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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Cancer

July 31, 2003

News this month
Sentinel node biopsy offers fewer side effects

Sentinel node biopsy for breast cancer—which means removing only one or a few lymph nodes—offers fewer side effects than traditional axillary node dissection, a new study reports. While many surgeons have hailed sentinel node biopsy for these reasons, this is the first and only study to date to document the outcomes. The study, reported in the American Journal of Surgery in January 2002, is good news for the thousands of women diagnosed with early breast cancer each year.

Sentinel node biopsy offers fewer side effects than the more radical axillary node dissection.

Authored by William E. Burak Jr., MD, of Ohio State University, the study compared the post-operative side effects and socioeconomic impact of sentinel node biopsy with axillary node dissection in 98 patients with early stage breast cancer. The patients underwent breast conservation surgery and lymphatic mapping at the Ohio hospitals over two years. All patients had a tumor 4 cm or less in size and none had undergone prior chemotherapy or radiation therapy for their breast cancer.

Using radioactive isotope and blue dye
For the sentinel node biopsy (SLNB), all study patients received an injection of a radioactive isotope called 99-technetium sulfur colloid near the breast tumor or in the biopsy cavity two hours before their surgery. After general anesthesia was administered, the patient received a second injection of blue dye. During surgery, a detector was held above the nodes. Sentinel lymph nodes were identified as nodes that were radioactive, blue or both. If a sentinel node was positive for cancer, then a complete axillary node dissection was performed.

Separating into groups
Based on the findings of the sentinel node biopsy, the 98 patients were put into two groups, which formed the basis of this study. After surgery, all patients in both groups underwent whole breast irradiation.

  • Group A consisted of patients who had a negative sentinel node biopsy and did not go on to have a complete axillary node dissection.
  • Group B patients underwent a sentinel node biopsy followed by axillary node dissection because their sentinel node contained cancer.

At least six months after their procedure, the patients filled out questionnaires and underwent arm measurements (to check for swelling) at an outpatient clinic. Patients in Group B were more likely to have positive axillary nodes and as a result were more likely to receive chemotherapy as well.

Reducing lymphedema
Lymphedema (arm swelling) is a well-known side effect of axillary node dissection. To check to see if there was a difference between the groups, the upper arms of both groups were measured. Patients in Group A (only sentinel node biopsy) had significantly less swelling than patients in Group B.

Patients in Group A also had significantly fewer arm complaints (including numbness), had a shorter hospital stay and required less wound drainage than did Group B.

Only 16 percent of patients in Group A required the placement of a wound drain compared to 100 percent of Group B.

Quicker return to normal life
Regarding return to active lifestyle, patients in Group A noted that they were able to return to regular duties (whether at work or at home) much sooner than in Group B. The majority in Group A (70.7 %) returned to normal activity in less than three days. In Group B, 73.8 percent of patients undergoing axillary node dissection did not return to normal activity until more than seven days after their procedure.


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Donald Lannin, MD

Benefits of sentinel node biopsy

When a woman is diagnosed with breast cancer, it's crucial to find out whether the cancer has spread beyond the initial site to nearby lymph nodes. Knowing this will direct which treatment she receives as well as her overall prognosis.

“With breast cancer, it's crucial to find out whether the cancer has spread beyond the initial site to nearby lymph nodes.”

In the past, surgeons removed all of the lymph nodes from under the arm, a procedure called an axillary node dissection. Each of the 10 to 20 lymph nodes was then tested in the lab for the presence of cancer.

Looking for a better way
While axillary node dissection offered good information about whether the cancer had spread, it also resulted in a fairly long recovery time for the patient. Many patients experienced short-term side effects, which included wound drainage and several days of recuperation.

Other patients also noted long-term side effects, such as numbness from nerve damage, swelling of the arm and/or wrist (lymphedema) and limited range of motion of the arm.

Sentinel node biopsy is as accurate as removing all the nodes while producing a shorter recovery time and fewer side effects.

When the first sentinel node biopsy trials began in 1995, with which I was involved, we hoped the procedure would be as accurate as removing all the nodes while producing a shorter recovery time and fewer side effects. As this study and other studies show, surgeons using sentinel node biopsy—during which only one to three nodes are removed—have now accomplished both.

Proof of fewer side effects
For the first time, this study documents something surgeons have known for years—patients who undergo sentinel node biopsy experience significantly fewer side effects and can resume normal activities much faster than patients undergoing axillary node biopsy. Sentinel node biopsy is also proving to be at least as accurate as axillary node biopsy in detecting the presence of cancer.

Because of these benefits, in just a few years time, sentinel node has gone from being an experimental procedure to the procedure of choice for selected patients in many larger medical centers. The sentinel node biopsy procedure is usually performed during a lumpectomy or mastectomy.

Finding the sentinel node
How does the surgeon find the sentinel node? First off, a sentinel node is simply the first node to which cancer cells may have spread. Any node can be a sentinel node.

To track the spread of cancer, doctors inject two different dyes into the breast—a blue dye and a radioactive dye. By using hand-held detectors, doctors can tell where the dye went first. These nodes—called the sentinel nodes—are then removed and tested in the lab. More than one node can be a sentinel node. The average is two. If the sentinel node is positive, then all lymph nodes are removed. But if the sentinel node is negative, no other nodes need be removed.

More accurate?
Sentinel node biopsy may even be more accurate in detecting cancer because of sheer numbers. When a pathologist must test 10 to 20 lymph nodes for the presence of cancer, only limited tests are done. However, with only one to three nodes to test, several tissue samples from each node can be checked and a variety of special stains can be used to detect any cancer cells.

Unlike some studies that prompt controversy, I can't imagine anyone not agreeing with the outcome of this study. Another plus: The majority of women with breast cancer are good candidates for this procedure. The exceptions include women with ductal carcinoma in situ—very, very early breast cancer that has not spread—or women with advanced disease who would automatically require more advanced treatment.

With this in mind, I would suggest that women who do not fall into one of these categories and who are not recommended for sentinel node biopsy consider getting a second opinion.

Donald Lannin, MD, is co-director of the Yale-New Haven Breast Center and a professor of surgical oncology at Yale University School of Medicine.

2002 Best Hospital--U.S. News Online

Yale-New Haven was recognized this year by U.S. News & World Report for its cancer services.


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