ABSTRACT
Introduction .............................................................................................................................83 D etailed Technique................................................................................................................84 C om plications......................................................................................................................... 88 Su m m ary ................................................................................................................................. 89
INTRODUCTION
The status o f the axillary lymph nodes remains the most important factor as sociated with survival o f patients with primary breast cancer. The standard method for staging is complete axillary lymph node dissection (ALND). Whether there is a survival benefit or local-regional benefit from ALND is controversial, with the debate far beyond the scope o f this chapter. ALND to stage curable breast cancer patients will be performed in large numbers o f patients without nodal disease and will subject them to the risks o f nerve injury and lymphedema unnecessarily. The procedure using intraoperative lymphatic mapping and sentinel lymphadenec tomy (SLND), as developed by M orton1 to identify regional metastases from a primary cutaneous melanoma, was adapted by our group in an effort to identify axillary metastases in patients with breast cancer. The intent was to determine if the technique could be a viable alternative to routine ALND, accurately predicting the presence or absence o f axillary metastases, without the associated morbidity o f ALND. Using 1% isosulfan vital blue dye (Lymphazurin®) as the lymphatic mapping agent, 174 consecutive SLND procedures were performed in our initial feasibility study, followed by completion axillary lymph node dissection.2 One goal was to establish the optimal technique necessary to identify the sentinel node. The sentinel node was identified in 114 o f the 174 procedures (66% ) and it accu rately predicted the axillary nodal status in 109 (96% ) cases. With the SLND pro cedure standardized, in a follow-up study using immunohistochemistry (IHC) stained on sections o f the sentinel node, we found that SLND significandy in creases the accuracy o f detecting metastases in the axilla and also increases the
Radioguided Surgery, edited by Eric D. Whitman and Douglas Reintgen. © 1999 Landes Bioscience
rate o f detection when compared to ALND with routine histopathologic process ing of random lymph nodes.3 Furthermore, to validate the power o f the sentinel node in predicting the entire axilla, 1087 nonsentinel nodes were examined in 60 patients whose sentinel nodes were tumor-free by both IHC and hematoxylin/ eosin staining. Only one additional tumor-positive node was identified, indicat ing that the sentinel node is the most likely axillary node to contain metastases.4 In our last report o f 107 SLND procedures, using all refinements except preopera tive lymphoscintigraphy for medial lesions, the technique was successful in iden tifying a sentinel node in 94% o f cases, and was 100% predictive o f axillary sta tus.5 Currently we identify the sentinel node in more that 99% of cases. The fol lowing is a description o f this refined technique in detail, with key features of each step presented, which will hopefully serve to augment the accuracy of the proce dure utilized by those surgeons who have been trained in the technique.
