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Clinical practice guidelines for the care and treatment of breast cancer: 13. Sentinel lymph node biopsy

Dr. Cantin is Associate Professor at the University of Montreal and is with the Centre hospitalier de l'Université de Montréal, Montreal, Que.; Dr. Scarth is Assistant Professor, Department of Surgery, Dalhousie University, and is with the Atlantic Health Sciences Corporation, Saint John, NB; Dr. Levine is Professor in the Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffet Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont.; and Dr. Hugi is with Providence Health Care, Vancouver, BC.Members (and nominating organizations) of the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer Chair: Dr. Mark Levine (Cancer Care Ontario), Hamilton Regional Cancer Centre and McMaster University, Hamilton, Ont. Members: Dr. David M. Bowman (Manitoba Cancer Treatment and Research Foundation), Manitoba Cancer Treatment and Research Foundation, Winnipeg, Man.; Dr. Judy Caines (Federal/Provincial/Territorial Advisory Committee on Health Services), Nova Scotia Cancer Centre, Halifax, NS; Dr. Jacques Cantin (Royal College of Physicians and Surgeons of Canada), Centre hospitalier de l'Université de Montréal, Montreal, Que.; Ms. Chris Emery (Canadian Nurses Association), BC Cancer Agency, Delta, BC; Dr. Eva Grunfeld (College of Family Physicians of Canada), Ottawa Regional Cancer Centre, Ottawa, Ont.; Dr. Maria R. Hugi (Canadian Breast Cancer Network), Providence Health Care, Vancouver, BC; Dr. Alan W. Lees (Alberta Cancer Board), Cross Cancer Institute, Edmongon, Alta.; Ms. Sabina Mallard (Canadian Breast Cancer Network), consumer representative, Stratford, PEI; Dr. Mohamed Mohamed (Saskatchewan Cancer Foundation), Saskatoon Cancer Centre, Saskatoon, Sask.; Dr. Ivo A. Olivotto (BC Cancer Agency), Vancouver Island Cancer Centre and University of British Columbia, Victoria, BC; Dr. Leonard Reyno (Cancer Care Nova Scotia), Nova Scotia Cancer Centre, Halifax, NS; Dr. Carol Sawka (Cancer Care Ontario), Toronto Sunnybrook Regional Cancer Centre, Toronto, Ont.; Dr. Hugh Scarth (Atlantic Health Sciences Corporation), Saint John Regional Hospital, Saint John, NB; Ms. Donna Seymour (Health Canada), Adult Health Division, Centre for Chronic Disease and Control, Health Canada, Ottawa, Ont.; Dr. S. Kishore Thain (Newfoundland Cancer Treatment and Research Foundation), Dr. H.B. Murphy Cancer Centre, St. John's, Nfld.; Dr. Timothy Whelan (Cancer Care Ontario), Hamilton Regional Cancer Centre and McMaster University, Hamilton, Ont.; and, at the time of writing, Dr. Jean Deschênes (Comité consultatif sur le cancer du Québec), Jewish General Hospital, Quebec, Que.; Dr. L. Arthur Firth (Saskatchewan Cancer Foundation), Allan Blair Cancer Centre, Regina, Sask.; Dr. Maureen C. Nolan (Cancer Treatment and Research Foundation of Nova Scotia), Nova Scotia Cancer Centre, Halifax, NS; and Dr. John W. Sellors (College of Family Physicians of Canada), McMaster University, Hamilton, Ont.

Correspondence to: Dr. Mark Levine, c/o Ms. Humaira Khan, Faculty of Health Sciences, McMaster University Health Sciences Centre, Rm. 2C6, 1200 Main St. W, Hamilton ON L8N 3Z5; fax 905 577-0017.

Objective: To provide information and recommendations to women with breast cancer and their physicians regarding what is now known about sentinel lymph node (SLN) biopsy.

Options: Axillary dissection; SLN biopsy followed by backup axillary dissection; SLN biopsy.

Outcomes: Accurate determination of cancer stage, resulting in better-informed therapeutic decisions.

Evidence: Systematic review of English-language literature published from January 1991 to December 2000 retrieved primarily from MEDLINE and CANCERLIT.

Recommendations: · Axillary dissection is the standard of care for the surgical staging of operable breast cancer. · If a patient requests or is offered SLN biopsy, the benefits and risks as well as what is and is not known about the procedure should be outlined. · Patients should be informed of the number of SLN biopsies performed by the surgeon and the surgeon's success rate with the procedure, as determined by the identification of the SLN and the false-negative rate (the presence of tumour cells in the axillary nodes when the SLN biopsy result is negative). · Before surgeons replace axillary dissection by SLN biopsy as the staging procedure at their institution, they should (a) familiarize themselves with the literature on the topic and the techniques needed to perform the procedure, (b) follow a defined protocol for all 3 aspects of the procedure (nuclear medicine, surgery, pathology) and (c) perform backup axillary dissection until an acceptable success rate (as determined by the identification of the SLN and the false-negative rate) is achieved. · A surgeon who performs breast cancer surgery infrequently should not perform SLN biopsy. · A positive SLN biopsy result or failure to identify an SLN should prompt full axillary dissection. · SLN biopsy is contraindicated in women who have clinically palpable nodes, locally advanced breast cancer, multifocal tumours, previous breast surgery or previous irradiation of the breast. · Staining of tissue sections with hematoxylin and eosin, and not immunohistochemical analysis for cytokeratin, should determine adjuvant therapy. · Participation in randomized clinical trials is encouraged. [A patient version of these guidelines appears in Appendix 1.]

Validation: Internal validation within the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer; no external validation.

Sponsor: The steering committee was convened by Health Canada.

Completion date: Apr. 9, 2001.

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