Practical guidelines for optimal gamma probe detection of sentinel lymph nodes in breast cancer: Results of a multi-institutional study

doi:10.1067/msy.2000.108064

Surgery

Volume 128, Issue 2, August 2000, Pages 139-144

Presented at the 61st Annual Meeting of the Society of University Surgeons, Toronto, Ontario, Canada, February 10-12, 2000.

https://doi.org/10.1067/msy.2000.108064 Get rights and content

Abstract

Introduction: Multiple radioactive lymph nodes are often removed during the course of sentinel lymph node (SLN) biopsy for breast cancer when both blue dye and radioactive colloid injection are used. Some of the less radioactive lymph nodes are second echelon nodes, not true SLNs. The purpose of this analysis was to determine whether harvesting these less radioactive nodes, in addition to the “hottest” SLNs, reduces the false-negative rate. Methods: Patients were enrolled in this multicenter (121 surgeons) prospective, institutional review board–approved study after informed consent was obtained. Patients with clinical stage T1-2, N0, M0 invasive breast cancer were eligible. This analysis includes all patients who underwent axillary SLN biopsy with the use of an injection of both isosulfan blue dye and radioactive colloid. The protocol specified that all blue nodes and all nodes with 10% or more of the ex vivo count of the hottest node should be removed and designated SLNs. All patients underwent completion level I/II axillary dissection. Results: SLNs were identified in 672 of 758 patients (89%). Of the patients with SLNs identified, 403 patients (60%) had more than 1 SLN removed (mean, 1.96 SLN/patient) and 207 patients (31%) had nodal metastases. The use of filtered or unfiltered technetium sulfur colloid had no impact on the number of SLNs identified. Overall, 33% of histologically positive SLNs had no evidence of blue dye staining. Of those patients with multiple SLNs removed, histologically positive SLNs were found in 130 patients. In 15 of these 130 patients (11.5%), the hottest SLN was negative when a less radioactive node was positive for tumor. If only the hottest node had been removed, the false-negative rate would have been 13.0% versus 5.8% when all nodes with 10% or more of the ex vivo count of the hottest node were removed (P =.01). Conclusions: These data support the policy that all blue nodes and all nodes with 10% or more of the ex vivo count of the hottest SLN should be harvested for optimal nodal staging. (Surgery 2000;128:139-44.)

Section snippets

Methods

Patients were enrolled in the University of Louisville Breast Cancer Sentinel Lymph Node Study, a prospective multicenter (121 surgeons) study, between August 1997 and August 1999. The study was approved by the institutional review board at each institution. Patients with biopsy-proven clinical stage T1-2, N0, M0 invasive breast cancer were eligible. Some patients with T3 tumors were included; the tumors of these patients were clinically staged as T2 N0 tumors, but after the operation the tumor

Results

The clinicopathologic characteristics of the patients who entered into the study are shown in Table I.

. Clinicopathologic characteristics of the study population

Variable	No. of patients (%)
Age (y)
<50	170 (22)
>50	588 (78)
T stage
T1	541 (71)
T2	196 (26)
T3	21 (3)
Location
Upper outer quadrant	395 (52)
Upper inner quadrant	120 (16)
Lower outer quadrant	95 (13)
Lower inner quadrant	51 (7)
Central	97 (12)
Pathologic feature
Infiltrating ductal	649 (85)
Infiltrating lobular	82 (11)
Other	26 (4)
Type of surgery
Mastectomy	249 (33)

Discussion

Numerous studies have documented that SLN biopsy can accurately determine the nodal status in breast cancer. However, the high false-negative rates in some of the published studies have raised concern about the accuracy of the technique in widespread use. Despite the abundant literature, there has been no clear consensus regarding a practical issue that faces surgeons who perform this procedure: When multiple radioactive nodes are found, which ones should be removed? It is generally accepted

Acknowledgements

We thank Diana Simpson, RN, Vicki Viar, RN, MSN, Carla Shelton, and Sherri Matthews for the data management and coordination of the study, and the members of the University of Louisville Breast Sentinel Lymph Node Study Group for their active participation.

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^*: Reprint requests: Kelly M. McMasters, MD, PhD, University of Louisville-Brown Cancer Center, 529 S Jackson St, Louisville, KY 40202.

^**: Supported by the Center for Advanced Surgical Technology (CAST) of Norton Hospital, Louisville, Ky.

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Society of University SurgeonsPractical guidelines for optimal gamma probe detection of sentinel lymph nodes in breast cancer: Results of a multi-institutional study*,**

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

J Am Coll Surg

Surgery

J Am Coll Surg

Sentinel lymphadenectomy in breast cancer

J Clin Oncol

The role of intraoperative lymphatic mapping and sentinel lymphadenectomy in the management of patients with breast cancer

Adv Surg

Sentinel lymph node biopsy and axillary dissection in breast cancer: results in a large series

J Natl Cancer Inst

Sentinel lymph node mapping in breast cancer

Oncology

Lymphatic mapping in the treatment of breast cancer

Oncology

Society of University Surgeons
Practical guidelines for optimal gamma probe detection of sentinel lymph nodes in breast cancer: Results of a multi-institutional study*,**