillary dissection in breast cancer with clinically negative nodes. Lancet 1997, 349:1864–1867.PubMedCrossRefGoogle Scholar
  55. 55.
    Guenther JM, Krishnamoorthy M, Tan LR, et al.: Sentinel lymphadectomy for breast cancer in a community managed care setting. Cancer J Sci Am 1997, 3:336–340.PubMedGoogle Scholar
  56. 56.
    Linehan D, Hill ADK, Akhurst T, et al.: Intradermal radiocolloid and intraparenchymal blue dye injection optimize sentinel node identification in breast cancer patients. Ann Surg Oncol 1999, 6:450–454.PubMedCrossRefGoogle Scholar
  57. 57.
    Rahusen F, Pijpers R, van Diest PJ, et al.: The implementation of the sentinel node biopsy as a routine procedure for patients with breast cancer. Surgery 2000, 128:6–12.PubMedCrossRefGoogle Scholar
  58. 58.
    Borgstein P, Meijer S, Pijpers RJ, et al.: Functional lymphatic anatomy for sentinel node biopsy in breast cancer. Ann Surg 2000, 232:81–89.PubMedCrossRefGoogle Scholar
  59. 59.
    Giuliano AE, Jones RC, Brennan M, et al.: Sentinel lymphadectomy in breast cancer. J Clin Oncol 1997, 15:2345–2350.PubMedGoogle Scholar
  60. 60.
    Bedrosian I, Reynolds C, Mick R, et al.: Accuracy of sentinel lymph nodded biopsy in patients with large primary breast tumors. Cancer 2000, 88:2540–2545.PubMedCrossRefGoogle Scholar
  61. 61.
    Greco M, Agresti R, Cascinelli N, et al.: Breast cancer patients treated without axillary surgery: clinical implications and biologic analysis. Ann Surg 2000, 232:1–7.PubMedCrossRefGoogle Scholar
  62. 62.
    Ferno M: Prognostic factors in breast cancer: a brief review. Anticancer Res 1998, 18:2167–2171.PubMedGoogle Scholar
  63. 63.
    Chung MH, Ye W, Giuliano AE: Role for sentinel lymph node dissection in the management of large (> 5cm) invasive breast cancer. Ann Surg Oncol 2001, 8:688–692.PubMedGoogle Scholar
  64. 64.
    Gentilini O, Masullo M, Rotmensz N, et al.: Breast cancer diagnosed during pregnancy and lactation: biological features and treatment options. Eur J Surg 2005, 31:232–236.Google Scholar
  65. 65.
    Keleher A, Wendt R, Delpassand E, et al.: The safety of lymphatic mapping in pregnant breast cancer patients using Tc-99m sulfur colloid. Breast J 2004, 10:492–495.PubMedCrossRefGoogle Scholar
  66. 66.
    Cserni G: The impact of axillary lymphadenopathy on further treatment in breast cancer? A model for clinical staging. Pathol Oncol Res 1998, 4:301–303.PubMedGoogle Scholar
  67. 67.
    Specht MC, Fey JV, Borgen PI, Cody HS: Is the clinically positive axilla in breast cancer really a contraindication to sentinel lymph node biopsy? J Am Coll Surg 2005, 200:10–14.PubMedCrossRefGoogle Scholar
  68. 68.
    Nason KS, Anderson BO, Byrd DR, et al.: Increased false negative sentinel node biopsy rates after preoperative chemotherapy for invasive breast carcinoma. Cancer 2000, 89:2187–2194.PubMedCrossRefGoogle Scholar
  69. 69.
    Breslin TM, Cohen L, Sahin A, et al.: Sentinel lymph node biopsy is accurate after neoadjuvant chemotherapy for breast cancer. J Clin Oncol 2000, 18:3480–3486.PubMedGoogle Scholar
  70. 70.
    Stearns V, Ewing CA, Slack R, et al.: Sentinel lymphadenectomy after neoadjuvant chemotherapy for breast cancer may reliably represent the axilla except for inflammatory breast cancer. Ann Surg Oncol 2002, 9:235–242.PubMedGoogle Scholar
  71. 71.
    Fernandez A, Cortes M, Benito E, et al.: Gamma probe sentinel node localization and biopsy in breast cancer patients treated with a neoadjuvant chemotherapy scheme. Nucl Med Commun 2001, 22:361–366.PubMedCrossRefGoogle Scholar
  72. 72.
    Haid A, Tausch C, Lang A, et al.: Is sentinel lymph node biopsy reliable and indicated after preoperative chemotherapy in patients with breast carcinoma? Cancer 2001, 92:1080–1084.PubMedCrossRefGoogle Scholar
  73. 73.
    Reitsamer R, Peintinger F, Rettenbacher L, et al.: Sentinel lymph node biopsy in breast cancer patients after neo-adjuvant chemotherapy. J Surg Oncol 2003, 84:63–67.PubMedCrossRefGoogle Scholar
  74. 74.
    Miller AR, Thomason VE, Yeh IT, et al.: Analysis of sentinel lymph node mapping with immediate pathologic review in patients receiving preoperative chemotherapy for breast carcinoma. Ann Surg Oncol 2002, 9:243–247.PubMedCrossRefGoogle Scholar
  75. 75.
    Piato JR, Barros AC, Pincerato KM, et al.: Sentinel lymph node biopsy in breast cancer after neoadjuvant chemotherapy. A pilot study. Eur J Surg Oncol 2003, 29:118–120.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2006

Authors and Affiliations

  • Farin Amersi
  • Nora M. Hansen
    • 1
  1. 1.Lynn Sage Comprehensive Breast CenterNorthwestern University Feinberg School of MedicineChicagoUSA

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