Before You Donate
Think very seriously before donating to any breastcancer organization, or fundraising program until you read their Annual Report to see who their top contributors are, and if they have a product that appears frequently in the message the organization sends to the public. That would be unethical and its illegal. The same applies to a request that the public buys products, but does not receive a "donor receipt" for tax-deductible purpose. Read any and all food labels that breastcancer "non-profits" are promoting to raise money. Some organizations tell the public to help them raise money by asking you to visit their websites, but that only gives them "hits" to increase their sponsors.
Another tip, "signing" an online Petition is not acceptable, so don't fall for such antics. An ethical non-profit, or professional will not request your visit to their website, nor use "cookies" placed on your computer when you visit their site.
Purchase the Breastcancer Postage Stamp, the Post Office will always give you your charitable deduction receipt. Its a valid form of fund raising.
Here, I am attempting to help you understand more about this sentinel lymph node dissection, or SLND. I have put items of importance in italics or bold for your convenience, these were not in the original text of Dr. Sikov's review of the research on SLND presented at the San Antonio, Texas Cancer Symposium, December 1998.
Much of what you read may initially seem like Greek to you; however, I think if you review this page slowly, you will be able to gain a more clear understanding of this recent procedure, and how it relates to you, but also, my own rationale. On IMPORTANT UPDATES page, under New Research information, you'll find more information, and articles on this procedure.
SENTINEL LYMPH NODE DISSECTION (SLND)
EXPLANATION: At times I think that we are not thinking when we review articles, nor the editors of medical journals question enough the authors, researchers about their data. I certainly am not one to stand in judgment, however, I am consistently reading that women are treated for metastasis to the lymph depending on the number of lymph nodes which were positive.
At the time of surgery, a breast surgeon trained and approved (by the American Society of Breast Surgeons) to perform the SLND, injects a dye into the lymph vessel. It goes to the Sentinel Node, where it can be visualized because the dye also has contrast properties, and it can be removed along with others near it. Some women have many more axillary lymph nodes (under the arms) than others. Surgeons doing the SLND generally (unless they have reason to) do not take the lymph nodes they would take prior to the SLND. Therefore,, basing the number of nodes removed and positive is like comparing apples to oranges.
In the SLND just a few nodes are taken. So if someone says, "I had twelve positive nodes," the physician obviously took more than a few nodes. The woman with 2 positive nodes out of 3…may have metastatic disease as much as the person with "….twelve nodes…" out of 15.
Please note: If the Sentinel Lymph Node, and even a few others are dissected, other nodes are left behind. We must either proved the nodes left behind show no infiltration of malignant cells, or - we must accept that this procedure is evidencing a projection based on the analytical prowess of the pathologist.
Would you risk that there was no more evidence of metastatic changes in those non-examined lymph nodes? For my own personal life, I could not.
Therefore, I am not conservative. If it is metastatic in 3 nodes, I prefer to believe I would want to be treated for metastatic breast cancer….macrometastasis or micrometastases, a new finding (micromet., by pathologist using cytokeratin staining).
As you know, first I had a 'partial' which was a "majority" in fact, and still the wise oncological radiologist would not use radiation until further surgery was done to obtain larger margins (away from the malignant cells = they were in two sites, in calcifications). He had no SLND data to go on either.
I did run, as fast as I could to obtain better care - and ended up with a wonderful surgeon who 1) knew the index into which I was above "safe levels (Van Nuy's)," and was approved in SLND by the American Society of Breast Surgeons.
The oncologist I was blessed to have, upon the finding of micrometastasis in the lymph nodes, with my surgeon, present my case to specialists in this newly discovered type of metastasis. He sent me for two other opinions at major cancer centers, and my pathology was reviewed and diagnosed first by the pathologist at the time of the mastectomy (the staining takes another day), another pathologist in town, National Institutes of Health Pathology Div., M.D. Anderson Cancer Center in Houston, TX., and The Cancer Therapy Research Center in San Antonio, Texas (where the gurus of micromet were at that time). All pathologist concurred agreed). Only MDA oncologist disagreed with the protocol, however he could hardly speak English, and was extremely demeaning about my surgeon. Therefore, I had no respect for his opinion, nor considered him at all competent.
With the window of time nearly closing, I began aggressive chemotherapy, with Adriamycin and Cytoxin, determined to fight this monster, but with my oncologist by my side.
1998 San Antonio Breast Cancer Symposium
Day 2 - December 13, 1998
Sentinel Lymph Node Explorations
Author: William Sikov, M.D. -- Writer: Michelle
Plante, Pharm.D.
Introduction
Since Giuliano and colleagues at the
John Wayne Cancer Institute
published their initial series in 1994, there
has been a rapid rise of interest
in the use of sentinel lymphadenectomy (SLN) to
limit the morbidity and cost of standard axillary dissection in patients
with early stage breast
cancer [1].
There is a recognized learning curve
for this procedure, but, in
experienced hands, sentinel nodes can be identified
in 90% of cases with
injections of blue dye and radiocolloid for localization.
The false negative rate
(the incidence of finding positive axillary nodes
despite negative sentinel
nodes) is low, ranging from 0 to 13%, and sentinel
nodes are the only
nodes found to be involved in more than half of
the cases [2-5].
Several posters at today's session focused on improving the technique and diagnostic accuracy of SLN.
Prognostic factors for nodal involvement
Wong and colleagues retrospectively assessed 722
patients with
infiltrating ductal carcinomas and clinically
negative nodes to determine whether tumor size and the presence or absence
of lymphatic vessel invasion (LVI) was predictive of the number of axillary
nodes involved [6]. They found only 3-4% of patients with T1-2 tumors without
LVI had >3 lymph nodes involved (vs. 11-15% of T1-2 tumors with LVI, p<0.01).
Based on these data, they suggest that women with T1-2, LVI-negative tumors
who have not undergone axillary dissection do not need a third radiation
field to treat the axillary and supraclavicular nodes. They plan to evaluate
this in a prospective trial.
Ditkoff and colleagues examined the relationship
between the number of axillary lymph nodes removed and survival in patients
with stage I breast cancer [7]. In this retrospective review of 483 patients,
they found no correlation between the number of axillary nodes removed
(<10 vs. > or =10) and disease-free or overall survival. The authors
suggest that these results support the use of sentinel node sampling in
this patient population.
While it is likely that this is an appropriate
population for limited axillary
sampling, it is not clear that these findings
can extrapolated to argue
against standard axillary dissection in patients
with 1-3 negative sentinel
nodes.
False negative rate unaffected by prior surgery
Two posters addressed an issue of concern
to many surgeons and medical oncologists, whether prior excisional biopsy
or lumpectomy affects the accuracy of sentinel node identification.
Pendas and colleagues at the Moffitt Cancer Center
in Tampa conducted a
prospective study of 700 patients who underwent
SLN to answer this question [8]. They found that patients who had undergone
prior excisional biopsy had a higher number of identified sentinel
nodes than patients diagnosed by FNA, core or incisional biopsy (mean
2.2 vs.1.9). This group also had a greater likelihood of having 3 or more
sentinel nodes harvested,
suggesting some effect of more extensive surgery
on lymphatic drainage. However, this did not affect the surgeon's ability
to identify sentinel nodes or raise the false negative rate.
Similarly, Tafra and colleagues compared 130 patients who had a prior FNA or core biopsy to patients with prior open biopsy or lumpectomy [9]. The overall success rate for identifying sentinel nodes was low at 80%, but did not differ by prior surgical treatment, nor did the false negative rate of 7.4%. Thus, the efficacy of lymphatic mapping and SLN does not appear to be affected by prior excisional surgery.
Immunohistochemical analysis improves yield
A number of posters demonstrated the
value of adding
immunohistochemical (IHC) staining for
cytokeratin
to
standard histologic examination for examining sentinel nodes.
Pendas and colleagues performed lymphatic mapping
and cytokeratin IHC
in 478 newly diagnosed breast cancer patients
[10]. 134 patients had positive sentinel nodes (28%) identified,
but 41 patients (30.6% of patients with positive nodes) had nodes
that were missed by standard H&E histology and were positive by IHC
alone. Many of these patients had microinvasive or T1a/b tumors. Patients
identified with positive nodes by IHC were as likely to have additional
axillary nodes involved as those identified by standard histologic examination.
Dowlat and colleagues compared 2 mm H&E sectioning
to 0.25 mm IHC
staining to quantitate upstaging in patients with
T1-2 tumors undergoing SLN
[11]. Only 12% of 52 patients had positive nodes by H&E, in contrast to 58% by IHC. Kuerer and colleagues from MD Anderson treated 191 patients with FNA-positive axillary lymph nodes with neo-adjuvant chemotherapy [12]. After completing treatment, 43 patients (23%) had negative nodes on standard histologic exam, but when they were reevaluated using cytokeratin IHC nodal metastases were found in 4 patients (10%).
These studies suggest that IHC should be incorporated in the standard analysis of sentinel nodes, particularly if the results of SLN are going to be used to determine further treatment.
Predictive value of findings
Chu and colleagues from the John SLN Wayne Cancer Institute presented data suggesting that the number and extent of involvement of positive sentinel nodes may be of value in predicting the extent of additional nodal involvement [13]. In patients found to have only one involved sentinel node containing a micrometastasis (< or = 2 mm), only 1 of 62 patients had > or =4 total positive nodes. Patients with more than one positive sentinel node with micrometastatic disease were a much smaller group, but were also unlikely to have > or =4 positive nodes (1 in 7). In contrast, patients with macrometastases" (>2mm) were much more likely to have extensive nodal disease, whether they had only one (14 of 61 patients) or more than one (14 of 28 patients) involved sentinel nodes. In a multivariate analysis, only the number of positive sentinel nodes and the extent of disease in those nodes was predictive of extensive lymph node involvement, while tumor size, grade, the presence of lymphatic vessel invasion, and other tested characteristics were not.
Lymphoscintigraphy -- does it increase SLN identification rate?
The question of whether lymphoscintigraphy (LS)
can facilitate the identification of sentinel nodes, and improve the efficacy
of SLN was addressed. In patients with medial breast carcinomas LS identified
6 of 42 who had primary or sole drainage to the internal mammary or supraclavicular
nodes [14]. The authors suggest that LS may be of value in those cases
to identify patients likely to fail axillary sentinel node detection.
However, it is likely that the radiocolloid used for standard SLN could be followed to those sites of nodal drainage, thus the additional information gained by the LS is unclear.
Burak and colleagues examined whether there was
an added benefit of LS to
standard interoperative lymphatic mapping and
SLN [15]. They found a higher rate of intraoperative sentinel node detection
(90% in 50 patients) than with preoperative LS (71% in 24 patients), and
none of the tumors, including 5 inner quadrant tumors, showed drainage
to the internal mammary nodes on LS. The authors concluded that routine
use of LS does not appear to be justified given the efficacy of SLN.
Confirming the Efficacy of SLN -- The ALMANAC Trial
A number of centers reported their experience with SLN, including Clarke and colleagues, who reported a 95% success rate at identifying one or more sentinel nodes and a 5% false negative rate [16]. Theirs was a pilot study for the ALMANAC trial, which plans to accrue 2500 patients at a number of centers in the United Kingdom. Each center must demonstrate its ability to achieve 90% success at identifying sentinel nodes, and false negative rates of <5% before opening accrual to the national study, which will randomize patients between SLN and standard axillary dissection. Patients with negative sentinel nodes will receive no further treatment to their axilla, while patients will positive sentinel nodes will undergo full axillary dissection or receive radiation to their axilla, at the discretion of the treating physician. Patients will be monitored for local and distant relapse-free survival. Only large randomized studies such as this one will determine if SLN is the appropriate treatment for women with early stage breast cancer.
Summary
Centers around the world are gaining experience with SLN, and some are generating data that will help identify which patients are most appropriate for this approach, and which patients are best served by standard axillary dissection. Centers initiating SLN testing must have the expertise and equipment for accurate sampling and adequate pathologic support for IHC, as well as thin section histologic examination of the sentinel nodes.
The question on whether we should discourage surgeons
from performing SLN alone, without a randomized trial demonstrating at
least equal efficacy for this approach, is moot. This is because
patients
will ask for and receive this approach to management regardless of
recommendations. However, surgeons should refrain from this approach
until they can demonstrate success in identifying sentinel nodes and false
negative rates similar to those being required of the UK centers for the
ALMANAC trial, and patients must be made aware of the risk, even if small,
of false negative results.
References
1.Giuliano AE, Kirgan DM, Guenther JM, et al. Lymphatic
mapping and
sentinel lymphadenectomy for breast cancer. Ann
Surge 1994; 220:391-8.
2.Albertini JJ, Lyman GH, Cox C, et al. Lymphatic
mapping and sentinel
node biopsy in the patient with breast cancer.
JAMA 1996; 276:1818-1822.
3.Giuliano AE, Jones RC, Brennan M, et al. Sentinel
lymphadenectomy in
breast cancer. J Clin Oncol 1997;
15:2345-2350.
4.Veronesi U, Paganelli G, Galimberti V, et al.
Sentinel-node biopsy
to avoid axillary dissection in breast cancer
with
clinically negative lymph-nodes. Lancet 1997;
349:1864-1867
5.Krag D, Weaver D, Ashikaga T, et al. The sentinel
node in breast
cancer -- a multicenter validation study. N Engl
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Med 1998; 339:941-6.
6.Wong JS, O'Neil A, Recht A, et al. The relationship
between
lymphatic vessel invasion, tumor size, and pathologic
nodal
status: can we predict who can avoid a third field
in the absence of
axillary dissection? [Abstract 201]. 21st Annual
San
Antonio Breast Cancer Symposium, San Antonio,
TX, 1998.
7.Ditkoff BA, Schnabel F, Troxel A, et al. Relationship
between the
number of axillary lymph nodes removed and survival
in patients with stage I (T1N0) breast cancer [Abstract 203]. 21st Annual
San Antonio Breast Cancer Symposium, San Antonio, TX, 1998.
8.Pendas S, Giuliano R, Cox CE, et al. Diagnostic
breast biopsy can
influence the number of sentinel lymph nodes harvested
[Abstract 206].
21st Annual San Antonio Breast Cancer
Symposium, San Antonio, TX, 1998.
9.Tafra L, Hale JC, Pearshall DW, et
al. Lymphatic mapping and
sentinel node biopsy results with prior lumpectomy
and
biopsy vs. intact tumor [Abstract 205]. 21st Annual
San Antonio Breast
Cancer Symposium, San Antonio, TX, 1998.
10.Pendas S, Guiliano R, Schreiber R, et al. Upstaging
breast cancer
patients using cytokeratin staining of the sentinel
lymph node [Abstract 207]. 21st Annual San Antonio Breast Cancer Symposium,
San Antonio, TX, 1998.
11.Dowlat K, Bloom KJ, Ming F, et al.
Sentinel node micrometastases in
early breast cancers [Abstract 217]. 21st Annual
San Antonio Breast Cancer Symposium, San Antonio,
TX, 1998.
12.Kuerer HM, Sahin A, Hunt KK, et al.
Incidence and impact of occult
breast cancer axillary lymph node micrometastases
in patients with complete conversion to a histologic node negative status
after neoadjuvant chemotherapy [Abstract 204].
21st Annual San Antonio Breast Cancer Symposium,
San Antonio, TX,
1998.
13.Chu KU, Giuliano AE. Extent of axillary metastases
from breast
carcinoma can be predicted by sentinel lymph node
examination [Abstract 209]. 21st Annual San Antonio Breast Cancer Symposium,
San Antonio, TX, 1998.
14.Ollila DW, Haigh PI, Hansen NM, et
al. Lyphatic drainage pattern of
medial breast carcinomas [Abstract 211]. 21st
Annual San Antonio Breast Cancer Symposium, San Antonio, TX, 1998.
15.Burak WE, Saha S, Walker MJ, et al. Is preoperative lymphoscintigraphy necessary for successful lymphadenectomy in patients with breast cancer [Abstract 212]. 21st Annual San Antonio Breast Cancer Symposium, San Antonio, TX,1998.
16.Clarke D, Daoud R, Sweetland H, et
al. Sentinel lymph node biopsy
in breast cancer: early experience [Abstract 215].
21st Annual San Antonio Breast Cancer Symposium,
San Antonio, TX,
1998.