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Editorial |
Department of Surgical Oncology, Unit 444, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
Correspondence: Address correspondence and reprint requests to: Henry Mark Kuerer, MD, PhD, FACS; E-mail: hkuerer{at}mdanderson.org
I can not remember the last time I went to the barber and did not get a haircut. After all, you go to a barber—you get a haircut. You go to a surgeon doing breast surgery and you get a sentinel lymph node (SLN) biopsy? We are not barbers ladies and gentleman, and not every patient undergoing breast surgery should receive a SLN biopsy. The list of reasons to do a SLN biopsy seems to be endless: if you have ductal carcinoma in situ (DCIS), if you have a chance on an excisional biopsy that there might be cancer, if you had a preneoadjuvant chemotherapy SLN biopsy that showed metastases, if you are receiving prophylactic mastectomy, if you have an in-breast cancer recurrence, and even if you have a clinically palpable axillary lymph node before surgery.1–6
The 1–2% of patients treated for DCIS who eventually die of metastatic breast cancer do not die from DCIS; they die from missed invasive carcinoma in the primary breast tissue that was removed.3 Of all comers with DCIS, only about 3% will, indeed, have evidence of micrometastases; and the clinical significance of these cells in patients without invasive breast cancer detected in the primary breast specimen remains to be determined.7
About 20–25% of patients with DCIS diagnosed with a core biopsy will be found to also harbor an invasive component when the lesion is completely excised.3 If an invasive component is identified in the segmental resection specimen, a SLN biopsy can be offered to the patient as a second procedure for staging information (rather than performing SLN biopsy in 75–80% of patients who would not benefit from such a procedure). Looking at M. D. Anderson Cancer Center’s early experience with SLN biopsy for DCIS, we identified several independent risk factors for finding occult invasive carcinoma when the initial core biopsy showed DCIS.3 These factors included: age 55 or younger [odds ratio (OR) 2.19; p = 0.024], diagnosis by core-needle biopsy (OR 3.76; p = 0.006), mammographic DCIS size of at least 4 cm (OR 2.92; p = 0.001), and high-grade DCIS (OR 3.06; p = 0.002). However, none of these factors were sufficiently discriminatory to select a majority of patients who might benefit from a SLN biopsy. Based on these findings, patients at M. D. Anderson Cancer Center with a diagnosis of DCIS who are scheduled to undergo mastectomy are offered SLN biopsy as part of their initial surgical management: patients in this situation would necessitate an axillary dissection for appropriate staging information if an invasive component was subsequently identified within the specimen.
The beauty and art of SLN biopsy is the fact that it selects patients who may benefit from more extensive surgery and spares the majority of patients with an invasive breast cancer and a clinically normal axilla the sometimes debilitating morbidity associated with complete axillary lymph node dissection. Let us not perform a relatively less morbid procedure in every one of our patients just because we can. If this is to occur, our patients lose, and our years of painstaking training are worth nothing more or less than training to become a barber.
Received for publication March 28, 2006. Accepted for publication June 5, 2006.
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