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Expanding Indications for Lymphatic Mapping and Sentinel Lymph Node Biopsy in the Breast Cancer Population

From the H. Lee Moffitt Cancer Center, University of South Florida, Tampa, Florida.

Correspondence: Address correspondence to: Douglas S. Reintgen, MD, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612; Fax: 813-979-7211; E-mail: reinrgds{at}moffitt.usf.edu

In this issue of Annals of Surgical Oncology, investigators from the John Wayne Cancer Institute¹ report on their success in performing lymphatic mapping in breast cancer patients with large (5 cm) tumors. Forty-one patients were "selected" for the study based on the size of the tumor (presumably determined on pathology exam after the surgical procedure) and whether the patients received a sentinel lymph node (SLN) biopsy followed immediately by an axillary lymph node dissection(ALND). One always is concerned about interpreting results from a "selected" population, but one of the strengths of the study is the fact that all the patients received an immediate ALND after the SLN was harvested. In this way, the "skip metastases" rate or false-negative SLN biopsy rate could be ascertained immediately.

Thirty of 41 women had positive SLNs for a metastatic rate equal to 73%. One would question whether this procedure should be performed in patients with large tumors, because most of the patients will have a positive SLN and will need a second trip to the operating room with a second anesthesia for a level I and II axillary node dissection. Can SLN procedures be justified when most of the patients will need a second procedure? I would agree with the authors and suggest that this approach is justifiable. Twenty-seven percent of the patients will be spared the morbidity of a level I and II node dissection, which can be substantial. In our series from Moffitt Cancer Center, 40% of women who undergo the standard level I and II node dissection develop some degree of acute lymphedema (that is if you actually measure the arm differences during the postoperative period), and in 5% of women the arm swelling will be chronic, persistent, and a significant problem. In addition, intraoperative techniques have been developed to determine the status of the SLN, such as touch preparation cytology, intraoperative immunohistochemical staining, and frozen section analysis. With these advanced histologic procedures, 50% of women with metastatic disease in their SLN can have that determination made intraoperatively. These patients can then be converted to a level I and II node dissection and spared a second procedure.

By inference, the analysis also addresses the use of this staging procedure in patients who will undergo neoadjuvant therapy. The article would seem to support performing the mapping procedure before chemotherapy treatment. This would allow the axilla to be staged accurately. Neoadjuvant chemotherapy may clear the axilla of disease in up to 23% of patients, may cause fibrosis of the afferent lymphatics thereby increasing the technical failure rate of lymphatic mapping, and may cause a differential response of the metastatic disease in the SLN versus non-SLNs. In addition, if the initial SLN biopsy before the neoadjuvant therapy is negative, the patient can be more confidently spared a level I and II node dissection after the neoadjuvant therapy.

Investigators at the John Wayne Cancer Institute were the pioneers in developing the vital blue dye method of lymphatic mapping. This technique has changed the standard of care for patients with melanoma, will soon do so for all types and sizes of breast cancers, and will continue to be applied to other solid tumors as the surgical nodal staging procedure of choice.

Received for publication July 30, 2001. Accepted for publication August 3, 2001.

REFERENCES

1. Chung MH, Ye W, Giuliano AE. Role for sentinel lymph node dissection in the management of large (5 cm) invasive breast cancer. Ann Surg Oncol 2001; 8: 688–92.[Abstract/Free Full Text]

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