Lymphatic visualisation and biopsy in breast cancer

Abstract

Background: Pathological examination of axillary lymph nodes is accepted as the most useful prognostic factor in patients with localised breast cancer. The therapeutic value of axillary dissection (AD) is debated, and lymphoedema is well known' A technique to adequately examine axillary nodes, avoid AD and reduce sampling error in routine pathological examination of large specimens is needed' It was felt that the technique for targeted lymph node biopsy developed in melanoma surgery might be applicable to breast cancer. Introduction: A literature review was carried out looking at axillary dissection and factors leading to the concept of selective node biopsy. Methods: 30 patients with breast cancer underwent preoperative Lymphoscintigraphy (LS) and intraoperative dye localisation to identify a sentinel node (SN) in the axilla, which was biopsied prior to AD and breast swgery. Detailed clinical and histological analysis was carried out on the SN to assess its reliability as a marker of axillary status, and the feasibility of the procedure in various clinical and pathological circumstances. Results: LS located nodes in 23 patients although lymphatic channels were only seen in 5. Dye localisation identified a SN in 21 patients. Operating time increased by approximately 15 minutes. Routine histology of the AD specimen revealed one 'false negative' SN. Detailed histology of the SN revealed that 2 patients thought to be node negative had metastatic disease in the SN. Of the 14 patients who had node positive disease, 7 patients had disease only in the sentinel node. Conclusions: Sentinel Node Biopsy (SNB) is feasible in patients with breast cancer and is independent of tumour location, size, grade, type, or nodal status. Various recommendations with respect to improvements in the technique are discussed. Detailed histology of the SN alone appears to be a more accurate method of staging the axilla than routine examination of a complete AD specimen. Sentinel node biopsy can identify the only node in the axilla containing metastatic disease. The procedure has a false negative rate. Consideration should be given to a trial of SNB alone reserving complete AD for patients found to have metastatic disease in the SN