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Selective Use of Sentinel Lymph Node Surgery in Patients Undergoing Prophylactic Mastectomy Using Intraoperative Pathology

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

Abstract

Background

Routine sentinel lymph node (SLN) surgery during prophylactic mastectomy (PM) is unnecessary, because most PMs do not contain cancer. Our institution utilizes intraoperative pathology to guide the surgical decision for resection of SLNs in PM. The purpose of this study was to review the effectiveness of this approach.

Methods

We identified all women aged ≥18 years who underwent bilateral PM (BPM) or contralateral PM (CPM) at our institution from January 2008 to July 2016. We evaluated the frequency of SLN resection and rate of occult breast cancer (DCIS or invasive disease) in the PM. We used the following definitions: over-treatment—SLN surgery in patients without cancer; under-treatment—no SLN surgery in patients with cancer; appropriate treatment—no SLN in patients without cancer or SLN surgery in patients with cancer.

Results

PM was performed on 1900 breasts: 1410 (74.2%) CPMs and 490 (25.8%) BPMs. Cancer was identified in 58 (3.0%) cases (32 invasive disease and 26 DCIS) and concurrent SLN surgery was performed in 44 (75.9%) of those cases. Overall, SLN surgery guided by intraoperative pathology resulted in appropriate treatment of 1787 (94.1%) cases: 1319 (93.5%) CPMs and 468 (95.5%) BPMs, by avoiding SLN in 1743/1842 cases without cancer (94.6%), and performing SLN surgery in 44/58 cases with cancer (75.9%).

Conclusions

Use of intraoperative pathology to direct SLN surgery in patients undergoing PM minimizes over-treatment from routine SLN in PM and minimizes under-treatment from avoiding SLN in PM, demonstrating the value of intraoperative pathology in this era of focus on appropriateness of care.

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References

  1. Mattos D, Gfrerer L, Reish RG, et al. Lifetime costs of prophylactic mastectomies and reconstruction versus surveillance. Plast Reconstr Surg. 2015;136:730e–40e.

    Article  CAS  PubMed  Google Scholar 

  2. Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25:5203–09.

    Article  PubMed  Google Scholar 

  3. de la Pena-Salcedo JA, Soto-Miranda MA, Lopez-Salguero JF. Prophylactic mastectomy: is it worth it? Aesthetic Plast Surg. 2012;36:140–48.

    Article  PubMed  Google Scholar 

  4. Erdahl LM, Boughey JC, Hoskin TL, Degnim AC, Hieken TJ. Contralateral prophylactic mastectomy: factors predictive of occult malignancy or high-risk lesion and the impact of MRI and genetic testing. Ann Surg Oncol. 2016;23:72–77.

    Article  PubMed  Google Scholar 

  5. Goldflam K, Hunt KK, Gershenwald JE, et al. Contralateral prophylactic mastectomy. Predictors of significant histologic findings. Cancer. 2004;101:1977–86.

    PubMed  Google Scholar 

  6. Yi M, Meric-Bernstam F, Middleton LP, et al. Predictors of contralateral breast cancer in patients with unilateral breast cancer undergoing contralateral prophylactic mastectomy. Cancer. 2009;115:962–71.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Boughey JC, Khakpour N, Meric-Bernstam F, et al. Selective use of sentinel lymph node surgery during prophylactic mastectomy. Cancer. 2006;107:1440–47.

    Article  PubMed  Google Scholar 

  8. King TA, Gurevich I, Sakr R, Patil S, Stempel M, Morrow M. Occult malignancy in patients undergoing contralateral prophylactic mastectomy. Ann Surg. 2011;254:2–7.

    Article  PubMed  Google Scholar 

  9. Ashikaga T, Krag DN, Land SR, et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010;102:111–18.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Ikeda T. Re-sentinel node biopsy after previous breast and axillary surgery. Surg Today. 2014;44:2015–21.

    Article  PubMed  Google Scholar 

  11. Karam A, Stempel M, Cody HS, 3rd, Port ER. Reoperative sentinel lymph node biopsy after previous mastectomy. J Am Coll Surg. 2008;207:543–48.

    Article  PubMed  Google Scholar 

  12. Boughey JC, Cormier JN, Xing Y, et al. Decision analysis to assess the efficacy of routine sentinel lymphadenectomy in patients undergoing prophylactic mastectomy. Cancer. 2007;110:2542–50.

    Article  PubMed  Google Scholar 

  13. Bunting PW, Cyr AE, Gao F, Margenthaler JA. Sentinel lymph node biopsy during prophylactic mastectomy: is there a role? J Surg Oncol. 2014;109:747–50.

    Article  PubMed  Google Scholar 

  14. Kuwajerwala NK, Dekhne NS, Pentiak PA, et al. Sentinel lymph node biopsy in contralateral prophylactic mastectomy: are we overtreating? Experience at a tertiary care hospital. Clin Breast Cancer. 2013;13:287–91.

    Article  PubMed  Google Scholar 

  15. Murthy V, Chamberlain RS. Prophylactic mastectomy in patients at high risk: is there a role for sentinel lymph node biopsy? Clin Breast Cancer. 2013;13:180–87.

    Article  PubMed  Google Scholar 

  16. Nagaraja V, Edirimanne S, Eslick GD. Is sentinel lymph node biopsy necessary in patients undergoing prophylactic mastectomy? A systematic review and meta-analysis. Breast J. 2016;22:158-–65.

    Article  PubMed  Google Scholar 

  17. Zhou WB, Liu XA, Dai JC, Wang S. Meta-analysis of sentinel lymph node biopsy at the time of prophylactic mastectomy of the breast. Can J Surg. 2011;54:300–06.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Boughey JC, Attai DJ, Chen SL, et al. Contralateral prophylactic mastectomy consensus statement from the American Society of Breast Surgeons: additional considerations and a framework for shared decision making. Ann Surg Oncol. 2016;23:3106–11.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Czyszczon IA, Roland L, Sahoo S. Routine prophylactic sentinel lymph node biopsy is not indicated in women undergoing prophylactic mastectomy. J Surg Oncol. 2012;105:650–54.

    Article  PubMed  Google Scholar 

  20. Soran A, Falk J, Bonaventura M, Keenan D, Ahrendt G, Johnson R. Is routine sentinel lymph node biopsy indicated in women undergoing contralateral prophylactic mastectomy? Magee-Womens Hospital experience. Ann Surg Oncol. 2007;14:646–51.

    Article  PubMed  Google Scholar 

  21. Nasser SM, Smith SG, Chagpar AB. The role of sentinel node biopsy in women undergoing prophylactic mastectomy. J Surg Res. 2010;164:188–92.

    Article  PubMed  Google Scholar 

  22. Gebruers N, Verbelen H, De Vrieze T, Coeck D, Tjalma W. Incidence and time path of lymphedema in sentinel node negative breast cancer patients: a systematic review. Arch Phys Med Rehabil. 2015;96:1131–39.

    Article  PubMed  Google Scholar 

  23. 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.

    Article  PubMed  Google Scholar 

  24. McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008;26:5220–26.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Langer I, Guller U, Berclaz G, et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg. 2007;245:452–61.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007;25:3657–63.

    Article  PubMed  Google Scholar 

  27. Soran A, Ozmen T, McGuire KP, et al. The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphat Res Biol. 2014;12:289–94.

    Article  PubMed  Google Scholar 

  28. Burger A, Thurtle D, Owen S, et al. Sentinel lymph node biopsy for risk-reducing mastectomy. Breast J. 2013;19:529–32.

    Article  PubMed  Google Scholar 

  29. Cant EL, Shivas AA, Forrest AP. Lymph-node biopsy during simple mastectomy. Lancet. 1975;1:995–97.

    Article  CAS  PubMed  Google Scholar 

  30. Williams RN, Jones L, Stotter A. Lymph nodes in the tail of the breast can be missed in standard axillary dissection. Eur J Surg Oncol. 2009;35:271–75.

    Article  CAS  PubMed  Google Scholar 

  31. Intra M, Veronesi P, Mazzarol G, et al. Axillary sentinel lymph node biopsy in patients with pure ductal carcinoma in situ of the breast. Arch Surg. 2003;138:309–13.

    Article  PubMed  Google Scholar 

  32. NCCN Guidelines Ductal Carcinoma in Situ (DCIS)2016;Version 2.2016.

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Acknowledgement

The authors acknowledge the support of the Mayo Clinic Departments of Surgery, Anatomic Pathology, and the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery as substantial contributors of resources to the project.

Funding

The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery provides salary support for Dr. Habermann, Dr. Murphy, and Ms. Glasgow. No external funding was used.

Disclosure

All authors disclose no conflicts.

Author information

Authors and Affiliations

  1. Department of Surgery, Mayo Clinic, Rochester, MN, USA

    Brittany L. Murphy MD, Elizabeth B. Habermann PhD & Judy C. Boughey MD

  2. The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA

    Brittany L. Murphy MD, Amy E. Glasgow MHA & Elizabeth B. Habermann PhD

  3. Department of Lab Medicine and Pathology, Mayo Clinic, Rochester, MN, USA

    Gary L. Keeney MD

Authors
  1. Brittany L. Murphy MD
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  2. Amy E. Glasgow MHA
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  3. Gary L. Keeney MD
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  4. Elizabeth B. Habermann PhD
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  5. Judy C. Boughey MD
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Corresponding author

Correspondence to Judy C. Boughey MD.

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Murphy, B.L., Glasgow, A.E., Keeney, G.L. et al. Selective Use of Sentinel Lymph Node Surgery in Patients Undergoing Prophylactic Mastectomy Using Intraoperative Pathology. Ann Surg Oncol 24, 3032–3037 (2017). https://doi.org/10.1245/s10434-017-5925-0

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  • DOI: https://doi.org/10.1245/s10434-017-5925-0

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