Elsevier

The Lancet

Volume 349, Issue 9069, 28 June 1997, Pages 1864-1867
The Lancet

Articles
Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes

https://doi.org/10.1016/S0140-6736(97)01004-0Get rights and content

Summary

Background

Axillary lymph-node dissection is an important staging procedure in the surgical treatment of breast cancer. However, early diagnosis has led to increasing numbers of dissections in which axillary nodes are free of disease. This raises questions about the need for the procedure. We carried out a study to assess, first, whether a single axillary lymph node (sentinel node) initially receives malignant cells from a breast carcinoma and, second, whether a clear sentinel node reliably forecasts a disease-free axilla.

Methods

In a consecutive series of 163 women with operable breast carcinoma, we injected microcolloidal particles of human serum albumin labelled with technetium-99m. This tracer was injected subdermally, close to the tumour site, on the day before surgery, and scintigraphic images of the axilla and breast were taken 10 min, 30 min, and 3 h later. A mark was placed on the skin over the site of the radioactive node (sentinel node). During breast surgery, a hand-held γ-ray detector probe was used to locate the sentinel node, and make possible its separate removal via a small axillary incision. Complete axillary lymphadenectomy was then done. The sentinel node was tagged separately from other nodes. Permanent sections of all removed nodes were prepared for pathological examination.

Findings

From the sentinel node, we could accurately predict axillary lymph-node status in 156 (97·5%) of the 160 patients in whom a sentinel node was identified, and in all cases (45 patients) with tumours less than 1·5 cm in diameter. In 32 (38%) of the 85 cases with metastatic axillary nodes, the only positive node was the sentinel node.

Interpretation

In the large majority of patients with breast cancer, lymphoscintigraphy and γ-probe-guided surgery can be used to locate the sentinel node in the axilla, and thereby provide important information about the status of axillary nodes. Patients without clinical involvement of the axilla should undergo sentinel-node biopsy routinely, and may be spared complete axillary dissection when the sentinel node is disease-free.

Introduction

Axillary lymph nodes are the commonest site of metastasis in breast carcinoma. Metastatic involvement of the axilla is known to progress regularly, from the first, via the second, to the third axillary level; skip metastases are found in roughly 2% of cases only.1, 2

Axillary-node status is one of the most important prognostic indicators in breast cancer, and of particular value in the choice of adjuvant therapy.3, 4 The prognostic information is gained from histological examination of all or most axillary nodes; the treatment of operable breast carcinoma almost always involves lymph-node dissection.5 However, if a non-invasive or minimally invasive diagnostic procedure could provide accurate preoperative staging of the axilla, axillary dissection could be avoided in patients with no involved nodes. Sentinel-node biopsy has been developed for this purpose. The technique was first used by Morton and colleagues with blue dye,6, 7 and later by van der Veen and colleagues8 with lymphoscintigraphy to select melanoma patients for regional node dissection. These researchers showed that early metastasis of melanoma almost always occurs in the first node, or sentinel node, to receive lymph from the area containing the primary tumour. In breast cancer, cells that detach from the primary tumour are likely to arrive at, and be held by, the first node to receive lymph from the involved breast area. If this sentinel node can be reliably identified, and if careful examination reveals no cancer cells, the other axillary nodes should also be clear.

In most previous investigations of the sentinel node, blue dye was injected into the peritumoral area, and the coloured node was sought through axillary incision.9 A few studies on small series of patients used the lymphoscintigraphic technique.10, 11 The validity of the sentinel-node strategy has thus been established in breast cancer.

We designed this study to assess the value of sentinel-node biopsy in breast cancer by means of a lymphoscintigraphic technique and, in particular, a γ-ray detection probe to facilitate identification and dissection of the lymph node. We had three objectives: first, to assess the reliability of external-body lymphoscintigraphy for identification of the node that receives lymph from the region of the primary carcinoma; second, to assess the usefulness of a γ-ray detection probe in identification and removal of the sentinel node during axillary surgery; and, third, to measure, by histological analysis of all axillary nodes, the extent to which the sentinel node is a predictor of axillary-node status.

Section snippets

Patients

We studied 163 consecutive patients with operable breast carcinoma (T1-T3) scheduled to receive axillary dissection at the European Institute of Oncology, from March to December, 1996. We excluded pregnant or lactating women, those who had previously undergone biopsy or received radiotherapy to the breast. Patients with clinically extensive metastatic involvement were also excluded, as were those with tumours shown to be non-infiltrating on histological examination. Patients with carcinomas of

Results

The status of the axillary nodes correlated with several pathological variables (table 2). The most important predictive factor was peritumoral vascular invasion.

Discussion

We found radioguided resection of sentinel nodes in breast cancer simple and effective. Lymphoscintigraphy revealed the first lymph node within 30 min in most cases, and this node was the most radioactive in later scans in all cases. In 104 cases, one lymph node was identified by the probe and removed, 41 cases had two lymph nodes identified, and, 15, three nodes.

An incision of 2–3 cm was sufficient to permit removal of the sentinel node; this process was made much easier by use of the probe

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