Annals of Surgical Oncology Cite Track
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
10.1245/s10434-006-9264-9
Annals of Surgical Oncology 14:646-651 (2007)
© 2007 Society of Surgical Oncology
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Soran, A.
Right arrow Articles by Johnson, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Soran, A.
Right arrow Articles by Johnson, R.

Original Article

Is Routine Sentinel Lymph Node Biopsy Indicated in Women Undergoing Contralateral Prophylactic Mastectomy? Magee-Womens Hospital Experience

Atilla Soran, MD, MPH, FACS, Jeffrey Falk, MD, FACS, Marguerite Bonaventura, MD, Donald Keenan, MD, PhD, Gretchen Ahrendt, MD, FACS and Ronald Johnson, MD, FACS

Department of Surgery, Magee-Womens Hospital of UPMC, 300 Halket St. Suite 2601, Pittsburgh, PA 15213, USA

Correspondence: Address correspondence and reprint requests to: Atilla Soran, MD, MPH, FACS, E-mail: asoran{at}magee.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Introduction: The routine use of sentinel node biopsy (SLNB) at the time of prophylactic mastectomy remains controversial. This retrospective study was undertaken to determine if SLNB is justified in patients undergoing CPM.

Methods: Between 1999 and 2004, 155 patients underwent contralateral prophylactic mastectomy (CPM) at the Magee-Womens Hospital of University of Pittsburgh Medical Center. Eighty patients (51.6%) had SLNB performed at the time of CPM. The therapeutic mastectomy and the CPM specimens were evaluated for histopathology. Goldflam’s classification was used to determine the risk of malignancy in the CPM specimens.

Results: Pathology in the therapeutic mastectomy specimens included 105 (68%) invasive carcinomas and 50 (32%) insitu carcinomas. Multicentricity and/or multifocality were reported in 49.7%, and 70% were estrogen receptor positive. Two invasive breast cancers and three cases of DCIS were diagnosed in 155 CPM specimens (n = 5, 3.2%). The median number of SLN identified was 2 (range 1–6) from the CPM axilla. Two patients had positive SLNB for metastatic carcinoma (n = 2/80, 2.5%) with no primary tumor identified in the prophylactic mastectomy specimen. In both patients the therapeutic mastectomy was for recurrent invasive carcinoma in patients with a prior history of axillary node dissection. Occult carcinoma was found in five prophylactic mastectomy specimens: two invasive and three DCIS. Only 1 out of the 75 patients not undergoing SLNB at the time of their initial surgery would have required axillary staging for a previously undiagnosed invasive cancer in the CPM specimen on final pathology. Of all 155 patients undergoing CPM, only 4 (2.5%) had identified final pathologic findings where axillary staging with SLNB was beneficial. There was no evidence of arm lymphedema in any patient who had undergone CPM and SLNB at a median follow-up of 24 months.

Conclusion: Although SLNB is a minimally invasive method of axillary staging, this retrospective study does not support its routine use in patients undergoing CPM.

Key Words: Sentinel lymph node • Contralateral • Prophylactic • Mastectomy


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
A subset of patients with a new diagnosis of unilateral breast cancer who either require or opt for a total mastectomy as therapeutic treatment for their cancer may consider a contralateral, prophylactic, risk-reduction mastectomy. The decision for contra-lateral prophylactic mastectomy (CPM) may be based on risk stratification, family history, patient age, BRCA 1 or 2-gene mutation status, cosmetic/ symmetry issues, or personal choice. The reported frequency of CPM over the past three decades is 1.9–4.8% for patients with a unilateral breast cancer and comprises 2.2% of all mastectomies performed.2–4 By the year 2006, the estimated number of new breast cancer cases among females will be 214,640 in the USA. If approximately 30% of newly diagnosed breast cancer patients are treated with therapeutic mastectomy and up to 4.8% request CPM, and it can be estimated that more than 3,000 women will undergo prophylactic mastectomy in the USA annually.1

The American Society of Clinical Oncology (ASCO) guidelines for sentinel node biopsy (SLNB) in early-stage breast cancer do not comment on the use of SLNB with CPM.2 Supporters of SLNB in CPM patients advocate that it eliminates the need for a delayed axillary lymph node dissection (AD) if an occult invasive cancer is discovered in the CPM specimen. In addition, SLNB may detect occult nodal disease that has metastasized from the index tumor. Pathology studies of prophylactic mastectomy specimens report a 3.5%–5% incidence of occult carcinoma.3–5 In patients who undergo bilateral dynamic contrast enhanced breast MRI to evaluate the extent of disease in the ipsilateral cancer breast, occult contralateral breast cancer is reported in 6.5%.6 We performed a retrospective study to determine if routine SLNB is clinically indicated in patients undergoing CPM.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Between 1999 and 2004, 155 patients at Magee-Womens Hospital of the University of Pittsburgh Medical Center underwent CPM and were included in the analysis. This study was approved by the institutional review board of the University of Pitts-burgh. The physical examination and radiographic evaluation of the contralateral breast was negative for all CPM patients. SLNB was performed during CPM at the discretion of the operating surgeon. Of the 155 CPM patients, 80 patients (Group 1) had SLNB and 75 patients did not have SLNB (Group 2). Lymphatic mapping was performed with dual filtered technetium-labeled sulfur colloid 450–495 µCi and lymphazurin blue dye in 76 patients (95%). Four patients underwent intra-operative lymphatic mapping using only blue dye.

The prophylactic mastectomy was performed either at the time of mastectomy for the known unilateral cancer or in a delayed fashion. Breast reconstruction and timing was performed at patients’ preference. The sentinel biopsy was performed through the mastectomy incision while the breast was intact but reflected laterally. The SLN was defined as any lymph node or nodes, which were either radioactive, blue, or palpable. All SLNs were excised and submitted for pathological evaluation with hematoxylin and eosin stains as well as cytokeratin immunohistochemical stains.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The median age of the patients was 47 years for all 155 CPM cases and it was 47.5 years in group 1 and 47 years in group 2 (Table 1Go). A family history of breast cancer was present in 52% of patients. Genetic testing for BRCA-1 and BRCA-2 mutation was performed on 17 patients and was positive for a mutation in 11 (65% of tested). The immediate CPM rate was the same and it was 85% in CPM patients with or without SLNB.


View this table:
[in this window]
[in a new window]

  		TABLE 1. Age, family history, genetic test result, timing of CPM and malignant histology of CPM patients
 
The majority of patients undergoing CPM (59%) had infiltrating ductal carcinoma as their index tumor with multicentricity or multifocality reported in 49.7% of the final pathology specimens (Table 2Go). The histopathology findings in the CPM specimens are reported in Table 3Go. Five occult carcinomas (3.2%), two invasive and three DCIS were identified in the CPM specimens. An additional 12.3% of specimens contained moderate- to high-risk pathology including atypical ductal or lobular hyperplasia or LCIS. The majority of the CPM specimens (56.1%) showed benign histology such as fibrocystic mastopathy, benign adenosis or adenomatoid nodules (Table 4Go)7 with no increased risk for malignancy according to Goldflam’s classification.


View this table:
[in this window]
[in a new window]

  		TABLE 2. Histopathological results of index tumor (n = 155)
 

View this table:
[in this window]
[in a new window]

  		TABLE 3. Histopathological results of CPM (n = 155)
 

View this table:
[in this window]
[in a new window]

  		TABLE 4. Histologic findings in the CPM according to Goldflam’s classification (Cancer 2004; 101; 1977–86)
 
The SLNB utilization increased steadily over the last 5 years; 14% of CPM patients underwent SLNB in 1999, but 85% of patients underwent SLNB with CPM in 2004 (Fig. 1Go). The mean number of SLN identified in the CPM axilla was 2.6 ± 1.3 (range 1–6). The median follow-up was 24 months (range 12–72). One patient developed a persistent axillary seroma requiring aspiration. There were no reports of lymphedema following CPM with SLNB.


Figure 1
View larger version (21K):
[in this window]
[in a new window]

  		FIG. 1. The contralateral prophylactic mastectomy with sentinel lymph node biopsy rate in the last 5 years at Magee-Womens Hospital.

 
Two patients in group 1 had metastatic carcinoma identified in the SLNB of the CPM and one of them underwent subsequent radiation therapy for her metastatic SLN. One of these patients had recurrent ipsilateral invasive breast cancer for which she was undergoing therapeutic completion mastectomy, and the other patient had been lately diagnosed of breast cancer with 24 positive LN and extracapsular involvement. The pathology report from the CPM showed no evidence of cancer on final pathology. The findings in the SLN were felt to represent metastasis from the recurrent carcinoma and not from occult cancer in the prophylactic mastectomy specimen.

Three cases of DCIS were diagnosed in CPM specimens; two were less than 1 cm in size while one was reported as multicentric. Two cases of occult invasive carcinoma; one invasive tubular carcinoma in group 1 and one invasive lobular carcinoma in group 2 were identified.

Overall, unexpected malignancy was identified in 7 out of 155 patients (4.5%) undergoing CPM: two SLNB were positive at axillary staging and five cancers were diagnosed in the CPM specimens, two invasive and three DCIS. Only 1 out of the 75 patients not undergoing SLNB at the time of their initial surgery would have required axillary staging for a previously undiagnosed invasive cancer in the CPM specimen on final pathology. Of all 155 patients undergoing CPM, only 4 (2.5%) had final pathologic findings where axillary staging with SLNB was beneficial.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Current indications for consideration of CPM as a risk-reducing procedure include high-risk patients with a strong family history of breast cancer, BRCA-1 or 2-gene mutation, personal history of atypia, LCIS, or personal diagnosis of breast cancer. Women who have a strong family history of breast cancer or germline BRCA-1 or BRCA-2 mutations have an increased risk of contralateral breast cancer (CBC).8–10 The Society of Surgical Oncology published a liberal position statement describing factors that might justify CPM at the time of ipsilateral mastectomy for breast cancer. These include the following: age less than 40, family history of bilateral breast cancer, lobular carcinoma in situ (LCIS) or atypical hyper-plasia, dense, nodular breasts or diffuse microcalcifications, and multiple breast biopsies.11 There also may be a cost benefit of surgery compared to long-term surveillance. Retrospective studies of bilateral prophylactic mastectomy in high-risk women report a reduction greater than 90% in subsequent breast cancer incidence and death.12 Prophylactic mastectomy has been shown to be effective in reducing the incidence of breast cancer in women with documented BRCA-1 or 2 gene mutations.13–15 As the use of genetic testing for breast cancer susceptibility increases, the number of women who consider the procedure also will likely increase.11,16–19

The reported frequency of CPM over the past three decades was 1.9–4.8% among all unilateral breast cancer patients and accounted for 2.2% of all mastectomies.2–4 At our institution, over the past 2 years, the total mastectomy rate was 30%. Our CPM rate is 7–10 times higher than literature during the last 8 years. (A total of 14–22% of patients had CPM among patients with mastectomy.) Our high rate of CPM could be related to patient self-selection. At an institution with high rates of breast conserving surgery, women who elect a therapeutic total mastectomy may have risk factors of personal preferences that lead them to also elect CPM. In addition, a large population of women is followed in our high-risk consultation service. Patients followed in the high-risk program who develop breast cancer are knowledgeable about their risk of future breast cancer events. When faced with a new diagnosis of breast cancer, long-term breast cancer prevention with bilateral mastectomies may be a relevant goal. The increase in CPM rate at our institution over the past 5 years reflects the increase in women followed in our high-risk program (Fig. 1Go).

Despite considerable controversy in the medical community, CPM remains a sought-after procedure among anxious patients with unilateral breast carcinoma who hope to reduce their risk of a contralateral breast cancer.20 Removal of a normal breast for prophylaxis is a more ablative surgical procedure than most women require for management of a screening detected early breast cancer. However, most patients requesting CPM stipulate a strong desire to avoid another breast cancer event and the treatment that entails. Informing a patient that a prophylactic mastectomy may have no impact on the overall survival from their ipsilateral cancer usually does not affect the decision for prophylactic surgery.10

It is reported that up to 5% of prophylactic mastectomy specimens harbor an occult breast cancer.4 The current MRI literature supports this incidence of occult contralateral disease.6,21 Goldflam et al. reported that 4.6% of 239 patients who underwent CPM were found to have occult contralateral malignancies.7 In the same study, the authors identified moderate to high-risk pathology (lobular carcinoma in situ, atypical lobular hyperplasia, atypical ductal hyperplasia) in 44 (18.4%) patients. Patients with a history of sporadic carcinoma in one breast have an estimated risk of 0.5–1.0% per year of developing a CBC. Significantly higher risks for CBC are present in those women who have a BRCA-1 or 2-gene mutation.10 In our study two invasive carcinomas (1.3%) were detected in the CPM speicmens and both axilla were negative for metasteses. We found 12.25% of patients had moderate- to high-risk pathology in their CPM specimens. The two patients with positive sentinel nodes identified on the side of the CPM were unique cases. One patient was diagnosed with recurrent invasive carcinoma 8 years ago after breast conserving therapy and prior axillary node dissection. It is well documented that recurrent ipsilateral breast cancer can metastasize to the contralateral axilla.22,23 It is reported that 89% (8/9) of the sentinel node specimens identified by isotope mapping were located in the contralateral axillae in patients undergoing completion mastectomy for locally recurrent breast cancer.23 The other patient had been lately diagnosed of breast cancer with 24 positive LN and extracapsular involvement. These clinical scenarios may represent an indication for considering SLNB at the time of CPM to detect occult nodal disease; however, it would not be viewed as a routine indication.

The need for routine SLNB in women undergoing CPM remains unclear. If a patient is discovered to have an occult invasive cancer in a CPM specimen and has not had a SLNB, the opportunity for an SLNB has been missed. Such patients require an axillary node dissection for staging to plan further treatment. An SLNB performed during a CPM may eliminate the need for ALND if occult invasive disease is detected. Once mastectomy is completed, the opportunity to go back to perform SLNB is lost as an option for axillary staging. The ability to accurately localize an SLN after total mastectomy is largely unknown. A small, single-institution, retrospective study has reported that the identification rate of SLN after previous mastectomy is 50% and after lumpectomy is 85%.24 Until larger prospective studies are reported, attempting SLNB after mastectomy should be viewed as experimental.

In prior studies, axillary dissection or SLNB had not been routinely performed in patients undergoing CPM.3,7,12,13,18 In our study, 51.6% of patients undergoing CPM had SLNB. The frequency of SLNB being performed in conjunction with CPM increased sixfold over the time period of this study. Dupont et al. reported 57 patients with SLNB performed at the time of CPM.5 Occult nodal disease was identified in two patients by immunohistochemical staining without an identifiable malignancy in the prophylactic breast. Two additional patients were found to have occult invasive carcinoma and were spared an axillary node dissection based on the finding of a negative sentinel node. The conclusion in the Dupont study was that 7% of patients benefited from the SLNB procedure. The identification of IHC positive-only SLN remains a clinical dilemma although may indicate a need for additional axillary node dissection. A finding of isolated tumor cells in the SLN of a prophylactic mastectomy specimens without a documented ipsilateral cancer raises more questions than it answers. Both patients with occult invasive breast cancer were found to have negative sentinel nodes suggesting that clinically occult disease may have a low risk of SLN metastasis. If the two patients with IHC-only positive nodes are excluded in Dupont’s study, only 3.5% of patients benefited from the SLN procedure.

In our study final pathology revealed unexpected malignancy in 7 patients out of 155 undergoing CPM (4.5%): two SLNB were positive at axillary staging and five cancers were diagnosed in the CPM specimens, two invasive and three DCIS. Of all 155 patients undergoing CPM, only 4 (2.5%) had identified final pathologic findings where axillary staging with SLNB was beneficial. If we exclude the patient who had a therapeutic mastectomy for recurrent cancer where one could argue that re-staging the recurrent cancer is indicated, only 3 out of 155 (2%) patients benefited from routine SLNB. A major advantage of SLNB is that it reduces, but does not eliminate, the incidence of lymphedema by decreasing the number of unnecessary ALND in patients who are pathologically node negative. Based on our results, the routine use of SLNB during CPM is not warranted.

Although there are complications and morbidities associated with SLNB, there is a higher rate of morbidity for axillary dissection such as greater risk of infection, lymphedema and decreased range of motion25–27. A major advantage of SLNB is that it may reduce the incidence of lymphedema by decreasing the number of unnecessary ALND in patients who are pathologically node negative. Potential morbidities from SLNB include: 3–7% rate of lympedema, 6–28% arm pain, sensory disorders/ parasthesia 0–25%, motion restriction 0–31%, impact on daily life activities 0–17%, 7% seroma formation, and 3% infection which were reported in SLNB only patients.28

By the year 2006, the estimated number of new breast cancer cases among females will be 214,640 in the USA. One may estimate that more than 3,000 women will undergo prophylactic mastectomies. If 2% of these patients benefit from routine SLNB, final treatment decision of approximately 60 patients might be affected if all patients would have undergone SLNB. Cost analysis demonstrated that adding SLNB to prophylactic mastectomy costs $644 per prophylactic mastectomy performed21. In other words, while SLNB allows the rare patient with occult cancer to avoid ALND, SLNB adds nearly $2,000,000 if all CPM patients undergo this procedure, and does not influence management in the vast majority of patients.

In conclusion, although SLNB is a minimally invasive method of axillary staging, this retrospective study does not support its routine use in patients undergoing CPM. Selective use of SLNB during CPM may be indicated, particularly for patients with recurrent invasive carcinoma who may harbor occult nodal metastases and patients who have more than 10 positive LN with extracapsular involvement.

Received for publication July 27, 2006. Accepted for publication October 4, 2006.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. http://www.cancer.org/downloads/stt/CAFF06EsCsMc.pdf.
  2. Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005; 23:7703–20.[Abstract/Free Full Text]
  3. Peralta EA, Ellenhorn JD, Wagman LD, et al. Contralateral prophylactic mastectomy improves the outcome of selected patients undergoing mastectomy for breast cancer. Am J Surg 2000; 180:439–45.[CrossRef][Medline]
  4. Boughey, JC, Khakpour N, Meric-Bernstam F, et al. Routine use of sentinel lymph node surgery in prophylactic mastectomy is not warranted. Ann Surg Oncol (Suppl) 2006; 13:P64, page 53.
  5. Dupont EL, Kuhn MA, McCann C, et al. The role of sentinel lymph node biopsy in women undergoing prophylactic mastectomy. Am J Surg 2000; 180:274–7.[CrossRef][Medline]
  6. Cripe MH, Lehr A, Beran L, Liang W, Sickle-Santanello B. Incidence of occult contralateral breast cancer detected by magnetic resonance imaging. Ann Surg Oncol (Suppl) 2006; 13:26,P195, page 90.
  7. Goldflam K, Hunt KK, Gershenwald JE, Singletary SE, Mirza N, Kuerer HM, Babiera GV, Ames FC, Ross MI, Feig BW, Sahin AA, Arun B, Meric-Bernstam F. Contralateral prophylactic mastectomy. Predictors of significant histologic findings. Cancer 2004; 101:1977–86.[CrossRef][Medline]
  8. Ford D, Easton DF, Stratton M, et al. Genetic heterogeneity and penetrance analysis of the BRCA1 and BRCA2 genes in breast cancer families. The Breast Cancer Linkage Consortium. Am J Hum Genet 1998; 62:676–89.[CrossRef][Medline]
  9. Struewing JP, Hartge P, Wacholder S, et al. The risk of cancer associated with specific mutations of BRCA1 and BRCA2 among Ashkenazi Jews. N Engl J Med 1997; 336:1401–8.[Abstract/Free Full Text]
  10. Scott CI, Iorgulescu DG, Thorne HJ, Henderson MA, Phillips KA. Clinical, pathological and genetic features of women at high familial risk of breast cancer undergoing prophylactic mastectomy. Clin Genet 2003; 64:111–21.[CrossRef][Medline]
  11. Bilimoria M, Morrow M. The woman at increased risk for breast cancer: evaluation and management strategies. CA Cancer J Clin 1995; 45:263–78.[Abstract]
  12. Hartmann LC, Schnaid DJ, Woods JE, Crotty TP, Myers JL, Arnold PG, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999; 340:77–84.[Abstract/Free Full Text]
  13. Kroll SS, Miller M, Schusterman M, et al. Rationale for elective contralateral mastectomy with immediate bilateral reconstruction. Ann Surg Oncol 1994; 1:457–61.[Abstract]
  14. Barone JE, Tucker JB, Perez JM, Odom SR, Ghevariya V. Evidence-based medicine applied to sentinel lymph node biopsy in patients with breast cancer. Am Surg 2005; 71:66–70.[Medline]
  15. Mamounas EP, Brown A, Anderson S, et al. Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol. B-27. JCO 2005; 23:2694–702.[Abstract/Free Full Text]
  16. Rebbeck TR, Friebel T, Lynch HT, Neuhausen SL, van’t Veer L, Garber JE, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE Study Group. J Clin Oncol 2004; 22:1055–62.[Abstract/Free Full Text]
  17. Meijers-Heijboer H, van Geel B, van Putten WL, Henzen-Logmans SC, Seynaeve C, Menke-Pluymers MB, et al. Breast cancer after prophylactic bilateral mastectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med 2001; 345:159–64.[Abstract/Free Full Text]
  18. Geiger AM, Yu O, Herrinton LJ, Barlow WE, Harris EL, Rolnick S, et al. A population-based study of bilateral prophylactic mastectomy efficacy in women at elevated risk for breast cancer in community practices. Arch Intern Med 2005; 165:516–20.[Abstract/Free Full Text]
  19. Meijers-Heijboer H, Brekelmans CT, Menke-Pluymers M, Seynaeve C, Baalbergen A, Burger C, et al. Use of genetic testing and prophylactic mastectomy and oophorectomy in women with breast or ovarian cancer from families with a BRCA1 or BRCA2 mutation. J Clin Oncol 2003; 21:1675–81.[Abstract/Free Full Text]
  20. Kern KA, Borgen P, Mamounas EP, McMasters KM, Singletary E. Contemporary surgery 2005; 6:63–72.
  21. Lee JM, Dominguez F, Gadd M, et al. Detecting occult breast cancer in prophylactic mastectomies: sentinel node biopsy vs preoperative MRI. Ann Surg Oncol 2006; (Suppl) 13–26, P26, page 9.
  22. Sood A, Youssef IM, Heiba SI, et al. Alternative lymphatic pathway after previous axillary node dissection in recurrent/ primary breast cancer. Clin Nucl Med 2004; 29:698–702.[CrossRef][Medline]
  23. Newman EA, Cimmino VM, Sabel MS, et al. Lymphatic mapping and sentinel lymph node biopsy for patients with local recurrence after breast-conservation therapy. Ann Surg Oncol 2006; 13:52–7.[Abstract/Free Full Text]
  24. Port ER, Fey J, Gemignani ML, et al. Reoperative sentinel lymph node biopsy: a new option for patients with primary or locally recurrent breast carcinoma. J Am Coll Surg 2002; 195:167–72.[CrossRef][Medline]
  25. Bass SS, Cox CE, Ku NN, Reintgen DS. The role of sentinel lymph node biopsy in breast cancer. J Am Coll Surg 1999; 189:183–94.[CrossRef][Medline]
  26. Cody HS. Management of the axilla in early stage breast cancer: will sentinel node biopsy end the debate? J Surg Oncol 1999; 71:137–39.[CrossRef][Medline]
  27. Cox CE, Bass SS, McCann CR, et al. Lymphatic mapping and sentinel node biopsy in patients with breast cancer. Annu Rev Med 2000; 51:525–42.[CrossRef][Medline]
  28. Leidenius M, Leivonen M, Vironen J, von Smitten K. The consequences of long-time arm morbidity in node-negative breast cancer patients with sentinel node biopsy or axillary clearance. J Surg Oncol 2005; 92:23–31.[CrossRef][Medline]



This article has been cited by other articles:


Home page
 Ann. Surg. Oncol.Home page
J. V. Kiluk, A. A. Santillan, P. Kaur, C. Laronga, T. Meade, D. Ramos, and C. E. Cox
Feasibility of Sentinel Lymph Node Biopsy Through an Inframammary Incision for a Nipple-Sparing Mastectomy
Ann. Surg. Oncol., December 1, 2008; 15(12): 3402 - 3406.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Soran, A.
Right arrow Articles by Johnson, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Soran, A.
Right arrow Articles by Johnson, R.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS