Sentinel lymph node biopsy in breast cancer: Techniques
- Seth P Harlow, MD
Seth P Harlow, MD
- Associate Professor of Surgery
- University of Vermont College of Medicine
- Donald L Weaver, MD
Donald L Weaver, MD
- Professor of Pathology
- University of Vermont College of Medicine
- Section Editor
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
According to the sentinel lymph node (SLN) hypothesis, tumor cells migrating from a primary tumor metastasize to one or a few lymph nodes (LNs) before involving other LNs. Injection of blue dye and/or radiolabeled colloid into the skin and breast tissue around the area of the tumor or the subareolar area permits identification of one or more SLNs in the majority of patients. The status of the sentinel nodes accurately predicts the status of the remaining axillary LNs.
Sentinel lymph node biopsy (SLNB) is used to provide staging information and to assist in determining the need for axillary lymph node dissection (ALND) in breast cancer patients. A properly performed negative SLNB should accurately identify those patients without axillary node involvement, thereby obviating the need for a more morbid ALND. The risk of arm morbidity, particularly lymphedema, is significantly lower after SLNB than ALND. (See "Clinical features and diagnosis of peripheral lymphedema".)
The technique of SLNB in patients with breast cancer will be reviewed here. The indications, contraindications and outcomes of this approach are discussed separately. (See "Diagnosis, staging and the role of sentinel lymph node biopsy in the nodal evaluation of breast cancer".)
Radioactive colloid and/or blue dye is injected into the skin of the breast (intradermal, subdermal) or parenchyma of the breast, usually in the vicinity of the tumor or a subareolar location. These tracers then enter lymphatic channels, and passively flow to LNs. One or a few LNs are labeled, making it possible to identify those first receiving drainage from the tumor. The SLN can be variably located, but is usually within the low axilla (level I) . (See "Management of the regional lymph nodes in breast cancer", section on 'Extent of dissection'.) Significant debate continues regarding the optimal agent for lymphatic mapping as well as the technique for use. Each surgeon needs to find the method that works best for them and be consistent in their practice.
Blue dye — The patient is prepped and draped in the operating room. The surgeon injects 3 to 5 mL of blue dye (classically isosulfan blue) around the tumor periphery, at the palpable edge of the biopsy cavity or into the subareolar plexus. It is important not to inject the dye into the tumor itself (because the lymphatics can be occluded by tumor) or into the seroma cavity following breast biopsy (as the seroma itself does not contain lymphatic channels). These errors in technique are likely to lead to a failure of mapping. Breast massage is then carried out for about five minutes to dilate breast lymphatics [2,3]. The use of isosulfan blue dye for SLNB is associated with severe anaphylactic reactions requiring resuscitation in 0.7 to 1.1 percent of cases [1,4-6]. Prophylactic treatment with 100 mg of hydrocortisone (or 20 mg of methylprednisolone or 4 mg of dexamethasone), 50 mg of diphenhydramine, and 20 mg of famotidine intravenously just before or at the induction of anesthesia appears to decrease the severity but not the incidence of dye reactions .
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- Blue dye
- Radioactive colloid
- - Lymphoscintigraphy
- Investigational techniques
- DEFINING THE EXTENT OF SLN BIOPSY
- DECREASING THE FALSE NEGATIVE RATE OF SLN BIOPSY
- INTRAOPERATIVE EVALUATION OF THE SLN
- Intraoperative RT-PCR evaluation of sentinel nodes
- IMPORTANCE OF SURGEON EXPERIENCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS