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Differences in Sentinel Lymph Node Pathology Protocols Lead to Differences in Surgical Strategy in Breast Cancer Patients

¹ Department of Surgery, Radboud University Nijmegen Medical Center, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
² Department of Pathology, Radboud University Nijmegen Medical Center, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
³ Department of Pathology, Viecuri Medical Center, Tegelseweg 210, NL-5912 BL, Venlo, The Netherlands
⁴ Department of Pathology, Rijnstate Hospital, P.O. Box 9555, NL-6800 TA, Arnhem, The Netherlands
⁵ Department of Surgery, Canisius-Wilhelmina Hospital, P.O. Box 9015, NL-6500 GS, Nijmegen, The Netherlands
⁶ Department of Surgery, Viecuri Medical Center, Tegelseweg 210, NL-5912 BL, Venlo, The Netherlands
⁷ Department of Surgery, Rijnstate Hospital, P.O. Box 9555, NL-6800 TA, Arnhem, The Netherlands
⁸ Department of Epidemiology and Biostatistics, Radboud University Nijmegen, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
⁹ Department of Medical Oncology, University Hospital Maastricht, P.O. Box 5800, NL 6202 AZ, Maastricht, The Netherlands

Correspondence: Address correspondence and reprint requests to: Marieke J. Bolster, MD; E-mail: m.bolster{at}chir.umcn.nl

Background: Internationally, there is no consensus on the pathology protocol to be used to examine the sentinel lymph node (SN). At present, therefore, various hospitals use different SN pathology protocols of which the effect has not been fully elucidated. We hypothesized that differences between hospitals in SN pathology protocols affect subsequent surgical treatment strategies.

Methods: Patients from four hospitals (A–D) were prospectively registered when they underwent an SN biopsy. In hospitals A, B, and C, three levels of the SN were examined pathologically, whereas in hospital D, at least seven additional levels were examined. In the absence of apparent metastases with hematoxylin and eosin examination, immunohistochemical examination was performed in all four hospitals.

Results: In total, 541 eligible patients were included. In hospital D, more patients were diagnosed with a positive SN (P < .001) as compared with hospitals A, B, and C, mainly because of increased detection of isolated tumor cells. This led to more completion axillary lymph node dissections in hospital D (66.3% of patients (P < .0001), compared with 29.0% in hospitals A, B, and C combined). Positive non-SNs were detected in 13.9% of patients in hospital D, compared with 9.7% in hospitals A, B, and C (P = .70). That is, in 52.4% of patients in hospital D, a negative completion axillary lymph node dissection was performed, compared with 19.3% of patients in hospitals A, B, and C combined.

Conclusions: Differences in SN pathology protocols between hospitals do have a substantial effect on SN findings and subsequent surgical treatment strategies. Whether ultrastaging and, thus, additional surgery can offer better survival remains to be determined.

Key Words: Breast cancer • Sentinel lymph node • Pathology protocol • Micrometastasis • Surgical treatment • Nonsentinel lymph node metastasis

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