Sentinel lymph node biopsy

The first possible site of metastases along the route of lymphatic drainage detectable with injection of dyes or radioactive nuclides.

100% predictive of axillary node status in breast cancer.

False negative rate varies between 0 and 17% with a mean of 8-9%.

See sentinel node biopsy in breast cancer.

Most important predictor of survival of patients with melanoma.

7% lymphedema rate.

3% have decreased upper arm range of motion.

7% have axillary paresthesias.

Small risk of allergic reaction to isosulfan blue dye if used for biopsy.

Adverse or allergic reactions occur with isosulfan 1% blue dye in 0.7-1.9% of patients undergoing such procedures.

Allergic reactions to isosulfan includes urticaria, pruritus, generalized rash and hypotension.

Advantages over traditional axillary dissection including a less invasive surgical procedure, elimination of postoperative drainage of the axilla, less patient discomfort and decreased incidence of lymphedema or neurovascular injury.

The use of radioactive isotope combines with blue dye is the procedure of choice for mapping the sentinel lymph node in breast cancer.

Has become increasingly accepted as and alternative to axillary lymph node dissection for nodal staging in breast cancer.

About 15% of patients with breast cancer have multiple sentinel lymph nodes.

False negative rates of 7-10% have been found in large prospective studies, but recurrent cancer in the axilla is seen in fewer than one percentage of patients with no metastases on the SLN.

Two key parameters of successful biopsy are identification of the sentinel lymph node and false negative rate.

Has not affected survival in melanoma patients.

Surgeons should perform at least 20 sentinel lymph node biopsies before abandoning routine axillary dissection.

For patients with clinically node negative disease, evidence supports the use of sentinel lymph node biopsy is the standard of care.



In early breast cancer SLNB alone  is standard of care in patients with clinically nodal negative disease based on a low axillary recurrence rate: 0.4% with SLNB and  0.2% with SLNB plus  axillary node dissection.


Breast cancer patients with a positive sentinel lymph node biopsy should undergo standard axillary dissection to achieve locoregional control and to increase nodal tumor staging.

No randomized trials have evaluated the need for completion axillary lymph node dissection following SLNB for patients with nodal metastases.

The American College of Surgeons Oncology Group reviewing the National Cancer Data base from more than 450 hospitals and 1,144,397 women with breast cancer and found that patients with microscopic nodal metastases, a completion axillary lymph node dissection (ALND) did not improve outcomes compared with sentinel lymph node biopsy alone.

The American College of Surgeons Oncology Group reviewing the National Cancer Data base from more than 450 hospitals and 1,144,397 women with breast cancer and found that patients with macroscopic nodal metastases, a nonsignificant trend toward better outcomes was seen with completion ALND compared with sentinel lymph node biopsy alone.

AMAROS trial of women with early sentinel lymph node positive breast cancer comparing axillary radiation to axillary lymph node dissection: rates of axillary recurrence 1% vs 0.5% after 5 years, with no differences in 5 year disease free or overall survival (Rutgers EJ et al).

In the above study axillary resection associated with more lymphedema than axillary radiotherapy.

Has increaed detection rate of positive lymph nodes in breast cancer by its ability to identify isolated tumor cell metastases pN0 known as nanometastases and micrometastases pN1mi.

Breast cancer patients with a positive sentinel lymph node have only a 10% likelihood of having four or more positive lymph nodes at axillary dissection (Katz A).

Decreases the complications of axillary surgery, but only for patients whose sentinel lymph node biopsy was negative.

Among patients without involved nodes 24% of patients assigned to axillary node dissection had a postoperative axillary seroma, while those patients managed with only sentinel node biopsy the postoperative axillary seroma rate was 11%.

Among patients with positive lymph nodes 12% of patients with axillary lymph node dissection developed a seroma while patients assigned to sentinel lymph node biopsy followed by axillary lymph node dissection have a 20% axillary seroma rate.

Tumor size and peritumoral vascular invasion of the primary tumor are the most powerful independent risk factors of sentinel lymph nodes metastases.

Allows for more precise pathological analysis of nodal disease than axillary lymph node dissection.

Assessment involves serial sectioning of paraffin blocks with hematoxylin and eosin staining of sections, and immunohistochemical staining with antibodies to cytokeratin to determine the presence of metastases.

The American College of Surgeons Oncology Group Z0010 trial involving 5210 patients who underwent breast conserving surgery for invasive breast cancer clinically stage T-1-T2 N0M0: Sentinel lymph node specimens were examined for hematoxylin-eosin or immunohistochemistry tests- patients with evidence of immunohistochemical positive SLN metastases did not have a different overall survival than women with hematoxylin-eosin negative lymph nodes (Guiliano A et al).

Touch imprint cytology for patients with larger tumors is more effective than standard assessment.

No negative effect is associated with delayed SLNB beyond 30 days in early melanoma.

SLNB is indicated for melanomas ≥ 0.75 mm.

Sentinel node biopsy staging of intermediate thickness or thick primary melanomas compared to wide resection and nodal observation vs immediate lymphadenectomy for positive nodes associated with prolonged disease free survival, and distant disease free survival for intermediate thickness melanomas (Morton DL et al).

A study describing the prognostic impact of the SN-procedure in colon carcinoma after 5-year-follow-up: Only one patient had recurrent disease after a negative SN procedure with a disease-free-survival 96%, indicating patients that are lymph node negative after an SN-procedure have an excellent prognosis and do not need adjuvant treatment.

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