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Article Title

Variability in Sentinel Lymph Node Biopsy Retrieval for Breast Cancer at Aurora Health Care

Abstract

Background: Axillary lymph node involvement has always been one of the most important factors in determining treatment and prognosis for breast cancer. Routine axillary lymph node dissection (ALND) was the standard treatment for breast cancer until the mid-1990s, when sentinel lymph node biopsy (SLNB) became the standard.

Purpose: We undertook an evaluation of the SLNB procedure, comparing dedicated breast surgeons (4) with general surgeons who also perform breast procedures (25) to see if there were any differences and to standardize the approach throughout Aurora Health Care.

Methods: We performed a retrospective chart review at Aurora to evaluate patients undergoing surgical treatment for breast cancer. The audit revealed that over a 6-month period from January 1, 2016, to June 30, 2016, 25 general surgeons and 4 dedicated breast surgeons performed 275 surgeries for primary operable breast cancer (stages I–III). There were 180 lumpectomies (LUMP) and 95 mastectomies (MAST) performed.

Results: In the 275 breast cancer operations, 253 (92%) SLNB procedures were attempted (163 LUMP, 90 MAST). For various reasons, 13 patients in the LUMP group and 10 patients in the MAST group did not undergo SLNB and were excluded from this analysis. Nonmigration of contrast was noted in 6 patients (3 in LUMP group, 3 in MAST group); 4 of these subsequently had an ALND and 2 had no further axillary treatment. A mean of 2.26 and a median of 2.0 sentinel lymph nodes per patient were removed in the LUMP group. The full-time breast surgeons performed 112 SLNB operations (44%) (range: 22–43 operations/surgeon). The SLNB variability between groups showed the breast surgeons removed a mean of 2.37 nodes/patient for LUMP and 2.67 nodes/ patient for MAST. The general surgeons removed a mean of 2.66 nodes/patient for LUMP and 3.28 nodes/patient for MAST.

Conclusion: The following recommendations were made within the hospital system: Dual tracer imaging should be used. One sentinel lymph node is insufficient for complete evaluation, and more than 4 nodes does not improve staging. Goal is to remove all sentinel lymph nodes that are hot, blue, or palpable, with a goal of 2 to 4 nodes per patient. A complete ALND can be safely omitted in stage I–III patients having LUMP with radiation when there are only 1 to 2 sentinel lymph nodes involved. In patients > 70 years of age who have a T1 or T2 estrogen receptor-positive tumor, SLNB can be safely omitted. SLNB after neoadjuvant therapy can be done even with an initially positive lymph node.