| Japanese Journal of Clinical Oncology | Pages |
What Is the Optimal Method to Predict Axillary Lymph Node Metastases in Breast Cancer Patients? - Is Sentinel Lymph Node Biopsy Ready to Be an Alternative to Complete Axillary Dissection?
In this issue of Japanese Journal of Clinical Oncology, Motomura et al. publish a paper entitled `Sentinel Node Biopsy Guided by Indocyanin Green Dye in Breast Cancer Patients' (1). Sentinel lymph node (SLN) biopsy is a new technique with few complications for diagnosing axillary lymph node metastasis. Many foreign researchers have so far documented the usefulness of SLN biopsy (SLNB) using dye-guided and/or radiocolloid-guided methods in the management of breast cancer patients (2-5). Based on these data, SLNB is a highly accurate, minimally invasive modality to evaluate axillary lymph node involvement. A sentinel lymph node is defined as the first lymph node to receive drainage from breast cancer. The basic problems lie in the complex lymphatic drainage system of breast cancer and the technical aspects of SLNB. Motomura et al. report a relatively high identification rate with a low false-negative rate of SLN, using an indocyanin green dye-guided method alone (1). However, it is reported that blue dye and radiocolloid are complementary and that they should be used together to identify the SLN more accurately (3,4). Concerning the combination procedure, large series of studies dealing with SLNB have already been reported (4,5). From these reports, the SLN identification rate and the overall accuracy were approximately 90-95%. However, the use of a gamma probe and/or lymphoscintigraphy is considered to be slightly complicated in a general hospital setting. In addition, many other problems also still remain unresolved. How does one obtain immediate and reliable histopathological information on the SLN intraoperatively? How does one detect micrometastases in SLN? Neither all hot nodes nor all stained nodes are SLNs. There is a possibility that the blue-but-not-hot nodes contain metastases. It has been reported that if only the hottest node was removed, an unacceptable false-negative rate was found (6). The false-negative rate should be fully reduced. As for the surgical technique, much experience is required to master the SLNB procedure. Meanwhile, alternative strategies for diagnosing axillary lymph node involvement, such as the use of imaging modalities and/or the histopathological prognostic factors of primary tumors which are closely linked to lymph node metastases, are still under investigation. The incidence of lymph node metastases was as high as 10-20% even for tumors that are <1 cm in diameter. Lymphatic invasion by tumor cells is a significant predictor of lymph node metastases. However, until now, tumor size with or without other histological/biological predictive factors cannot reliably select a subgroup of breast cancers at low risk of nodal involvement.
Even today, histopathologically confirmed axillary lymph node metastasis is the most important prognostic factor and axillary dissection has been regarded as a reliable method of locoregional control of the disease. However, the concept of removing lymph nodes in patients with breast cancer has partly changed from therapeutic value to staging procedure. Complete axillary dissection is associated with significant morbidity. Motomura et al. documented that axillary nodal status, lymphatic or vascular invasion in the tumor and patient age affected the success rate of this technique in identifying sentinel nodes. Even though the SLNB is only indicated for patients with clinically negative axilla, it is expected to be introduced rapidly into general clinical practice in Japan. The SLNB technique should therefore be established as soon as possible and brought into routine use in the community hospitals of Japan.
References
- Motomura K, Inaji H, Komoike Y, Kasugai T, Noguchi S, Koyama H. Sentinel node biopsy guided by indocyanin green dye in breast cancer patients. Jpn J Clin Oncol 1999;29:000-00.
- Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994;220:391-401.
- Giuliano AE, Jones RC, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer. J Clin Oncol 1997;15:2345-50.
- Veronesi U, Paganelli G, Viale G, Galimberti V, Luini A, Zurrida S, et al. Sentinel lymph node biopsy and axillary dissection in breast cancer: results in a large series. J Natl Cancer Inst 1999;91:368-73.
- Albertini JJ, Lyman GH, Cox G, Yeatman T, Balducci L, Ku N, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. J Am Med Assoc 1996;276:1818-22.
- Lannin D, Maede P, Moran J, Newton J, Edwards M, Tafra L. Is the hottest node the most likely to be positive in lymphatic mapping for soft tissue tumors? J Am Soc Clin Oncol 1998;1432 (Abstract).
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