Elsevier

Surgery

Volume 138, Issue 1, July 2005, Pages 56-63
Surgery

Society of University Surgeons
Factors predicting failure to identify a sentinel lymph node in breast cancer

https://doi.org/10.1016/j.surg.2005.03.003Get rights and content

Background

Although sentinel lymph node (SLN) biopsy is widely accepted as a minimally invasive method of nodal staging, failure to identify an SLN mandates a level I/II axillary node dissection. The purpose of this study was to elucidate factors that independently predict failure to identify an SLN.

Methods

Using a large multicenter prospective study of SLN biopsy for patients with invasive breast cancer, we performed univariate and multivariate regression analyses to determine clinicopathologic factors predictive of failure to identify an SLN.

Results

Of the total 4131 patients in the study, an SLN was not identified in 249 (6.0%). Tumor location (P = .409), biopsy type (P = .079), surgery type (P = .380), and histologic subtype (P = .999) were not significant predictors of failure to identify an SLN. On multivariate analysis, age greater than 60 years (OR = 1.469; 95% CI, 1.116-1.934, P = .006), nonpalpable tumors (OR = 0.639; 95% CI, 0.479-0.852, P = .002), injection technique with blue dye alone (OR = 0.389, 95% CI, 0.259-5.86, P < .001), and surgical experience of less than 10 SLN biopsy cases (OR = 1.886; 1.428-2.492, P < .001) were significant independent predictors of failure to identify an SLN. Optimal SLN biopsy technique using an intradermal and/or subareolar injection of radioactive colloid and blue dye can improve SLN identification rates regardless of patient and tumor characteristics.

Conclusions

Patient age and tumor palpability significantly affect the ability to identify an SLN in patients with breast cancer. Optimal injection technique can significantly improve sentinel node identification rate regardless of these factors.

Section snippets

Methods

The University of Louisville Breast Cancer Sentinel Lymph Node study is a prospective multicenter study in which patients underwent SLN biopsy followed by planned completion level I/II axillary lymph node dissection. More than 300 surgeons participated in this study, many of whom had heretofore little to no experience with the technique of SLN biopsy. The technique of SLN biopsy in terms of injection material (blue dye and/or radioactive colloid) and injection site was left to the discretion of

Results

Between November 1996 and July 2004, 4131 patients enrolled. The median patient age was 60 years (range, 27-100 years). Clinicopathologic tumor features are shown in Table I.

Three-hundred thirty-six surgeons participated in this study. Many surgeons did not have extensive SLN biopsy experience before participating in this study. The median number of SLN procedures performed by each surgeon in this study was 9 (range, 1-89). Type of biopsy for diagnosis, choice of operative procedure, and

Discussion

While SLN biopsy was designed to avoid the unnecessary morbidity of an axillary node dissection in node-negative patients,3, 4, 5, 6, 7 the success of SLN biopsy requires that surgeons be able to identify an SLN. A number of studies have demonstrated variable identification rates for this procedure, ranging from 64% to 100%, depending on surgeon experience and technique (Table VI).8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37

References (55)

  • K. Sato et al.

    Clinicopathologic and technical factors associated with the uptake of radiocolloid by sentinel nodes in patients with breast cancer

    Surg Today

    (2003)
  • S.S. Bass et al.

    Learning curves and certification for breast cancer lymphatic mapping

    Surg Oncol Clin N Am

    (1999)
  • K.M. McMasters et al.

    Sentinel node biopsy for breast cancer-not yet the standard of care

    New Engl J Med

    (1998)
  • S.L. Wong et al.

    The effect of lymphatic tumor burden on sentinel lymph node biopsy results

    Breast J

    (2002)
  • D.K. Blanchard et al.

    Relapse and morbidity in patients undergoing sentinel lymph node biopsy alone or with axillary dissection for breast cancer

    Arch Surg

    (2003)
  • M. Golshan et al.

    Sentinel lymph node biopsy lowers the rate of lymphedema when compared with standard axillary lymph node dissection

    Am Surg

    (2003)
  • P. Schrenk et al.

    Morbidity following sentinel lymph node biopsy versus axillary lymph node dissection for patients with breast carcinoma

    Cancer

    (2000)
  • A.E. Guiliano et al.

    Lymphatic mapping and sentinel lymphadenectomy for breast cancer

    Ann Surg

    (1994)
  • A.E. Giuliano et al.

    Incidence and predictors of axillary metastasis in T1 carcinoma of the breast

    J Am Coll Surg

    (1996)
  • A.E. Giuliano et al.

    Sentinel lymphadenectomy in breast cancer

    J Clin Oncol

    (1997)
  • J.M. Guenther et al.

    Sentinel lymphadenectomy for breast cancer in a community managed care setting

    Cancer J Sci Am

    (1997)
  • D. Krag et al.

    The sentinel node in breast cancer: a multicenter validation study

    New Engl J Med

    (1998)
  • P.M. Schlag et al.

    Specification of potential indications and contraindications of sentinel lymph node biopsy in breast cancer

    Recent Results Cancer Res

    (2000)
  • R.E. Nwariaku et al.

    Sentinel lymph node biopsy, an alternative to elective axillary dissection for breast cancer

    Am J Surg

    (1998)
  • V. Klimberg et al.

    Subareolar versus peritumoral injection for location of the sentinel lymph node

    Ann Surg

    (1999)
  • M.H. Doting et al.

    Lymphatic mapping with intralesional tracer administration in breast carcinoma patients

    Cancer

    (2000)
  • L.F. Smith et al.

    Subareolar injection is a better technique for sentinel lymph node biopsy

    Am J Surg

    (2000)
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    Presented at the 66th Annual Meeting of the Society of University Surgeons, Nashville, Tennessee, February 9-12, 2005.

    Supported by Center for Advanced Surgical Technologies (CAST) of Norton Hospital, Louisville, KY.

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