Sentinel Node Biopsy for Breast Cancer

J. Michael Guenther M.D., F.A.C.S.

There are two major issues that confront most women diagnosed with invasive breast cancer: (1) what should be done with the breast? and (2) can it be determined whether or not the cancer has spread?

Numerous large national and international studies have proven that mastectomy and breast conservation (lumpectomy with or without radiation therapy) are equally effective treatments for breast cancer that achieve identical survival rates. Similarly, the chances of cancer coming back where it started (the skin of the chest or the breast itself) are the same for mastectomy and for breast conservation. Most women are good candidates for breast preservation and do not usually require mastectomy.

The single most important predictor of survival from breast cancer is the presence or absence of tumor in the lymph nodes that receive lymphatic drainage from the breast.
These are nearly always located in the axilla (armpit) closest to the primary breast cancer. If lymph nodes are found to be tumor-free, it is likely that the cancer will be curable.

If, on the other hand, the breast cancer has spread to lymph nodes, then the cancer might be able to spread to other organs. This condition is more serious and more significant treatments such as chemotherapy or chest wall radiation may be recommended.

For decades the standard method of determining whether a cancer could spread to lymph nodes was to remove most or all the axillary lymph nodes (usually 15-25 nodes), cut them in half (bivalve) and examine each one microscopically. This procedure, called an axillary lymph node dissection (ALND), has remained the gold standard for staging breast cancer until recently. ALND can result in several potential complications, however. The most significant of these is called lymphedema (arm swelling), and happens to about 10-15% of the women who undergo ALND. It is usually a permanent condition but does not limit arm motion or strength. In addition, most patients have clean lymph nodes and do not benefit from removal of healthy tissue.

A recent surgical breakthrough called Sentinel Node Biopsy has focused on the identification of the first (sentinel) node in the chain of nodes usually found under the arm. The ability to reproducibly identify the first node that receives drainage from a breast cancer allows surgeons to remove only the node(s) most likely to contain cancer. Pathologists using specialized techniques can analyze sentinel nodes very carefully. This focused analysis of 1-3 lymph nodes is more sensitive (likely to find cancer) than traditional axillary dissection.  

The main benefit, however, of sentinel node biopsy for breast cancer is for the majority of patients who have negative sentinel nodes - they do not require any other lymph node tissue to be removed and have virtually no chance of developing lymphedema. This surgical breakthrough greatly reduces the number of patients who undergo ALND and are at risk for lymphedema.

Sentinel lymph nodes are identified by injecting either blue dye or a blue dye/radioisotope mixture into the breast. The dye and/or radioactive tracer travel very quickly to the first or sentinel node. The surgeon makes an incision under the armpit and is able to identify the sentinel node. This is removed and examined by a pathologist. No drains are used. The entire procedure of sentinel node biopsy usually lasts less than 20 minutes and is an outpatient procedure. Most patients can use their arm normally the next day.

Sentinel node biopsy is suitable for nearly all patients undergoing either mastectomy or breast conservation.

Sentinel node biopsy is rapidly becoming the standard of care for treating women with breast cancer; it is certainly the state of the art. Numerous scientific articles and presentations have demonstrated the superiority of sentinel node biopsy when compared to traditional radical axillary surgery. Extensive surgeon experience is a key for successful identification of sentinel lymph nodes. Surgeons at CSA are experts in application of sentinel node biopsy for breast cancer, colon cancer, and malignant melanoma.

Ask your doctor if you are a candidate for this procedure. Most women with invasive breast cancer should consider this surgical option.

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