Is a completion axillary dissection indicated for micrometastases in the sentinel lymph node?

Presented at the Second Annual Meeting of the American Society of Breast Surgeons, La Jolla, California, May 3–6, 2001.
https://doi.org/10.1016/S0002-9610(01)00738-3Get rights and content

Abstract

Objective: The purpose of this study is to determine if a completion axillary dissection (CAD) is necessary when microscopic metastasis (<2 mm) is detected in the sentinel lymph node (SLN) of patients diagnosed with breast cancer.

Methods: A retrospective chart review was performed on 227 consecutive breast cancer patients who underwent SLN mapping (SLNM) between June 1998 and March 2001. These patients underwent intraoperative lymphatic mapping with peritumoral injections of blue dye alone or in combination with technetium-labeled sulfur colloid. The SLN was assessed by touch preparation or frozen section at the time of surgery, and later, by hematoxylin and eosin stain. Patients in whom the SLN showed evidence of metastatic disease on frozen section underwent immediate CAD.

Results: One patient was excluded because of inability to identify the SLN. Of the 226 patients in whom SLNM was successful, 67 (27%) had macrometastasis in the SLN, and a completion CAD was performed. Thirty-four of these 67 patients (51%) had additional disease in the axilla. A total of 15 patients (6.7%) was determined to have micrometastasis. In 11 patients, micrometastasis was identified and CAD was performed with no further evidence of disease. The 4 patients diagnosed with micrometastatic disease on permanent staining did not have further surgical intervention. The 15 patients identified with micrometastasis show no evidence of local recurrence to date, with a mean follow-up of 13.5 months (range 1 to 27).

Conclusions: This study suggests that CAD may not be necessary for the subset of breast cancer patients with micrometastasis detected upon SLNM. A larger randomized prospective study with long-term follow up is necessary to confirm these data.

Section snippets

Methods

Between June 1998 and March 2001, 227 breast cancer patients underwent SLNM at Grant Medical Center. Their charts were retrospectively reviewed for this study. All surgeries were performed by two fellowship trained surgical oncologists (BJSS, TAN) who had completed SLNM courses at the National Cancer Institute. Patients with palpable lymphadenopathy or neoadjuvant chemotherapy were excluded. All patients underwent intraparenchymal injection of 5 cc 1% isosulfan blue dye (Lymphazurin; U.S.

Results

Over a 33-month period, 227 patients were identified as candidates for SLNM at Grant Medical Center. One patient was excluded from this study owing to inability to identify the SLN. In the 226 remaining patients, 82 (36%) were found to have metastatic disease in the SLN. Of these patients, 15 (6.7%) had microscopic metastasis. The tumor histology of the 15 patients with micrometastatic disease in the SLN was as follows: 13 invasive ductal carcinoma, 1 invasive lobular carcinoma, and 1 mucinous

Comments

As SLNM evolves into the gold standard in the staging of breast cancer patients, many issues need to be addressed: optimal technique, learning curve, accuracy in neoadjuvant patients, accuracy in patients with previous breast or axillary surgery, reliability in repeat SLNM, and, of course, the need for CAD. Small tumor size and micrometastatic disease in the axilla may be able to predict the negative status of non-SLNs and avoidance of CAD [1], [2], [3].

Micrometastasis in the SLN has been

Conclusion

Micrometastases in the SLN is an issue that warrants further investigation as SLNM evolves into the standard of care for breast cancer management. Standardizations in techniques, definition, histologic staining, and pathologic reporting will need to be in place for the data to be of value.

This study suggests that micrometastasis in the SLN may be the sole site of disease in the axilla. Other studies have confirmed this finding, especially in the presence of small primary tumors and in the

References (14)

  • I.A Nasser et al.

    Occult axillary lymph node metastases in “node negative” breast carcinoma

    Human Pathol

    (1993)
  • C Reynolds et al.

    Sentinel lymph node biopsy with metastasiscan axillary dissection be avoided in some patients with breast cancer?

    J Clin Oncol

    (1999)
  • K Chu et al.

    Do all patients with sentinel node metastasis from breast carcinoma need complete axillary node dissection?

    Ann Surg

    (1999)
  • M.R Weiser et al.

    Lymphovascular invasion enhances the prediction of non-sentinel node metastases in breast cancer patients with positive sentinel nodes

    Ann Surg Oncol

    (2000)
  • A.G Huvos et al.

    Significance of axillary macrometastases and micrometastases in mammary cancer

    Ann Surg

    (1971)
  • F.D Rahusen et al.

    Letter

    Ann Surg

    (2000)
  • R.B Black et al.

    The search of occult metastases in breast cancerdoes it add to established staging methods?

    Aust NZ J Surg

    (1980)
There are more references available in the full text version of this article.

Cited by (0)

View full text