Radical axillary node resection in node-negative breast cancer: can its indication be individualized by examining the (primary tumour-draining) sentinel node?

Background and objective: The status of the axillary lymph node(s) is an important prognostic factor in breast cancer and thus decisive in the indication for adjuvant treatment. This study investigated the extent to which examination of the sentinel node (SN) can individualize the need for axillary resection and the diagnosis of lymph nodes be optimized. Patients and methods: 96 consecutive patients with breast cancer were studied (94 women, 2 men; mean age 59 [36-84] years) in whom no lymph node enlargement had been diagnosed clinically. After preoperative lymph-drainage scintigraphy with Tc-99m Nanocoll combined with intraoperative scintillation probe detection the SN node was identified in 77 of the 96 patients and was removed. Subsequently the axillary lymph nodes in level I and II were removed by a standard technique and all removed lymph nodes and material then compared histoiogically. Results: In nine of 77 patients with identifiable SN it was the only lymph node with metastasis. In 18 patients both the SN and other axillary lymph nodes were infiltrated. The SN and other axillary lymph nodes were free of metastases in 44 patients. In six patients the SN was not representative, since it was free of tumour, but other axillary nodes were not. Identification of a SN and prognostication of lymphogenic axillary metastases depended on tumour size. Among T3 and T4 tumours, ten of 16 had a verifiable SN, but in six of them it was not representative for axillary metastasization. But in 62 of 73 patients with tumours up to 5 cm in diameter without involvement of skin or chest wall (T1 and T2, respectively) a SN could be identified that was not representative for axillary metastases in only two cases. Conclusions: SN resection in breast cancer makes it possible to individualize axillary node resection as part of primary treatment. Specific histological examination of serial sections and immunohistological testing may possibly increase the accuracy of histological diagnosis.