Skip to main content
SpringerLink
Log in

Paradigm of metastasis for melanoma and breast cancer based on the sentinel lymph node experience

  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Lymph node status is the most reliable prognostic indicator for patients with melanoma and breast cancer. Because it is the first node draining the primary cancer, the sentinel lymph node (SLN) is most likely to harbor metastatic cancer cells. The Breslow thickness of the primary melanoma and the size of primary breast cancer are highly correlated with SLN metastasis. If the SLN is negative, its negative predictive value for the remaining nodal basin exceeds 95%; thus, survival rates for melanoma and breast cancer increase when the SLN is negative. The rate of SLN identification is more than 95%, and the false-negative rate is about 5%. SLN data from melanoma and breast cancer are so convincing that they have been incorporated into the new American Joint Committee on Cancer classification of these cancers. The therapeutic value of additional lymph node dissection after a positive SLN for melanoma or breast cancer is still controversial. In melanoma, a 3-year follow-up may confirm better survival when the SLN is negative. However, about 25% of histologically negative SLNs may be upstaged by molecular techniques, and patients whose SLNs are positive by polymerase chain reaction (PCR) assay may develop recurrence. In most cases, melanoma and breast cancer follow an orderly progression of metastasis to the SLN; however, a small subgroup may develop systemic dissemination without SLN involvement. Current SLN experience has confirmed that the earlier the cancer, the less its potential for metastasis. Since treatments for metastatic cancer are still limited, early detection and resection are imperative. Better understanding of the molecular and genetic mechanisms of metastasis will be critical to select high-risk patients for adjuvant therapy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Reintgen D, Balch CM, Kirkwood J, Ross M. Recent advances in the care of the patient with malignant melanoma.Ann Surg 1997; 225:1–14.

    Article  PubMed  CAS  Google Scholar 

  2. Zettersten E, Shaikh L, Ramirez R, Kashani-Sabet M. Prognostic factors in primary cutaneous melanoma.Surg Clin North Am 2003;83:61–75.

    Article  PubMed  Google Scholar 

  3. Clark WH, Elder DE, DuPont G, et al. Model predicting survival in stage I melanoma based on tumor progression.J Natl Cancer Inst 1989;81:1893–904.

    PubMed  Google Scholar 

  4. Liu V, Mihm MC. Pathology of malignant melanoma.Surg Clin North Am 2003;83:31–60.

    Article  PubMed  CAS  Google Scholar 

  5. Balch CM, Ac B, Soong S, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma.J Clin Oncol 2001;19:3535–648.

    Google Scholar 

  6. Niederhuber JE. Seeking calmer waters in a sea of controversy.Oncologist 2002;7:172–3.

    Article  PubMed  Google Scholar 

  7. Von Eschenbach AC. NCI remains committed to current mammography guidelines.Oncologist 2002;7:170–1.

    Article  Google Scholar 

  8. Cady B, Stone MD, Schuler JG, et al. The new era in breast cancer. Invasion, size, and nodal involvement dramatically decreasing as a result of mammographic screening.Arch Surg 1996;131:301–8.

    PubMed  CAS  Google Scholar 

  9. Andersen LD, Remington P, Trentham-Dietz A, Reeves M. Assessing a decade of progress in cancer control.Oncologist 2002; 7:200–4.

    Article  PubMed  Google Scholar 

  10. Begg CB. The mammography controversy.Oncologist 2002;7:174–6.

    Article  PubMed  Google Scholar 

  11. Nemoto T, Vana J, Bedwani RN, et al. Management and survival of female breast cancer: results of a national survey by the American College of Surgeons.Cancer 1980;45:2917–24.

    Article  PubMed  CAS  Google Scholar 

  12. Tabar L, Vitak B, Chen HH, et al. The Swedish Two-County Trial twenty years later. Updated mortality results and new insights from long-term follow-up.Radiol Clin North Am 2000;38:625–51.

    Article  PubMed  CAS  Google Scholar 

  13. Ibarra JA. The pathologist in breast cancer: contemporary issues in the interdisciplinary approach.Surg Oncol Clin N Am 2000;9:295–317.

    PubMed  CAS  Google Scholar 

  14. Chung MA, Cady B. New lessons from the sentinel node.Surg Oncol Clin N Am 2001;10:461–73, xi–xii.

    PubMed  CAS  Google Scholar 

  15. Halsted WS. The results of operations for the cure of cancer of the breast performed at The John Hopkins Hospital from June, 1889 to January, 1894. In:Operations for Cure of Cancer of the Breast. Vol. 4. Baltimore: The Johns Hopkins Press, 1894–95:497–553.

    Google Scholar 

  16. Fisher B, Redmond C, Fisher ER, et al. Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation.N Engl J Med 1985;312:674–81.

    Article  PubMed  CAS  Google Scholar 

  17. Harris JR, Osteen RT. Patients with early breast cancer benefit from effective axillary treatment.Breast Cancer Res Treat 1985; 5:17–21.

    Article  PubMed  CAS  Google Scholar 

  18. Reintgen DS, Cruse CW, Wells K, et al. The orderly progression of melanoma nodal metastases.Ann Surg 1994;220:759–67.

    Article  PubMed  CAS  Google Scholar 

  19. Adjuvant therapy for breast cancer.NIH Consens Statement 2000; 17:1–35.

    Google Scholar 

  20. Seaman W, Powers W. Studies on the distribution of radioactive colloidal gold in regional lymph nodes containing cancer.Cancer 1955;8:1044–6.

    Article  PubMed  CAS  Google Scholar 

  21. Gould EA, Winship T, Pholbin PH, Hyland Kerr H. Observations on a “sentinel node” in cancer of the parotid.Cancer 1960;13:77–8.

    Article  PubMed  CAS  Google Scholar 

  22. Cabanas RM. An approach for the treatment of penile carcinoma.Cancer 1977;39:456–66.

    Article  PubMed  CAS  Google Scholar 

  23. Wong JH, Cagle LA, Morton DL. Lymphatic drainage of skin to a sentinel lymph node in a feline model.Ann Surg 1991;214:637–41.

    PubMed  CAS  Google Scholar 

  24. Morton DL, Wen DR, Wong JH, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma.Arch Surg 1992;127:392–9.

    PubMed  CAS  Google Scholar 

  25. Leong SPL. Selective sentinel lymphadenectomy for malignant melanoma.Surg Clin North Am 2003;83:157–85.

    Article  PubMed  Google Scholar 

  26. Leong SPL, Wong JH.Sentinel Lymph Nodes in Human Solid Cancer. Vol. 80, Philadelphia: WB Saunders, 2000.

    Google Scholar 

  27. Borgstein P, Meijer S. Historical perspective of lymphatic tumour spread and the emergence of the sentinel node concept.Eur J Surg Oncol 1998;24:85–9.

    Article  PubMed  CAS  Google Scholar 

  28. Morton DL, Thompson JF, Essner R, et al. Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: a multicenter trial.Ann Surg 1999;230:453–65.

    Article  PubMed  CAS  Google Scholar 

  29. Albertini JJ, Lyman GH, Cox C, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer.JAMA 1996;276:1818–22.

    Article  PubMed  CAS  Google Scholar 

  30. Thompson JF, McCarthy WH, Bosch CM, et al. Sentinel lymph node status as an indicator of the presence of metastatic melanoma in regional lymph nodes.Melanoma Res 1995;5:255–60.

    PubMed  CAS  Google Scholar 

  31. Cody HS 3rd. Sentinel lymph node mapping in breast cancer.Oncology 1999;13:25–34.

    PubMed  Google Scholar 

  32. Coit D, Wallack M, Balch C. Society of Surgical Oncology practice guidelines: melanoma surgical practice guidelines.Oncology 1997;11:1317–23.

    PubMed  CAS  Google Scholar 

  33. Emilia JCD, Lawrence W. Sentinel lymph node biopsy in malignant melanoma: the standard of care?J Surg Oncol 1997;65:153–4.

    Article  PubMed  CAS  Google Scholar 

  34. Houghton A, Coit D, Bloomer W, et al. NCCN melanoma practice guidelines. National Comprehensive Cancer Network.Oncology 1998;12:153–77.

    PubMed  CAS  Google Scholar 

  35. Reintgen DS. Changing standards of surgical care for the melanoma patient.Ann Surg Oncol 1996;3:327–8.

    Article  PubMed  CAS  Google Scholar 

  36. Carpenter R. Sentinel node biopsy should be introduced into routine practice before results of randomized trials are available.Breast 2001;10:281–4.

    Article  PubMed  CAS  Google Scholar 

  37. Cherpelis BS, Haddad F, Messina J, et al. Sentinel lymph node micrometastasis and other histologic factors that predict outcome in patients with thicker melanomas.J Am Acad Dermatol 2001; 44:762–6.

    Article  PubMed  CAS  Google Scholar 

  38. Gershenwald JE, Thompson W, Manifield PF, et al. Multi-institutional melanoma lymphatic mapping experience: the prognostic value of sentinel lymph node status in 612 stage I or II melanoma patients.J Clin Oncol 1999;17:976–83.

    PubMed  CAS  Google Scholar 

  39. Statius Muller MG, van Leeuwen PA, de Lange-De Klerk ES, et al. The sentinel lymph node status is an important factor for predicting clinical outcome in patients with Stage I or II cutaneous melanoma.Cancer 2001;91:2401–8.

    Article  PubMed  CAS  Google Scholar 

  40. Clary BM, Mann B, Brady MS, et al. Early recurrence after lymphatic mapping and sentinel node biopsy in patients with primary extremity melanoma: a comparison with elective lymph node dissection.Ann Surg Oncol 2001;8:328–37.

    Article  PubMed  CAS  Google Scholar 

  41. Essner R, Conforti A, Kelley MC, et al. Efficacy of lymphatic mapping, sentinel lymphadetectomy, and selective complete lymph node dissection as a therapeutic procedure for early-stage melanoma.Ann Surg Oncol 1999;6:442–9.

    Article  PubMed  CAS  Google Scholar 

  42. Gadd MA, Cosimi AB, Yu J, et al. Outcome of patients with melanoma and histologically negative sentinel lymph nodes.Arch Surg 1999;134:381–7.

    Article  PubMed  CAS  Google Scholar 

  43. Starz H, Balda BR, Kramer KU, et al. A micromorphometry-based concept for routine classification of sentinel lymph node metastases and its clinical relevance for patients with melanoma.Cancer 2001;91:2110–21.

    Article  PubMed  CAS  Google Scholar 

  44. Starz H, De Donno A, Balda BR. The Augsburg experience: histological aspects and patient outcomes.Ann Surg Oncol 2001; 8(9 Suppl):48S-51S.

    PubMed  CAS  Google Scholar 

  45. Morton D, Essner R, Hoon DS, et al.Long-Term Results of Lymphatic Mapping and Sentinel Lymphadenectomy for Early-Stage Melanoma: Implications of Nodal Microanatomy and Molecular Staging on Detection of Nodal Micrometastasis. American Surgical Association 123rd Annual Meeting. Washington, DC: American Surgical Association, 2003:60.

    Google Scholar 

  46. Huvos AG, Hutter RV, Berg JW. Significance of axillary macrometastases and micrometastases in mammary cancer.Ann Surg 1971;173:44–6.

    Article  PubMed  CAS  Google Scholar 

  47. Rosen PP, Saigo PE, Braun DW, et al. Axillary micro-and macrometastases in breast cancer: prognostic significance of tumor size.Ann Surg 1981;194:585–91.

    PubMed  CAS  Google Scholar 

  48. Rosen PP, Saigo PE, Braun DW, et al. Prognosis in stage II (T1N1M0) breast cancer.Ann Surg 1981;194:576–84.

    Article  PubMed  CAS  Google Scholar 

  49. Clayton F, Hopkins CL. Pathologic correlates of prognosis in lymph node-positive breast carcinomas.Cancer 1993;71:1780–90.

    Article  PubMed  CAS  Google Scholar 

  50. Fisher ER, Costantino J, Fisher B, et al. Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) Protocol B-17. Intraductal carcinoma (ductal carcinoma in situ). The National Surgical Adjuvant Breast and Bowel Project Collaborating Investigators.Cancer 1995;75:1310–9.

    Article  PubMed  CAS  Google Scholar 

  51. Byrne J, Horgan PG, England S, et al. A preliminary report on the usefulness of monoclonal antibodies to CA 15-3 and MCA in the detection of micrometastases in axillary lymph nodes draining primary breast carcinoma.Eur J Cancer 1992;28:658–60.

    Article  PubMed  CAS  Google Scholar 

  52. Chen ZL, Wen DR, Coulson WF, et al. Occult metastases in the axillary lymph nodes of patients with breast cancer node negative by clinical and histologic examination and conventional histology.Dis Markers 1991;9:239–48.

    PubMed  CAS  Google Scholar 

  53. Cote R, Peterson HF, Chaiwun B, et al. Role of immunohistochemical detection of lymph node metastases in management of breast cancer. International Breast Cancer Study Group.Lancet 1999; 354:896–900.

    Article  PubMed  CAS  Google Scholar 

  54. Sedmak DD, Meineke TA, Knechtges DS, Anderson J. Prognostic significance of cytokeratin-positive breast cancer metastases.Mod Pathol 1989;2:516–20.

    PubMed  CAS  Google Scholar 

  55. Trojani M, de Mascarel I, Bonichon F, et al. Micrometastases to axillary lymph nodes from carcinoma of breast: detection by immunohistochemistry and prognostic significance.Br J Cancer 1987;55:303–6.

    PubMed  CAS  Google Scholar 

  56. Braun S, Cevatli BS, Assemi C, et al. Comparative analysis of micrometastasis to the bone marrow and lymph nodes of nodenegative breast cancer patients receiving no adjuvant therapy.J Clin Oncol 2001;19:1468–75.

    PubMed  CAS  Google Scholar 

  57. Giuliano AE, Dale PS, Turner RR, et al. Improved axillary staging of breast cancer with sentinel lymphadenectomy.Ann Surg 1995; 222:394–9.

    Article  PubMed  CAS  Google Scholar 

  58. Wang X, Heller R, Van Voorheis N, et al. Detection of submicroscopic lymph node metastases with polymerase chain reaction in patients with malignant melanoma.Ann Surg 1994;220:768–74.

    Article  PubMed  CAS  Google Scholar 

  59. Bostick P, Morton DL, Turner RR, et al. Prognostic significance of occult metastases detected by sentinel lymphadenectomy and reverse transcriptase-polymerase chain reaction in early-stage melanoma patients.J Clin Oncol 1999;17:3238–44.

    PubMed  CAS  Google Scholar 

  60. Morton DL, Hoon DS, Cochran AJ, et al. Lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: therapeutic utility and implications of nodal microanatomy and molecular staging for improving the accuracy of detection of nodal micrometastases.Ann Surg 2003;238:538–49.

    PubMed  Google Scholar 

  61. Davis EG, Chao C, McMasters KM. Polymerase chain reaction in the staging of solid tumors.Cancer J 2002;8:135–43.

    Article  PubMed  Google Scholar 

  62. McMasters K, Reintgen D, Ross M, et al. Sunbelt Melanoma Trials: sensitivity and specificity of reverse transcriptase polymerase chain reaction (RT-PCR) markers for sentinel lymph nodes (SLN).Proc Am Soc Clin Oncol 1999;18:537a.

    Google Scholar 

  63. Cox CE, Salud CJ, Harrinton MA. The role of selective sentinel lymph node dissection in breast cancer.Surg Clin North Am 2000;80:1759–77.

    Article  PubMed  CAS  Google Scholar 

  64. Chen M, Palleschi S, Khoynezhad A, et al. Role of primary breast cancer characteristics in predicting positive sentinel lymph node biopsy results: a multivariate analysis.Arch Surg 2002;137:606–9.

    Article  PubMed  Google Scholar 

  65. Giuliano AE, Jones RC, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer.J Clin Oncol 1997;15:2345–50.

    PubMed  CAS  Google Scholar 

  66. Greene FL, Page DL, Fleming ID, et al., eds.AJCC Cancer Staging Manual. 6th ed. New York: Springer, 2003.

    Google Scholar 

  67. Harris JR, Henderson CI. Natural history and staging of breast cancer. In: Harris JR, Henderson CI, Hellman S, Kinne DW, eds.Breast Diseases. Philadelphia. Lippincott, 1987:233–58.

    Google Scholar 

  68. Leong SPL. Future perspectives on malignant melanoma.Surg Clin North Am 2003;83:453–6.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, University of California, 1600 Divisadero Street, Room C333, 94143-1674, San Francisco, CA

    Stanley P. L. Leong MD, FACS

  2. UCSF Comprehensive Cancer Center, 1600 Divisadero Street, Room C333, 94143-1674, San Francisco, CA

    Stanley P. L. Leong MD, FACS

  3. UCSF Medical Center at Mount Zion, 1600 Divisadero Street, Room C333, 94143-1674, San Francisco, CA

    Stanley P. L. Leong MD, FACS

Authors
  1. Stanley P. L. Leong MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Stanley P. L. Leong MD, FACS.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Leong, S.P.L. Paradigm of metastasis for melanoma and breast cancer based on the sentinel lymph node experience. Annals of Surgical Oncology 11 (Suppl 3), 192S–197S (2004). https://doi.org/10.1007/BF02523627

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02523627

Key Words

Search

Navigation