The proof of principle was demonstrated by complete histopathologic analysis of all axillary nodes by Giuliano and colleagues in These results have been substantiated by others and have lead to the acceptance of intraoperative lymphatic mapping as an accurate and less invasive option for staging of the axilla in women with early breast cancer.
The sentinel node hypothesis states that the sentinel node is the first draining lymph node from the primary tumor and that the sentinel node is the most likely node to harbor metastases if present. It is a functional, biological definition, not an operational, technical definition. The optimal number of nodes removed is really not the issue. The issue is the identification and removal of the true sentinel node.
The presence of second-echelon nodes may occur because of injection technique, timing to dissection, location of tumor, surgeon experience, and patient characteristics. Identification of a second-echelon node may occur upon entry into the axillary space at the level of a secondary blue or hot node distal to the true sentinel node. Therefore, it is not unreasonable to discover that a more proximal node or deeper node is the true sentinel node. Many different techniques have been described to identify a node stained with vital dye, containing radioactivity or a combination of indicators.
The removal of multiple nodes, up to 11, as described in this study represents the equivalent of an axillary dissection and really defeats one of the goals of sentinel lymphadenectomy ie, less morbidity with a minimally invasive technique , but this must be contrasted against a false-negative staging that could impair the adjuvant treatment decisions for a given patient.
The American Society of Breast Surgeons has proposed guidelines for surgeons learning the technique of sentinel node biopsy. These include the performance of 20 cases with a backup axillary lymph node dissection or the performance of sentinel node biopsy in the mentored situation in 20 cases. Most surgeons had minimal experience prior to entry into the study. In previous studies from the Louisville Sentinel Node Registry, the predominant cluster of false-negative cases occurred within the first 10 cases in a surgeon's experience.
My first question is: Did the number of sentinel nodes removed change as a function of the number of sentinel node procedures performed by each surgeon who initially required more than 4 nodes removed to accurately stage the axilla?
Can the authors determine if the outliers in their study ie, those who needed to remove more than 4 sentinel nodes to stage the axilla accurately were the surgeons with lower rates of identifying any sentinel node? The goal of axillary staging with either axillary dissection or lymphatic mapping is to accurately stage the axilla for local control and adjuvant systemic treatment decisions and to minimize morbidity.
In this cohort of surgeons, the false-negative rate even with multiple sentinel nodes removed was 7. The false-negative rate in this trial was 9. Cox and colleagues have demonstrated that identification is higher by surgeons who perform more than 6 sentinel lymphadenectomies per month. My third question: What is the surgical volume for breast cases for each of the surgeons who removed more than 4 nodes to finally remove the true sentinel node and was there a difference in success rates for those who performed fewer cases than those who performed more cases?
I would like to congratulate the authors on presenting the cumulative experience of a large number of surgeons representing academic practices, breast-only practices, and those with typical general surgery practices with limited volume of breast disease, using a variety of sentinel lymph node mapping techniques. Dr Chagpar: To begin with, it is clear that the false-negative rate associated with sentinel lymph node biopsy does improve with surgical experience.
We and others have previously reported that having at least 20 cases does improve the false-negative rate.
However, this is independent of the number of sentinel lymph nodes removed. Relative to the second question regarding surgeons who needed to remove more than 4 sentinel nodes having a lower rate of identifying any sentinel node, I need to be clear that this study was restricted to the patients in whom a sentinel node was identified.
So those surgeons who could not identify any sentinel node clearly would not be in this cohort. Finally, as to the question of surgical volume and its impact on sentinel lymph node biopsy false-negative rates, this has also previously been reported. We did not look at surgical volume per se in determining whether surgical volume impacted whether surgeons removed more than 4 nodes or not. Anton J. Would you suggest to the surgeons here that perhaps if more than 1 to 2 sentinel nodes are found that the surgeon proceed with an axillary lymph node dissection?
Dr Chagpar: I think that we need to be clear as to whether you mean 1 to 2 sentinel lymph nodes can't be found or whether those 1 to 2 sentinel lymph nodes are negative. Radioactivity may be detected over several nodes during sentinel node biopsy SNB , thus indicating that they all should be excised for examination. Biopsy of an insufficient number of lymph nodes LNs may produce a false negative result, while excision of too many contradicts the SNB idea itself, turning it into an incomplete lymphadenectomy.
We aim at establishing the minimal number of LNs that must be removed without compromising the reliability. During years to , 1, SNBs were performed in our department. Invasive cancer was diagnosed in 1, cases and these were included in our present study. All LNs were marked in order of their expressed radioactivity and subsequent removal. The number of excised sentinel nodes varied from one to nine, the average was 2. Table 1 presents groups of patients with particular numbers of sentinel LNs excised and percentages of metastases found.
Maxillary sampling involves removing four nodes from the lower maxilla by palpation and study of removing four nodes had minimal long-term arm morbidity in very carefully designed prospective studies [ 15 ].
Concerns about removing too many nodes are real but providing the number is four or less then our long-term data shows morbidity is very small in removing this number of maxillary lymph nodes. The current study suggests that the number of sentinel nodes removed per surgeon perhaps should become a quality measure collected by each surgeon and audited and considered at their annual appraisal. Surgeons removing consistently too many or too few sentinel nodes need then to amend their practice.
Since the presentation of this study to the surgeons in the unit, there has been a clear change and the variation is now much less than it was during this study. This study is strengthened by the sample size of procedures from the largest breast unit in the UK and provides a meaningful analysis of current breast cancer care.
A single centre analysis is important in removing some of the variables such as technique and consistent pathology reporting. The exclusions from the study were small because the Edinburgh Breast Unit collects all pathology data and pathology reporting is consistent in all cases. The largest amount of missing data was on grade and that was missing in only 3. The study was largely successful at getting approximately 50 cases from each of the 10 surgeons.
Most surgeons were consultants but also included were associate specialists and staff grade surgeons. All were experienced breast surgeons and no trainees were included in this study. Tanis PJ History of sentinel node and validation of the technique. Breast Cancer Res [Internet] 3 2 — CA Cancer J Clin 67 2 — Article PubMed Google Scholar. JAMA 22 — Dixon J Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with breast cancer. Futur Med 4 6 — CAS Google Scholar.
Lancet Oncol 8 10 — Eur J Cancer 45 5 — Lancet Oncol 14 7 — J Clin Oncol 33 30 — JAMA Surg 2 — Am J Surg 3 — Medicine 95 14 :e Br J Surg. Article Google Scholar. Br J Surg 1 — Download references. You can also search for this author in PubMed Google Scholar. Correspondence to J. Michael Dixon. This article does not contain any studies with human participants or animals performed by any of the authors.
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