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Sentinel Node Treatment

Axillary lymph node metastasis is significant for the pathologic staging of breast cancer. Current postoperative adjuvant chemotherapy recommendations are based on metastases in the axillary lymph nodes removed during surgery for clinical stage I or stage II breast cancer.

Standard surgical resection

Standard surgical resection involves either partial or total mastectomy with axillary dissection. Approximately eight to 20 lymph nodes are found within the axillary dissection specimen. The surgical pathologist dissects these nodes from the surrounding adipose tissue. Nodes are fixed in formalin and examined for metastatic disease by microhistopathologic evaluation. The presence and number of nodal metastases are significant prognostic indicators of future recurrence risk.

The postoperative pathologic staging of axillary lymph nodes figures prominently in determining the duration and intensity of postoperative adjuvant therapy for breast cancer. A significant difference exists between the five-year survival rate for patients who have no microscopic evidence of axillary lymph node metastases (node-negative) and those with microscopic evidence of nodal metastases (node-positive).

Adriamycin/Cytoxan (AC) regimen

In general, node-negative breast cancer patients whose primary tumor is greater than 1 centimeter in diameter should receive four cycles of an Adriamycin/Cytoxan (AC) regimen. Data now show that if node-positive/ER-negative cancer patients are treated with AC, then the five-year disease-free survival (DFS) is 54 percent, and the five-year survival is 70 percent. DFS for node-positive/ER-positive patients treated with AC is 71 percent. Five-year survival is 83 percent.

Taxene therapy

Current protocols include AC plus taxenes (paclitaxel and docetaxel) for node-positive patients. Taxenes are a new class of chemotherapeutic drugs derived from the Pacific yew tree that inhibit cellular division. Data show that measurable breast cancer responds well to taxene therapy. A large cooperative group trial has found that the addition of paclitaxel to the postoperative AC regimen improves survival in node-positive patients.¹ Therefore, current postoperative adjuvant treatment protocols depend on accurate nodal staging.

SLN biopsy

The sentinel lymph node (SLN) biopsy was described for melanoma but now is being peformed for breast cancers to determine nodal metastases. The SLN is defined as the first regional node draining the primary tumor. For breast cancer, this node usually is an axillary node, but occasionally internal mammary nodes are seen. Intraoperative techniques now are available to find and remove the SLN with an accuracy of 100 percent, a specificity of 100 percent and a sensitivity of 97 percent. Usually, two SLNs are found and submitted to the surgical pathologist.

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