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Recommendations for use of Sentinel node biopsy

Clinical practice recommendations

Recommendations to individuals should be based on their risks without sentinel node biopsy, the absolute benefits and harms of the procedure, and their preference. These factors should be discussed with the woman. Recommendations should also take account of any uncertainties about the long-term effects of sentinel node biopsy.

RECOMMENDATIONS LEVEL OF EVIDENCE19 REFERENCE
In women with early (operable) breast cancer:

Sentinel node biopsy should be offered as a suitable alternative to axillary dissection for women with:

  • unifocal tumours equal to or less than three centimetres in diameter and
  • clinically negative nodes

Sentinel node biopsy is not recommended for women with clinically or pathologically positive nodes

There are no randomised trial results to support the use of sentinel node biopsy in:

  • women with multicentric/multifocal tumours
  • pregnant or breastfeeding women
  • women with known allergies to radioisotopes or blue dye
  • women with previously treated breast cancer or axillary surgery on the affected side
II Milan4,5
ALMANAC6
SNAC I8
NSABP B-329 Cambridge10
GIVOM11,12

Information about procedures should be discussed with the patient. The patient should be adequately prepared for the procedure

For sentinel node biopsy this includes:

  • a clear description of sentinel node biopsy
  • clear information about the objective of the procedure
  • the potential of an unsuccessful sentinel node biopsy or false negative result
I NBCC* & NCCI25

If the sentinel node is identified at the time of sentinel node biopsy:

  • for a positive sentinel node—axillary dissection is recommended (with due consideration of the risks and benefits to the individual woman)
  • for a negative sentinel node—clinical follow-up of the axilla is recommended

If the sentinel node is not identified at the time of sentinel node biopsy:

  • axillary dissection should be performed
II

Milan4,5
ALMANAC6
SNAC I8
NSABP B-329 Cambridge10
GIVOM11,12

Team, training and experience

The outcome of women with breast cancer is better if they are treated by a clinician who has access to the full range of treatment options in a multidisciplinary care setting

The team for performing sentinel node biopsy should comprise a surgeon, nuclear physician (where nuclear medicine facilities are available), pathologist, anaesthetist and appropriate nursing support throughout and following the procedure

Ongoing data collection and audit of sentinel node biopsy performance by the team should be conducted

III NBCC1 *

The surgeon performing sentinel node biopsy should be appropriately trained and experienced in the sentinel node biopsy techniques and have evidence of successful identification of sentinel node(s)

The Australian SNAC I22 protocol states the surgeon performing sentinel node biopsy should have completed sentinel node biopsy in at least 20 consecutive cases with a greater than 90% success rate in locating the sentinel node(s)

  Milan4,5
ALMANAC6
SNAC I8
NSABP B-329
Technique
Where possible, lymphatic mapping with pre-operative lymphoscintigraphy in combination with intraoperative use of the gamma probe and blue dye should be used to locate the sentinel node(s) II Radovanovic13 
Hung14 
Meyer-Rochow15

Where combination technique is not available or suitable, use of blue dye or radioisotope alone is an appropriate option

Blue dye alone could be used where no nuclear facilities are available; however, the individual surgeon’s sentinel node biopsy technique and results should be audited

II Radovanovic13 Meyer-Rochow15 Hung14 
Milan4,5 
GIVOM11,12

Trial results do not indicate that any site of injection (peritumoural, periareolar or intradermal) is superior in detecting the sentinel node(s) in the axilla

  FRANSENODE16
Povovski17

All identified sentinel nodes should be excised, including non-axillary sentinel nodes, if they can be accessed and excised without increased morbidity

  SNAC I22
False negative rates

To reduce false-negative rates, surgeons should aim to remove all identified sentinel and/or clinically suspicious nodes at the time of surgery

However, removal of four or more nodes from the axilla can increase risk of morbidity, and does not lower the false negative rate significantly compared with removing up to three nodes

II NSABP B-32(2007)20
Pathology

Detailed, definitive histological assessment (including immunohistochemistry and serial sectioning) of the sentinel node is recommended for the detection of metastatic disease

  NBOCC* & ACN23

Intraoperative assessment of the sentinel node may be performed, allowing those cases identified as positive for metastatic disease to proceed to immediate axillary dissection as a single procedure

Intraoperative assessment should be confirmed with detailed, definitive histological assessment

II NSABP B-329 
GIVOM11
Adverse events
Surgeons and anaesthetists should be aware of the possibility of adverse reactions (including allergies) in patients and, in the event of an adverse reaction, agreed protocols should be in place IV MSAC24
TGA26
Clinical trials
When sufficient evidence does not exist to guide definitive recommendations for the use of sentinel node biopsy, if possible, patients should be offered entry into properly conducted clinical trials where indicated and/or appropriate III NBCC 1 *

* In February 2008, National Breast Cancer Centre (NBCC), incorporating the Ovarian Cancer Program, changed its name to National Breast and Ovarian Cancer Centre (NBOCC). In July 2011, NBOCC amalgamated with Cancer Australia to form a single national agency, Cancer Australia, to provide leadership in cancer control and improve outcomes for Australians affected by cancer.

Published using CeCC Docbook Manager