10.1245/s10434-006-9199-1
Annals of Surgical Oncology 14:218-221 (2007)
© 2007 Society of Surgical Oncology
Sentinel Lymph Node Biopsy During Pregnancy: Initial Clinical Experience
Matthew M. Mondi, MD1,
Rosa E. Cuenca, MD2,
David W. Ollila, MD3,
John H. Stewart, IV, MD1 and
Edward A. Levine, MD1
1 Surgical Oncology Services, Wake Forest University, Winston-Salem, North Carolina, USA
2 East Carolina University, Greenville, North Carolina, USA
3 University of North Carolina, Chapel Hill, North Carolina, USA
Correspondence: Address correspondence and reprint requests to: Edward A. Levine, MD, Surgical Oncology Service, Wake Forest University, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA; E-mail: elevine{at}wfubmc.edu
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ABSTRACT
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The diagnosis of breast cancer or melanoma in a pregnant patient presents some unique and difficult challenges for both patients and providers. Lymphatic mapping and sentinel lymph node (SLN) biopsy has become an attractive alternative to elective lymphadenectomy procedures for patients with breast cancer and melanoma. However, there is no data on the safety or utility of sentinel node mapping in pregnant patients. Therefore, we reviewed our experience with mapping in gravid patients. Academic institutions throughout North Carolina were asked to contribute cases of mapping performed during pregnancy. A total of nine women underwent sentinel node mapping during pregnancy. All nine were Caucasian with an average age of 32. SLN were found in all cases and mapping procedures were for breast cancer (three), and melanoma (six). There were no adverse reactions to the SLN procedures and one patient developed a seroma at a biopsy site. All went on to have term deliveries without known adverse effects.
This limited experience shows that SLN mapping procedures are feasible in pregnant patients. However, this is not a general endorsement of such procedures in pregnant patients. We suggest that potential risks of vital dye or radioactive tracers be clearly explained to the parents when the mother is a candidate for a mapping procedure, and be balanced against the risk of delaying therapy or omitting nodal staging.
Key Words: Sentinel node mapping • Pregnancy • Safety • Melanoma • Breast cancer
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INTRODUCTION
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Approximately 1:1,000 pregnant women in the U.S. are diagnosed with a new malignancy each year.1 The prevalence of breast cancer in pregnancy is estimated at 1:3,000 deliveries, and between 0.2% and 3.8% of all breast cancers are diagnosed in pregnant or lactating mothers.2,3 Breast cancer in pregnancy may, in fact, become more common as women postpone childbearing until later in life.4 Melanoma is the most common malignancy in women between the ages of 25–29 and is the sixth most common malignancy in women of any age.5 Properly managing these diseases during pregnancy can be complex and should incorporate a multimodality approach. There is a paucity of data in the literature to direct the diagnosis and treatment of these cancers during pregnancy.
Regional lymph node status continues to be the most important prognostic factor for both melanoma and breast cancer. For early-stage melanoma and breast cancer with clinically negative regional lymph nodes, SLN biopsy has become an appropriate alternative to routine staging regional or axillary lymph node dissection (ALND).5–7 The SLN biopsy technique relies on an injection of a radioactive colloid, a vital dye or both in the proximity of the primary lesion. There are justifiable concerns regarding the use of any of these agents in pregnant women and the subsequent implications to the developing fetus. There have been few reports or studies addressing this complex and important component in managing melanoma and breast cancer during pregnancy. The purpose of this study is to describe the combined experience of three academic centers in North Carolina in the use of sentinel node mapping and biopsy in pregnant patients with early melanoma and breast cancer.
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PATIENTS AND METHODS
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A total of nine pregnant patients between the ages of 23 and 37 were treated at one of the three participating academic centers in North Carolina for melanoma or breast cancer. Of these, six were treated for melanoma in stages IA and IB, and three patients were treated for breast cancer in stages I, IIA and IIB. By institution, four patients were treated at East Carolina University in Greensville, North Carolina; three patients were seen at Wake Forest University in Winston-Salem, North Carolina and two cases were contributed by the University of North Carolina at Chapel Hill. The majority (78%) of patients underwent mapping procedures during their second trimester, and two patients (22%) were in their first trimester. All of the patients underwent surgical procedures under general anesthesia. For mapping purposes, two patients received isosulfan blue intraoperatively, and four patients were injected with 99Tc-labeled sulfur colloid particles preoperatively. The remaining three patients received both intraoperative vital dye injection and preoperative radiocolloid injection for mapping. SLN were then identified intraoperatively utilizing a handheld gamma probe, in the cases where radiocolloid had been injected, or by visually mapping out the lymphatic drainage after injection of either fluorescein or isosulfan blue. All lymph nodes were sent for permanent processing with hematoxylin and eosin staining. Any nodal basins identified to contain metastases then underwent completion lymph node dissection for further staging and local control purposes. IRB approval was obtained to review these cases retrospectively without specific patient identifiers.
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RESULTS
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For the nine patients in this study, a total of 21 SLN were identified, with an average of 2.3 SLN per patient (see Table 1
). There were two positive SLN found and two subsequent axillary lymphadenectomies performed for patients with breast cancer. Procedures performed included wide local excision with SLN biopsy (five), lumpectomy with SLN biopsy followed by ALND (one), simple mastectomy with SLN biopsy (one), great-toe amputation with SLN biopsy (one), and core needle biopsy with SLN biopsy followed by lumpectomy and ALND (one). The patient who underwent the toe amputation and ipsilateral groin SLN biopsy developed a wound seroma that resolved with aspiration. Both patients with positive SLN in this series were breast cancer patients in their second trimester at the time of SLN mapping, and both received systemic therapy during the third trimester. One patient was treated with neoadjuvant doxorubicin and cyclophosphamide, followed by taxol and then lumpectomy and completion ALND. The other patient underwent lumpectomy and SLN, followed by completion ALND and adjuvant chemotherapy. All nine offspring of these pregnancies were delivered at term. There have been no birth defects or discernable malformations in any of the children to date.
Received for publication July 7, 2006.
Accepted for publication July 13, 2006.
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ABSTRACT
INTRODUCTION
