Pre-mastectomy Sentinel Lymph Node Biopsy: A Strategy to Enhance Outcomes in Immediate Breast Reconstruction

Abstract

The pre-mastectomy sentinel lymph node biopsy (PM-SLNB) is a technique that provides knowledge regarding nodal status prior to mastectomy. Because radiation exposure is associated with poor outcomes in breast reconstruction and reconstructed breasts can interfere with the planning and delivery of radiation therapy (RT), information regarding nodal status has important implications for patients who desire immediate breast reconstruction. This study explores the safety and utility of PM-SLNB as part of the treatment strategy for breast cancer patients desiring immediate reconstruction. We reviewed the charts of adult patients (≥18 years old) who underwent PM-SLNB from January 2004 to January 2011 at our institution. PM-SLNB was offered to patients with stage I or IIa, clinically and/or radiographically node-negative breast cancer who desired immediate breast reconstruction following mastectomy. PM-SLNB was also offered to patients with ductal carcinoma in situ if features concerning for invasive carcinoma were present. Ninety-one patients underwent PM-SLNB of 94 axillae. PM-SLNB was positive in 25.5% of breasts (n = 24). Nineteen node-positive patients (79.2%) have undergone or planning to undergo delayed reconstruction at our institution. Seventeen of these 19 node-positive patients (89.5%) have received adjuvant RT. Two patients (10.5%) elected against RT despite our recommendation for it. No biopsy-positive patient underwent immediate reconstruction or suffered a radiation-induced complication with their breast reconstruction. There were two minor complications associated with PM-SLNB, both in node-negative patients. This study demonstrates the utility of PM-SLNB in providing information regarding nodal status, and therefore the need for adjuvant RT, prior to mastectomy. This knowledge can be used to appropriately counsel patients regarding optimal timing of breast reconstruction.

Immediate Reconstruction of the Radiated Breast: Recent Trends Contrary to Traditional Standards

“…A problem with this strategy is that as many as 32% of breasts expanders exposed to radiation fail during the reconstruction process and require explantation 28 . An alternative approach that allows for a better determination of the need for PMRT prior to mastectomy and immediate reconstruction is the pre-mastectomy sentinel lymph node biopsy (PM-SLNB) 33 . This is the technique employed at our institution wherein the sentinel lymph node biopsy is performed days to weeks in advance of the mastectomy.…”

Development and Validation of Prediction Models for Sentinel Lymph Node Status Indicating Postmastectomy Radiotherapy in Breast Cancer: a Population-Based Study of 18 185 Women

“…Additionally, it complicates surgical planning, impacting the required time in the operating theatre and the necessary intraoperative resources. Several studies suggested a staged SLNB procedure prior to mastectomy when IBR is planned [34][35][36] . While enabling a complete pathological evaluation of the SLN status before breast surgery, this strategy comes with the drawback of a two-step surgical procedure, including increased risk for infections, delay in definitive surgery, and increased arm morbidity and hospital costs 37,38 .…”

Breast Reconstruction Trends in the Setting of Postmastectomy Radiation Therapy: Analysis of Practices among Plastic Surgeons in the United States

“…At some centers, a sentinel lymph node biopsy is performed 2–3 weeks prior to mastectomy to eliminate the uncertainty surrounding PMRT. 33 Whether this would change management in patients who indeed require PMRT is an interesting question for future research.…”