Lymphatic Mapping and Sentinel Lymphadenectomy for Breast Cancer

Abstract

ObjectiveThe authors report the feasibility and accuracy of intraoperative lymphatic mapping with sentinel lymphadenectomy in patients with breast cancer. Summary Background DataAxillary lymph node dissection (ALND) for breast cancer generally is accepted for its staging and prognostic value, but the extent of dissection remains controversial. Blind lymph node sampling or level dissection may miss some nodal metastases, but ALND may result in lymphedema. In melanoma, intraoperative lymph node mapping with sentinel lymphadenectomy is an effective and minimally invasive alternative to ALND for identifying nodes containing metastases. MethodsOne hundred seventy-four mapping procedures were performed using a vital dye injected at the primary breast cancer site. Axillary lymphatics were identified and followed to the first ("sentinel") node, which was selectively excised before ALND. ResultsSentinel nodes were identified in 1 14 of 174 (65.5%) procedures and accurately predicted axillary nodal status in 109 of 1 14 (95.6%) cases. There was a definite learning curve, and all falsenegative sentinel nodes occurred in the first part of the study; sentinel nodes identified in the last 87 procedures were 100% predictive. In 16 of 42 (38.0%) clinically negative/pathologically positive axillae, the sentinel node was the only tumor-involved lymph node identified. The anatomic location of the sentinel node was examined in the 54 most recent procedures; ten cases had only level 11 nodal metastases that could have been missed by sampling or low (level 1) axillary dissection. ConclusionsThis experience indicates that intraoperative lymphatic mapping can accurately identify the sentinel node-i.e., the axillary lymph node most likely to contain breast cancer metastases-in some patients. The technique could enhance staging accuracy and, with further refinements and experience, might alter the role of ALND.The presence or absence of axillary lymph node me-for patient management. Historically, nodal involvetastases remains the most important prognostic factor in ment was determined by radical axillary lymph node dispatients with potentially curable carcinoma ofthe breast, section, usually as part of a radical mastectomy. Recent and the development ofeffective adjuvant systemic ther-data suggest that less radical axillary procedures may reapies has made recognition of these metastases critical sult in adequate axillary staging and regional control, but 391

Quantitative evaluation of metastases in axillary lymph nodes of breast cancer

“…Therefore, a tumour-free sentinel lymph node implies the absence of lymph node metastases in the entire lymphatic basin. This sentinel node concept had been previously confirmed by H&E examinations, immunohistochemical study and nonquantitative RT -PCR assays (Giuliano et al, 1994;Albertini et al, 1996;Veronesi et al, 1997;Krag et al, 1998;Kataoka et al, 2000;Manzotti et al, 2001;Branagan et al, 2002;Ishida et al, 2002).…”

“…In addition, no post-PCR manipulations are required with this method, and quantification and calculation of the results are all automated. Currently, many investigators reported sentinel lymph node biopsy for the diagnosis of axillary lymph node metastases from breast cancer (Giuliano et al, 1994;Albertini et al, 1996;Veronesi et al, 1997;Krag et al, 1998). The sentinel lymph node is the first lymph node to receive drainage from the primary tumours in early stage cancers (Morton et al, 1992).…”

The value of immunohistochemistry in sentinel lymph node histopathology in breast cancer

“…More recently, sentinel lymph node biopsy (SLNB) has been proposed as an alternative method for staging the axilla in women who have early breast cancer with clinically node negative axillae (Giuliano et al, 1994;Veronesi et al, 1997;McIntosh and Purushotham, 1998;Veronesi et al, 1999;Veronesi et al, 2003). The SLN is the first lymph node to receive lymphatic drainage from a tumour.…”

Detection of metastases in sentinel lymph nodes of breast cancer patients by multiple mRNA markers

“…A less invasive method for the assessment of lymph node status is the sentinel lymph node biopsy (SLNB). Thereby, the lymphatic route of tumour cells to the lymph node(s) that primarily drains the tumour and most likely harbours metastatic disease are mapped (Giuliano et al, 1994). The sentinel lymph node (SN) is highly predictive of the histo-pathology of the remaining lymphatic basin and can accurately predict axillary nodal status in at least 98% of cases (Giuliano et al, 1995(Giuliano et al, , 1997.…”