Abstract
Background and Methods
Sentinel lymph node (SLN) biopsy is a useful way of assessing axillary nodal status in breast cancer patients. Recently, several surgeons have begun to abandon routine axillary dissection on the basis of negative SLN biopsy results. However, there is no long-term data comparing outcomes of SLN biopsy alone with those of axillary dissection. This paper reviews and discusses the significance of ongoing prospective randomized clinical trials aiming at the elimination of axillary dissection.
Results
SLN biopsy is known to have a false-negative rate. It can thus be assumed that SLN biopsy alone may fail to remove the disease completely from the axilla in some patients. As a result, it is not known whether SLN biopsy alone will increase the axillary recurrence rate, particularly in patients with a high risk of axillary lymph node metastasis. Recently, moreover, locoregional control appears to be important for enhancing survival in conjunction with adjuvant systemic therapy. It is therefore still unclear to what extent the benefits of SLN biopsy outweigh the risks and, if so, for which patient groups.
Conclusion
Before SLN biopsy can replace routine axillary dissection, research using long-term regional controls and investigation of survival in a prospective randomized trial are essential. Except for clinical research studies, routine axillary dissection should not be abandoned until and unless there is documentation of extensive experience and a low false negative rate. Even with such evidence, however, patients undergoing SLN biopsy without concomitant axillary dissection should be informed of the risk of a false-negative result.
Similar content being viewed by others
Abbreviations
- SLN:
-
Sentinel lymph node
- NSABP:
-
National Surgical Adjuvant Breast and Bowel Project
- IHC:
-
Immunohistochemistry
- RT-PCR:
-
Reverse transcriptase-polymerase chain reaction
References
Krag DN, Weaver OJ, Alex JC, Fairbank JT: Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe.Surg Oncol 2: 335–340, 1993.
Giuliano AE, Kirgan DM, Guenther JM, Morton DL: Lymphatic mapping and sentinel lymphadenectomy for breast cancer.Ann Surg 220: 391–401, 1994.
Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N, Shivers S, Berman C, Wells K, Rapaport D, Shons A, Horton J, Greenberg H, Nicosia S, Clark R, Cantor A, Reintgen DS: Lymphatic mapping and sentinel node biopsy in the patients with breast cancer.J Am Med Assoc 276: 1818–1822, 1996.
Giuliano AE, Haigh PI, Brennan MB, Hansen NM, Kelley MC, Ye W, Glass EC, Turner RR: Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer.J Clin Oncol 18: 2553–2559, 2000.
Schrenk P, Hatzl-Griesenhofer M, Shamiyeh A, Waynad W: Follow-up of sentinel node negative breast cancer patients without axillary lymph node dissection.J Surg Oncol 77: 165–170, 2001.
Roumen RMH, Kuijt GP, Liem IH, van Beek MWPM: Treatment of 100 patients with sentinel node-negative breast cancer without further axillary dissection.Br J Surg 88: 1639–1643, 2001.
Noguchi M: Sentinel lymph node biopsy in breast cancer. An overview of the Japanese experience.Breast Cancer 8: 184–194, 2001.
Veronesi U, Galimberti V, Zurrida S, Pigatto F, Veronesi P, Robertson C, Paganelli G, Viale G: Sentinel lymph node biopsy as an indicator for axillary dissection in early breast cancer.Eur J Cancer 37: 454–458, 2001.
Noguchi M: Does regional treatment improve the survival in patients with operable breast cancer?Breast Cancer Res Treat 76: 269–282, 2002.
Ross MI: Sentinel node dissection in early-stage breast cancer: Ongoing prospective randomized trials in the USA.Ann Surg Oncol 8: 77–81, 2001.
Cody HS III, Hill ADK, Tran KN, Brennan MF, Borgen PI: Credentialing for breast lymphatic mapping: How many cases are enough?Ann Surg 229: 723–728, 1999.
Rosen PP, Lesser ML, Kinne DW, Beattie EJ: Discontinuous or “skip” metastases in breast carcinoma: Analysis of 1228 axillary dissection.Ann Surg 197: 276–283, 1983.
Van Lancker M, Goor C, Sacre R, Lamote J, Van Belle S, De Coene N, Roelstraete A, Storme G: Pattern of axillary lymph node metastasis in breast cancer.Am J Clin Oncol 18: 267–272, 1995.
Veronesi U: Sentinel-node biopsy in breast cancer.Lancet 250: 808–809, 1997.
McMasters KM, Giuliano AE, Ross MI, Reintgen DS, Hunt KK, Byrd DR, Klimberg VS, Whitworth PW, Tafra LC, Edwards MJ: Sentinel-lymph node biopsy for breast cancer -not yet the standard of care.N Engl J Med 339: 990–995, 1998.
Noguchi M, Motomura K, Imoto S, Miyauchi M, Sato K, Iwata H, Ohta M, Kurosumi M, Tsugawa K: A multicenter validation study of sentinel lymph node biopsy by the Japanese Breast Cancer Society.Breast Cancer Res Treat 63: 31–40, 2000.
Noguchi M, Katev N, Miyazaki I: Diagnosis of axillary lymph node metastases in patients with breast cancer.Breast Cancer Res Treat 40: 283–293, 1996.
Noguchi M: Sentinel lymph node biopsy as an alter native to routine axillary lymph node dissection in breast cancer patients.J Surg Oncol 76: 144–156, 2001.
Wong JS, Recht A, Beard CJ, Busse PM, Cady B, Chaffey JT, Come S, Fam S, Kaelin C, Lingos TI, Nixon AJ, Shulman LN, Troyan S, Silver B, Harris JR: Treatment outcome after tangential radiation therapy without axillary dissection in patients with early-stage breast cancer and clinically negative axillary nodes.Int J Radiat Oncol Biol Phys 39: 915–920, 1997.
Bass SS, Cox CE, Ku NN, Berman C, Reintgen DS: The role of sentinel lymph node biopsy in breast cancer.J Am Coll Surg 189: 183–194, 1999.
Fisher B, Redmond C: Systemic therapy in node-negative patients: Updated findings from NSABP clinical trials -National Surgical Breast and Bowel Project.J Natl Cancer Inst Monogr 11: 105–116, 1992.
Early Breast Cancer Trialists’ Collaborative Group: Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy: 133 randomised trials involving 31,000 recurrences and 24,000 deaths among 75,000 women.Lancet 339: 71–85, 1992.
Early Breast Cancer Trialists’ Collaborative Group: Tamoxifen for early breast cancer: An overview of the randomised trials.Lancet 351: 1451–1467, 1998.
Fisher B, Bryant J, Wolmark N, Mamounas E, Brown A, Fisher ER, Wickerham DL, Begovic M, DeCillis A, Robidoux A, Margolese RG, Cruz AB Jr, Hoehn JL, Lees AW, Dimitrov NV, Bear HD: Effect of preoperative chemotherapy on the outcome of women with operable breast cancer.J Clin Oncol 16: 2672–2685, 1998.
Fisher B, Redmond C, Fisher ER, Bauer M, Wolmark N, Wickerham L, Deutsch M, Montague E, Margolese R, Foster R: Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation.N Engl J Med 312: 674–681, 1985.
Baxter N, McCready D, Chapman JA, Fish E, Kahn H, Hanna W, Trudeau M, Lickley HL: Clinical behavior of untreated axillary nodes after local treatment for primary breast cancer.Ann Surg Oncol 3: 235–240, 1996.
Recht A, Pierce SM, Abner A, Vicini F, Osteen RT, Love SM, Silver B, Harris JR: Regional nodal failure after conservative surgery and radiotherapy for earlystage breast cancer.J Clin Oncol 9: 988–996, 1991.
Noguchi M, Miwa K, Michigishi T, Yokoyama K, Nishijima H, Takanaka T, Kawashima H, Nakamura S, Kanno H, Nonomura A: The role of axillary lymph node dissection in breast cancer management.Breast Cancer 4: 143–153, 1997.
Krag D: Why perform randomized clinical trials for sentinel node surgery for breast cancer?Am J Surg 182: 411–413, 2001.
Harlow SP, Krag DN: Sentinel lymph node -why study it; Implications of the B-32 study.Semin Surg Oncol 20: 244–229, 2001.
Lythgoe JP, Leek I, Swindell R: Manchester regional breast study: Preliminary results.Lancet I (8067): 744–747, 1978.
Lythgoe JP, Palmer MK: Manchester regional breast study: 5 and 10 year results.Br J Surg 69: 693–696, 1982.
Cancer Research Campaign Working Party. Cancer research campaign (King’s/Cambridge) trial for early breast cancer: a detailed update at the tenth year.Lancet II (8185): 55–60, 1980.
Ribeiro GG, Magee B, Swindell R, Harris M, Banerjee SS: The Christie Hospital breast conservation trial: an update at 8 years from inception.Clin Oncol 5: 278–283, 1993.
Early Breast Cancer Trialists’ Collaborative Group: Effects of radiotherapy and surgery in early breast cancer.N Engl J Med 333: 1444–1455, 1995.
Singletary S: Systemic treatment after sentinel lymph node biopsy in breast cancer: who, what, and why?J Am Coll Surg 192: 220–230, 2001.
Ragaz J, Jackson SM, Le N, Plenderleith IH, Spinelli JJ, Basco VE, Wilson KS, Knowling MA, Coppin CML, Paradis M, Coldman AJ, Olivotto IA: Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer.N Engl J Med 337: 956–962, 1997.
Ragaz J, Jackson SM, Le N, Manji M, Wilson K, Olivotto I, Coldman A, Spinelli J: Postmastectomy radiation outcome in node positive breast cancer patients among N1-3 versus N4+subsets: impact of extracapsular spread. Update of the British Columbia randomized trial.Proc Am Soc Clin Oncol 18: 73, 1999.
Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F, Kjaer M, Gadeberg CC, Mouridsen HT, Jensen M-B, Zedeler K: Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy.N Engl J Med 337: 949–955, 1997.
Overgaard M, Jensen M-B, Overgaard J, Hansen PS, Rose C, Andersson M, Kamby C, Kjaer M, Gadeberg CC, Rasmussen BB, Blichert-Toft M, Mouridsen HT: Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial.Lancet 353: 1641–1648, 1999.
Whelan TJ, Julian J, Wright J, Jadad AR, Levine ML: Does locoregional radiation therapy improve survival in breast cancer? A meta-analysis.J Clin Oncol 18: 1220–1229, 2000.
Krag D, Weaver D, Ashikaga T, Moffat F, Himberg VS, Shriver C, Feldman S, Kusminsky R, Gadd M, Kuhn J, Harlow S, Beitsch P: The sentinel node in breast cancer -a multicenter validation study.N Engl J Med 339: 941–946, 1998.
Veronesi U, Paganelli G, Viale G, Galimberti V, Luini A, Zurrida S, Robertson C, Sacchini V, Veronesi P, Orvieto E, Cicco CD, Intra M, Tosi G, Scarpa D: Sentinel lymph node biopsy and axillary dissection in breast cancer: results in a large series.J Natl Cancer Inst 91: 368–373, 1999.
Hill ADK, Tran KN, Akhurst T, Yeung H, Yeh SDJ, Rosen PP, Borgen PI, Cody HS III: Lessons learned from 500 cases of lymphatic mapping for breast cancer.Ann Surg 229: 528–535, 1999.
Grube BJ, Giuliano AE: Observation of the breast cancer patient with a tumor-positive sentinel node: Implications of the ACOSOG Z0011 trial.Sem Surg Oncol 20: 230–237, 2001.
Giuliano AE: Mapping pathway for axillary staging, A personal perspective on the current status of sentinel lymph node dissection for breast cancer.Arch Surg 134: 195–199, 1999.
Chetty U, Jack W, Prescott RJ, Tyler C, Rodger A: Management of the axilla in operable breast cancer treated by breast conservation: a randomized clinical trial.Brit J Surg 87: 163–169, 2000.
Cabanes PA, Salmon RJ, Vilcoq JR, Durand JC, Fourquet A, Gautier C, Asselain B: Value of axillary dissection in addition to lumpectomy and radiotherapy in early breast cancer.Lancet 339: 1245–1248, 1992.
Clarke D, Khonji NI, Mansel RE: Sentinel node biopsy in breast cancer: ALMANAC Trial.World J Surg 25: 819–822, 2001.
European Organization for the Research and Treatment of Cancer (EORTC) Breast Cancer Cooperative Group. EORTC Protocol 10981: After Mapping of the Axilla: Radiotherapy or Surgery (AMAROS). Brussels: EORTC Data Center, 1999.
Giuliano AE, Dale PS, Turner RR, Morton DL, Evans SW, Krasne DL: Improved axillary staging of breast cancer with sentinel lymphadenectomy.Ann Surg 222: 394–401, 1995.
Noguchi M: Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes.Br J Surg 89: 1505–1515, 2002.
Viale G, Maiorano E, Mazzarol G, Zurrida S, Galimberti V, Luini A, Renne G, Pruneri G, Maisonneuve P, Veronesi U: Histologic detection and clinical implications of micrometastases in axillary sentinel lymph nodes for patients with breast carcinoma.Cancer 92: 1378–1384, 2001.
Turner RR, Chu KU, Qi K, Botnick LE, Hansen NM, Glass EC,et al: Pathologic features associated with nonsentinel lymph node metastases in patients with metastatic breast cancer in a sentinel lymph node.Cancer 89: 574–581, 2000.
Dowlatshahi K, Fan M, Snider HC, Habib FA: Lymph node micrometastases from breast carcinoma: reviewing the dilemma.Cancer 80: 1188–1197, 1997.
Dowlatshahi K, Fan M, Bloom KJ, Spitz DJ, Patel S, Snider HC Jr: Occult metastases in the sentinel lymph nodes of patients with early stage breast carcinoma. A preliminary study.Cancer 86: 990–996, 1999.
Fiztgibbons PL, Page DL, Weaver D, Thor AD, Allred DC, Clark GM, Ruby SG, O’Malley F, Simpson JF, Connolly JL, Hayes DF, Edge SB, Lichter A, Schnitt SJ: Prognostic factors in breast cancer. College of American Pathologists Consensus Statement 1999.Arch Pathol Lab Med 124: 966–978, 2000.
Kataoka A, Mori M, Sadanaga N, Ueno H, Tsuji K, Rai Y, Barnard G, Sugimachi K: RT-PCR detection of breast cancer cells in sentinel lymph nodes.Int J Oncol 16: 1147–1152, 2000.
Wascher RA, Bostick PJ, Huynh KT, Turner R, Giuliano AE, Hoon DSB: Detection of MAGE-A3 in breast cancer patients’ sentinel lymph nodes.Brit J Cancer 85: 1340–1346, 2001.
Branagan G, Hughers D, Jeffrey M, Crane-Robinson C, Perry PM: Detection of micrometastases in lymph nodes from patients with breast cancer.Br J Surg 89: 86–89, 2002.
Meyer JS: Sentinel lymph node biopsy: strategies for pathologic examination of the specimen.J Surg Oncol 69: 212–218, 1998.
Min CJ, Tafra L, Verbanac KM: Identification of superior markers for polymerase chain reaction detection of breast cancer metastases in sentinel lymph nodes.Cancer Res 58: 4581–4584, 1998.
Schrenk P, Rieger R, Shamiyeh A, Wayand W: Morbidity following sentinel lymph node biopsy versus axillary lymph node dissection for patients with breast carcinoma.Cancer 88: 608–614, 2000.
Burak WE, Hollenbeck ST, Zervos EE, Hock KL, Kemp LC, Young DC: Sentinel lymph node biopsy in less postoperative morbidity compared with axillary lymph node dissection for breast cancer.Am J Surg 183: 23–27, 2002.
Howard-Jones E: A preliminary study of cost. In: Keshtgar MRS, Waddington WA, Lakhani SR, Ell PJ, eds, The Sentinel Node in Surgical Oncology, Springer, Berlin, pp 181–186, 1999.
Gemignani ML, Cody III HS, Fey JV, Tran KN, Venkatraman E, Borgen PI: Impact of sentinel lymph node mapping on relative charges in patients with earlystage breast cancer.Ann Surg Oncol 7: 575–580, 2000.
Author information
Authors and Affiliations
Additional information
Reprint requests to Masakuni Noguchi, Surgical Center, Kanazawa University Hospital, Takara-macni, 13-1, Kanazawa 920-8640, Japan.
About this article
Cite this article
Noguchi, M. Is it necessary to perform prospective randomized studies before sentinel node biopsy can replace routine axillary dissection?. Breast Cancer 10, 179–187 (2003). https://doi.org/10.1007/BF02966716
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF02966716