Annals of Surgical Oncology

, Volume 16, Issue 9, pp 2442–2449 | Cite as

Survey of ASCO Members on Management of Sentinel Node Micrometastases in Breast Cancer: Variation in Treatment Recommendations According to Specialty

Breast Oncology



American Society of Clinical Oncology (ASCO) guidelines recommend axillary dissection (ALND) as the primary treatment for sentinel node micrometastases (SNMM) in breast cancer. We hypothesized that variation exists in adherence to these guidelines and management of SNMM as a result of the medical specialty of the treating physician.


A questionnaire was e-mailed to 2511 active members of ASCO who specialize in breast cancer and who are board certified in surgery, medical oncology, or radiation oncology. Questions covered treatment of SNMM and factors influencing clinical decisions. Survey responses were analyzed by the Kruskal–Wallis and Fisher’s exact test.


Of 612 questionnaires viewed by recipients, 537 (88%) were completed by 382 medical oncologists, 100 surgeons, and 55 radiation oncologists. Most (98.5%) regarded SNMM as clinically important. Unexpectedly, ALND for SNMM was recommended by only 23% of surgeons, 23% of medical oncologists, and 15% of radiation oncologists (no statistically significant intergroup difference). Factors identified as important in selecting patients for ALND were tumor size, age, tumor grade, lymphovascular invasion, and size of metastases. Most respondents in each specialty (89% overall) would consider adjuvant chemotherapy for primary tumors <1 cm if SNMM were present. Tumor size, age, size of metastases, estrogen receptor/progesterone receptor status, HER-2 neu status, and gene expression profile would influence this decision. Radiation oncologists (76%) were more likely than medical oncologists (57%) or surgeons (47%) to consider axillary radiation instead of ALND for SNMM (P = 0.0021).


Guidelines recommending ALND for SNMM are not being followed by most of the ASCO members we surveyed.


  1. 1.
    Giuliano AE, Kirgan DM, Guenther JM, et al. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst. 2006;98:599–609.PubMedGoogle Scholar
  3. 3.
    Giuliano AE, Dale PS, Turner RR, et al. Improved axillary staging of breast cancer with sentinel lymphadenectomy. Ann Surg. 1995;222:394–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Kahn HJ, Hanna WM, Chapman JA, et al. Biological significance of occult micrometastases in histologically negative axillary lymph nodes in breast cancer patients using the recent American Joint Committee on Cancer breast cancer staging system. Breast J. 2006;12:294–301.PubMedCrossRefGoogle Scholar
  5. 5.
    Greene FL, Page DL, Fleming ID. AJCC cancer staging manual. 6th ed. New York: Springer, 2002.Google Scholar
  6. 6.
    Mittendorf EA, Hunt KK. Significance and management of micrometastases in patients with breast cancer. Expert Rev Anticancer Ther. 2007;7:1451–61.PubMedCrossRefGoogle Scholar
  7. 7.
    McCready DR, Yong WS, Ng AK, et al. Influence of the new AJCC breast cancer staging system on sentinel lymph node positivity and false-negative rates. J Natl Cancer Inst. 2004;96:873–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol. 2005;23:7703–20.PubMedCrossRefGoogle Scholar
  9. 9.
    Wasif N, Ko CY, Giuliano AE. Underutilization of axillary dissection for the management of micrometastases in breast cancer. Presented at: Pacific Coast Surgical Association 80th annual meeting, San Francisco, 2009.Google Scholar
  10. 10.
    Cox CE, Kiluk JV, Riker AI, et al. Significance of sentinel lymph node micrometastases in human breast cancer. J Am Coll Surg. 2008;206:261–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Tan LK, Giri D, Hummer AJ, et al. Occult axillary node metastases in breast cancer are prognostically significant: results in 368 node-negative patients with 20-year follow-up. J Clin Oncol. 2008;26:1803–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Chen SL, Hoehne FM, Giuliano AE. The prognostic significance of micrometastases in breast cancer: a SEER population-based analysis. Ann Surg Oncol. 2007;14:3378–84.PubMedCrossRefGoogle Scholar
  13. 13.
    Cserni G, Gregori D, Merletti F, et al. Meta-analysis of non-sentinel node metastases associated with micrometastatic sentinel nodes in breast cancer. Br J Surg. 2004;91:1245–52.PubMedCrossRefGoogle Scholar
  14. 14.
    Orr RK. The impact of prophylactic axillary node dissection on breast cancer survival—a Bayesian meta-analysis. Ann Surg Oncol. 1999;6:109–16.PubMedCrossRefGoogle Scholar
  15. 15.
    Chu KU, Turner RR, Hansen NM, et al. Do all patients with sentinel node metastasis from breast carcinoma need complete axillary node dissection? Ann Surg. 1999;229:536–41.PubMedCrossRefGoogle Scholar
  16. 16.
    Turner RR, Chu KU, Qi K, et al. Pathologic features associated with nonsentinel lymph node metastases in patients with metastatic breast carcinoma in a sentinel lymph node. Cancer. 2000;89:574–81.PubMedCrossRefGoogle Scholar
  17. 17.
    Van Zee KJ, Manasseh DM, Bevilacqua JL, et al. A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003;10:1140–51.PubMedCrossRefGoogle Scholar
  18. 18.
    Schlembach PJ, Buchholz TA, Ross MI, et al. Relationship of sentinel and axillary level I–II lymph nodes to tangential fields used in breast irradiation. Int J Radiat Oncol Biol Phys. 2001;51:671–8.PubMedGoogle Scholar
  19. 19.
    Fisher B, Jeong JH, Anderson S, et al. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567–75.PubMedCrossRefGoogle Scholar
  20. 20.
    Louis-Sylvestre C, Clough K, Asselain B, et al. Axillary treatment in conservative management of operable breast cancer: dissection or radiotherapy? Results of a randomized study with 15 years of follow-up. J Clin Oncol. 2004;22:97–101.PubMedCrossRefGoogle Scholar
  21. 21.
    Langer I, Marti WR, Guller U, et al. Axillary recurrence rate in breast cancer patients with negative sentinel lymph node (SLN) or SLN micrometastases: prospective analysis of 150 patients after SLN biopsy. Ann Surg. 2005;241:152–8.PubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2009

Authors and Affiliations

  1. 1.John Wayne Cancer Institute at Saint John’s Health CenterSanta MonicaUSA

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