Complications of level I and II axillary dissection in the treatment of carcinoma of the breast

Axillary treatment in conservative management of operable breast cancer: dissection or radiotherapy? Results of a randomized study with 15 years of follow-up

PURPOSE

Axillary dissection is the standard management of the axilla in invasive breast carcinoma. This surgery is responsible for functional sequelae and some options are considered, including axillary radiotherapy. In 1992, we published the initial results of a prospective randomized trial comparing lumpectomy plus axillary radiotherapy versus lumpectomy plus axillary dissection. We present an update of this study with a median follow-up of 180 months (range, 12 to 221 months).

PATIENTS AND METHODS

Between 1982 and 1987, 658 patients with a breast carcinoma less than 3 cm in diameter and clinically uninvolved lymph nodes were randomly assigned to axillary dissection or axillary radiotherapy. All patients underwent wide excision of the tumor and breast irradiation.

RESULTS

The two groups were similar for age, tumor-node-metastasis system stage, and presence of hormonal receptors; 21% of the patients in the axillary dissection group were node-positive. Our initial results showed an increased survival rate in the axillary dissection group at 5 years (P =.009). At 10 and 15 years, however, survival rates were identical in both groups (73.8% v 75.5% at 15 years). Recurrences in the axillary node were less frequent in the axillary dissection group at 15 years (1% v 3%; P =.04). There was no difference in recurrence rates in the breast or supraclavicular and distant metastases between the two groups.

CONCLUSION

In early breast cancers with clinically uninvolved lymph nodes, our findings show that long-term survival does not differ after axillary radiotherapy and axillary dissection. The only difference is a better axillary control in the group with axillary dissection.

Lymphedema after treatment of breast cancer

BACKGROUND

Lymphedema is one of the major long-term complications of axillary dissection. This study was designed to investigate the risk factors that are predicted to effect the development of lymphedema after complete axillary dissection.

METHODS

Two hundred forty patients who had undergone modified radical mastectomy with complete axillary dissection were examined at least 18 months after the surgery. The effects of age, diabetes, smoking, hypertension, chemotherapy, radiotherapy, tamoxifen use, stage, body mass index, number of the removed and metastatic lymph nodes, and total volume of the wound drainage on the development of lymphedema were analyzed.

RESULTS

Lymphedema developed in 68 (28%) of the 240 cases. Axillary radiotherapy and body mass index were found to increase the incidence of the lymphedema.

CONCLUSIONS

Women who had the combination of full axillary dissection and axillary radiotherapy carry a significant risk of lymphedema.

Validation of axillary sentinel lymph node detection in the staging of early lobular invasive breast carcinoma

BACKGROUND

Previous reports have shown that regional lymph node involvement in patients with early-stage breast carcinoma can be evaluated by resection of axillary sentinel lymph nodes (ASLN). Axillary lymphadenectomy may be unnecessary in the absence of ASLN involvement. In the current study, the authors compared the results of ASLN resection in patients with lobular invasive carcinoma (LIC) with the results from patients with ductal invasive carcinoma (DIC) in terms of detection rates and false-negative rates.

METHODS

For ASLN detection, technetium 99m sulfur-colloid and patent blue were injected around the tumor. Each patient underwent both ASLN resection and complete axillary lymphadenectomy. Detection rates and false-negative rates were evaluated in patients with LIC and in patients with DIC.

RESULTS

Two hundred forty-three patients with invasive, early-stage breast carcinoma were enrolled in the study (208 patients with DIC and 35 patients with LIC). The median patient age, pathologic tumor size, hormone receptor status, and rates of involved lymph nodes were equivalent for both groups. ASLN detection and false-negative rates did not differ for patients with LIC and patients with DIC.

CONCLUSIONS

The ASLN detection rate was not dependent on the pathologic type of invasive carcinoma. Pathologic examination of ASLN in patients with LIC and in patients with DIC predicted axillary lymph node status with the same predictive value in terms of lymph node metastasis. For patients with LIC, ASLN examination overestimated the rate of micrometastasis as diagnosed by immunohistochemical techniques. These results will require confirmation in larger studies.

Sentinel node biopsy for nonpalpable breast tumors requires a preoperative diagnosis of invasive breast cancer

A sentinel node biopsy done at the time of initial tumor resection allows for a one-stage surgical procedure. In addition, sentinel node identification may be impaired when done after a previous tumor excision. This study evaluates the sentinel node biopsy in patients with nonpalpable breast cancer and assesses whether a sentinel node biopsy for mammographically suspect breast lesions is justified when preoperative needle biopsy is inconclusive for invasive malignancy. A sentinel node biopsy was done in 67 patients with nonpalpable breast lesions after injection of radioactive tracer (intraparenchymal in 35 and subdermal in 32) and blue dye (para-areolar). A preoperative core needle biopsy was positive for malignancy in 42 patients. Thirteen patients had positive cytology or ductal carcinoma in situ (DCIS). In 12 patients the needle biopsy was nondiagnostic, but the lesions remained highly suggestive of malignancy on mammography. Sentinel node biopsy was successful in 64 patients (96%). In these, the sentinel node was both radioactive and blue in 58 patients (91%). Only 4 of 13 patients with positive cytology or DCIS on preoperative needle biopsy and only 5 of 12 patients without a preoperative diagnosis had an invasive cancer after resection. Sentinel nodes were positive for nodal metastases in 9 of 49 patients (18%) with a successful sentinel node biopsy for invasive malignancy. None of the eight patients with DCIS had nodal metastases. The sentinel node procedure avoids the potential morbidity of an axillary dissection in more than 80% of patients with nonpalpable breast cancer. A sentinel node biopsy for mammographically detected suspect breast lesions is not justified without a preoperative histologic diagnosis of invasive breast cancer.

Reassessing the role of axillary lymph-node dissection in patients with early-stage breast cancer

INTRODUCTION

There is considerable controversy regarding the value of axillary lymph-node dissection in the adjuvant systemic therapy of patients with early-stage breast cancer. Our objective was to assess the impact of nodal status in assigning adjuvant chemotherapy to these patients.

METHODS

We carried out a review of all patients with stage I or II breast cancer treated at 3 university-affiliated hospitals in Saskatoon between Jan. 1, 1998, and Dec. 31, 2000. Data collected included: patient age, sex, tumour size, hormone receptor status, nuclear grade and presence of lymphovascular invasion. Patients were categorized as being at low, high or intermediate risk for recurrence based on Canadian consensus guidelines and at low or high risk according to criteria established by the United States National Institutes of Health (NIH). The influence of nodal status on subsequent treatment was determined assuming that all patients younger than 70 years at high risk of recurrence would receive chemotherapy.

RESULTS

We identified 327 women with stage I or II breast cancer in whom all prognostic factors were available for analysis. Applying the Canadian criteria to determine the need for adjuvant chemotherapy, 68% of women would receive chemotherapy regardless of lymph-node status. Applying the NIH criteria, 82.5% of women younger than 70 years would receive adjuvant chemotherapy regardless of nodal status.

CONCLUSIONS

Nodal status has little influence on subsequent management. Adoption of a selective approach to axillary lymph-node dissection could avoid the potential morbidities of this procedure in many patients with early-stage breast cancer.

A model for teaching sentinel lymph node mapping and excision and axillary lymph node dissection

BACKGROUND

The surgical skills laboratory increasingly provides opportunities for training and practice in basic surgical procedures.

STUDY DESIGN

This article describes a new method for teaching trainees sentinel lymph node mapping and excision and level I/level II axillary dissection. The training session uses cadaver head and torso segments through T6 implanted with radioactive discs to simulate the sentinel node. This model is the first described to provide trainees the opportunity to practice mapping of the sentinel node and excision of the node once identified.

RESULTS

A group of PGY2 and PGY3 residents participated in this laboratory experience with defined objectives, syllabus material, and training session. All participants successfully harvested the sentinel node and completed a level I/level II axillary dissection with faculty supervision and feedback. The residents rated the experience as outstanding and felt that it increased their confidence in their ability to perform the procedure in the operating room.

CONCLUSIONS

Use of cadavers for surgical skills training is only one of a variety of options currently available to provide practice for surgical housestaff in the surgical skills laboratory. Such a model might well have application in training courses for surgeons in practice and courses accompanying clinical trials for sentinel lymph node mapping and excision.

Learning curve for the detection of axillary sentinel lymph node in breast cancer

AIM

Sentinel axillary lymph node (SALN) detection is a new technique. Surgeons must progress up a learning curve in order to guarantee quality and safety equivalent to axillary lymphadenectomy. To ensure accurate staging of patients this learning curve must include SALN detection and an axillary lymphadenectomy. The aim of our work was to validate the principles and evaluate the consequences of learning curve for SALN detection from a prospective series of 200 consecutive patients.

METHOD

Prospective assessment was made of the detection and false negative rates, post operative morbidity as abcess and seroma, and length of hospital stay.

RESULTS

We evaluated the performance from the first to the hundredth case for each surgeon. Detection rate improved to 85% after patient number 10. False negative rate was less than 6%. Post operative axillary morbidity included 11% of seromas and 2% of abcess. Mean hospital stay was 2.8 days.

CONCLUSION

Multidisciplinary validation of the learning period contributes to an accurate and safe SALN.

Octreotide in the treatment of lymphorrhea after axillary node dissection: a prospective randomized controlled trial

BACKGROUND

Axillary lymph node dissection for staging and local control of nodal disease is an integral part of breast cancer therapy. Lymphorrea is a serious and disabling complication of axillary lymphadenectomy, but no effective therapy is currently available. Octreotide is a hormone with general antisecretory effects that has been used to control lymphorrhea in thoracic duct injury and after radical neck dissection. The aim of the study we describe in this article was to determine whether octreotide has a role in the treatment of post axillary lymphadenectomy lymphorrhea.

STUDY DESIGN

This is a prospective randomized controlled trial. Two hundred sixty-one consecutive patients with various stages of breast cancer who underwent axillary lymph node dissection were randomized and followed for 7 years. The treatment group received 0.1 mg octreotide subcutaneously three times a day for 5 days, starting on the first postoperative day, while the control group received no treatment. Of the 261 patients undergoing axillary node dissection, 136 were assigned to the control group and 125 composed the treatment group. The control group and the treatment group were evaluated for amount and duration of lymphorrhea as well as inflammatory and infectious complications.

RESULTS

In the control group, the mean quantity (+/- standard deviation) of lymphorrhea was 94.6 +/- 19 cc per day and the average duration was 16.7 +/- 3.0 days. In comparison, the mean quantity of lymphorrhea in the treatment group was 65.4 +/- 21.1 cc (p < 0.0001) per day and the average duration was 7.1 +/- 2.9 days (p < 0.0001). We did not find an important difference in the number of infectious complication or hematomas formation between the study groups.

CONCLUSIONS

Octreotide can be used successfully for the treatment of post-axillary dissection lymphorrea, and potentially, in the prevention of post-axillary lymph node dissection lymphosarcoma, since the amount and duration of lymphorrhea in this setting are known to be important risk factors for its development. Potentially, octreotide might be used in similar situations where lymphorrhea is detrimental, such as peripheral vascular surgery and regional lymph node dissection for melanoma.

Lymphoedema and reduced shoulder function as indicators of quality of life after axillary lymph node dissection for invasive breast cancer

BACKGROUND

The aim was to explore measurements of arm circumference and shoulder abduction as indicators of quality of life after axillary lymph node dissection for invasive breast cancer.

METHODS

Differences in arm circumference and shoulder abduction were measured in 465 consecutive women who underwent axillary lymph node dissection. These women received a treatment-specific questionnaire on the severity of physical disability and the effects on their daily life and well-being.

RESULTS

The questionnaire was returned by 400 women (86 per cent). Of these 400, only the 332 women who did not receive axillary radiotherapy were included in the analysis. Their mean time since axillary lymph node dissection was 4.2 (range 0.3-28) years. For 86 patients (26 per cent) there was a difference in arm circumference of 2 cm or more, or a difference in abduction of 20 degrees or more. These patients found it more difficult to do household chores, were more likely to have given up hobbies, felt more disabled and were more likely to be treated by a physiotherapist. However, complaints also occurred among the women with smaller differences in arm circumference and shoulder abduction, although the frequency and severity of their complaints were similar to those in women without swelling of the arm or without restricted shoulder abduction.

CONCLUSION

Measuring arm circumference and shoulder abduction during control visits identifies only some of the women whose daily life and well-being is affected by the side-effects of axillary lymph node dissection.

Will we need lymph node dissection at all in the future?

Traditionally in the treatment of primary breast cancer, axillary lymph node dissection (ALND) plays an important role. However, a substantial and increasing percentage of patients appear to have no nodal involvement and have been subjected to ALND unnecessarily. The first reason to perform an ALND is axillary nodal staging. After reviewing the literature, it can be concluded that in clinically node-negative patients an adequately conducted lymphatic mapping by sentinel node procedure is equal to ALND for this purpose. The second reason to perform an ALND is to establish the extent of nodal involvement, which might have an impact on adjuvant treatment recommendations. However, there is no evidence available that patients with extensive nodal involvement (= 4 positive nodes) benefit more from adjuvant systemic treatment (either standard or high dose) in terms of reduction of odds of recurrence and mortality compared to patients with limited nodal involvement and optimally administered so-called standard adjuvant treatment. The third reason to perform an ALND is to ensure axillary tumor control. Reviewing the different treatment options, it can be concluded that in clinically node-negative patients axillary control after axillary radiotherapy appears to be similar to axillary control after ALND. In clinically overt axillary involvement, ALND (with or without adjuvant radiotherapy) may result in an improved regional control. In the near future, ALND will not be the standard of care but will be reserved for those patients with proven axillary lymph node involvement. In microscopic disease, radiotherapy may be an alternative with equal control and less morbidity.

Women's perceptions of seroma and their drainage following mastectomy and axillary lymph node dissection

AIM

The aim of this research was to study the effect of seroma on women's perception of daily functional and emotional status after surgical treatment for breast cancer. Furthermore, the experiences of the actual drainage procedure of seroma was studied.

METHOD

The study had a prospective and comparative design. A study specific questionnaire was developed and used. Eighty-two women operated with modified radical mastectomy completed the forms. Forty-one women with seroma were compared with the 41 without seroma. The items focused on women's perceptions of daily-life situations, postoperative pain, problems with the surgical scar, preoperative information, general health, levels of anxiety, depression, psychosocial support and contact with the registered nurse in the hospital.

RESULTS

Overall the perceived emotional and functional status, pain and general health did not differ between the two groups. Women with seroma contacted the registered nurse in the hospital more frequently after hospital discharge. Most women with seroma had no or little pain and anxiety during the aspiration and found the procedure fully acceptable. Practical information concerning self-care and the aspiration procedure was considered insufficient. The return visit to the nurse for wound observation was important and provided psychosocial support.

CONCLUSION

Seroma and its drainage is well accepted. Patients should be better informed about the possibility of a seroma and its treatment. Staff continuity and particularly the presence of a special trained nurse for wound control and for psychosocial support are much appreciated.

Sensory morbidity after sentinel lymph node biopsy and axillary dissection: a prospective study of 233 women

BACKGROUND

We prospectively compared the sensory morbidity and lymphedema experienced after sentinel node biopsy (SLNB) and axillary dissection (ALND) over a 12-month period by using a validated instrument.

METHODS

Patients undergoing breast-conserving therapy completed the Breast Sensation Assessment Scale (BSAS) at baseline and 3, 6, and 12 months after surgery. Repeated-measures analysis of variance was used to compare ALND and SLNB over the 12-month period. Upper- and lower-arm circumference measurements at baseline and 12 months were used to assess lymphedema.

RESULTS

SLNB was associated with substantial sensory morbidity, although significantly less than ALND, over time on all four subscales and the summary score. A statistically significant improvement in sensory morbidity occurred for both groups in the first 3 months, with no further change thereafter. For both types of axillary surgery, younger patients had significantly higher BSAS scores than older patients. There was no significant difference in arm circumference between patients with SLNB and ALND at 12 months.

CONCLUSIONS

Among women undergoing breast-conserving therapy, SLNB has significant sensory morbidity, although approximately half that of ALND. Sensory morbidity improves in the first 3 months after surgery, but patients continue to report sensory morbidity at 1 year. Longitudinal follow-up is required to further assess lymphedema.

Optimal use of sentinel lymph node biopsy versus axillary lymph node dissection in patients with breast carcinoma: a decision analysis

BACKGROUND

There are no data available from randomized controlled trials that compare the efficacy of sentinel lymph node (SLN) biopsy with Level I/II axillary lymph node dissection (ALND) in patients with breast carcinoma. We performed a formal decision analysis to determine whether SLN biopsy is appropriate, compared with ALND, for patients with T1, T2, and T3 tumors and to quantify the relative value of these two procedures in the management of patients with breast carcinoma.

METHODS

All clinically relevant outcomes were modeled for both SLN biopsy and ALND. The probabilities of complications and outcomes were derived using data from the University of Louisville Breast Cancer Sentinel Lymph Node Study and from extensive review of previous studies. Utilities were assigned by the authors, incorporating values from the literature whenever possible.

RESULTS

The expected utility of SLN biopsy was higher than the expected utility for ALND for T1 and T2 tumors that were 4.0 cm or smaller. There was no clear preference for either procedure with tumors that were larger than 4.0 cm. The T1 and T2 results were robust to sensitivity analysis.

CONCLUSIONS

The results of this decision analysis suggest that SLN biopsy is preferred over ALND for patients with breast tumors that are 4.0 cm or smaller. Patients should be aware of the potential for false-negative results in SLN biopsy, but this risk is outweighed by the decreased morbidity associated with the procedure itself.

Long-term complications associated with breast-conservation surgery and radiotherapy

BACKGROUND

Breast-conservation surgery plus radiotherapy has become the standard of care for early-stage breast cancer; we evaluated its long-term complications.

METHODS

We selected patients treated with surgery and radiotherapy between January 1990 and December 1992 (an era in which standard radiation dosages were used) with follow-up for at least 1 year. Patients were prospectively monitored for treatment-related complications. Median follow-up time was 89 months.

RESULTS

A total of 294 patients met the selection criteria. Grade 2 or higher late complications were identified in 29 patients and included arm edema in 13 patients, breast skin fibrosis in 12, decreased range of motion in 4, pneumonitis in 2, neuropathy in 2, fat necrosis in 1, and rib fracture in 1. Arm edema was more common after lumpectomy plus axillary node dissection than after lumpectomy alone. Arm edema occurred in 18% of patients who underwent surgery plus irradiation of the lymph nodes and 10% who underwent surgery without nodal irradiation.

CONCLUSIONS

Breast-conservation surgery plus radiotherapy was associated with grade 2 or higher complications in only 9.9% of patients. Half of these complications were attributable to axillary dissection, it is hoped that lower complication rates can be achieved with sentinel lymph node biopsy. Breast-conservation surgery and radiotherapy is associated with grade 2 or greater complications in only 9.9% of patients. Nearly half of these complications are attributable to axillary dissection.

Lymphatic mapping in solid neoplasms: state of the art

BACKGROUND

Lymphatic mapping and sentinel lymph node biopsy is an established technique for the staging and treatment of melanoma. The success of lymphatic mapping in this realm has broadened its application to other solid neoplasms. This update reviews the status of sentinel lymph node biopsy in its most widely cited applications.

METHODS

Seminal manuscripts on lymphatic mapping in melanoma, breast, colon, vulvar, cervical, lung, gastric, and head and neck cancers are reviewed.

RESULTS

Studies suggest that the application of lymphatic mapping as a staging tool in breast cancer and melanoma is justified when applied by trained surgeons. Additional validation is necessary before sentinel node biopsy is advocated in gynecologic, colon, lung, and head and neck cancer.

CONCLUSIONS

As in breast cancer and melanoma, validation of the sentinel node concept in other solid tumors must occur in institutions other than those in which the technique is being developed before it is generally applied to other neoplasms.

Utilitarian shoulder approach for malignant tumor resection

Malignant tumors involving the shoulder girdle can arise from four distinct locations: the proximal humerus, scapula, periscapular muscles, and axillary structures. This article describes a utilitarian shoulder approach that can be used to resect these tumors.

Early and late morbidity associated with axillary levels I-III dissection in breast cancer

BACKGROUND AND OBJECTIVES

Axillary dissection may cause substantial morbidity in breast cancer patients. The purpose of this study was to investigate the value of a registration method of morbidity of the arm and shoulder, which is frequently used by surgeons and which includes the measurement of range of movement, strength, and pain.

METHODS

We surveyed 148 patients who had received an axillary dissection as part of breast cancer surgery. Of these patients, 77 had undergone axillary dissection 6-12 months ago and 71 patients more than 5 years ago. In all patients, an objective measurement of shoulder movement and a subjective measurement of pain and arm strength was performed.

RESULTS

A difference of more than 20 degrees in abduction, ventral elevation, or dorsal elevation occurred in 12% of the patients. Pain or loss of strength were measured in half of the patients. Shoulder movement, pain, and arm strength were not significantly different between the patients who underwent mastectomy or breast conserving surgery. Also, no significant difference could be found in shoulder movement, pain, and arm strength between the patients who underwent axillary dissection 6-12 months ago and those who underwent it more than 5 years ago.

CONCLUSIONS

Pain, loss of arm strength, and limitation of shoulder movement are frequent complaints after axillary dissection for breast cancer and appear to be independent of the length of follow-up and the type of surgery (i.e., breast-conservation or mastectomy).

Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer

The aim of this study was to investigate the nature and severity of the arm complaints among breast cancer patients after axillary lymph node dissection (ALND) and to study the effects of this treatment-related morbidity on daily life and well-being. 400 women, who underwent ALND as part of breast cancer surgery, filled out a treatment-specific quality of life questionnaire. The mean time since ALND was 4.7 years (range 0.3-28 years). More than 20% of patients reported pain, numbness, or loss of strength and 9% reported severe oedema. None of the complaints appeared to diminish over time. Irradiation of the axilla and supraclavicular irradiation were associated with a 3.57-fold higher risk of oedema (odds ratio (OR) 3.57; 95% confidence interval (CI) 1.66-7.69) causing many patients to give up leisure activities or sport. Women who underwent irradiation of the breast or chest wall more often reported to have a sensitive scar than women who did not receive radiotherapy. Women <45 years of age had an approximately 6 times higher risk of numbness of the arm (OR 6.49; 95% CI 2.58-16.38) compared with those > or = 65 years of age; they also encountered more problems doing their household chores. The results of the present study support the introduction of less invasive techniques for the staging of the axilla, sentinel node biopsy being the most promising.

Surgical outcomes after breast cancer surgery: measuring acute lymphedema

BACKGROUND

Studies of lymphedema have used inconsistent measures and criteria. The purpose of this pilot study was to measure the onset and incidence of acute lymphedema in breast cancer survivors using strict criteria for limb evaluation.

MATERIALS AND METHODS

Eligible women were those undergoing breast cancer surgery that included axillary staging and/or radiation therapy of the breast. Arm volume, strength, and flexibility were measured preoperatively and quarterly. Lymphedema was defined as a greater than 10% increase in limb volume. Additional strength and flexibility assessments were done at these times.

RESULTS

In 30 evaluable patients, half underwent modified radical mastectomy and half lumpectomy, with half of the lumpectomy patients undergoing axillary node staging. Of the 30 patients 27% were Stage 0; the rest were Stage I (27%), IIA (13%), IIB (23%), and IIIA (7%). One subject was IIIB postoperatively. There were 2 women with a 10% or greater change in limb volume; the change was detected in one woman at 3 months (5% incidence) and in the second woman at 6 months (11% incidence). Both had undergone mastectomy and axillary dissection and one of these two women had symptoms of tingling and numbness in the affected arm that began at 3 months. Overall, 35% of the sample experienced symptoms by 3 months, which included numbness, aching, and tingling of the entire upper extremity, but without volume changes. The relationship between undergoing modified radical mastectomy and experiencing symptoms in the affected limb at 3 months was significant (P = 0.05).

CONCLUSIONS

In this interim report strict methods of measurement and limb volume comparisons detected acute lymphedema at 3 months in 5% of the sample, and at 6 months in 11% of the sample. Furthermore, symptoms were detected in 35% without volume changes at 3 months postoperatively, which may warn of lymphedema occurrence within the next 3 months. This may assist clinical evaluation of symptoms in the postoperative period and support early referral to lymphedema experts.

Localizing the sentinel node outside of the specialty center: success of a lymphatic mapping course in disseminating new technology

BACKGROUND

Sentinel node biopsy (SNB) is an evolving technology in the management of breast cancer. The purpose of this study was to determine the success of an SNB course in emphasizing principles for participants to successfully initiate an SNB program at their institution.

METHODS

Participants in a university-sponsored course were queried 6 to 18 months after the course regarding their success in initiating SNB in their practice. Univariate analysis was used to determine the likelihood of implementing a SNB program.

RESULTS

Ninety-one participants responded. Of these respondents, 56 had initiated an SNB program at their hospital, and 20 had completed a "validation" phase. "Validation" consisted of less than 10 cases for 11 respondents, 11 to 20 cases for 5 respondents, and 20 to 30 cases for 3 respondents and >30 cases for 1 respondent. Twenty-eight percent initiated the learning curve without an Institutional Review Board (IRB) protocol, and a further 20% went on to utilize SNB without axillary dissection in sentinel node-negative patients without IRB approval. Univariate analysis revealed that surgeons practicing in a group whose caseload consisted of more than 25% breast surgery cases were most likely (P < 0.05) to implement SNB in their practice.

CONCLUSIONS

Success in applying SNB after a course is high among surgeons in groups with a significant breast caseload, although recommendations for obtaining institutional approval and completing a 30-case validation series are often disregarded.

Long-term morbidity following axillary dissection in breast cancer patients--clinical assessment, significance for life quality and the impact of demographic, oncologic and therapeutic factors

OBJECTIVE

This study describes in detail the surgery-related symptoms following axillary lymph node dissection in breast cancer patients and considers both their significance for long term quality of life and the impact of possible influencing factors.

MATERIAL AND METHODS

Three hundred and ninety six patients were studied retrospectively using a self-report questionnaire and a clinical examination. The symptoms, numbness, pain, edema, arm strength and mobility were evaluated. The subjective assessment of the degree of symptom intensity was compared with objective measurements. The extent of surgery (number of resected nodes, level of dissection) as well as the influence of demographic, oncologic and adjuvant measures (age, time interval, number of involved nodes, chemotherapy) were evaluated.

RESULTS

Shoulder-arm morbidity and fear of cancer recurrence were the most important long-term sources of distress following breast cancer surgery in our study population. Demographic, oncologic and therapeutic measures including the extent of surgery had no influence on long-term morbidity. The intensity of all evaluated symptoms was reported to be more severe in patients' subjective statements than in the results of clinical assessment.

CONCLUSION

Shoulder-arm morbidity following axillary dissection is a frustrating polysymptomatic disease that seems to be relatively unaffected by therapeutic measures. The surgical trauma necessary for adequate tumor staging (removal of 10 lymph nodes) seems decisive for the postsurgery syndrome following axillary dissection. For node-positive patients complete axillary clearing may improve tumor control without worsening long-termmorbidity. New techniques, such as the sentinel-node-biopsy, that selects patients with negative axillary status while preserving the integrity of axillary structures, may improve the overall morbidity.

Sentinel lymphadenectomy accurately predicts nodal status in T2 breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) has emerged as a reliable, accurate method of staging the axilla for early breast cancer. Although widely accepted for T1 lesions, its use in larger tumors remains controversial. This study was undertaken to define the role of SLNB for T2 breast cancer.

STUDY DESIGN

From a prospective breast sentinel lymph node database of 1,627 patients accrued between September 1996 and November 1999, we identified 223 patients with clinical T1-2N0 breast cancer who underwent 224 lymphatic mapping procedures and SLNB followed by a standard axillary lymph node dissection (ALND). Preoperative lymphatic mapping was performed by injection of unfiltered technetium 99 sulfur colloid and isosulfan blue dye. Data about patient and tumor characteristics and the status of the sentinel lymph nodes and the axillary nodes were analyzed. Statistics were performed using Fisher's exact test.

RESULTS

Two hundred four of 224 sentinel lymph node mapping procedures (91%) were successful. Median tumor size was 2.0 cm (range 0.2 to 4.8 cm). One hundred forty-five of the 204 patients had T1 lesions and 59 patients had T2 lesions. There were 92 pathologically positive axillae, 5 (5%) of which were not evident either by SLNB or by intraoperative clinical examination. The false-negative rate and accuracy were not significantly different between the two groups, but axillary node metastases were observed more frequently with T2 than with T1 tumors (p = 0.005); other factors, including patient age, prior surgical biopsy, upper-outer quadrant tumor location, and tumor lymphovascular invasion were not associated with a higher incidence of false-negative SLNB in either T1 or T2 tumors.

CONCLUSIONS

SLNB is as accurate for T2 tumors as it is for T1 tumors. Because no tumor or patient characteristics predict a high false-negative rate, all patients with T1-2N0 breast cancer should be considered candidates for the procedure. Complete clinical examination of the axilla should be undertaken to avoid missing palpable axillary nodal metastases.