Sentinel Lymphadenectomy: Accurate Histopathologic Staging of the Axilla

We agree with the need to reexamine the routine use of axillary dissection in the management of breast cancer patients, as advocated by Manjeet Chadha and Deborah Axelrod, in their article, "Is Axillary Dissection Always Indicated in Invasive Breast Cancer?" (11:1463-1479, 1997). No patient with tumor-free axillary lymph nodes, however, derives a therapeutic benefit from either axillary irradiation or dissection. Axillary irradiation may be equivalent to dissection in terms of locoregional control, but it offers no staging information. Thus, clinicians should continue to pursue the least morbid method available to accurately stage the axilla histopathologically.

Sentinel lymphadenectomy achieves this goal. Sentinel lymphadenectomy in breast cancer patients has been well-described by our group[1,2] and other investigators,[3-5] and the removal of one or two sentinel nodes has virtually no associated morbidity.

A patient with a tumor-free sentinel node or nodes probably needs no further local treatment of the axilla, either irradiation or dissection. The clinically intriguing question is, what should be done with the rest of the axilla in patients with tumor-involved sentinel node(s)--completion axillary dissection, axillary irradiation, or no regional therapy?

References:

1. Giuliano AE, Kirgan DM, Guenther JM, et al: Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 220:391-401, 1994.

2. Giuliano AE, Dale PS, Turner RR, et al: Improved axillary staging of breast cancer with sentinel lymphadenectomy. Ann Surg 222:394-401, 1995.

3. Krag DN, Weaver DL, Alex JC, et al: Surgical resection and radiolocalization of the sentinel node in breast cancer using gamma probe. Surg Oncol 2:335-340, 1993.

4. Albertini JJ, Cruse CW, Rappaport D, et al: Intraoperative radiolymphoscintigraphy improves sentinel node identification for patients with melanoma. Ann Surg 223:217-224, 1996.

5. Veronesi U, Paganelli G, Galimberti V, et al: Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet 349:1864-1867, 1997.