Original Paper
Tagging sentinel lymph nodes: a study of 100 patients with breast cancer

https://doi.org/10.1016/S0959-8049(99)00009-XGet rights and content

Abstract

The aim of this study was to evaluate in breast cancer patients the feasibility of sentinel lymph node (SLN) identification and the sensitivity of this technique to detect node metastases. Between January and July 1997, SLNs were tracked with Evans Blue dye in 100 patients with breast cancer who then underwent complete level I/II axillary lymph node dissection (ALND). All SLNs were examined by haematoxylin–phloxin–saffron (HPS) staining and immunohistochemistry (IHC) of multiple sections. The findings for the SLNs were compared with results on ANLD. Axillary SLNs were identified in 83 patients (detection rate=83%; 95% confidence interval (CI) 74–90%). Axillary SLNs were detected in 58/83 cases (70%) at level I only, and in 69/83 (83%) at levels including level I. Histologically positive axillary SLNs were found in 45% (37/83) of patients, including 2 patients with malignancy (micrometastases) detected by IHC only. The sensitivity of axillary SLN to detect axillary lymph nodes metastases was 37/39=95% (95% CI 83–99%). SLNs of the internal mammary chain (IMC) were dissected for 33 tumours of the median or inner quadrants and detected in 26/33=79% of cases (95% CI 61–91%). In our experience, the overall sensitivity of SLN identification as a predictor of node (axillary or IMC) metastases was 41/43=95% (95% CI 84–99%), confirming the usefulness of the procedure.

Introduction

Axillary lymph node dissection (ALND) is central to staging operable breast cancer, affording regional control of disease, establishing a prognosis, and identifying those patients who might benefit from adjuvant therapy and especially from intensified chemotherapy1, 2, 3, 4. The practice is nevertheless considered controversial. Indeed, it has yet to be definitively established whether early breast cancer is a local disease or not[4]. Over 90% of patients with small (<1 cm) tumours treated by breast-conserving surgery, ALND and radiotherapy have a disease-free survival of at least 10 years[5]. However, according to the National Cancer Institute's 1988 Clinical Alert[6]and the recent results of NSABP trials7, 8, 9, all patients should be prescribed systemic adjuvant therapy regardless of nodal status. This obviates the need for an ALND and means that patients who, on ALND, are node-negative, would nevertheless receive such adjuvant treatment10, 11, 12. Furthermore, with the expansion of mass screening programmes, more and more patients are being treated for infraclinical lesions where the risk of metastatic nodal involvement is less than 20%13, 14, 15. In such cases, ALND becomes unacceptable because of its associated morbidity16, 17, 18.

Clearly, therefore, there is a need to reappraise the role of systematic ALND in clinically node-negative breast cancer19, 20, 21and to develop a reliable and non-invasive surgical technique with minimal morbidity for tumour staging that will identify pN1 cases requiring ALND. One such technique is intra-operative tagging of the first nodes with a high risk of metastases, the sentinel lymph nodes (SLNs), that was pioneered by Morton and colleagues[22]for stage I melanoma and transposed by Giuliano and colleagues to breast cancer[23]. It rests on the hypothesis that if the first node(s) tagged by dye injected around the primary tumour is (are) negative, then the risk of metastases elsewhere is close to nil. SLN identification avoids depriving a patient with positive nodes of an ALND, whilst sparing patients with negative nodes.

We report here our results on the feasibility of SLN detection and its sensitivity in forecasting node involvement in a series of 100 patients with breast cancer. We focus, in particular, on SLNs of the internal mammary chain for inner quadrant and median tumours.

Section snippets

Patients and methods

From January to July 1997, 100 patients (median age 50.5 years; range, 30–82) with breast cancer, in whom either mastectomy or lumpectomy was indicated, underwent sentinel lymph node (SLN) biopsy followed immediately by standard level I and II axillary lymph node dissection (ALND). Patients with in situ multicentric or multifocal cancers, or who had relapsed after previous breast conservative surgery were excluded. 16 patients with inflammatory cancers received neoadjuvant chemotherapy after

Description of patient population

The clinical characteristics of patients and tumours are given in Table 1. All 100 patients underwent an investigation for SLNs, then a complete ALND. The IMC was dissected in 33 patients. Overall, 42 patients had pathologically confirmed invaded axillary lymph nodes (pN1) and, in 6 of them, metastatic spread had already been noted on clinical examination.The mean number of excised nodes (SLNs and ALND) was 14 (range 2–31) for axillary nodes and 3 (range 1–6) for IMC nodes.

Tumours were pT1 (≤2 

Discussion

These results on axillary SLN detection compare favourably with those in the literature23, 24, 25, 26.

The overall sensitivity of our method (which used Evans Blue dye) for axillary nodal status was 95% (37/39) and 94% (31/33) on exclusion of the 6 patients with clinically N1 tumours. In comparison, Giuliano and colleagues in their study using Isosulfan Blue dye identified axillary SLNs in 93.5% of patients and Veronesi and colleagues, using a radioisotope, in 98% (160/163). The slight

Acknowledgements

We thank the Comité de la Ligue contre le Cancer de Haute Savoie (French Anti-Cancer Ligue) for their support.

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