Axillary Lymphatics: A Case Study
Once the SLN is localized, a suture is placed through the node to provide traction. The node is then dissected free from the surrounding tissue. All feeding blood vessels, afferent and efferent lymphatics may be ligated.
Using the radiocolloid method, the gamma probe is used to locate any other SLNs and to confirm low radioactivity counts in the axilla and no residual SLNs. Ex vivo and in vivo radioactivity counts are recorded for each node.
The axillary tissue is also carefully palpated for any nodes that seem suspicious and that may not have taken up radioactive tracer or dye. Hemostasis is then obtained, and the wound is closed in layers. (Dirbas & Scott-Conner, 2011)
G. Number of Nodes Removed During SLNB
Multiple studies have demonstrated that removal of 2 to 3 nodes identifies 93% to 99% of node positive patients, and removal of 4 nodes identifies 100% of node positive patients (McCarter, et al., 2001) (Duncan, et al., 2004) (Zakaria, et al., 2007). The Axillary Lymphatic Mapping Against Nodal Axillary Clearance (ALMANAC) Trialists group found that 99.6% of node positive patients were identified by removing no more than 4 SNs. The false negative rate was 10% when 1 sentinel node was removed and 1% when 3 or …show more content…
more sentinel nodes were removed (Goyal, et al., 2005). These studies suggest that removal of more than 4 SLNs is unnecessary. (Kuerer, 2010)
H. Failed Sentinel Lymph Node Biopsy
With increasing experience, the success rate of SLN biopsy approaches but does not equal 100%. For that small fraction of failed SLN biopsy procedures or for a SLNB procedure that is technically unsatisfactory in any other way, it is reasonable to perform ALND (Cody & Borgen, 1999).
Pathology of Sentinel Lymph Node(s) Biopsy
The increasing use of immunohistochemical staining and molecular biology techniques has led to the ability to detect extremely small metastatic lesions in axillary sentinel lymph nodes. Sentinel node metastasis is described as macrometastasis (tumor deposit > 2.0 mm), micrometastasis (tumor deposit 0.2 to 2.0 mm), isolated tumor cells (tumor clusters < 0.2 mm), and molecular positive only (reverse transcriptase polymerase chain reaction RT-PCR). (Bland & Klimberg, 2010)
Management after Sentinel Lymph Node Biopsy
A. SLNB with No Metastasis
The recommendations of the American Society of Clinical Oncology (ASCO) guidelines in 2014 (Lyman, et al., 2014) which were reviewed in 2016 with no change were as follows:
Women without sentinel lymph node (SLN) metastases should not receive axillary lymph node dissection (ALND).
The NSABP B-32 trial enrolled 5611 early stage breast cancer patients with clinically negative nodes and compared (SLNB followed by ALND) vs. (SLNB followed by ALND only if the sentinel lymph node was positive) (Krag, et al., 2007) (Krag, et al., 2004). No significant differences were observed in regional control, overall survival, or disease free survival between the groups at a median follow up period of almost eight years (American Society of Clinical Oncology, 2010) (Krag, et al., 2010).
B. SLN with Metastasis (T1 & T2 tumors)
1. SLNB with Occult Metastasis
In patients with occult metastasis (Micrometastases, Isolated Tumor Cells or Molecularly Positive) found by SLNB, no completion ALND is needed, and no alteration in subsequent adjuvant therapy is recommended (Weaver, et al., 2011) (Giuliano, et al., 2011) (Reed, et al., 2009) (Chagpar, et al., 2005) (Pugliese, et al., 2009).
The NSABP B-32 trial demonstrated that the presence of occult metastases was associated with a 1.2% lower overall survival rate and a 2.8% lower disease free survival rate; patients with occult metastases did not have a higher incidence of regional or distant recurrences (Weaver, et al., 2011).
The American College of Surgeons Oncology Group (ACOSOG) Z-0010 trial found a 0.6% lower overall survival rate in patients with occult metastases, but this was not statistically significant (Giuliano, et al., 2011). The two trials used different protocols for detecting occult metastases, and although the B-32 trial had higher statistical power, both trials demonstrated similar outcomes related to occult metastases.
2. SLN with Frank Metastasis (Macrometastases)
Historically, patients with any SLN metastasis underwent completion ALND as per the recommendations of the American Society of Clinical Oncology (Lyman, et al., 2005). However, only approximately 40% of patients with a clinically negative axilla and positive sentinel lymph node biopsy had residual disease in the axilla (Lyman, et al., 2005) (Albertini, et al., 1996) (Borgstein, et al., 1998) (Krag, et al., 1993) (Guiliano, et al., 1994) (Krag, et al., 2007) (Krag, et al., 1998) (Giuliano, et al., 1997) (Veronesi, et al., 1997) (Turner, et al., 2000) (Lyman, et al., 2004); the rest had no benefit from the addition of ALND. Stating that, the practice of performing axillary clearance for all patients with positive sentinel lymph node biopsy becomes challenged.
a. One or Two SLN Metastasis
The American Society of Clinical Oncology changed its guidelines from recommending ALND for all patients with a positive sentinel lymph node (2005) to recommending against ALND for patients with fewer than three positive sentinel lymph nodes (2014) (Lyman, et al., 2014).
Two randomized trials, the ACOSOG Z-0011 trial and the International Breast Cancer Study Group 23-01 (IBCSG 23-01) trial, demonstrated that many of these patients with one or two metastatic sentinel nodes can safely avoid a completion axillary node dissection.
b. Three or more SLN Metastasis
The guidelines from the American Society of Clinical Oncology (2014) recommends a completion ALND for patients with three or more pathologically involved sentinel nodes, for staging purposes and to maximize local control (Lyman, et al., 2014). This recommendation is also supported by data from a 2013 systematic review that included 17 studies with at least two years of follow up (Rao, et al., 2013).
C. SLNB with Metastasis (T3 and Larger Tumors)
The 2014 guidelines of American Society of Clinical Oncology and the 2010 International Expert Panel guidelines on SLNB recommend against the use of SLNB in patients with locally advanced breast cancer (T3 and T4) (Lyman, et al., 2014) (Kaufmann, et al., 2010). The false negative rate is high in such patients, presumably because of partially obstructed and/or functionally abnormal subdermal lymphatics (Harlow & Weaver, 2017). Axillary lymph node dissection (ALND) is recommended for this group of patients to maximize locoregional control (Lyman, et al., 2005).
However, some studies have shown that SLNB can be accurate in patients with T3 tumors and clinically negative axilla (Chung, et al., 2001) (Wong, et al., 2001). Thus, many clinicians do not recognize T3 tumors as an absolute contraindication to SLNB, as long as the axilla is clinically negative. Also the National Comprehensive Cancer Network (NCCN) Guidelines (2017) recommends the use of SLNB for tumors of T3N1M0 with clinically negative axilla (National Comprehensive Cancer Network (NCCN), 2017).
Figure 29 - NCCN guideline on surgical axillary staging.
(National Comprehensive Cancer Network (NCCN), 2017)
Complications of SLNB
Complications similar to those reported for ALND have been reported for SLNB. These include numbness/paresthesia, restriction of shoulder movement, and lymphedema. However, these complications have been reported at a much lower rate for SLNB than for ALND.
The ALMANAC trial, a multicenter randomized trial, confirmed these findings (Mansel, et al., 2006).
In this study, 1,031 patients with clinically node negative invasive breast cancer were randomly assigned to undergo SLNB or standard ALND. Patients with a positive SLN underwent completion ALND. At 12 months, patients assigned to the SLNB group experienced much less arm lymphedema and sensory loss compared to the group assigned to standard ALND. Furthermore, drain usage, length of hospital stay, and time to resumption of normal day to day activities after surgery were significantly lower in the SLNB group. Overall, patient quality of life and arm functioning scores were better in the SLNB group as well (Mansel, et al., 2006). (Dirbas & Scott-Conner,
2011)
Using the radiocolloid method, the gamma probe is used to locate any other SLNs and to confirm low radioactivity counts in the axilla and no residual SLNs. Ex vivo and in vivo radioactivity counts are recorded for each node.
The axillary tissue is also carefully palpated for any nodes that seem suspicious and that may not have taken up radioactive tracer or dye. Hemostasis is then obtained, and the wound is closed in layers. (Dirbas & Scott-Conner, 2011)
G. Number of Nodes Removed During SLNB
Multiple studies have demonstrated that removal of 2 to 3 nodes identifies 93% to 99% of node positive patients, and removal of 4 nodes identifies 100% of node positive patients (McCarter, et al., 2001) (Duncan, et al., 2004) (Zakaria, et al., 2007). The Axillary Lymphatic Mapping Against Nodal Axillary Clearance (ALMANAC) Trialists group found that 99.6% of node positive patients were identified by removing no more than 4 SNs. The false negative rate was 10% when 1 sentinel node was removed and 1% when 3 or …show more content…
more sentinel nodes were removed (Goyal, et al., 2005). These studies suggest that removal of more than 4 SLNs is unnecessary. (Kuerer, 2010)
H. Failed Sentinel Lymph Node Biopsy
With increasing experience, the success rate of SLN biopsy approaches but does not equal 100%. For that small fraction of failed SLN biopsy procedures or for a SLNB procedure that is technically unsatisfactory in any other way, it is reasonable to perform ALND (Cody & Borgen, 1999).
Pathology of Sentinel Lymph Node(s) Biopsy
The increasing use of immunohistochemical staining and molecular biology techniques has led to the ability to detect extremely small metastatic lesions in axillary sentinel lymph nodes. Sentinel node metastasis is described as macrometastasis (tumor deposit > 2.0 mm), micrometastasis (tumor deposit 0.2 to 2.0 mm), isolated tumor cells (tumor clusters < 0.2 mm), and molecular positive only (reverse transcriptase polymerase chain reaction RT-PCR). (Bland & Klimberg, 2010)
Management after Sentinel Lymph Node Biopsy
A. SLNB with No Metastasis
The recommendations of the American Society of Clinical Oncology (ASCO) guidelines in 2014 (Lyman, et al., 2014) which were reviewed in 2016 with no change were as follows:
Women without sentinel lymph node (SLN) metastases should not receive axillary lymph node dissection (ALND).
The NSABP B-32 trial enrolled 5611 early stage breast cancer patients with clinically negative nodes and compared (SLNB followed by ALND) vs. (SLNB followed by ALND only if the sentinel lymph node was positive) (Krag, et al., 2007) (Krag, et al., 2004). No significant differences were observed in regional control, overall survival, or disease free survival between the groups at a median follow up period of almost eight years (American Society of Clinical Oncology, 2010) (Krag, et al., 2010).
B. SLN with Metastasis (T1 & T2 tumors)
1. SLNB with Occult Metastasis
In patients with occult metastasis (Micrometastases, Isolated Tumor Cells or Molecularly Positive) found by SLNB, no completion ALND is needed, and no alteration in subsequent adjuvant therapy is recommended (Weaver, et al., 2011) (Giuliano, et al., 2011) (Reed, et al., 2009) (Chagpar, et al., 2005) (Pugliese, et al., 2009).
The NSABP B-32 trial demonstrated that the presence of occult metastases was associated with a 1.2% lower overall survival rate and a 2.8% lower disease free survival rate; patients with occult metastases did not have a higher incidence of regional or distant recurrences (Weaver, et al., 2011).
The American College of Surgeons Oncology Group (ACOSOG) Z-0010 trial found a 0.6% lower overall survival rate in patients with occult metastases, but this was not statistically significant (Giuliano, et al., 2011). The two trials used different protocols for detecting occult metastases, and although the B-32 trial had higher statistical power, both trials demonstrated similar outcomes related to occult metastases.
2. SLN with Frank Metastasis (Macrometastases)
Historically, patients with any SLN metastasis underwent completion ALND as per the recommendations of the American Society of Clinical Oncology (Lyman, et al., 2005). However, only approximately 40% of patients with a clinically negative axilla and positive sentinel lymph node biopsy had residual disease in the axilla (Lyman, et al., 2005) (Albertini, et al., 1996) (Borgstein, et al., 1998) (Krag, et al., 1993) (Guiliano, et al., 1994) (Krag, et al., 2007) (Krag, et al., 1998) (Giuliano, et al., 1997) (Veronesi, et al., 1997) (Turner, et al., 2000) (Lyman, et al., 2004); the rest had no benefit from the addition of ALND. Stating that, the practice of performing axillary clearance for all patients with positive sentinel lymph node biopsy becomes challenged.
a. One or Two SLN Metastasis
The American Society of Clinical Oncology changed its guidelines from recommending ALND for all patients with a positive sentinel lymph node (2005) to recommending against ALND for patients with fewer than three positive sentinel lymph nodes (2014) (Lyman, et al., 2014).
Two randomized trials, the ACOSOG Z-0011 trial and the International Breast Cancer Study Group 23-01 (IBCSG 23-01) trial, demonstrated that many of these patients with one or two metastatic sentinel nodes can safely avoid a completion axillary node dissection.
b. Three or more SLN Metastasis
The guidelines from the American Society of Clinical Oncology (2014) recommends a completion ALND for patients with three or more pathologically involved sentinel nodes, for staging purposes and to maximize local control (Lyman, et al., 2014). This recommendation is also supported by data from a 2013 systematic review that included 17 studies with at least two years of follow up (Rao, et al., 2013).
C. SLNB with Metastasis (T3 and Larger Tumors)
The 2014 guidelines of American Society of Clinical Oncology and the 2010 International Expert Panel guidelines on SLNB recommend against the use of SLNB in patients with locally advanced breast cancer (T3 and T4) (Lyman, et al., 2014) (Kaufmann, et al., 2010). The false negative rate is high in such patients, presumably because of partially obstructed and/or functionally abnormal subdermal lymphatics (Harlow & Weaver, 2017). Axillary lymph node dissection (ALND) is recommended for this group of patients to maximize locoregional control (Lyman, et al., 2005).
However, some studies have shown that SLNB can be accurate in patients with T3 tumors and clinically negative axilla (Chung, et al., 2001) (Wong, et al., 2001). Thus, many clinicians do not recognize T3 tumors as an absolute contraindication to SLNB, as long as the axilla is clinically negative. Also the National Comprehensive Cancer Network (NCCN) Guidelines (2017) recommends the use of SLNB for tumors of T3N1M0 with clinically negative axilla (National Comprehensive Cancer Network (NCCN), 2017).
Figure 29 - NCCN guideline on surgical axillary staging.
(National Comprehensive Cancer Network (NCCN), 2017)
Complications of SLNB
Complications similar to those reported for ALND have been reported for SLNB. These include numbness/paresthesia, restriction of shoulder movement, and lymphedema. However, these complications have been reported at a much lower rate for SLNB than for ALND.
The ALMANAC trial, a multicenter randomized trial, confirmed these findings (Mansel, et al., 2006).
In this study, 1,031 patients with clinically node negative invasive breast cancer were randomly assigned to undergo SLNB or standard ALND. Patients with a positive SLN underwent completion ALND. At 12 months, patients assigned to the SLNB group experienced much less arm lymphedema and sensory loss compared to the group assigned to standard ALND. Furthermore, drain usage, length of hospital stay, and time to resumption of normal day to day activities after surgery were significantly lower in the SLNB group. Overall, patient quality of life and arm functioning scores were better in the SLNB group as well (Mansel, et al., 2006). (Dirbas & Scott-Conner,
2011)